i

MC LC
Danh mc cc k hiu, cc ch vit tt ................................................................. iii
Danh mc cc bng ................................................................................................. iv
Danh mc cc hnh v, th ................................................................................... v
CHNG 1: UNG TH V CC PHNG PHP IU TR ............................. 3
1.1. Tng quan v ung th ....................................................................................... 3
1.2. Cc phng php iu tr ung th ..................................................................... 3
1.3. C s x tr ung th ........................................................................................... 4
1.3.1. C s sinh hc ............................................................................................ 4
1.3.2. C s vt l ................................................................................................ 6
1.3.2.1. Tng tc ca bc x ion ho ln t chc sinh hc ............................ 6
1.3.2.2. C ch tc dng sinh hc ca bc x ion ho ...................................... 7
1.4. Cc loi hnh iu tr bng bc x .................................................................... 9
1.4.1. iu tr bng ngun xa ............................................................................... 9
1.4.2. iu tr p st ........................................................................................... 10
CHNG 2: MY GIA TC TUYN TNH V K THUT X TR 3D-CRT
TRONG IU TR UNG TH .......................................................... 12
2.1. Nhng hn ch ca my x tr cobalt trong iu tr ........................................ 12
2.2. Tng quan v my gia tc tuyn tnh .............................................................. 14
2.2.1. Cu to my gia tc tuyn tnh ................................................................. 15
2.2.2. Nguyn l hot ng ................................................................................ 16
2.3. K thut x tr 3D-CRT................................................................................... 17
2.3.1. H thng lp k hoch iu tr TPS ......................................................... 18
2.3.2. Quy trnh thc hnh lm sng k thut x tr 3D-CRT ............................ 18
2.3.2.1. nh gi bnh nhn v quyt nh x tr ........................................... 19
2.3.2.2. C nh t th bnh nhn ................................................................... 19
2.3.2.3. M phng ........................................................................................... 20
2.3.2.4. Ghi nhn v x l hnh nh bnh nhn .............................................. 21
2.3.2.5. Khoanh vng iu tr v vng bo v ................................................ 22
ii

2.3.2.6. Thit lp trng chiu v s dng cc thit b h tr ........................ 25
2.3.2.7. Tnh ton liu lng v phn b liu ................................................. 25
2.3.2.8. nh gi k hoch .............................................................................. 26
CHNG 3: K THUT X TR IU BIN CNG JO-IMRT .............. 29
3.1. Nguyn l ca k thut x tr iu bin cng IMRT ............................... 30
3.2. Bi ton lp k hoch ngc trong k thut x tr IMRT ............................... 33
3.2.1. Bi ton lp k hoch xui v lp k hoch ngc .................................. 33
3.2.2. Quy trnh v cc m hnh ti u ha trong k thut IMRT ..................... 37
3.3. M hnh ti u ha theo liu ........................................................................... 41
3.3.1. Hm mc tiu ........................................................................................... 42
3.3.1.1. Cng thc ton hc ............................................................................ 42
3.3.1.2. C s xy dng hm mc tiu............................................................ 44
3.3.2. Mc tiu v liu lng ............................................................................. 45
3.3.3. Mc tiu liu lng-th tch ..................................................................... 47
3.3.4. Mc tiu v EUD ..................................................................................... 48
3.3.5. H s quan trng ...................................................................................... 50
3.4. Thut ton ti u ha trc tip m (DAO) ................................................ 50
CHNG 4: NG DNG K THUT X TR JO-IMRT V KT QU O
THC NGHIM TI BNH VIN A KHOA NG NAI .......... 55
4.1. Trang thit b cn thit trin khai k thut x tr JO-IMRT ....................... 55
4.2. Quy trnh k thut x tr iu bin cng (JO-IMRT) ............................... 55
4.2.1. Lp k hoch x tr JO-IMRT vi phn mm Prowess panther ............... 56
4.2.2. Quy trnh o liu kim tra cht lng (QA) cho JO-IMRT ..................... 60
4.3. Kt qu lp k hoch x tr JO-IMRT v kt qu QA .................................... 64
4.4. Kt lun ........................................................................................................... 70
KT LUN ............................................................................................................... 71
KIN NGH .............................................................................................................. 72
TI LIU THAM KHO ......................................................................................... 73
PH LC .................................................................................................................. 75
iii

DANH MC CC K HIU, CC CH VIT TT
3D-CRT: Three dimensional conformal radiotherapy
AFC: Automatic frequency control
CT: Computed comography
CT SIM: Computed tomography simulation
CTV: Clinical target volume
DAO: Direct aperture optimazation
DICOM: Digital imaging and communications in medicine
DNA: Deoxyribo nucleic acid
DVH: Dose volume histogram
EUD: Equivalent uniform dose
GTV: Gross tumor volume
IAEA: International atomic energy agency
ICRU: International commission on radiation units
IGRT: Image guided radiation therapy
IMRT: Intensity modulated radiation therapy
MLC: Multileaf collimator
MRI: Magnetic resonance imaging
NTCP: Normal tissue complication probability
OAR: Organs at risk
PET: Position emission tomography
PTV: Planning target volume
RNA: Ribonucleic acid
SAD: Source axis distance
SPECT: Single photon emission computed tomography
SSD: Source surface distance
TCP: Tumor control probability
JO-IMRT: Jaw only Intensity modulated radiation therapy
iv

DANH MC CC BNG
Bng 4.1: Kt qu so snh liu hp th gia 2 k hoch JO-IMRT v 3D-CRT ............ 66
Bng 4.2: Sai s gia liu tnh v liu o ca bnh nhn Nguyn Th M, ung th
vm ti bnh vin a khoa ng Nai ...................................................... 67
Bng 4.3: Sai s gia liu tnh v liu o ca bnh nhn ung th vm ti bnh vin
K-H Ni ................................................................................................. 67
Bng 4.4: Sai s gia liu tnh v liu o ti bnh vin Bch Mai-H Ni ............. 68
Bng 4.5: Sai s gia liu tnh v liu o ca bnh nhn Trn Vn H, ung th vm
ti bnh vin a khoa ng Nai .............................................................. 70
v

DANH MC CC HNH V, TH
Hnh 1.1: Chu k t bo ............................................................................................. 5
Hnh 2.1: My gia tc tuyn tnh ti bnh vin a khoa ng Nai ......................... 14
Hnh 2.2: Cu to my gia tc tuyn tnh ................................................................. 15
Hnh 2.3: K thut x tr thng thng 2D (a) v k thut x tr 3D-CRT (b) ........ 17
Hnh 2.4: Quy trnh lp k hoch x tr .................................................................... 19
Hnh 2.5: H thng my CT m phng ti bnh vin a khoa ng Nai ................ 20
Hnh 2.6: Cc vng th tch khc nhau cn xc nh theo ICRU ............................ 23
Hnh 3.1: So snh phn b liu lng gia k hoch 3D (tri) v IMRT (phi) ..... 30
Hnh 3.2: Phn b liu ca k thut x tr 3D-CRT v IMRT ................................. 31
Hnh 3.3: Hnh dng chm tia c to ra bi MLC (tri) v Jaw (phi) ................ 32
Hnh 3.4: Bn liu lng phc hp ..................................................................... 32
Hnh 3.5: Bi ton k hoch xui ............................................................................. 33
Hnh 3.6: Bi ton lp k hoch ngc .................................................................... 34
Hnh 3.7: Ngun c chia thnh nhiu chm tia n v ........................................ 36
Hnh 3.8: Quy trnh ti u ha trong k thut IMRT ............................................... 38
Hnh 3.9: Chm tia v c th bnh nhn c chia thnh nhiu phn nh .............. 43
Hnh 3.10: t iu kin cho bi ton ngc ........................................................... 46
Hnh 3.11: th mc tiu liu-th tch ................................................................... 48
Hnh 3.12: Quy trnh thut ton DAO ...................................................................... 51
Hnh 3.13: Bc u tin trong qu trnh ti u ...................................................... 52
Hnh 3.14: Cc tiu a phng v cc tiu ton cc .............................................. 53
Hnh 3.15: Cc phn on trng chiu (segment) v bn cng ................. 54
Hnh 4.1: Quy trnh k thut x tr JO-IMRT .......................................................... 56
Hnh 4.2: Cc trng chiu: 72
0
, 100
0
, 155
0
, 180
0
, 210
0
, 265
0
, 300
0
....................... 57
Hnh 4.3: Biu din cc hm mc tiu trong phn mm Prowess panther ............... 58
Hnh 4.4: ng DVH thay i khi iu chnh trng s ca PTV .......................... 59
Hnh 4.5: ng DVH ca k hoch cui cng ...................................................... 59
Hnh 4.7: Thit b o liu Dose 1 ............................................................................. 61
vi

