Lâm sàng phụ khoa và giải phẫu bệnh

M oi Ion • Thu'ong bi duo'c tao bdi bieu m o vay lat tang • Chan bi cd cac nang long va ba loai tuyen... Cac ton thuong am ho trong cac benh he thong A.. • Chan doan: Cac th£ Dono van tr

GS.BS OINH VAN TUNG, FACOG, FASCP

lA m s A n g p h u k h o avA

g i a i p h Au b e n h

IflM SANG PHU KHOfl

v a

Glffl PHfiU B€NH

B ien dich ban sach

xuat bcin Ian thu hai

GS.BS DINH VAN TUNG MD, FACOG, FASCP

Giao su San phu khoa

G iao su Giai ph6u benh

B ie n d ic h :

- BS DANG THE CAN

- BS NGUYEN PHI HUNG

- BS DAO TIEN C'U'C

- BS TRAN NAM THANG

- BS TRAN VAN THUAN

S Y L L A B U S OI G Y N E C O L O G I C P A T H O L O G Y

WI T H C L I N K AI C O R R E L A T I O N S

L()I t u a

LAN XUAT BAN LAN THL/ 2

T r ong nhieu nam, giao su' Dinh da say me nghien cu'u

n ga nh giai phau benh phu khoa, va gianh nhieu con g sue trong viec gia ng day bo m o n nay ch o cac sinh vien y khoa va bac si noi tru c h u y e n khoa Toi cun g ehia se niem say me eua o ng va

c u ng nhu o ng deu tiec khi thay hien nay tain quan trong eua viec

gi an g day giai phau benh phu k hoa cho sinh vien y khoa va bac

sT noi tru c h u y e n khoa ch ua du'oc chu y Su' hieu biet n hu n g van

de c o ban ve giai phau benh phu khoa hoan loan la dieu can thiet doi vo'i n h un g thay thuoc lain sang ve cac benh phu nu'

Neu k h o n g co nen tang nay thi ngu'di thay thuoc lam sang

se k h o n g the phat trien von hieu biet ve lich sir tu' nhien c ua can benh va n hu ng n g uy en tac chii'a tri

Lan xuat ban thir hai cuon sach nay la mo t su' thanh cong xuat sac N o rat de doc va lam theo, no con cu ng cap rat nhieu

t hong tin va nhu'ng dieu quy bau

T h e o y kien toi cuo n sach nay la giao trinh m a tat ca sinh vien deu phai hoc trong qua trinh hoc san phu khoa cu ng nhu' bac si noi tru du'oc dao tao ve Ilnh vuc nay Cac thay thuoc

c h u y e n khoa lam sang trong thirc hanh c u ng se lam tot hon khi

co cuon s ach nay trong tay nhu' mot tai lieu tra cu'u nhanh Cuon sach du'oc vict tot chi nh xac va nhieu t hong tin Moi chirong deu

co bang tra cu'u rieng tong h op de ngu'di doc q uan tam co the tra cu'u t hem n h u n g t h on g tin chi tiet

R a y m o n d H K a u fm a n MI)

T r u o n g dai hoc Y khoa B aylor

H o u sto n , T ex a s

1 A m ho■

I Ban thai hoc

II M o hoc

III Cac benh da thirong gap

IV Cac ton thirong am ho trong cac benh he t hong

V N h i em trung

VI Cac u lanh tinh

VII Cac ton thu'ong bieu m o khong u

VIII Cac t6n thu'ong noi bieu m o u

IX Cac u ac tinh xam nhap

I Bao thai hoc

A Bo phan sinh due ngoai bat dau ban g mot giai doan

k ho ng biet hoa d tuan thur 4 Cu sinh due cac nep nieu due va cac loi biu- am ho deu co ngu on goc tir ngoai bi

B C a c d a c tr u' ng v& g i d i duo' c x a c d i n h o' t u a n thu'

9 Co' q u a n s i n h d u e n g o a i di ro c h i n h t h a n h d a y d u o' t u a n thu' 12

C Cu sinh d ue hinh thanh am vat nep nieu- due hinh thanh cac moi nho, loi biu- am ho hinh thanh cac moi Ion m u va cac m e p sau a m ho

D Cac tu yen Bartholin: Duo'c hinh thanh tir x oang nieu -

due (co ngu on goc noi bi) tuo'ng ung voi cac tuyen hanh nieu dao o' nam

E Tien dinh: La viing giua m a n g trinh va moi nho du'o'c

gidi han bdi h am moi a m ho d phia sau A m d ao va nieu dao m d

ra d day Tien dinh co n gu o n goc noi bi

II Mo hoc (da)

A M oi Ion

• Thu'ong bi duo'c tao bdi bieu m o vay lat tang

• Chan bi cd cac nang long va ba loai tuyen

- T u y en nguyen ven (tuyen m o hoi)

- T u y e n toan buy (tuyen ba)

- T u y en ban buy la tuyen dac hieu cho cac \ i i n g a m ho,

q u a nh o ng hau mon, nach va vu Bat dau che tie! th e o c hu ky khi

co kinh nguyet , g om cac te bao Ion co bao tirong m a u hong

• G o m hai the hang ( m o cu'ong ma c h)

• K ha c vo'i dirong vat la k h on g co the xop

D C a c tu yen B arth olin (cac tuyen ti£n dinh chfnh)

• Cac tuyen tui: Duo'c tao boi cac te bao bieu mo tru che nhay

• Cac o ng du’oc lot boi cac te bao c h u y e n tiep

• Mieng ong du’oc lot boi bieu m o lat tang giong cua am dao

• Cac tuyen phu vung lien dinh: o xu n g q u a nh tien dinh

• La vung duy nhat cua ong sinh due nu' co nguon goc noi bi

III Cac benh da thuong gap

A \ iem da tiep \ u c (viem am ho phan irng)

• Do kich thich tai cho: nu'oc hoa thuoc \it mvi ton>_: hop cac du n g cu tranh thai am dao

• Da viem phu lie do.

