nhận xét đặc điểm lâm sàng, cận lâm sàng và kết quả hóa trị trên bệnh nhân ung thư tụy tại bệnh viện K

Bộ giáo dục và đào tạo bộ y tế
Trờng đại học y hà nội

NHậN XéT ĐặC ĐIểM LÂM SàNG, CậN LÂM SàNG
Và KếT QUả HóA TRị TRÊN BệNH NHÂN UNG THƯ
TụY TạI BệNH VIệN K
Chuyên ngành: Ung th
Mã số: 60.72.23
Luận văn tốt nghiệp bác sỹ nội trú
Ngời hớng dẫn khoa học:

Hà Nội - 2012


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1.1. Dịch tễ học và những yếu tố nguy cơ gây ung thư tụy 3
___V`ab
1.2. Giải phẫu tụy 7
_c_E`H&Bd
__cePf
_cc59&:g

1.3. Chẩn đoán ung thư tụy 10
_b_I[B'P_h
_bcI[BQ__
_bbI[B) 'P9"_i
_biZ9_d
1.4. Điều trị ung thư tụy 18
_i_CjQ'P_f
_ic2(`'Pch
_ibU9`'Pci
_iiIk`$l'Pci
!+, --1
234563667-1
2.1. Đối tượng nghiên cứu 26
c__Z) mcn
c_cZ9Ycn
2.2. Phương pháp nghiên cứu 27
cc_""cd
cccojcd
ccbC'A33Q3 cd
cci4?cf
cc*CH&pq bi
!+, 008
9%/708
3.1. Đặc điểm lâm sàng, cận lâm sàng 37
b__I[Bbd
b_cI[BQih
3.2.Kết quả điều trị ung thư tụy 43
bc_5$3'A33k`ib
bccI3k`&4Hii
bcbr*h

!+, :;<
5;<
4.1. Đặc điểm lâm sàng, cận lâm sàng 58
i__D*f
4.2. Đánh giá đáp ứng điều trị và độc ;nh của phác đồ hóa chất 68
ic_I3k`nf
iccI4H3sd_
icbrdc
9%<=
9%<-
5>9
6''
?'
@ -*A6!#BCBCDEF!DGH!IHD!JEEKL!MNOE!PDQRD!SDT  H
E!U00
@ 0*OMEV MND,0<
@ 0-!WX XHY!ZE!X[\[!QRY!ZE!X[EZXY!ZE]E!Z ^0<
@ 00_`aQRaQX[0b
@ 0:KX[MD!S c#deR :=
@ 0;DBXfdDGHM E!+EgNEKL!h!@!DiEcjYQXEF!:=
@ 01"EKFMEgNEKLD@!Id !XLDSM:-
@ 08k BC*bb:-
@ 0bXHXBalM E!+EgN:0
@ 0*=XLmMH XnH XHXBalQRk BC*bb:0
@ 0**ZDY!+, Y!ZYBXoMEK":0
@ 0*-ZYS BXoMEK"::
@ 0*0XLmMH XnHBZYS BXoMEK"QjXdCEeVBDBXfdc#d
eR pDUc#deR :1
@ 0*:XLmMH XnHBZYS BXoMEK"QjXY!ZDBkQReVBqEBXoMEK"
BXoMEK":8