Hnh 4.8: S h o kim tra cht lng............................................................... 62
Hnh 4.9: V tr cc im o liu trong k hoch QA JO-IMRT .............................. 62
Hnh 4.10: Thit lp plastic phantom o h s hiu chnh my ............................... 63
Hnh 4.11: Liu tnh ton v liu o c ti im kho st. .................................. 64
Hnh 4.12: Hnh nh lt ct CT c xc nh GTV, CTV ................................ 65
Hnh 4.13: So snh k hoch x tr JO-IMRT v 3D-CRT ...................................... 65
Hnh 4.14: So snh 2 DVH: JO-IMRT (nt t) v 3D-CRT (nt lin) .......................... 66
Hnh 4.15: ng isodose k hoch JO-IMRT bao st khi u hn 3D-CRT .......... 69
Hnh 4.16: So snh 2 DVH: JO-IMRT (nt lin) v 3D-CRT (nt t) ......................... 69
1

M U
Nh vo s pht trin ca khoa hc v cng ngh, thi gian qua c rt
nhiu k thut hin i gip iu tr ung th t hiu qu cao v cu sng c rt
nhiu bnh nhn. Hin nay, chng ta c nhiu phng php iu tr cho bnh
nhn ung th nh phu thut, ha cht, x tr,... Tuy nhin, x tr vn l mt trong
nhng phng php ph bin i vi hu ht cc loi ung th.
C th ni, x tr l mt trong nhng ngnh ng dng k thut ht nhn vo y
hc mnh m nht. Cc k thut x tr hin ti c nhng tin b vt bc v gip
cho s phn b liu ti u ti th tch bia (khi u), ng thi gim n mc ti thiu
s nguy hi cho cc t chc lnh lin quan. T k thut phn b hai chiu (2-D); ba
chiu theo hnh dng khi u (3D-CRT) n x tr iu bin cng (IMRT); x tr
di s hng dn ca hnh nh (IGRT); x tr ct lp (tomotherapy) v x tr bng
ht nng (heavy ion),... v ang c ng dng rng ri ti nhiu nc trn Th
Gii.
K thut x tr ba chiu theo hnh dng khi u (3D-CRT) l mt k thut c
s dng ph bin hin nay ti cc trung tm x tr trong c nc. Tuy nhin, k
thut ny c mt vi hn ch nht nh trong vic xc nh s phn b liu, nht l
vi nhng trng hp khi u c hnh dng phc tp v p st cc vng c quan lnh
cn bo v. Trong ti ny chng ti trnh by k thut x tr iu bin cng
(IMRT). K thut ny c tha nhn v ng dng rng ri trong lm sng vi
h thng my c ng chun trc a l (MLC). Nhng i vi mt s h thng my
gia tc khng c MLC vn c th thc hin k thut IMRT ch vi bn l ngm
(jaw only). K thut ny l k thut JO-IMRT c tch hp trong phn mm lp k
hoch x tr Prowess panther v c p dng ti Trung tm ung bu-bnh vin
Bch Mai t nm 2008 n nay. Mc ch ca lun vn l nghin cu nhm ng
dng, trin khai k thut x tr JO-IMRT ti bnh vin a khoa ng Nai.
2


Ni dung ca lun vn ny gm 4 chng
Chng 1: Ung th v cc phng php iu tr. Trong chng ny trnh by
v c s ca x tr cng nh c s dit t bo ung th bng bc x ion ha.
Chng 2: My gia tc tuyn tnh v k thut x tr 3D-CRT trong iu tr ung
th: Trnh by s lc v cu to, nguyn l ca my gia tc tuyn tnh s dng
trong x tr, v nhng hn ch ca k thut x tr 3D-CRT.
Chng 3: K thut x tr iu bin cng JO-IMRT: Trong chng ny
chng ti trnh by tng quan v k thut x tr iu bin cng (IMRT), cc m
hnh ti u ha trong k thut x tr IMRT, thut ton ti u ha.
Chng 4: ng dng k thut x tr JO-IMRT v kt qu o thc nghim ti
bnh vin a khoa ng Nai: Trnh by v vic lp k hoch, o kim tra trn thc
t nh gi chnh xc, tin cy ca k thut x tr iu bin cng JO-IMRT,
so snh kt qu o ti bnh vin a khoa ng Nai vi kt qu o ti bnh vin
Bch Mai v bnh vin K.
3

CHNG 1
UNG TH V CC PHNG PHP IU TR
1.1. Tng quan v ung th
Ung th l mt trong nhng nguyn nhn hng u gy t vong cho con ngi
trn ton cu. Hin nay, vic phng chng ung th i vo ba hng chnh: Phng
bnh, pht hin sm v ng dng khoa hc cng ngh hin i vo iu tr ung th.
Vic iu tr ung th cn c vo nhiu yu t nh c quan, v tr b ung th, th gii
phu bnh l, giai on bnh, cng nh tnh trng chung ca bnh nhn. Pht hin
sm cng nh chn on ng giai on bnh c ngha tin quyt trong vic quyt
nh phng php iu tr em li hiu qu cao cho ngi bnh.
Trn Th Gii, theo s liu ca T chc Ung th M cng b th nm 2007 c
khong 7,6 triu ngi cht do bnh ung th. Ngoi ra cn c 12 triu ngi mang
trong ngi cn bnh ung th trn ton Th Gii. Cn theo T chc kim sot ung
th Th Gii th trong nm 2005, t l ngi cht do bnh ung th l 13% trong
tng s 58 triu ngi cht trn Th Gii. Trong khong hn 70% s ngi cht
v bnh ung th xy ra cc nc c thu nhp thp v trung bnh. Theo c tnh th
s ngi cht v ung th s tip tc tng khong 9 triu ngi vo nm 2015 v 11,4
triu ngi trong nm 2030 [4].
Ti Vit Nam, theo nghin cu ca GS.Nguyn B c th ung th vn l
nguyn nhn gy t vong hng u, mi nm c khong 150.000 ngi mc bnh
ung th mi v khong 75.000 ngi t vong v bnh ny. Theo c tnh n nm
2010 s ngi mc bnh l 200.000 v t vong l 100.000 ngi [4].
1.2. Cc phng php iu tr ung th
Hin nay c 3 phng php iu tr ung th: Phu thut, x tr, ha tr. Ngoi
ra c th iu tr kt hp cc phng php t c hiu qu mong mun.
Phu thut: L phng php iu tr ung th c in nht. Khi phu thut, cc
t bo ung th c ly i cng nhiu cng tt. i khi nhng t bo ln cn xung
quanh khi u cng c ct b m bo chc chn t bo ung th c loi b
hon ton. Phng php ny hiu qu cho nhng khi u cn khu tr, cha di cn.
4

X tr: L phng php s dng bc x ion ha tiu dit khi u. V c bn,
x tr c chia ra lm 2 loi: X tr ngoi v x tr trong.
Ha tr: L phng php s dng ha cht iu tr ung th. N c dng
khi ung th lan ra ngoi v tr ban u, di cn nhiu ni, hoc khi u qu ln.
1.3. C s x tr ung th
1.3.1. C s sinh hc
T bo l n v cn bn ca c th. Nhiu t bo hp li thnh m: M si,
m m, m c, m lin kt, m xng, m sn, m thn kinh, nhiu m hp
thnh c quan: Tim, phi, mt, mi, tay, chn, rut, gan, cc c quan to thnh c
th sng. Do nhu cu hot ng ca cc c quan, nht l b p cho cc t bo
gi ci cht i, cc t bo phi sinh sn thm bng cch phn chia thnh 2 t bo
con. Qu trnh phn chia t bo gi l chu k t bo [1].
Chu k t bo l chui cc s kin lin quan n s sao chp DNA (deoxyribo
nucleic acid) v s phn b cn bng ca n i vi cc th h t bo con chu c
sinh ra do s phn chia. S phn chia t bo c din tin qua mt s giai on
(cn gi l pha). Tt c cc t bo, k c c tnh v khng c tnh trong qu trnh
u tri qua 5 pha ca chu k t bo l G
0
, G
1
, S, G
2
v M (hnh 1.1).
Pha G
0
(pha ngh sau phn bo). Pha G
0
l giai on trong chu k khi m cc
t bo c kh nng thay mi bnh thng v khng tng sinh. Trong pha ny, cc t
bo hnh thnh mi chc nng, ngoi tr nhng chc nng lin quan ti tng sinh.
Pha ny gm c cc t bo ang phn chia ln cc t bo ang trong trng thi ngh.
Cc t bo bnh thng trong pha G
0
c hot ho ch bng mt kch thc no
i vo chu k ti sinh sn ngha l s cht ca t bo cng loi.
Pha G
1
l pha pht trin hoc giai on sau phn bo/tin tng hp. Pha G
1

din ra trong khong t 12-14 gi, ko di t khi hon thin s phn chia t bo
trc cho ti thi im bt u sao chp nhim sc th. Cc t bo mang theo
cc chc nng sinh l c phn cng ca chng v tng hp cc protein v axit
ribonucleic (RNA). Pha G
1
l s khi u, sn sng cho cc t bo chun b bc
vo giai on tng hp - pha S.
5