• Di6u in: Loai ho cac tac nhan gay benh d un g cac Cor ti co st er oi d tai c ho de gia m ngu'a

B V iem da m an tinh

- D a i the: T 6 n thu' ong co m a u hoi d o, x a m h o a c t r a n g ( g i o n g voi q u a s a n b i e u m o vay h o a c l oan d ir dn g t a n g san

n g u ’di g i a )

- Vi the: Day sung, tang gai, xam nhap viem m a n tmh

- Di eu trj: Rita h oac boi kern Fluorinated Corticosteroid, tiem diro'i da T r ia mc i no lo n e

- Dai the: C a c m a n g do da du'oc bao phu boi cac vay bac

mi n (dau hieu Auspitz) Cac m a n g do da co the xuat hien 6 cac vung khac nliau tren co' the o' a m ho ton thirong co the bi che lap boi sir a m u'ol va co the g io n g vo'i mot viem da k ho ng dac hieu

- Vi the: A sung, ma o bieu m o thong noi hinh truy va hinh tlion dai lop bieu m o tren cac nhu mong nhieu ma o mach trong cac nhu chan bi K h on g co ap- xe Mu nr o trong lop thuo'ng bi

- Di eu tri: C a c Cor ti cos ter oid Fluor inated tai cho nhu

C yc l os po r in e, Meth ot r ex at e Trong tnr dng hop phiic tap nen tliam kliao cac bac sy da lieu

E. B en h n a m d a dui

• Nliiem trung be mat o' ben va plian tren dm do cac nam

da thirong ket hop \6'i nam da 6 cac \i tri khac ( ngon c h a n \ \ )

• I’on thu'ong do da kliu till, bogioi han ro Ngu'a tir n den nhieu

• Dieu tri: Du ng m o Imidazole

F L ik en p h ang

• Dai the: San tn n phang thuo ng la cac m a n g tr ang o' am

ho, co the t6n th uo n g o' am dao

• Vi the: Ta n g sung, tang gai x am n h a p l i m p h o d a n g dai sat lop thu'ong bl

• D i eu tri: M o Corticosteroid

IV Cac ton thuong am ho trong cac benh he thong

A B en h C ro h n

• Hiern khi tcm t h u o n g a m ho

• Dai the: Hi nh tha nh d u o n g do true t rang d ay c ha u hoac true tr ang a m d a o va cac x o a n g d i n

• Vi the: X a m n h a p v iem va u hat k h o n g hoai tii ba dau

• Di eu tri: N h u vo'i b en h Cr ohn ( k h an g sinh, Metr on id azo le

va Steroid tr uoc va sau khi su' tri cac duo'ng do)

B B en h B eh cet

• Nguyen nhan: Khong r5, co the la benh tir rnidn hoac do virut

• D ac tru'ng boi mo t hoi c h u n g g o m 3 trieu c hun g: Loet o'

m i en g, co' q uan sinh due ngoai va mat

• M o hoc: X a m n h a p viem day dac va vie m m a c h nhieu

m a o m a c h bi tac

• Dieu tri: Corti coster oid

C D ai tliao d u o n g

• Vi em am ho do n am C a n d i d a albicans

• Giai d oan cap: Ban do 6 moi Ion va nho

• Giai d oan man: T h u o n g bl d ay m a n x am va loet

• Ditjii tri: Cac t h uo c c h on g n am hien tai va k i e m snai dai

t hao duo'ng

10

• Rat hiem do true khuain lao.

• Do n h i i m true tiep tir ban tinh bi benh hoac do su lan

r ong t heo d u a n g ma u , hoac t heo ducrng true tiep tir voi triing, noi

V i e m ha ch ben k h o n g hoa mu

► Vi the: Ph an u ng viem cap va m a n tfnh phan ung viem

q u a n h m a c h m a u 1 0 ret, co rat nhieu t uong bao va xoan k hu an trong t6n t huong

Ton t hu o n g giai d o an II (u loi phang)

1 1

► Xuat hien sau ton thuong nguyen phat tir 6 tuan den 6 thang.

► Dai the:: Hinh anh hoai tu mau xam, loi cao hinh cao nguyen

► Vi the: Ta n g gai, qua san bieu mo , cac te b a o vie m man vdi rat nhieu t u on g bao viem d o n g m a c h T i m t hay nh ie u xoan khuain tro ng t6n t huong

- T 6 n t hu o n g giai d o an III ( g o m h o a c loet)

► H i e m gap, xuat hien sau vai t h a n g d en m ot nam ke tir khi nhi dm b e nh ducri d a n g cac u g o m ho ac cac vet loet

► Vi the: U hat vo'i cac te bao k h o n g 16, cac te bao dan

n h an va d a n g bieu mo T a n g sinh m a n h m a o m a c h va day thanh

ma c h X a m n h a p t u a n g b ao ro ret

• Ch an doan: Kfnh hien vi nen den, thir hu yet thanh (RPR,

V D R L ) va xet n g h i e m h ap thu k hang the T r e p o n e m a danh dau

b a n g h u y n h q u a n g (F TA - ABS)

• Di6u tri: Benzathin, Penicillin hoac Tetracyclin,

D oxy cy cl i n Benzathin Penicillin hoac E r y t h r o m y c i n khi co thai Giai m a n c a m c ho cac benh nh an di ung vori Penicillin

B H a ca m

• H i e m gap, g ay ra boi H e m o p h i l u s d u cr ey i , m ot loai vi

k h u an g r a m am k h o n g c h u y e n d o n g tren tieu ban va trong moi

t r u a ng nuoi cay

• U benh: Tir 3- 10 ngay

• Dai the: Loet don doc hoac nhi eu o, b o m e o m o khong deu kern viem hach ben san g m e m dau t ang cam

• Vi the: Phan ung viem m a n vo'i nhi eu l i m p h o bao va tuong bao

• Ch an doan: N h u o m g r am va nuoi cay d ich mu

• Dieu tri: A zi t hr om yc in , Cei t ri ax on C i pr o f l o xa c i n

Er v th ro mv ci n

C U hat b e n ( donovanos is )

• H i e m gap, gay ra boi Ca l y mm a t o ba c t e r i u m granulomatis, true khuain hinh que co vo gr am am, thuoc ho Ent erobact eriaceae

• U benh: 1 - 1 2 tuan

• Dai the: Kho i dau la vet san m e m nho, lan rong do loet

be mat doc theo v ung ben mu loet khong dau, bo go cao Co the

co mot ton t hu o n g a giai d o an tien ac tinh trong giai doan ma n tinh c u a benh

• Vi the: Phan u ng vie m ma n vo'i cac m o bao (te bao u hat), doi khi co q u a san d a ng gia u bieu mo voi bi6u hien tang gai bat thuong, thu an thuc bat t hu o n g o cac dinh m a o th uo ng bi Cac the’ Don ov an trong cac m o bao lorn hoc hoa

• Chan doan: Cac th£ Dono van trong cac te bao d on nhan tren cac phien d o hoac cac mSu benh p ham lay ra tir o loet

• Di eu tri: Tet racycl in, Ampicillin, Ch lo ra mp he ni c ol trong 2-3 tuan

D U hat Iim p h o hoa lieu ( benh Nicolas- Favre).