@ 0*;CDEF!DGHY!ZDBkcLdZM alXQX:<
@ 0*1CDEF!DGHY!ZDBkcLD!SDT  HpE!U:b
@ 0*8XLmMH XnHE!WX XH*TdE!ra XHXBal\[! ;-
@ 0*<XLmMH XnHE!WX XHeV E!LdEaR\C*TdQjX
*bb;0
@ 0*bXLmMH XnHE!WX XH*TdQjXBZYS BXoMEK";0
@ 0-=XLmMH XnHE!WX XHeV E!LdEaR\C*TdQjXY!ZD
BkBXoMEK";:
@ 0-*XLmMH XnHE!WX XH*TdQjXEXoesY!tME!MUE
;;
@ 0 XLmMH XnHE!WX XHQjXBXoMEK"!IHD!JEEXOY;8
@ 0-0XLmMHDGHdCEeVNOMEVc#deR QRDUc#deR u!ZD
QjXE!WX XH9QRE!WX XH;8
@ :*ZD`JM!X[ME!+W  YDGHM E!+EgNE!radCEeVEZD X@1-
@ :-vc[BZYS eHMBXoMEK"QjXdCEeVY!ZDBk!IHD!JEEKL
\[!!#M E!+EgNDGHdCEeV !XLDSM1b
@ :0@ uOEmM@eV E!LdDGHdCEeV !XLDSM8<
?')w
XfMBk0*6!#\VEMxX08
XfMBk0-6!#\V XjX0<
?'w
kE!"0*!WX XHeV E!Ldu!y EXOEKXf;=
kE!"0-!WX XHeV E!LdEaR\C;*
kE!"00XLmMH XnHE!WX XH*TdQR XHXBal\[!;-
kE!"0:XLmMH XnHE!WX XH*TdQRBZYS BXoMEK" ;0
kE!"0;XLmMH XnHE!WX XHeV E!Ld*TdQjXY!ZDBkBXoMEK"
;:
kE!"01XLmMH XnHE!WX XH*TdQjXEXoesY!tME!MUE
;;
kE!"08XLmMH XnHE!WX XH*TdQjXBXoMEK"!IHD!JE

EXOY;1
?'z
h!**A!XOEBkDiE H mMHEgN{*:|<
h!*-A2 EgN{*:|b
h!*0A E!+\XfMdyEMNOV {-b|*1
()
-'P49H(sY")P
(Ag*t')B"Pu3Y3:P9"
'R'P9"!$*t'3BY")$P
43:P4"&'R"3&(:4"vbw!v_dw
Ek?`a!'P_b) '
[3u"G&fp&
?'x FuX56!u3uXyI4&Dvihw!vidw!
v*_wzE <!x F'PZ0{h!d|_hhhhh?&
('G]=]:vbw-'P'r[3X
{Ydh"fh&)}=cG!4"A'
P'"&k?k!~!)•3!'r!'R!
&P!"&k'r& &"4]€v_dw!vicw
<r=")4& Z'P(k$
 ? ) 'ru 4&[
 fht) 'P'RZX9S
$]3jQF)•vicw
Ik`'P!3jQ&j3'A33k`A)$!'R
@`) X9GS$]F)•EG'P
9>>>!>E['P3(`3'A33
k`H&GPH$l &$ r
(k3s(u‚'R3?P%!
(3s0)0A:["R3&j'R03s
'k`'P9"Bvbw!vicw!'
P&j) ('Ru!r)'

P9"B9ƒYf+_c&X9(?]Yb+
nv_dw!vicw
_
2 X'G!(4&k'P'"
Q3&k&uk!`4• Q&Z
$Z) !&k3'A33k`3j
Q&"#$k`3jQvcw!vfwEukk`(u&
'Pk`(u"&j'($
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E&Q~k}!U~•EBDBXfdc#deR p
DUc#deR QRuOEmM@!IHEK"EKL\[!!#M E!+EgNElX\[!QX[9€
&GPm
1. Nhận xét một số đặc điểm lâm sàng, cận lâm sàng bệnh nhân ung thư
tụy giai đoạn không còn chỉ định phẫu thuật triệt căn hoặc tái phát
được điều trị tại bệnh viện K
2. Đánh giá kết quả hóa trị nhóm bệnh nhân trên
!+, *
./
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**?"D!E•!PDQR!n NOMEV MND, #NM E!+EgN
1.1.1. Dịch tễ học
-'P_b='[3u
"G&p&f
"?'<]chhc"G'GH(cbchhh
GF&(ccdhhhp&?'Pv_dw!vbhw!vbiw
x "?'P[3kX'G3B!(
p&?'*'3{!?9?!9%
&&~z'G3B!x F&x "Yd+g|_hhhhh?X
G&Yi!*+n|_hhhhhX=Gz„]chhn(nihhh
p&?'P!"*!*tp&?'z56!]chhd