Pha S (tng hp). Trong pha tng hp, ko di khong t 7-20 gi, RNA c
tng hp v l c s cho s tng hp nn DNA. S tng hp DNA ch c thc
hin pha ny. Cc t bo d b tn thng nht trong pha S ny.

Hnh 1.1: Chu k t bo
Pha G
2
(pha tin phn bo). Pha G
2
ko di t 1- 4 gi, nm trong nhng giai
on hot ng tng i yu v cc t bo ch i i vo pha phn bo, pha ny
bao gm khong thi gian t khi kt thc s tng hp DNA cho n khi bt u s
phn chia t bo. i khi tng hp protein b sung c th xy ra trong pha G
2
ny,
nhng ch yu pha ny tng hp nn cc cu trc protein ch khng phi thnh cc
enzym. Mt vi tng hp RNA b sung c th xy ra trong pha ny.
Pha M (s phn bo). Trong pha M, t 40 pht n 2 gi, din ra s phn bo
v phn chia cc t bo. S sao chp DNA phi c hon thin trc khi cc t
bo i vo chu k phn bo. Sau phn bo, cc t bo con hoc s quay v pha
G
0
v ngng phn chia, hoc nu c kch thch s phn chia th chng s i vo pha
G
1
v tip tc chu k sinh sn mi.
Cc t bo ung th c kh nng kt thc chu k t bo nhanh hn bng cch
gim khong thi gian trong pha G
1
. Chng rt t khi i vo hoc li pha G
0
ca
chu k t bo hn cc t bo lnh; bi th m chng phn chia mt cch lin tc [5].
c im ca t bo ung th l nhy cm vi cc tia bc x hn cc t bo khe
mnh bnh thng. iu ny c ngha l cc t bo ung th rt yu trong c ch sa
cha nhng sai hng trn DNA so vi cc t bo bnh thng. Khi c chiu x
6

mt liu thch hp th s tiu dit c cc t bo ung th ny nhng vn m bo
kh nng phc hi ca cc t bo lnh. Vic ny c thc hin bng cch chia qu
trnh iu tr thnh nhiu phn on chiu.
1.3.2. C s vt l
1.3.2.1. Tng tc ca bc x ion ho ln t chc sinh hc
Bc x ion ho khi gp vt cht s gy nn hin tng kch thch hoc ion ha
cc nguyn t v phn t cu to. Nh vy nng lng ca bc x b hao ht, mt
tia b suy gim v ng i c th b thay i. Kt qu l cng b suy gim
v hng i ca chm tia b thay i. S thay i ph thuc nhiu vo bn cht
tia, nng lng tia v c im ca vt cht m n i qua. Ti khi vt cht m tia
i qua do b hp thu nng lng nn xy ra nhng bin i trong . S bin i
tu thuc rt nhiu vo hin tng kch thch v ion ho. D c ch c khc nhau
ty loi tia nhng kt qu ca s tng tc ph thuc trc ht vo s lng cp ion
c to ra trong vt cht trn n v ng i [7].
a. Liu hp th
Liu hp th l nng lng b hp th trn n v khi lng ca i tng b
chiu x. Theo nh ngha ta c:
ht
E
D
m
A
=
A
(1.1)
Trong h SI n v ca liu hp th l J/kg hoc erg/g. n v ngoi h l rad:
1rad = 100erg/g. Ngy nay ngi ta thng dng n v Gray (Gy) 1Gy=100rad.
b. Liu chiu
Liu chiu ca tia X hoc tia gama l phn nng lng ca n mt i bin
i thnh ng nng ca ht mang in trong mt n v khi lng khng kh, kh
quyn iu kin tiu chun. K hiu
ch
D .
ch
Q
D
m
A
=
A

(1.2)
Trong h SI n v liu chiu l Coulomb trn kilgam (C/kg). n v ngoi
h l Rnghen (R). Gia R v C/kg c mi lin h sau.
7

1 R = 2,57976. 10
-4
C/kg hay 1 C/kg ~ 3876 R
Rnghen l liu chiu ca chm photon khi chiu vo 1 cm
3
khng kh (tc
1,293 mg) iu kin tiu chun s to ra mt s ion m in tch tng cng cc ion
cng du l mt n v in tch (tc l khong 2,09 x 10
9
cp ion). Rnghen(R) l
n v trc y hay dng trong y hc phng x v phng x sinh hc. Ngi ta
cn gi liu chiu l liu biu kin.
c. Liu tng ng
Trong thc nghim cho thy hiu ng sinh hc gy bi bc x khng ch ph
thuc vo liu hp th m cn ph thuc vo loi bc x. Mt i lng c dng
l liu tng ng. Liu tng ng l liu hp th trung bnh trong m hoc c
quan T do bc x r, nhn vi h s trng s phng x tng ng W
r
ca bc x
Liu tng ng = Liu hp th x W
r
(1.3)
n v ca liu tng ng l J/Kg, rem hoc sievert (Sv) vi 1Sv=100rem.
d. Liu hiu dng
Cc m khc nhau nhn cng mt liu tng ng nh nhau li c tn
thng sinh hc khc nhau. l do nhy cm phng x ca cc m khc nhau,
c trng cho tnh cht ny ngi ta a ra khi nim trng s ca m W
T
. Liu
hiu dng c tnh.
Liu hiu dng = Liu tng ng x W
T
(1.4)
1.3.2.2 . C ch tc dng sinh hc ca bc x ion ho [1]
cc phn trn chng ta kho st bn cht cc hin tng vt l trong qu
trnh tng tc gia bc x v vt cht. Tuy nhin qu trnh truyn nng lng ca
bc x ln t chc sinh hc v gy tc dng c nhng c ch phc tp hn.
Hin nay ngi ta vn cho rng c hai c ch tc dng ca bc x ion ha ln t
chc sinh hc:
- C ch tc dng trc tip
Nng lng ca bc x trc tip chuyn giao cho cc phn t cu to nn t
chc sinh hc m ch yu l cc i phn t hu c, nng lng gy nn cc qu
trnh kch thch v ion ha cc nguyn t, phn t. Tip theo l cc phn ng ha
8

hc xy ra gia cc phn t mi to thnh sau khi b kch thch hoc ion ha. Hai
giai on ny xy ra rt nhanh. Cc phn t hu c quan trng b tn thng gy
nn cc tc dng sinh hc tip theo nh tn thng chc nng hot ng, gy t
bin gen, hy dit t bo, v.v...
Cc qu trnh kch thch v ion ha cc nguyn t, phn t, cc phn ng ha
hc xy ra gia cc phn t trc ht gy nn cc tn thng ti v sau c th
lan truyn ra cc phn t khc xung quanh.
- C ch tc dng gin tip
Tuy nhin vi l thuyt c ch tc dng trc tip ngi ta khng gii thch
c mt s kt qu thc nghim v quan st thc t. Ta bit nc chim mt t l
rt cao (70% n 90%) trong cc t chc sinh hc. V vy c th xem t chc sinh
hc nh mt mi trng bao gm cc phn t hu c v nc. Do vy c th ngh
rng bn cnh c ch tc dng trc tip cn c mt c ch khc khng km phn
quan trng vi vai tr to ln ca cc phn t nc lm trung gian. l c ch tc
dng gin tip. C ch gin tip ca bc x ion ha ln t chc sinh hc l bc x
ion ha tc dng ln cc phn t nc, gy nn nhng bin i to ra cc sn
phm ha hc mi l cc ion dng hoc m (H
2
O
-
, H
2
O
+
, H
+
, OH
-
) v cc phn t
trng thi kch thch (H
2
O
*
, H
*
, OH
*
, HO
2
*
, v.v...). Cc phn t trng thi kch
thch H
*
, OH
*
rt d kt hp vi nhau to ra cc sn phm ha hc mi:

* * *
2
* * *
2
* *
2 2
H H H
OH H H O
OH OH H O
+
+
+

H
2
O
2
l mt hp cht rt c i vi cc phn t hu c v l mt cht oxy
ha rt mnh. Trn thc t lng H
2
O
2
c sn sinh ra nhiu hn v c cc phn
ng sau y nu trong t chc c nhiu O
2
.
Hoc:
( )
*
*
2 2 2
*
2 2
2 2 2 2 2
H O O OH HO
H O HO
HO HO H O O

+ +
+
+ +

9

Nu hm lng oxy trong mi trng cng nhiu th lng H
2
O
2
c sn
sinh cng ln. Nu trong nc c cc cht ha tan th (HO
2
)
*
s thu electron ca
cht v bin thnh (HO
2
)
-
ri sau tng tc vi H
+
cng thnh peroxyd.
( ) ( )
*
2 2 2 2
HO e HO H H O

+
+ +
Phn ln cc phn t hu c (RH) trong t chc b ph hy bi cc phn t
H
2
O
2
. Ngoi ra cc gc t do (phn t, nguyn t trng thi kch thch) H
*
, OH
*

cng d phn ng vi cc phn t hu c gy nn nhng bin i v to ra thm
nhng gc kch thch R
*
v RO
2
*
theo c ch sau y.

* *
2
RH H R H + +

v ( )
*
*
2
RH OH R H O + +
Cc gc R
*
b kch thch cng d gy ra cc phn ng ha hc mi lm cho s
lng cc phn t hu c b tn thng tng ln rt nhiu v cc phn ng dy
chuyn sau y.

* *
2 2
*
2
R O RO
RO RH ROOH+R
+
+

Da vo l thuyt ny ngi ta hiu c tc dng lan truyn ra xa, tc dng
ko di sau khi chiu x, tc dng ca hm lng nc, oxy trong mi trng chiu
v nhiu hin tng khc trong phng x sinh hc.
Trong c ch tc dng ca bc x ion ha ln t chc sinh hc, hai c ch tc
dng trc tip v tc dng gin tip u c gi tr quan trng ca n. Ty thuc mi
trng v iu kin m c lc c ch ny c vai tr v v tr ln hn c ch kia. Hai
c ch h tr cho nhau v gip chng ta hiu c su sc hn bn cht ca cc
qu trnh phng x sinh hc, chng ta tin hnh p dng bc x ion ha c hiu
qu hn trong cng tc thc tin.
1.4. Cc loi hnh iu tr bng bc x
1.4.1. iu tr bng ngun xa
Khi nim x tr chiu ngoi l trong phng thc ny tn ti mt khong
cch nht nh gia ngun x v i tng b chiu. Do trn thc t thng s
dng cc photon trong iu tr chiu ngoi. l tia X v tia gamma [1].
10

Khi s dng cc tia ny iu tr cn lu cc c im sau:
- Photon c nng lng cng cao th kh nng m xuyn cng ln v hiu qu
sinh hc cng cao. V vy ngi ta tm cch to ra cc thit b pht ngun photon c
nng lng ngy cng cao. Thc nghim cho thy su 10 cm di mt da liu
hp th tng dn theo nng lng tia v t hiu qu cao nht (gn 80% liu ti a)
vi cc photon c nng lng trung bnh l: 8 MeV (t 3 10 MeV).
- Tia m xuyn c nng lng cng ln khi vo c th bnh nhn cng to
nn sut liu iu tr trong su tt hn, ng thi liu gy hi cho cc m lnh trn
ng xuyn qua cng t hn.
- Nng lng tia cng ln th t l liu hp th khi u trn tng liu cng tng.
- S tn x (khuch tn) ra m lnh xung quanh u cng t hn khi nng lng
chm photon cng ln.
- Chm tia c cng cng mnh cng to ra mt phng ng liu (isodose)
trong m bnh tt hn.
1.4.2. iu tr p st (brachytherapy)
1.4.2.1. iu tr p st c in
Trong iu tr p st thng dng cc ng v phng x (VPX) pht ra beta
cng hoc gamma mm, c th dng ngun phng x kn hoc h. in hnh ca k
thut iu tr p st l s dng cc kim, ch, ht,...bng ngun radium hoc cobalt.
Cng vic ny thng c kt hp vi phu thut n gin hoc phc tp vng
cn iu tr p st. V vy to thnh cc phn khoa c th cho iu tr p st vng
u c, kh ph qun, ng tiu ho...
Radium-226 (
266
Ra) ln u tin c dng vo mc ch iu tr vo nm
1917. Ngi ta s dng nng lng tia gamma pht ra t cc ngun radium tiu
dit cc t bo ung th cc hc t nhin nh t cung, bng quang, i trc trng,
hc ming ... Tuy
266
Ra c chu k bn r (T
1/2
) l 1580 nm, dng c lu nhng
kh c c ngun ln. Cc c s iu tr thng ch c c cc ngun di dng
cc kim nh c 2 -10 g m thi. Vic sn xut n tn km, gi thnh t v phi tinh
lc t cc qung uran.
11

n nm 1951 ng v phng x nhn to
60
Co mi c s dng vo iu tr
v n ngy cng c thay th rng ri cho
266
Ra v ngi ta c th sn xut c
cc ngun
60
Co c phng x ln hn
266
Ra nhiu ln v r hn hng ngn ln.
1.4.2.2. iu tr p st np ngun sau (afterloading Brachytherapy)
Phng php iu tr p st c in i hi ngi thy thuc phi thao tc lu
v trc tip vi cc ngun x. V vy cc nc tin tin khng cn p dng na.
Gn y vi tin b ca tin hc, k thut in t ngi ta c th xc nh v tr, liu
lng ngun x v to ra ng dn trc, sau mi np ngun x theo ng
dn . Bng cch ny gim c liu chiu cho nhn vin iu tr v c gi l
k thut iu tr p st np ngun sau.
1.4.2.3. iu tr chiu trong bng ngun h
Khc vi 2 phng thc iu tr k trn, iu tr chiu trong l phng php
a cc ngun phng x h vo tn t bo, m bnh da theo cc hot ng sinh l
chc nng hoc ri lon bnh l ca c quan, c th. Dc cht phng x c th ch
l cht v c hoc hp cht hu c c gn cc VPX thch hp. C th a chng
vo c th bng ng ung, tim hoc truyn. Mc ch ch yu vn l km hm
s hot ng cng nng ca m, tuyn hoc tiu dit cc t bo bnh.
12

CHNG 2
MY GIA TC TUYN TNH V K THUT X TR 3D-CRT
TRONG IU TR UNG TH
Vic ng dng ca tia X vo iu tr ung th nng ngy cng phong ph.
Trong l cc my pht tia-X 150 kV v 300 kV c s dng rt hiu qu ln
lt cho iu tr ung th da v cho s lm gim bt cc triu trng tm thi. Tuy
nhin tnh cht vt l ca tia ny khng p ng c cc yu cu iu tr cc khi
u su bn trong. Vic nghin cu chm bc x vi mc nng lng cao hn, ng
ngha vi kh nng m xuyn ln hn, dn n s pht trin ca my x tr
cobalt-60. Ph chm tia gamma pht ra t ngun cobalt-60 c 2 nh nng lng ti
1,17 MeV v 1,33 MeV, cho nng lng photon trung bnh khong 1,25 MeV,
chm bc x ny c th c dng iu tr tt nhng khi u nm gn b mt da.
Tuy nhin tnh cht vt l ca chm tia gamma ny vn cn c mt s mt hn ch
vic iu tr cc khi u su bn trong nh: Liu b mt tng i ln v iu tr
km hiu qu vi cc khi u nm su trong da. V vy ngi ta phi s dng my
gia tc trong x tr ung th v s ra i my gia tc to ra bc ngot ln trong
iu tr ung th. Trong chng ny chng ti trnh by nhng li th ca my gia
tc so vi my cobalt dn ti s ra i ca my gia tc, sau i tm hiu nguyn
l cu to chung ca my gia tc. Cui cng l trnh by v k thut x tr thch ng
ba chiu (3D-CRT).
2.1. Nhng hn ch ca my x tr cobalt trong iu tr
My x tr cobalt l loi my s dng chm bc x gamma pht ra do s phn
r ca ng v phng x
60
Co iu tr. Ngun
60
Co c sn xut c dng ng
xu (ng knh 2cm) c ghp li thnh hnh tr. Hot ban u 6500 Ci. Thi
gian s dng khong 5 - 7 nm. Ngun
60
Co pht bc x gamma () vi hai mc nng
lng l 1,17 MeV v 1,33 MeV, nng lng trung bnh l 1,25 MeV, c thi gian
bn r 5,27 nm. Cc mc nng lng ca
60
Co c nh lm cho vic iu tr tr nn
km linh hot trong vic iu tr ung th vi cc v tr khi u khc nhau. i vi
13