• G a y ra boi C h l a m y d i a trachomat is tip L

• U b en h 4- 21 ngay

• Dai the: Thu'ong bat dau bang n h u n g vet loet n ho de bi

bo q ua va mot v ie m h a c h ben r5 ret Tien trie!n thanh phu a m ho

va cac x o an g bach m a c h dan den hep true trang va nieu dao Co kha n an g ac tinh o' giai do an m a n tinh (can sinh thiet)

• Vi the: X a m n h a p cac tuong bao va te bao don n han Ion gian bach m a c h va tang sinh noi mo Ta n g sinh d a ng gia u bieu

m o co the gap

• Chain doan: Bang cay mil hoac tim thay C hl a m y d i a vo'i cac moi a-xit nhan

• Dieu tri: Tet racycl in, Dox yc yc li n , E r y t h r o m y c i n

A zyt hr omyc in, Ofloxaci n Cho c hut cac ha ch h o a m u k ho n g chfch rach hoac d i n liru

E H erp es

• L a cac n h i e m trung thon g t hu o n g d o \ i r u t Herpes

s imp lex gay ra, the loai H o m i n i s tip 2 h oac 1 ( t h u o n g g ap tip 2)

• Te bao hoc: Cac te bao c o nhidu n h a n h in h k i n h m o ( ton

t h u o n g n g u y e n phat) va c o cac the vui trong n h a n o the: tai phat

• Chain d o an h i u het d u a v ao te b ao va n u oi cay

• Dieu tri: D u n g Bet adine tai c h6, u o n g Acyclovir, Valacyclovis, h oac F a mc i - clovir

• Tliii thuat ces ar o cac phu n u m a n g thai n eu cac t6n

t huo ng hoat dong

• Di^u tri : N a o bo hoac dot dien

• Ton thuong co the thoai trien mot c ac h n g i u nhien

G M a o ga

• Loai ton thirong pho bien, gay ra boi virut sinh u nhu 6 nguoi ( thu on g la HPV 6/1 1)

• U benh : 1- 8 thang, trung b'inh 3 thang

• Dai the: U I6i d on doc hoac nhiem diem kh ap a m ho

• Vi thei: Ta n g sung, a sung, benh u nhu tang gai, te bao

co vong sang q uanh nh an va viem ma n 6 lop chan bi

• Di6u tri: P h i u thuat Lazer, d on g dien, p h i u thuat lanh, phau thuat rong, Podophylli n trong con thuoc Benzoin axit trichloracetic, m o I mi qui mo d, Gel Podofilox ( chong chi dinh

d u n g thuoc khi co thai)

• N e n thuc hien thu thuat cesar trong truong hop ma o ga Ian rong K h o n g the ngan chan u nhu o' hong ti e so sinh bang thu thuat nay

• K h o n g sinh thiet t6n t huong m a o ga truoc 2 tuan sau khi dieu tri b an g P od ophylli n vi t6n thu ong co the gi ong ung t hu bieu m o tai ch6

H V iem tu ven m o hoi mu

• N h i l m trung tuy en ban huy do Staphyl ococus aureus

• Cac cuc du'o'i da d au am i Cac cuc nay co the’ thong noi thanh d a m t6n th u on g t u ong tu' n h u o' nach

• Dieu tri : Tr ich rach hoac mo' r ong vung da bi n hi em

k hua n va d u n g kliang sinh

I B en h F ox F o r d y c e

• Do cac tuye n ban huy bi tac

• Dai the: Cac not san nh o ngu'a chac, loi len mat da

• Vi the: X a m n ha p viem gian cac tuyen tiii tiet dich phu vao m o ke can

• D i e u tri : U o n g t h u o c t r a n h thai va d u n g t h u o c g i a m ngu'a tai c h 6

J V iem tuyen tien dinh

• Cac tuyen nho 6 tien dinh sirng to tha nh mo t v o n g quanh

lo vao am dao

• V i em gay ra c a m giac dau rat b o n g va dau khi g i a o hop

• Tren cac m a n h sinh thiet bie:u m o c h u y e n tiep cua cac

o ng d i n co the bi hieu n h a m la ung t h u bielu m o tai cho

• Dieu tri: Cat bo neu co trieu chung

VI Cac u lanh tinh

A N a n g

• N a n g o n g Bartholin

- Do tac va gian ong

- N a n g duo'c lot bo'i bieu m o c h u y e n tiep hoac bieu mo det tu cac tuy en tui tiet n hay lan can c ua tuy en Bartholin

- Co the bi n h ie m k hua n bo'i Neisser ia Staphyl ococcus, hoac cac tac nhan k ha c va tao th anh ap- xe tuyen Bartholin

- Dieu tri: Thong tui hoac dat catheter trong vong 4-6 tuan

• N a n g nhay:

- Duo'c lot boi bieu m o tiet nhay hinh tru ho ac hinh khoi

- Sinh ra tu' c a c x o a n g ni e u d u e ton d u h o a c t u cac

t u y e n t i en d i n h

- Dieu tri: Cat bo

• Cac nang cua ong Nuck trong o n g ben (cac n a n s duo'c lot boi phuc ma c hoac trail dich am ho)

- T uo ng tu trail dich tilling tinh

- T h a \ 6 moi Ion hoac 6 o n g ben

- Sinh ra do phuc m a c bi viii doc t heo d a \ c h a n e iron

16

- D i e u tri: Cat va that tui t h o n g noi vo'i k h o a n g p h uc

m a c ( c h a n d o a n p h an hiet voi t ho a t vi s u n g h a c h b en tinh

h o a n lac c h o )