'GH(bd_dhF'P&bbbdhp&?'P!
'p&?'v_hw!vbhw!v_hw!
vicw<]ch_hX56!'GH($ib_ih'rR3'RZ
'P&(bnfhhp&?'Px F&x p&
?'PX56:'=cQ3#vicw
0 56Y]_ggn+chhc!=) 'R
Z'P(ftX9~!b_tX9"B
9ƒ&n_t(?]x u3AX'G3B!(…
#G&ukG9&k{&Z) A
) v_dw!vicw
zE <]chhfH?!'P(x F
Z0{h!d|_hhhhh?2Afht'P'RZX
9{'R[?]vbw
-'Pu 4!'r[3X{dh+fhz„!
@(_ht) )B 'G{*h!(x F'PX
b
{Y*h+*igf|_hhhhh?!&X{Ydh+di*i|_hhhhh?z56!
{)Z'Pdc5[?†u X4{4
''P&jp&?'bX4{
Yih+*gv_dw
"G!'P(:u[3X]lA&G
=&X`&Gz56!x 'P]lX
=cQ3#!9('G$lX2 x 
'A'AXcG!(B?]@ 3P=~v_hw!vbhw!vicw
x *]'PXu$9@9*t!
@ ]4(q‡&G@ *]
'PY]_gd*+_gdd1ct7v_dw!vbhw!vicw
1.1.1. Các yếu tố nguy cơ
Y"Y"Y"Y" #\
D"(q‡u?%@ F&"?'P

<AF'Puu3b+iQ3:4r'
]4B{*h!4{[3'PuYnh+fh!
&G{)dc7v_dw
Y"Y"Y"Z" K8>%F
-'P(Hu?k[3X$*+_htu$'r
R3-'P(Hu?k(B}=4
'‚)"[(#G&P(Hu[A
v_cw!v_dw!vc_w
+24'&~&)s?k#G4)"
08L._&8L.c508L.c4)"(AF'P
]Yb!*+_h:v_cw!v_dw!vc_w
+24FB(Hu1W
33000?07&G4)"03_n504
i
)"(AF'P]Y_h+ch:!'A%&G]
AFFv_cw!v_dw
+24C0ˆ+/00![')X=&"F?'G?&
33X'r(8 (4A3B'
P]_hh:v_cw!v_dw
+24'9%?k33![')X
4)"0&#p=.<V152O_!
52Oc!€7v_cw!vc_w
+EP?k&G4)"0CLOO_!) 'r)B 
&P[X{‰&(A'P]*h:v_cw!v_dw
+5ukS‚9!4) "[3?k0[
aFB'r![')XukSB‚!‚9?F&
$a?`")!?`B;0Š#G]A
F) )9:!3!'&~!)s!?9?&$'P
v_cw!v_dw!vc_w
+-'P!B]P&'r'R$†

4#G0}aFBi#bc+biv_cw!v_dw!vc_w
Y"Y"Y"]" 0@8(
N"A(#‹u&G'P~
54Yfc4Q3)Y_g*h+chhd&k
?`a~&'PiP`CH‚u!
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Y"Y"Y"^" '_CA=
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F'_v*w
+IPm'4'o"30PCH(4
99#IP?49P+IP†&G
49&3::‡9}9Qv*w
d
Hình 1.1: Thiết đồ cắt ngang qua tụy[14]
1.1.2. Ống tụy

P4"&Y4"!&Y9"
+ C:4""&40&#
9"
+ C:9"m"B†{&G
ePH1Ž7m)F:YPX?'G'r9
)4"!Y#P0PPG"P)‰
?'G#:PBG~Gs†Q{&)(
E0z&P($_*+ch•{&PHv*w
eP3P1O7mXH!"G~
)•X3:v*w!v_iw
f
Hình 1.2: Ống tụy [14]
1.2.2. Mạch máu và thần kinh
+I49m
•I499mu3&P#c)
49&`&49v*w
I49&`"&P)Xcm49
…u3P&['G&PI4
9u3[v*w
I49"Pm49P'!4
9P?'G!49P!49PGv*w
•I4990m"&P)X4
9P?'GI49P'G?'G&P?'G
"['G&[3:?'GPv*w
+‡9m‡9P{%"3["3&‡9p
g
•‡9!‡9{&k‡9p
•‡9P?'G{&990
•‡9&P{&‡9
+89"m)9"P{%"3&=9:u!