nhng khi u rt nng, nm rt gn b mt da, khi iu tr bng my cobalt, liu hp
th cc i nm su su hn v tr ca khi u.
Nh vy, khi iu tr cc khi u nng bng my cobalt th liu khng tp trung
vo khi u, v nh hng ln n nhng vng m lnh nm su trong da. khc
phc iu ny, nu iu tr bng my cobalt th ngi ta phi s dng thm mt
dng c, gi l dng c b tr. Dng c b tr c tc dng a vng liu hp th
cc i v gn b mt da hn, nh vy s tp trung c liu vo nhng khi u nm
rt gn b mt da. Tuy nhin, vic s dng dng c b tr ny cng tng i bt
tin. khc phc hon ton nhng nhc im ny, khi iu tr nhng khi u
nng, ngi ta s dng chm bc x electron. Bi v cc chm tia electron mt
nng lng gn b mt da v cng chm tia suy gim nhanh chng v s mt
hn su 5 cm. iu ny khin nhng vng lnh t b tn thng hn.
Khng ch khng ph hp cho nhng khi u rt nng, my Co-60 cng khng
th p ng c vi nhng khi u nm su trong c th. V d : Mt khi u nm
gia phi, cch b mt da trung bnh 8 cm, liu x ca my cobalt khi vo n y
li qu thp bi. gip cho vic iu tr trong trng hp ny t hiu qu tt hn,
cn phi c chm bc x photon c mc nng lng cao, a vng liu cc i
su hn vo c th.
Nh vy, iu tr ung th linh hot vi nhng khi u nhng v tr khc
nhau trong c th i phi c nhng chm bc x khc nhau nh electron v photon,
ng thi vi iu l vi mi loi bc x phi c nhiu mc nng lng. S a
dng v linh ng ny gip cho ta c th iu tr c tt c cc khi u bt c v
tr no. My gia tc ra i hon ton c th p ng c nhng i hi ny. Ngoi
ra, s dng my gia tc trong x tr cn c nhng li th ni tri: My gia tc an
ton hn nhiu v n ngng pht tia khi tt my, cn my cobalt th ng v phng
x vn phn r lin tc v pht tia khi khng cn cn n. My Co-60 i hi phi
thay ngun nh k do phn r phng x. Ngun c b ra cn x l m bo an
ton bc x khng gy nhim mi trng. c bit sut liu bc x ca my
gia tc cao hn ngun cobalt (thng gp 2-3 ln).
14

2.2. Tng quan v my gia tc tuyn tnh
My gia tc c ng dng trong lm sng t u nhng nm 1950, hoc bng
cc chm electron hoc cc chm tia X v tr thnh thit b ch yu ti nhiu
trung tm x tr. V nguyn tc, khng c gii hn trong cng ngh ch to my gia
tc vi nng lng ca electron, ngoi tr bn thn cu trc chiu di tng tc ca
thit b. Gii hn nng lng chm electron hiu dng t c trong thc t lm
sng nm trong phm vi t 4-40 MeV.

Hnh 2.1: My gia tc tuyn tnh ti bnh vin a khoa ng Nai
Vi mc ch ng dng trong lm sng, cc loi my gia tc cn thit k sao
cho tha mn mt s nhng tiu chun, yu cu ch yu nh sau [2]:
- Chm tia bc x phi xc nh c r nng lng v thay i c v cc kch
thc chm tia.
- Liu lng bc x phi ng u bn trong chm tia.
- Liu lng ca thit b pht ra phi n nh khng ch trong giai on iu tr m
phi n nh sut trong qu trnh s dng.
15

- Liu lng bc x phn b trn bnh nhn phi c o c mt cch chnh xc.
- Chm tia bc x phi iu chnh v thay i c hng v v tr bt k trn bnh
nhn.
- An ton v n nh v c kh cng l mt thng s ht sc quan trng.
2.2.1. Cu to my gia tc tuyn tnh
Cc b phn chnh l sng in t, ngun pht sng cao tng klystron, ng gia
tc, h thng un chm tia, b phn kim sot liu lng v bia pht tia X.

Hnh 2.2: Cu to my gia tc tuyn tnh
- Cn my ng (gantry stand): c thit k chu ti, mt khc c th cha:
My pht sng, sng in t, v ng dn sng gia tc.
- My pht sng: Gm hai thnh phn chnh: Ngun pht sng (klystron hoc
magnetron) v b iu ch xung. Magnetron v klystron: L cc ngun pht vi
sng hot ng di dng xung ngn c mt vi s. C hai c lp thm b iu
chnh tn s t ng AFC (automatic frequency control) c th duy tr dao ng
vi tn s ti u.
- Sng in t: L thit b pht ra electron, n gm c hai loi chnh l loi hai cc
v loi ba cc. C ch cung cp nhit cho catt ca sng in t c th l trc tip
hoc gin tip tu theo nh sn xut.
16

- ng dn sng gia tc: Gm c ng dn sng v ng gia tc dng truyn n v
tng tc chm electron.
- Cn my (gantry): Cha h thng truyn ti electron, u my iu tr. Cn my
c gn vo cn my ng v c th quay c quanh trc vung gc vi n.
- H thng truyn ti electron: a electron n u my iu tr.
- u my iu tr bao gm: Bia tia - X c dng to ra chm photon x tr nh
hiu ng bc x hm khi chm electron ( c gia tc) tng tc vi bia; ng
chun trc (gm c cc loi: S cp, xc nh hnh dng chm bc x, i xng v
c lp) thng c cu to bi hai cp ngm (jaw) to dng (chun trc)
chm bc x theo hnh ch nht; cc khi che chn to hnh dng trng chiu
thch hp; cc b lc phng dng lm phng chm bc x to ra tnh ng nht;
b phn kim sot liu lng (monitor).
- Ging bnh: L ni t bnh nhn v b tr cc t th x tr. N c th quay c
quanh trc trn mt phng nm ngang v cng c th nng ln, h xung to
khong cch iu tr thch hp.
- Bng iu khin: L thit b iu khin cc hot ng ca my gia tc nh: Quay,
t v tr cho cc ngm trong ng chun trc nh v trng iu tr.
- Ngun cao p: Cung cp ngun in mt chiu cho my pht sng.
2.2.2. Nguyn l hot ng
Cc electron c sinh ra do bc x nhit t sng in t, c iu ch thnh
cc xung v phn vo ng gia tc. l cu trc dn sng m trong nng lng
dng cho electron c cung cp t ngun sng siu cao tn (vi tn s khong
3000 MHz bc sng 100 mm). Chm electron c gia tc c xu hng phn k
khi ra khi ng gia tc v c hi t theo mt qu o thng nh h thng in
trng ng trc. Sau chm electron c un theo mt gc 90
0
hoc 270
0.
. Nu
cn s dng chm tia electron th cho electron ra trc tip s dng, nhng nu s
dng tia X th cho chm electron sau khi gia tc chm vo mt bia kim loi (target).
Ti y electron b hm li v pht ra tia X (theo hiu ng bc x hm
bremstralung).
17

2.3. K thut x tr 3D-CRT
Nhng tin b trong cng ngh my tnh lm tng kh nng qu t lp
k hoch v thc thi k thut phn b liu theo 2-D cho n k thut phc tp hn,
hin i hn l phn b liu theo khng gian 3 chiu, ph hp vi hnh dng
khi u (3D-CRT).
3D-CRT l mt thut ng c s dng m t k thut phc tho v thc
hin mt k hoch x tr c da trn cc d liu t phim CT theo ba chiu cng
cc trng chiu c to theo hnh dng ring bit ph hp khi u.