• Cac nang bieu bi vui

Duo'c lot bo'i mot lop bieu m o vay sung hoa min nang chira chat ba dac

- Do cac ong tuyen ba bi tac hoac do cac vet thu on g vui bieu m o vao trong (thu thuat rach am ho)

- Di6u tri: Cat bo neu co trieu chung

• Na ng ong Skene:

- Cac nang nho canh nieu dao hiem khi gay tac nieu dao

- Du'oc lot boi bieu m o chuyen tiep

- Dieu tri: Cat bo neu nang Ion

B U dac

• M u n c om co c u o ng (da tua polfp xo bieu mo)

- Dai the: U lanh co c uong hoac khong co the co kich tlurdc Ion

- Vi the: Thu'ong bi binh thu'ong vo'i mo xo lien ket thua (mo

► Dai the: Khoi nhi eu thuy m a u tim c o the lan ro n g van

am dao xuat hien trong von g vai t h a n g dau sau de I co the lan r ong h oa c teo di sau mo t vai nam

► Vi the: Cac khoang clni'a ma u Ion kho ng deu duo'c loi boi cac te bao 1101 mo

► Dieu tri: Dot lanh laser, hoac phau thuat cat bo

- U m a u nguo'i gia(u ma n d a ng anil dao):

► Dai the: Cac san m£m, nho, lio'i do, co the ep xuong duo'c thu'ong thay o' cac phu nu' tru'o'c va sau m a n kinh

► Vi the: Cac m a o quan gian du'oc lot boi cac te bao noi

► Vi the: Cac m a o m a c h bi gian nam a tren lop chan bi;

T h u o n g bi co bieu hien tang sung a sung, cac m a o chan bi keo dai d a n g u nhu

► D ie u tri: Phau tlniat cat bo u

- U m a c h n hay tien trien

► Dai the: Khoi m e m 6 am ho

► Vi the: Rat nhieu m a o quan trong m o d e m n h a \ Ions leo

► D i eu tri: Cat bo rong rai U hay tai phat

- U tuyen m o hoi

► U lanh tinh cua tuyen ban huy hiem gaponhutisj nsuoi da den

► Co the bi chan doan nham la ung i hu bieu m o tuven

► Dai the: I nho hon 2 cm vi tri o' mo Ion hoac khe dira 2 moiIS

► Vi the: Co can true dang tuyen gom nhieu ong nho va tuven tui, dirge lot hoi mot lop bieu mo tru ( bao tuong u'a loan, nhan hoe hoa) va mot lop te bao co' bieu mo

► Dieu tri: Phau thuat eat bo Xet ngliiem m o hoc can than

- U te bao Schwann hoac u ng uy en bao co' te bao hat

► Dai I lie: U cua vo day than kinh, bieu hien la cac cuc nho ( 2- 3 cm) duoi da moi Ion

► Vi the: U g om cac o te bao da dien Ion, kich thuoc deu, bao tuong day dac cac hat u'a toan Tren lop th uo ng bi thay qua sail gia d a ng bieu mo giong vo'i ung thu' bieu m o vay xam nhap

► Dieu tri: Cat rong ton thu'ong dien cat sach

- Not ruoi (no' vi)

• Dai the: Ton thu on g noi c hung clni'a sac to, no' vi co the kho ng co sac to

• Vi the: Cac o te bao no' vi co nhan tron hoac trai xoan nam o' vung tiep giap chan bi va t huong bi ( n o vi chan bi- bieu bi), chan bi (no' vi ch an bi) hoac ca 2 (novi plioi hop)

► Dieu tri: Cat bo de chan doan (Chan d o an phan biet vo'i ung tlnr bieu m o tai cho, u liac to hoac benh s ung gai)

- Benh s ung gai

► Co the giong vo'i u hac to, novi hoac ung thu bieu mo tai cho

► Dai the: Ton t hu on g mau den kh o ng trieu cluing, kho ng

co kha nang ac tinh Ton thu'ong man nau co the gap bat ky noi nao tren co' the

► \ ; i the: Ta n g sung, tang gai benh nliii \ a cac nang sung

► Diem tri: Cat bo de chan doan ( K h o ng can dieu tri neu chan doan d a m bao chnili xae benh)

- Vii phu

► T h u o n g g ap tloc iheo du'ong su'a bao thai (nach ngu'c du'o'i bung Iren) hiem klu o ' am ho

► Moi Ion phinli to ket hop vo'i co thai.

► Ty le ac tinh cao ( 4 i rudng h op ung th u vu n g u ye n phat

o am ho da duo'c ghi nhan)

► Vi t h e : G io n g m o vu cac tuyen tui va ong dan

► Di eu tri: Cat bo ( T r u khi co thai)

- U co' noi m a c tu cung

► Do cay g h ep noi ma c tu cung khi de hoac phau thuat

► D a i the: C a c k hoi n a n g m a u do x a n h x a m to lcn

t h e o c h u ky

► Vi the: Cac tuyen noi m a c va m o dem

► Dicau tri: Ph&u thuat cat bo

- U on g m o hoi

► Dai the: Cac cuc m a u vang hoac ma u da nho khong co trieu c h u n g 6' ca 2 moi Ion

► Vi the: Cac tuyen ngoai tiet bi gian duo'c lot bo'i bieu

m o lat tang vo'i cac duoi hinh dau phay 6 tan cung

► Di eu tri: K ho ng can dieu tri

- U hat sinh mu:

► Dai the: Cue m a u nan do, ma u tliit loi tren mat da de chav mau

► \ i the: M o g iong to chiic hat g o m rat nhieu m a o mach nho duo'c bao q ua nh bo'i m o d em phu ne

► Di eu tri: Cat bo don thuan

- U xo va u x o m o

► D a i t he : T o n t h u o n g c h a c va nhfin m a u t r a i l s d u e

h o a c ghi nliat

► \ i the: Cac bo dai te bao \ o t h u o n g kern theo te him m 6

► Di eu tri: Phau thuat cat bo

20

VII Cac ton thu’ong bieu mo khong u

D u o c phan loai nam 1987 bo'i Hoi quoc te nghien cu'u cac

b en h a m ho va Hoi q u o c te cac nha G P B phu khoa, bao gom: li kern xo, q u a san te bao vay va cac ben h ve da khac