(4Q=Z[92 )9"
Pu33~&G'G{&k=H9?0
["&†!†&G 9~{&k*(9
Hm9!9?'G!9'G!!&9$*(R3
ƒ9P\(%'= 9)9"
P& )9")rG!)r•?9?v*w!v_iw
+:m:%PY9&9
0v_iw
*0!‚BaZM E!+EgN
1.3.1. Đặc điểm lâm sàng ung thư tụy
<= '•X9G~) 
GX3u‘&u(3 \ 
'RB ‹) 'r‚X9"B
+8 'r)F:&G  •!"30)P
su &F
+O~$&]'R?(]"P!Š
(B?‘•3vnw!vbbw
+I)PŠ[3'H?=?4'BA#[
•QI&†Š!'I
)B 'rQ![) P)`?‚\k!?=?4&
PA•‚3Bu&
  :    9!  &  &      3~  9  -  '  "  
1?07'rvnw!v*hw
_h
+E?&F]?:ZX':•&Gx Y
d*t'rR3x $&`HB?:&k)
3HPŠ(P)"?99>>
FQvnw
+<= H[3A'@•!)(!)s&
O&•u"u< ) 

(`&#F!Y() Bv*hw
+(Bruu3•?'G)r'r&~Q]?u
 HuA"}X&Pvbbw
+\$_ht'r'P()B 'r‹
!&cht()B  1('r'GB
&'rŠ7v_dw!vbbw
+x F9'Pu!%"
u"3 u 'RF9v*hw
+?u ')(E0!'Q&
'u&G':P(B(4B
) mA#[‹A!&F&?HQA&(~]
~$!'r(‘0&•'(B(?u
 Fl3&$vbbw
1.3.2. .Đặc điểm cận lâm sàng
Y"]"Y"Y"V_4
+8)]?u FQ?'P‘•3Q
’$))%"3j"3k]8u“) ( 
'R&?FQGu ())”_h|?Dk3$
‡( 'RFQ?'!:':•!"
uvnw!v*hw
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+U• 3u[3$ght) '•&
'#&†)(E0\$nht'rR3'
•(?u "]0'r[3$*t
I'r"p~(u]k'rR3I`'R0
O;T&O;CB9Y&vbbw
+u@B._g+g49"'
'R\3M3 ]_gdg!390Ba?`
?u._g+gu@B?H)$"s$3(
&r)x._g+gfvcw!vc*wZ

'P._g+gu@B(4Q&4[ !4@
`3•3'R9?]!$]Š'
3k`&0?‹{) -v_dw!v*hw
Y"]"Z"ZQ(4A(Ac7C(=G>
+O{)P
I4QZ&G'P{$
Ydnt+git“0Y)vbwOS'Rp?P
'4) 33?j'rQ~P)}•B
• ")v_dwv*hw
+P3FG3&H
P3FG3&Hu3$(4HA6Q
!Š($]'G?j~Z)}•
[3)"?:9k`9r1
'P947&"6QŠ'r'R%
#Z'P!=•[(H
a[) X&†:P9?a)`)•#3DEv*_w8
9`ZP!P3DES~3$]F
E†:•'R('AF!?†
$##'r‡9)F)4}Z{'A
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&†:P!u9&%4{'Aviw!v_dw!vcdw!
vicw!v*_w
+P34'XY
JB6Q(B% kFX[
3•!(Bu=)u'r&k['r
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CK&Gc+1_f,7W+c+?0+V+;01,V;7'Rp?Pk
=]:'r$]3 
={B3R3&G=#) q

v_fw
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$(Bu'R)smF…•!?)`9p!
$3x43:P)Xv_dw!vinw
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u?`~PB• Z")89
PHZ!3'A33S(B'Rp?P'43'A
 B% QHk`'?j''rQ9
r[&‡&a#4S[)SQ
[?j'Š+'rQ( 'RFQvinw
+O4
O4($]3 'R={'A•!%
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4&G$(43$(B'RP&A
#"Q
+<4{)P
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5[?†3'A33Z$ 93
B'& 3 {'A'?]&3~9k~
[3(]IB'A{'&Q!4{)P•4
3'A u= vcfw!vbbw<(Su43'A =H
& 3!u•&u~$
3j9#•vcfw
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1.3.3. Đặc điểm mô bệnh học của ung thư tụy ngoại tiết
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Y"]"]"Y")JN
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