Hnh 2.3: K thut x tr thng thng 2D (a) v k thut x tr 3D-CRT (b)
K thut x tr 3D-CRT l mt trong cc k thut x tr ngoi. So vi k thut
x tr thng thng 2D trc y, cc chm tia c pht ra ch c dng hnh ch
nht hoc hnh vung, th k thut 3D-CRT u vit hn rt nhiu. Vi s c mt
ca cc tm che chn ch, ng chun trc a l MLC, chm bc x pht ra c th
c iu chnh vi hnh dng bt k c th bao kht khi u theo tng hng
chiu (hnh 2.3b).
Mc ch ca x tr 3D-CRT l to c mt vng phn b liu hp th cao ti
th tch bia v do gim liu c hi cho cc t chc lnh xung quanh, qua s
lm gim thiu cc hiu ng ph hoc bin chng mun, tng xc sut kim sot
khi u v ci thin kt qu iu tr. thc hin c iu ny, bnh nhn cn phi
tri qua mt qu trnh m phng v lp k hch iu tr.
18

2.3.1. H thng lp k hoch iu tr TPS (Treatment planning system)
M phng v lp k hoch x tr thc cht l qu trnh thit k, m phng mt
ca iu tr trc khi tin hnh iu tr tht. Nh , cc bc s c th kim sot
c liu lng bc x ti khi u, ti cc t chc lnh xung quanh ca bnh nhn,
cng nh tin lng, nh gi c kh nng p ng ca bnh nhn trong qu
trnh iu tr.
Cng vi s pht trin ca tin hc, cc h thng lp k hoch x tr cng ngy
cng pht trin, lp k hoch nhanh chng v chnh xc hn. Trong cc h thng
ny, c c th bnh nhn v my iu tr cho bnh nhn u c m phng trn
phn mm lp k hoch. Thng tin bnh nhn c dng trong qu trnh m phng
chnh l tp hp d liu nh ct lp vi tnh (nh theo chun DICOM). nh ct lp vi
tnh khng nhng c s dng m t hnh dng, t th ngi bnh, xc nh v
tr khi u, cc c quan cn bo v m n cn cung cp thng tin chnh xc v mt
vt cht (c th l mt electron), gip ch cho vic tnh ton liu lng bc x
hp th. Vic m phng my iu tr trn phn mm c thc hin bng cch to
ra mt my o c cc thng s k thut ging ht vi my iu tr thc. Ph bc x
pht ra t my iu tr thc cng c m phng chnh xc trn phn mm bng
cch nhp b d liu o c thc t. Hin nay trn Th Gii c mt s h thng lp
k hoch x tr nh: Prowess, CMS, ADAC PinacleTuy cc h thng ny c
nhng im khc bit, nhng nhn chung, cc bc trong qu trnh lp k hoch u
theo mt quy trnh.
2.3.2. Quy trnh thc hnh lm sng k thut x tr 3D-CRT
Phn ny cp ni dung thc hnh lm sng ca chng trnh x tr theo 3D-
CRT. C nhiu khu k thut i hi phi thc hin trong chng trnh ny. Hnh
2.4: Gii thiu s khi bao gm cc bc c bn ca quy trnh k thut 3D-CRT.
Nhiu chi tit c th khc nhau gia cc trung tm, trong phn di y chng ti
trnh by quy trnh k thut x tr 3D-CRT ti khoa Y hc Ht nhn, bnh vin a
khoa ng Nai.
19

2.3.2.1. nh gi bnh nhn v quyt nh x tr
Bc u trong quy trnh l nh gi v quyt nh xem bnh nhn c th
c iu tr nh th no. Trong qu trnh nh gi tt c cc khu chn on, xt
nghim khc nhau c tin hnh xc nh tnh trng, cng nh giai on bnh.
Nhng yu t bao gm chn on hnh nh, cc xt nghim c bn v sinh ha
hay nhng thng tin v m bnh... gip xc nh loi bnh, giai on bnh cng
nh mc xm ln ca khi u. Sau , tiu ban chuyn mn a ra nhng quyt
nh iu tr cho bnh nhn.

Hnh 2.4: Quy trnh lp k hoch x tr
2.3.2.2. C nh t th bnh nhn
Trc khi i n quyt nh iu tr, tiu ban chuyn mn cn thng nht t
th bnh nhn c th p dng cho tng trng hp v phng php c nh t th
bnh nhn sao cho thch hp nht.
nh gi bnh nhn
C nh bnh nhn
M phng
Khoanh vng cc t
chc ch nh liu
Thit lp trng chiu
Tnh ton liu
nh gi
k hoch
iu tr
Chp nhn
Khng chp nhn
20

Vic p dng k thut 3D-CRT thng kt hp vi kh nng lm gim cc
mp ng bin ca th tch khi u. Phng php c nh hiu qu c th lm gim
thiu sai s t t th bnh nhn. Do , vic s dng phng tin c nh ph hp,
to s thoi mi cho bnh nhn v thao tc cho nhn vin k thut s l mt yu t
quan trng nh hng n ton b quy trnh v kt qu iu tr bnh nhn. Mi mt
c s x tr cn trang b y nhng phng tin, dng c c nh ph hp cho
tng v tr, tng loi bnh. Nhng dng c ny phi d dng ti to chnh xc t th
bnh nhn trong qu trnh iu tr.
2.3.2.3. M phng

Hnh 2.5: H thng my CT m phng ti bnh vin a khoa ng Nai
H thng m phng bao gm my m phng v h thng my tnh iu khin
my m phng cng nh lu tr v x l d liu m phng. Chc nng ca my m
phng l thu nhn d liu nh phc v cho qu trnh lp k hoch, ng thi n
cng c s dng m phng, kim tra vic iu tr v che chn c to ra t
h thng lp k trc khi a bnh nhn vo iu tr chnh thc trn my iu tr.
Ti khoa Y hc Ht nhn bnh vin a khoa ng Nai, h thng m phng l h
thng CT-SIM gm 2 phn chnh: My chp CT c phn gii cao cng my tnh
i km v h thng laser m phng.
21

Nh h thng m phng CT-SIM ny, vic x tr tr nn n gin v chnh
xc hn rt nhiu. H thng laser m phng c gn trong phng chp CT nh
v chnh xc v tr, t th v ta khi chp nh. Kt qu m phng c gi ti
phn mm iu khin chm laser v h thng lp k hoch o VPS (virtual planning
systems). Trong h thng VPS, bc s s xc nh v tr, kch thc khi u trong c
th ngi bnh. Sau , ta tm khi u s c truyn li v phn mm iu
khin ca h thng laser. Phn mm ny t ng tnh ra khong cch gia tm khi
u vi ta gc trn nh CT ca bnh nhn. Sau , n iu khin t ng s dch
chuyn ca ging a h laser v tm khi u ca bnh nhn (bnh nhn vn
nm c nh trn ging CT) v k thut vin s nh du v tr tm khi u trn
bnh nhn.
2.3.2.4. Ghi nhn v x l hnh nh bnh nhn
a. Chp nh CT
Vi nhiu loi v tr khi u khc nhau, nhng hnh nh chp CT s gip cho
vic xc nh chnh xc cc thng s nh kch thc cng nh v tr ca n. Nhng
hnh nh c thc hin trn CT dng cho qu trnh lp k hoch iu tr phi sao
cho cng st thc t cng tt, ngha l phi y nhng g s dng trn my iu
tr. Chng hn cc dng c c nh, gi chn tay, khung tr gip t th bnh
nhn, h thng laser nh v,... phi ging ht nhau.
b. Chp cng hng t-MRI
Trong x tr ung th, MRI c dng ch yu trong nhng trng hp cn b
xung nhng thng tin gii phu hoc kt hp vi cc phim CT ci thin s nh
gi mt cch chi tit v r rng hn tnh trng khi u, nht l nhng khi u tin lit
tuyn v khi u h thn kinh
Trong h thng VPS, d liu nh ca bnh nhn c th c x l gip cc
bc s quan st khi u cng nh vng cn bo v r hn. Nh , s v chnh xc
cc vng ny, nng cao chnh xc v kt qu ca qu trnh lp k hoch. Mt s
thao tc x l nh hay c s dng nh: iu chnh sng ti ca d liu nh,
in thm mt s thng tin c nhn khc ca bnh nhn: Tiu s bnh, nm sinh,
22