• Vi the: Ta n g sung, bieu m o mo ng mat cac cau noi chan

bi, lop c ol l ag en va co cac d a m te bao viem man

• D i eu tri: Cac loai m o clobetasol (steroid ma nh )

t est ost er one hoac progesterone

• Ty le ac tinh t hap (3 ,5%)

B Q u a san te bao vay (Tuong duong voi loan duong tang san )

• Dai the: Cac m a n g m a u hong sang hoac t r i n g r5 do, co the lan ron g h oac ranh gidi k h o n g ro

• Vi the: T a n g sung, tang gai, cac m a o chan bi rong ra va

co hinh dui cui, viem man K h on g co te bao bat thuong

• Chain doan : Sinh thiet: chan doan chu yeu bang sir loai tru

• D i e u tri: Cac Corti costeroid tai ch6

• Ty le ac tinh hoa: g an n h u bang k h o n g trong n h u n g tru'ong h op k h o n g co te bao bat thuong

VIII Cac ton thuong noi bieu mo u

A D jnh n g h ia ve sir bat th u o n g cu a bieu m o a m ho.

• Hinh th an h cau s ung 6 cac dau tan c u n g c ua m a o c ha n bi hoac o' lop day

• Cac te b ao bat tliuc san, k ho n g thuan thuc trong lop bieu

m o ( N h a n chia t ang ty le n h an / bao tuong)

• Hinh thanh cac the’ tron (ket dac nh an co vong sang

q ua nh nhan)

B P h a n loai c a c t o n t h i r o n g u noi h ie u m o o a m ho

• Tan san noi bieu m o a m ho (VI N)

- VIN1 ( lo an san n h e) : Bat t h u o n g t h a y o' 1/3 d uo i cua lop bi e u m o

- V I N 2 ( l o an san vua ): Bat t h u o n g t h a y o' 2/3 duoi cua lop bi e u m o

- VIN3: (loan san nang hoac ung t h u am ho tai cho)

Bat th uo n g te bao tren 2/3 chi eu day lop bieu mo

• Benh Paget

• U h i e to tai ch6

C C a c loai r oi l o a n t a n s i n h no i b i e u m o c u a a m ho

• Tan sinh noi bieu m o a m ho do III ( VI N3)

- T r u o c d a y duo'c goi la b e n h B o w e n , h 6 n g san Queyrat

u n g t h u b i e u m o d o n t h u a n , s an d a n g B o w e n , u n g t h u bieu

m o tai c h o)

- Dai the: T o n t h u o ng d on doc hoac nhi£u o, san hoac vet

M a u sac rat kh ac nhau: den, trang, xa m, hon g hoac do

- Vi the: 3 tip

• Ti p m u n c o m ( d a ng u loi)

- Lien q u a n vo'i nhieu H P V 16 v a i 8

- Bieu m o be mat co hinh Iuo'n s ong va hinh gai nhon

- Ta n g sung, a sung

- T ang gai nhan te bao da hinh thai tang sAc te bao khong

16 nhieu nhan hinh n han chi a bat t huong s u n g hoa te bao riena

le, te bao bong

• l ip d an g day

- Lien quan den nhi em HPV 16 va IS

- Lop thu'ong bi day len be mat phang mi n

- Lop hieu m o g om cac te bao can day khong thuan tliuc bat thu'ong ( giong CIN3) co rat nhieu hinh nhan chia

• Tip biet hoa ( lip don gian)

- K h on g lien quan den n hi em HPV

- C a c te bao bat t h u o n g gidi han d phan d a y va can

d a y c u a c a c m a o bieu mo : bao t u o n g u'a toan ro, h inh tha nh

c a c c a u s u ng

• VI N3: Tip mun coin va tip d an g day t huong thay o' vung

ke can cua ung t hu bieu m o va)' xam nhap tip mun c o m va dang day d cac benh nhan tie ( tuoi trung hinh 54) V1N3 tip biet hoa thay d vung ke can ung thu bieu m o vay dien hinh d cac benh nhan gia ( tuoi trung binh 77)

- Dieu tri: Cat rong tai cho, dien mo sach: vo'i cac ton thuo'ng nhieu d, cat da am ho + ghep da day Phau tluiat laser (dau chav mau nhiem trung nhung tham my tot hon)

- Tien trien thanh ung thu' bieu mo xam nhap it gap (6r/r) Thu'ong xay ra o' cac phu nu' sau man kinh va cac benh nhan bi lie che mi en dich

- Dai the: Ton thirong mau do gach trong ed cac dam mau trang

- Vi the: Cac o te bao Paget ( te bao to bao tuong rong sang, co hat mm: nhan to, hat nhan ro, phan ling d u on g tinh vdi

C E A va CK) d lop can day eua thirong bi Ton tlurong phan phu

da g ap 75% cac t rudng hop Cac t6n thirong x am nhap tha\ cac

te bao Paget va te bao day khong biet hoa xam nh ap thang xuong

• U h k to tai c h6 (noi bieu mo)

- Dai the: G i o n g u hac to ac tinh do I

- Tien luo ng tot, 100% benh nhan song

- Di£u tri: Cat rong ton th uo n g

IX Cac u ac tinh xam nhap

A C h i a giai d o a n :

• C h i e m tu 3 - 5% tong so cac u ac tinh c u a on g sinh due

• He thong phan giai doan c ua F I G O ( 1988) d u a tren cac

t ho ng so phau thuat: T (khoi u) N (hach) M (di can) FI GO la ten viet tat c ua Hiep hoi qu oc te ve san phu khoa

- Giai do an I: U gidi han d a m ho va / hoa c d ay chau dudng

k m h Ion nhat < 2 cm: k ho ng di can hach

►Gun iloan hr. Ton thuong < 2 cm xam nhap mo dem < 1 mm

►Giai Joan lb: Ton thuong < 2 cm xam nhap mo dem > I mm

- Giai d oan II: U gidi han d am ho va/ hoac o d a \ ch au : > 2

- G ia i d o a n IV: U x a m lan nieu d a o tren, b an g q u a n g ,

t r ue t r a n g x u o n g c h a u v a / h o a c di c an hach m o n g 2 ben va/

h o a c di c a n xa

►Giai doan IVa: U x am Ian bat ky mot trong nhung p h i n sau: Nieu d ao tren, n ie m m a c bang q uang niem mac hau mon,

x u o n g chau, va / hoac di can vung hach vung 2 ben

►Giai cloan l\ b: Khi co di can xa, ke ca hach chau

B U ng thu bieu m o vay x a m nhap be mat am ho ( 1995)

• Duo'c coi la giai d o an la: To n t huong < 2 cm d u o n g kmh, gidi han o' a m ho hoac vung day chau xam nhap m o d em < 1mm

K h o n g co di can hach

• Chi£u sau x a m n h ap duo'c do tu vung tiep giap cu a bi^u

m o vdi m o d e m c u a nhu chan bi k£ can nong nhat den d ie m xam

n hap sau nhat

• Wi l kins on: 12 t ru dn g hop xam nhap < 1,5mm kh o ng co tdn th uo n g hach, 18 t ru dn g hop xam nhap t u 1,5- 4 mm; 2

tr udng ho p co di can h ach (11 %)

• Di eu tri: Cat ro ng tai chd, dien cat cach b d ton thu on g 2

cm Di can hach g i n n h u k h o n g co

C U n g thu bieu m o vay x a m n hap

• Ch ie m toi 90 % cac u ac tinh cua am ho 5 % cac u ac tinh cua he sinh due nu'

• Benh tlurdng g ap d lira tuoi 70 -90: Neu m a c cac benh u hat benh xuat hien s d m hon 20 n am (1/ 2 5 000 d lua tuoi 60- 7<'

va 1,5/ 100.000 phu nu)

• Cac ton thuong bao tnrdc: VIN3: benh u hat; ngua keo dai

• 21% cac ung th u bieu m o am ho d cac benh nhan gia ( tuoi trung b'mh 77) \ a 81% cac benh nhan tie ( tuoi trung binh 50) c o n hi e m HPV 1 6

25

• Vi tri th u on g gap: Phan tren moi Ion

• Dai thd : Khoi hinh nam hoac cuc loet

• X a m n hap bach mach: Hach dui va hach ben nong ( hach ti6n tram) bi xam nh ap d i u tien sau d o la hach dui sau hach chau Ty le di can hach theo ki'ch thuoc u: < 2 cm : 20% : > 2 cm

4 5% ( G W Mor ley)

• Benh hoc:

- U ng t h u bieu m o sung hoa biet h oa cao

► C h i e m 7 5 % cac tdn thuong, g o m nhun g d am 16n bieu

m o vay bat t hu o n g vdi cac cau sung xam n hap trong m o dem

► T h u o n g g ap o’ b enh nhan gia hon, ket hop vdi the don thuan cua VI N hoac q u a san vay va k h o n g ch ua D N A cua HPV

- Ung t h u bieu m o dan g day hoac m u n com

► Dang day: Cac o tron Ion hoac cac dai nho te bao khong thuan thuc, c o ft bao t uo n g va it hoac k h o n g co sung giong vdi te bao day cua bieu m o b6 mat

► Tip m u n com: Hinh u loi ra ngoai a b£ mat cac o te bao vay kh o ng deu co nhan da hinh thai, bat t h u o n g te bao ( tang sac nhieu nhan bat th u dn g te bao bong)

► G a p d cac b en h nh an tie h on va ket h op vdi cac ton thu on g VIN t uong ung ( d a ng te bao d a y hoac m u n com) Co

c hu a D N A cua HPV

• Dieu tri: Cat a m ho triet de vet ha ch dui ben hai ben co the tha> doi neu ton t huo ng mot ben N eu di can h ac h ben thi nen tia xa hach chau

• Dien cat sach u va chi eu sau x a m n h ap la yeu to d u doan tai phat tai chd tot nhat

• Tinh trang hach ben la yeu to tien l uong d oc lap quan trong nhat

26

• Song them khong bi anh hirong bdi mu c do biet hoa cua

te bao u

• Ti en luong: Song t hem 5 nam: 70%

• Giai doan 1.2 : K h o ng di can hach : 90 %

• Giai d o an 1.2 : C o di can hach : 40%

• Ty le song them 5 n am cua cac benh nhan co di can hach

ch au la 7%

D l i n g thu hieu m o th e s^n

• Ten khac: U loi Buschke va Lowenstei n

• Dai the: Tcin t hu o n g giong u loi m a o ga: xam nhap va tai phat tai c ho k ho ng di can hach

• Sinh thiet: Lay sau, lay du'o'c nhieu to chuc d em cho chan

d o an giai p h i u benh

• M o hoc: Cac nhu hinh gan la duoc phu bdi cac te bao bieu m o vay lat tang thu an thuc cac m a o chan bi p hd ng ra ep vao m o dem T an g s u n g va tang gai Khong co cac hinh anh ac tinh nhu' bat thuc san nh an ngoai tru thinh t hoa ng co su' hinh tha nh cac cau s ung trong lop bieu mo nhu ng khon g a dinh cua cac m a o chan bi M o d e m bi xam nhap bdi cac te bao viem

• Dieu tri: Cat ron g tai cho dien cat sach u kho ng co di can hach trong 27 t ru dn g hop (Japaze va cs)

• Xa tri: C h o n g chi dinh do co kha nan g c hu ye n d ang cua cac te bao lanh thanh ac tinh

E U n g thu bieu m o tuyen:

• H i em nhat trong cac u ac tinh cua am ho

• Sinh ra tir cac tuyen Bartholin, hoac hiem hon tu dug Skene C d the sinh ra tu tuyen vu lac chd

• Tuoi trung hinh: 60 -70 tuoi ( tie lion 10 tuoi so vdi ung

t h u bieu m o va\ o' a m ho)

• Vi the: Hinh anh ung thu hieu mo tuyen, thirong kern biet hoa.