2.3.2.5. Khoanh vng iu tr v vng bo v
Qu trnh lp k hoch x tr da vo hnh nh c xc nh theo th tch
khi u v cc t chc nguy cp lin k. Cc vng th tch ny c v theo tng lt
ct da trn b d liu ca phim CT. Th tch khi u thng c v chu vi bng
th cng mc d nhng h thng phn mm hin i c kh nng phn bit cu trc
gii phu khi u. Cng vic ny c v tn thi gian nhng bc s x tr s yn tm
hn v chnh xc ca n. Khi v cc ng bin xc nh th tch khi u v cc
th tch lin quan khc, bc s x tr v k s vt l cn phi tnh n nhng x dch
c th xy ra ca bnh nhn v ca mt s t chc. Sau y l mt s hng dn chi
tit gip vic xc nh cc th tch ny.
Cn phi ht sc cn trng xc nh chnh xc cc vng th tch lin quan
bng k thut x tr 3D-CRT. Nh ni dung bn bo co s 50 v 62 ca ICRU,
hnh 2.6 m t hng dn vic xc nh v m t mt s vng th tch cng nh cc
t chc nguy cp lin quan.
a. Th tch khi u th GTV (gross tumor volume): L phm vi biu hin pht trin
ti ch ca cc t bo c tnh m qua c th nhn thy, s nn hoc thm khm
trc tip.
GTV thng c xc nh bng cc phng tin chn on hnh nh nh
CT, MRI, PET..., bng nhng thng tin t m bnh hc hay gii phu bnh do
thm khm trc tip lm sng.
b. Th tch bia lm sng CTV (clinical target volume): L th tch m m trong
bao gm th tch GTV v cc t chc c tnh biu hin mc vi th, kh pht
hin bng lm sng nhng cn phi loi b. V vy, th tch ny cng phi iu
tr mt cch y v liu lng c trong trng hp x tr triu chng hay trit
.
xc nh th tch bia lm sng, cn phi to dng mt mp ng bin
vi s tri rng vi xm ln ca cc t bo v nhng vng lin quan khc c coi
l c tnh, cn phi iu tr (ngha l nhng hch lympho dng tnh). Thng tin,
d liu ca nhng t chc ny cung cp bng xt nghim m bnh hc c ly
23

t mt s mu bnh phm ti vng c nghi ng. Vng th tch bia lm sng sau
phu thut, chng hn khi u v thng c tnh l ton b t chc nguyn pht
c ct b (GTV). Theo kinh nghim, khi xc nh ng bin CTV thng
c m rng thm 1 cm (ngha l CTV=GTV+1 cm).

Hnh 2.6: Cc vng th tch khc nhau cn xc nh theo ICRU
c. Th tch bia ni ti ITV (internal target volume): L mt khi nim mi c gii
thiu trong bn bo co s 62 ca ICRU. b tr cho nhng thay i v kch
thc, hnh dng v v tr ca CTV. Khi xc nh ITV, iu quan trng l phi
tnh n s bt i xng t nhin v s thay i ca t chc c th. Chng hn,
s thay i v hai pha bn ca tuyn tin lit s khc vi s thay i trc, sau.
S thay i bn trong nh vy l do bn cht sinh l ca c th, khng d kim
sot. khc phc nhng yu t ny, c nhiu cng trnh nghin cu p dng
k thut khng ch, kim sot nhp th hoc s cng y ca bng quang, trc
trng.
24

d. Th tch lp k hoch iu tr PTV (planning target volume): L mt khi nim
v hnh hc, c xc nh la chn s phn b cc chm tia mt cch thch
hp, trong c tnh n nh hng thc t ca nhng thay i v mt hnh hc
ln th tch CTV, m bo phn b liu lng theo ng yu cu trn .
m bo rng tt c cc m bn trong th tch bia lm sng nhn c
mt liu lng ch nh, v nguyn tc chiu x, ta phi lp k hoch chiu
x mt th tch hnh hc ln hn th tch bia lm sng. Th tch bia lp k hoch
c nh ngha l khi th tch bao gm th tch bia lm sng vi mt on mp
bao quanh th tch bia lm sng. on mp ny c xc nh da vo s di
chuyn khi u trong c th bnh nhn v nhng sai s lin quan n sai s ca
my mc. S di chuyn ca khi u trong c th bnh nhn c th k n nhng
nguyn nhn nh: S p ca tim, s th, s cha nc khng ging nhau ca
bng quang. Nhng sai s lin quan ti my mc c th l do sai s ca ging,
ca h laser Tuy nhin, xc nh c on mp t CTV ti PTV, ta khng
c php cng dn cc sai s k trn. on mp bao quanh CTV ny, bt k v
hng no, cng phi ln c th b p c nhng sai s trn. Tc l sao
cho theo bt k hng no, CTV lun lun nm gn trong PTV trong qu trnh
iu tr. Trong thc t lp k hoch, ta phi c gng lp k hoch sao cho ti
thiu 95% th tch bia lp k hoch PTV nhn 100% liu ch nh.
e. Th tch iu tr TV (treated volume): Th tch iu tr thng ln hn th tch
bia lp k hoch v ph thuc vo k thut iu tr c th. Khi lp k hoch, ta
mong mun mt th tch ng liu no n bao trn PTV. Tuy nhin, rt kh
th tch ng liu bng ng th tch PTV m n thng ln hn PTV. Ngi
ta gi th tch ng liu l th tch iu tr .
f. Th tch chiu x IV (irradiated volume): L vng th tch nhn mt lng liu
ng k (thng l 50% liu ch nh). Th tch chiu x ln hn th tch iu tr
v cng ph thuc vo k thut x tr c s dng. Vi k thut x tr 3D-CRT,
th tch chiu x gim khi s dng h thng my gia tc c ng chun trc a l
(MLC) v th tch chiu x tng khi s trng chiu tng.
25

2.3.2.6. Thit lp trng chiu v s dng cc thit b h tr
Vic thit lp trng chiu l la chn cc hng chiu v mc nng lng
ca tng chm tia. Vic ny ph thuc vo v tr, kch thc khi u trong tng
trng hp c th v theo kinh nghim ca tng ngi. S la chn mc nng
lng ca tng chm tia ph thuc vo bn cht ca chm tia bc x. Vi nhng
khi u nm trn da hoc v tr rt nng gn b mt da, ngi ta thng s dng
chm tia electron. Do liu lng do chm tia electron b li ln nht gn b mt
da v suy gim rt nhanh khi i su vo c th bnh nhn. Vi nhng khi u nm
su trong c th, ta c th s dng cc chm tia photon. Ty thuc vo mc su
ca khi u, m ta quyt nh la chn chm tia photon nng lng thp hay cao.
Vi khi u su hn th nn s dng chm photon c nng lng cao hn.
Vi tng trng hp c th, s lng chm tia v cc hng chiu chm tia
hon ton ph thuc vo v tr, kch thc khi u, cng nh kinh nghim ca ngi
lp k hoch.
Song song vi vic thit lp cc trng chiu, ta phi s dng cc thit b ph
tr to ra mt k hoch tt. s dng cc thit b ph tr mt cch hiu qu
nht, ngi lp k hoch cn phi hiu r v bn cht ca cc thit b .
2.3.2.7. Tnh ton liu lng v phn b liu
Sau khi thit lp cc trng chiu, v s dng cc thit b ph tr cn thit.
Ngi lp k hoch s tin hnh tnh ton liu. Hin nay, trong phn mm Prowess
panther, c hai phng php tnh liu cho k thut x tr 3D-CRT. l: Fast
Photon v fast photon effective.
S dng thut ton fast photon tnh ton liu lng cho nhng vng iu
tr l nhng vng tng i ng nht, h s m ca cc vng l tng ng nhau.
Trong thut ton ny khng tnh n s sai khc h s m gia cc vng iu tr.
Nhng khi vng iu tr l nhng vng khng ng nht, v d nh vng
ngc c nhiu khng kh, hay vng tiu khung c nhiu xng (v gia m mm,
khng kh v xng, h s m ca chng rt khc bit) chng ta s dng thut ton
fast photon effective.
26

2.3.2.8. nh gi k hoch
Sau khi tnh ton liu lng v xem phn b liu, ta tin hnh nh gi k
hoch. nh gi xem k hoch va thit k tt v ti u cha. Khi k hoch ny
c chp nhn th n s c a vo iu tr thc t. Vic iu tr thc t s c
thit lp ging ht nh thit k trn phn mm. Nu k hoch ny cha p ng
c cc yu cu v phn b liu lng nh bc s t ra ban u, cn phi lm t
bc thit lp trng chiu v s dng cc thit b ph tr.