• C h a n d o a n t h u o n g m u o n d o h ay co viem nhiem o

v un g nay ( n en si nh thi et n eu b e nh n h a n > 4 0 tudi va co viem

t u y e n B a r t h ol in )

• Di£u tri: Cat am ho triet de, vet hach ben va dui hai ben

• Tho'i gian song t h e m duo'c xac dinh boi giai doan 6 thai diem chan doan

F U n g thu hieu m o d a n g tu ven n an g

• Ung thu bieu m o tuyen kinh didn cua tuyen Bartholin, giong vo'i u cua tuyen nude hot ( 5 0 % ung th u bieu m o tuven Bartholin la te bao vay)

• Giai p h i u benh: Cac d te bao u co nhan tang sac tron hoac oval, bao tirong hep sap xep d o n g tam thanh dang mat sang quanh cac hoc giong tuyen

• Xam nh ap sau, tai phat tai ch6, va di can mu o n, thudng tdi phoi, hiem khi tdi hach ben

• Dieu tri: Cat rong tai chd, vet hach ben cu ng ben (Copeland va cs)

G U ng thu bieu m o te bao day

• Ch ie m 2% cac ung t hu am ho

• Dai the: Ton thu'ong loet b d tron g d cao < 2 c m dudng kinh thudng gap d moi ldn

• Vi the: Cac d a m te bao day nho sap xep d an g h an g dau

va d6 n g deu a ngoai vi

• Di can hach hiem gap ( 1 t rud ng h op duo'c ghi nhan )

• Dieu tri: Cat rong tai chd

H I hac to ac tinh

• Loai ung thu phd bien t h u 2 o' a m ho, chi e m 5% c ac u ai tinh cua am ho

28

• D a i the: To n thu'ong loi len co sac to va thu'd'ng bi loet

Cd 2 tip co' ban la tip cuc va tfp lan l on g be mat

• Vi the: Cac hac bao bat t hudng ky quai co hoat do ng ket noi nh ie u hat sac to me lani n, xam nhap sau vao m o xung quanh,

cd nh an c h i a bat t hudng Hinh anh vi the rat khac nhau chan

d o a n dira vao ky thuat ho a m o mi en dich (S- 100 H MB - 45)

• D o Clark: I trong bieu mo; II, nhu chan bi; III tiep giap giCia nhii c h a n bi va c h a n bi ludi: IV chan bi 1 u d i : V m d d u d i da

• Ch ie u d ay u th e o Breslow: N g uy co' thap, < 0 7 5 m m ;

n gu y c o vua, 0, 75- 1, 5 mm ; ng uy co' cao > 1.5 mm

• D i e u tri: Cat l o n g tai chd cat am ho triet de vet hach ben

va dui 2 ben doi vdi cac u co do Clark > III: vai tro c ua vet hach ben cd gia tri tien lu'ong lion la dieu tri

• Ti e n luong: Phu t huo c vao mu'c do ton thu'ong ( Clark 1: 100% s ong 5 nam; Clark II: 100%: Clark III: 75%: Clark IV:

5 0 % Cl ar k V: 3 0%) va di can hach Neu theo chieu day u cua Breslow thi s on g t h e m 8 n a m vdi cac u day 1,5mm la 100%: cac

u t u 1,5 - 4 m m la 6 5 % ; cac u > 4 m m la 25%

• Ch et d o di can lan ron g toi phoi gan nao

• Hoa tri k h o n g d a p ling

I C a c s a c d m

• H i em 2% cac u ng t h u a m ho

• Benh n han tie lion ( tudi trung binh 38 tudi)

- Saconi xo sacdm co' van sacdm xo' than kinh sacdm co tron ( hay gap n h a t )

► T h u d n g cd \ u h u d n g tai phat tai cho

► D i e u tri: Cat a m ho triet de va vet hach ben 2 ben

► Song them: kem

- S a c d m xo' bi loi:

► U h iem g ap a am ho

► T h u o n g tai phat tai ch6, kh ong di can hach

► Di£u tri: Cat ro ng tai ch6

J C a c u ac tinh thir phat

• Di can tu c 6 tu' cung, true trang noi mac

• U n g thu' bieu m o rau, ung t h u te bao than

• U l i m p h o ac tinh

30

I Bao thai hoc

A Bieu m o bat n g u o n tu phan noi bi bang q u a n g cua

x o a ng nieu due Mo t phan c o the xuat phat tu trung bi c ua ong trung than, n h u vay c o the d a p ling vdi h o r mo n estrogen

B To c h u c lien ket va c o tron phat trien tu trung bi tang lan can

C Cac tuyen q u a n h nieu d ao va du'di nieu d ao ( tuong tu vdi tien liet t uye n) la s u n h o ra tir bieu m o c ua phan dau nieu dao

III Cac benh nhiem trung

A N h ie m tr u n g c a c o n g q u a n h nieu d a o ( ong Skene)

• O n g tuven Skene n am tai hinh dien sail cua Id nieu dao ncoai ( m i e n g o ng bieu m o vay: dug: bieu m b c h u y e n tiep)

• L6 sao do, phu Ion ra ngoai

• Ta c nhan: lau cau Tr i ch omo na s

• D i eu tri: K h a n g sinh va Metr oni dazole

B N hi^m tr u n g tu y e n duori nieu d a o

• Dai the:: Tui t hua duoi nieu dao do n h ie m khuan tai phat

• M o nieu dao Ion mau, do, co the nham vdi u num hoac u khac

• Di eu tri tai cho bang Estrogen

II Cac u lanh tinh

A U n u m

• La u t h u d ng gap nhat

• Dai the: la ton thuong do mem dang pdlip tai Id nieu dao

• Vi the: cd 3 dang: d a ng u nhu dan g u ma c h va dan g u hat (cac ma ch ma u nho bao q ua nh bdi m o d em phu tham nhiem

te bao viem)

• Dieu tri: cat u xet n gh ie m giai phau benh ( nha m loai tru ung thu bieu m o nieu dao)

tr udng hop nghi n gd ve loai u Cat u tai chd

V Cac u ac tmh

A Cd 3 loai ung thu bieu mo

• Ung t h u bieu m o vay: th ud n g gap hon cac loai khac Gap

d do an nieu dao ngoai

• Ung thu' bieu ind te bao c hu y en tiep bieu the nieu dao:

tuong tu n h u ung t hu bieu m o nhu cua bang quang G a p o' doan nieu d ao trong hoac ngoai

• Ung t h u bieu m o tuyen: hiem gap xuat phat tir cac tuyen che nh av cua vung dudi nieu dao

B. D ieu tri ch o tat ca ca c u ng thu bieu m o

• Tia xa ke vao ton t h u o ng trung tarn: vet hach ben sau do tia xa tai chd va vung tieu k h u n g neu hach ben d u o n g tmh

• Ti en luong xau: song t hem 5 nam toan bo la 71% neu u o' phia tru'dc va 5 0 f < neu u plna sau

C Sacdm, u bac to u lympbd: thudng la thu phat rat hiem gap.

D Di can: tir cac ung t hu bieu m b bang q ua ng am ho am

dao cd tu cung b ud n g trung va ung t hu ng uyen bao nuoi

3 A m dao■

I Bao thai hoc

II M o hoc

III Cac ton th uo n g viem

IV Cac u lanh tinh

V Cac u ac tinh

I Bao thai hoc

A A m d ao xuat phat tu' o ng M u ll e r va mot phan noi bi cua

D Cac te bao vay tu x oa ng nieu due xam lan o n g Muller,

c h a p vao va thay the bieu m o tru cho tdi tan bieu m o phia ngoai

cd tu' cung

II Mo hoc

A Hieu mo: bieu m d va\ lat tang k h o n g sung hoa g o m ldp

be mat ldp tr ung gian ldp can day va ldp te bao day; d ap ling vdi ho rmo n

B L d p d u o i n ie m : la to c h u c d e m x o m a c h m a u

l o n e leo d o i khi c o te b a o d e m h i n h s a o h o a c h i n h d a d i e n

k h o n g d i e n IVinh

35

C Ldp co: cac bo co' iron trong vong ngoai doc [3 C hi so trudng thanh: ti le phan tram te bao

Rung tiling 0 4 0 60Thai nghen 0 95 5

- Dieu tri: Metr oni dazole

• Monilia: Benh nam Can d id a

• G a p o' phu n u co thai va 6 ngu'di suy tim

• Td n thu'ong se m a t sau dieu tri t ri chomonas

D V ie m a m d a o sau m a n kinh hoac sau de

• A m d a o mo ng : C h a v ma u bo n g rop, giao ho p dau

• M o hoc: Bieu m o m o n g k h o n g co su t ru d ng thanh be mat bieu mo, viem k h o n g dac hieu tai m o dem

• Di eu tri: Es tr ogen

E V ie m a m d a o d o lau cau

• A m d a o do, m e m k e m theo tiet dich mu

• C h a n d o an b ang nuoi cay hoac tun acid nhan

• 6 tie em hoac be gai trudc day thi: Nhiem khuan dai dang

• Lira ch on dieu tri: Ceft ri axone

F V ie m a m d a o di \ a t

• T h u d n g g ap d tie e m

• Ngu'di lan: Con sot nut gac

G V iem am d a o troc vay

• Khi' lur mii am dao nhieu

• A m dao udt: te bao can day, bach cau da nhan trung tinh

• Hiem va khd dieu tri

• Thudng kern theo vdi liken phang d am dao hoac o mieng

• Dieu tri: Corticosteroid C li nd amy ci n

H (Jiang mai

• Sang giang mai duo'c chain d oan bang kinh hien vi nen den sinh thiet, va n h u d m dac biet H ie m g ap d a m dao

I M o hat

• T h u d n g g ap tai dinh vom a m dao, sau cat tir cung

• Can phan biet vo'i sa vdi trung sau cat tu' cung

J Loet do ta m p o n

• T h u o n g kem theo vdi sir d u n g nut gac sieu tham

• Dai the: N i e m m a c do hoac loet

• Vi the: Bieu m o bi loet thay the bang to m o hat Cd the thay di vat tren m a u sinh thiet

• Dieu tri: kh o ng doi hoi Loet se lien sau khi ngirng sir

du ng tampon

• Cd the lien q u an tdi hoi c h u n g sdc n hi e m doc g a\ ra do

tu can vang

IV Cac u lanh tinh

A N a n g o n g G a r tn er

• La phan c on lai c ua o n g W o l f

• G a p o' vi tri thanh truo'c ben am dao

• Vi the: Du'oc lot boi mot lop bieu m b don tru thap

T h u o n g g a p di san vay

• D i e u tri: Phau thuat neu n a ng Ion

B N a n g vui a m dao

• G a p b thanh sau hoac thanh ben am dao

• Bieu m b a m d ao do bi vui trong qua trinh phau thuat

• Vi the1: N a n g duo'c lot ban g bieu m b vay

• D i eu tri: Phau thuat neu n an g Ion

• Vi tri t h u o n g gap: Tui c u ng sau am dao

• Vi the: Cac tuy en noi ma c tir c u n g va d e m bao

• D i eu tri: Phau thuat neu tbn t huo ng Ion

E B en h u tu yen

• Benh nh an thirong than phien tiet dich nhay qua nhieu

• Do bieu m o vav am dao k h o n g thay the het bieu mo inj

eb nguon goc o ng Muller

• Dai the: M a n g d a n g hat do k h o n g bat m a u lOt hoac soi cb tu c u n g bat tl ur bng t h u o n g tai 1/3 t r en a m d ao va a

t h a n h tru'dc

• Vi the: Cac tuyen bieu m b hinh tru che nhay tuong tu

n hu tuyen cb trong; doi khi cac te bao cb long c hu y en ma u sam hoac sang g i ong nhir bieu m b noi m a c tir cu ng hoac vdi tnrng (20% mau benh pham) Cac d a m u tuyen cb the cb di san \a\ (n hu b cb tu cung) tang sinh vi tuyen (vdi thuoc tranh than, hoac hien t u ong Arias-Stella

• Dang vdi trirng-noi m a c tir cu ng cu a benh u tuven thudng xuat hien c u ng vdi ung thu' bieu m o te bao sang

• T ro ng so nh un g benh nhan pho'i nhi em tir trong tu cung vai di'ethx Istilbestrol (DES) trong 8 tuan dau sau thu thai 9 0 ^

cb u tuyen; trong so nhung benh nhan pho'i nhidm sau 16 tuan 10f < cb u tuyen

• Tlurbng k em theo vo'i ton thu'o'ng d a ng sin m a o ngang hoac m a o do ng tarn a am dao hoac vdi siii m a o ga cd tu cuns

• Kha nang phat trien ung thir it ( 0 14 / 10 00 toi 1.4/1000 tie nir pho'i nh ie m vo'i DES)

• Benh u tuven th ud ng gap 40% benh nhan du'oc m o tu thi

cd ton th uo ng nay ma c dii k h o n g cb bat thirong tren dai the nhu ng phat hien thay ton thirong khi cat am d ao hang loat(S a n d b e r g )

• Dieu tri: K hon g

4 0