Hnh 2.7: nh gi k hoc da trn lt ct
C hai tiu ch c xt n khi nh gi k hoch, l liu lng ti khi u
v liu lng ti cc t chc nguy cp cn bo v. Mt k hoch tt l k hoch
m bo cc iu kin sau:
- liu bc s ch nh ti khi u, vng nhn liu ln nht nm trong khi u
v khng vt qu 107% liu ch nh.
- Liu ti cc t chc nguy cp cn bo v nm trong gii hn liu cho php.
27

nh gi mt k hoch x tr trong phn mm Prowess panther, ta c th
quan st cc ng ng liu (isodose line) trn tng lt ct (hnh 2.7) v trn bn
liu lng-th tch DVH (dose volume histogram - hnh 2.8).

Hnh 2.8: nh gi k hoch da trn biu DVH
Da trn lt ct hnh 2.7 ta thy ng 95% liu bao ht ton b khi u
(100%), cc ng liu cao trnh c ty sng, tim, phi. Hnh 2.8 m t liu hp
th trong mt qu trnh iu tr ca khi u v cc c quan cn bo v. Da vo hnh
ny ta c nhn xt: Cc c quan cn bo v u nhn liu di mc liu gii hn
cho php, v khi u nhn c 95% liu ch nh. Vy k hoch ny t c yu
cu ca bc s a ra.
2.3.2.9. Tin hnh iu tr
Sau khi k hoch c chp nhn, cc thng s lin quan n k hoch iu
tr c chuyn sang phng my gia tc thng qua h thng mng LAN. H thng
my tnh v phn mm s iu khin my gia tc pht tia iu tr mi ngy cho
bnh nhn.
28

Nh vy, k thut x tr 3D-CRT phn b liu hp th cao ti th tch bia v
gim liu c hi cho cc t chc lnh xung quanh nh vic s dng khi che chn
ch (block) hoc ng chun trc a l (MLC). Hn na, nh c cc dng c lc nm
(wedge), cc khi b m (bolus) th phn b liu c ti u t c yu
cu ca bc s a ra.
Tuy nhin, k thut ny c mt vi hn ch nh sau:
- Gy hin tng chy da cho bnh nhn.
- Chi ph cho vic ct xp lm khun ch, c ch kh tn km v c hi,
nguyn him.
- Mt thi gian tho lp ph kin che chn cho bnh nhn vi tng trng
chiu: Khi ch che chn, lc nm.
- Vi nhng ca ung th phc tp, khi u c hnh dng phc tp v nm ngy
cnh cc c quan nguy cp cn bo v th vi k thut 3D-CRT kh c th
a ra c mt phn b liu ti u.
khc phc nhng hn ch trn, ngi ta c ra mt k thut x tr mi.
l k thut x tr iu bin cng (IMRT). Nhng chng tip theo, chng
ti s trnh by c th hn v k thut x tr iu bin cng v ng dng trong
lm sng.
29

CHNG 3
K THUT X TR IU BIN CNG JO-IMRT
Nhng tin b trong cng ngh my tnh lm tng kh nng qu t lp
k hoch phn b liu lng theo 2D cho n k thut phc tp hn, hin i hn
l phn b liu lng theo khng gian 3D, ph hp vi hnh dng khi u (3D-
CRT). Mt k thut mi, hin i ang pht trin l k thut iu bin cng
IMRT (intensity modulated radiation therapy) s lm ti u s phn b liu theo
hnh dng khi u khng u [2].
X tr iu bin cng IMRT l mt k thut hin i trong iu tr ung th,
liu x c phn b ti a theo hnh dng khi u ng thi liu c hn ch ti
thiu cc t chc lnh xung quanh. Nh vic ti u ho liu ti khi u v gim
thiu cc c quan lnh m k thut IMRT hn ch c bin chng do tia x ng
thi nng cao hiu qu iu tr. cc nc pht trin, i vi cc khi u gn cc c
quan nhy cm, khi u c hnh dng phc tp, k thut ny c thc hin mt cch
thng quy vi cc my gia tc tuyn tnh c ng chun trc a l (MLC). Vit
Nam, do iu kin kh hu nng m, vic dng my gia tc vi MLC gp rt nhiu
kh khn trong vn hnh, bo dng. Tuy nhin vi phn mm Prowess panther ca
M, k thut IMRT vn c th thc hin c vi my gia tc khng c MLC qua
h thng ng chun trc vi cc ngm (jaws) chuyn ng c lp. K thut ny
c thc hin qua vic ng thi chia cc trng chiu (beams) nhiu gc
khc nhau thnh nhiu phn on hnh ch nht (segments) vi cc trng s khc
nhau (weights) nhm ti u ho liu cao nht theo hnh dng khi u v liu cho
php gii hn t chc lnh. Nh vy, IMRT cng c th thc hin ti Vit Nam
trn my gia tc ch vi cc ngm chuyn ng c lp m khng c MLC. iu
ny c bit c ngha trong iu kin nc ta cn nhiu kh khn, vic trang b
cc my gia tc vi MLC rt tn km. Mt khc, kh hu Vit Nam nng m, vic
vn hnh v bo dng my gia tc vi MLC rt phc tp. Do vy, vic nghin cu
v ng dng trin khai k thut x tr JO-IMRT tht s c ngha c mt y t ln
kinh t.
30

3.1. Nguyn l ca k thut x tr iu bin cng IMRT
3.1.1. K thut x tr IMRT l g?
K thut x tr IMRT xut hin trong iu tr lm sng nh l kt qu ca s
pht trin k thut x tr thch ng ba chiu (3D-CRT) trong nhng nm 1980. n
nhng nm 1990, IMRT c tha nhn v ng dng ti M. V mt vt l, tnh
nng chung ca IMRT l c gng tng cng vic kim sot phn b liu ba chiu
thng qua s chng chp ca cc trng chiu nh c lp nhau trong mt hng
ca chm tia. Ni cch khc, trong k thut ny, cng chm tia chiu ra c
iu bin, khng ng nht (hnh 3.1).

Hnh 3.1: So snh phn b liu lng gia k hoch 3D (tri) v IMRT (phi)
Hnh 3.1 cho ta thy, liu bc x ti k hoch 3D phn b ng u trong khi
ti k hoch IMRT liu bc x phn b theo hnh dng v mt t bo u: Ch m,
ch nht khc nhau.
3.1.2. V sao IMRT li tt hn 3D-CRT ?
Nh cp chng 2, k thut x tr 3D-CRT gm cc hng chiu, mi
hng chiu c che chn sao cho trnh c c quan bo v v khng lm che
khut khi u. K thut x tr IMRT c pht trin t k thut 3D-CRT, k thut
ny c thm mt bc t do na l s iu bin cng chm tia lp k hoch
iu tr. Chnh v th, k thut ny to ra phn b liu tt hn (hnh 3.2).
31

Hnh 3.2 l nh CT ca bnh nhn c cc bc s xc nh th tch khi u
v cc c quan cn bo v nh ty sng, tuyn mang tai. Th tch khi u thng
c chiu x t pha trc v hai bn vo, ng ng liu bao trm khi u ng
thi bao trm c ty sng v tuyn mang tai (hnh 3.2). Do , cc c quan cn bo
v nhn mt liu tng ng vi liu m khi u nhn c. Nhng vi k thut
IMRT th vng liu cao bao kht theo hnh dng khi u v trnh c ty sng. K
thut 3D-CRT kh c th lm c iu ny.

Hnh 3.2: Phn b liu ca k thut x tr 3D-CRT v IMRT
3.1.3. Lm th no iu bin cng chm tia ?
K thut IMRT c tha nhn rng ri l c th thc hin trn nhng my
gia tc c ng chun trc a l, tuy nhin IMRT cng c kh nng thc hin vi
my gia tc c cc ngm chuyn ng c lp. Trong k thut ny, chm tia c
chia nh thnh nhiu chm tia n v, trng s ca cc chm tia n v c ti u
ha to nn bn phn b cng cho mi chm tia. T bn phn b
cng , my tnh s tnh ton thit lp chm tia thnh cc trng chiu lin
tip theo mt trnh t nht nh ca my gia tc da trn vic di chuyn v tr ca
cc l ngm. Kt qu l hng lot cc trng chiu nh c hnh dng bt k i vi
my c MLC hoc cc trng hnh vung, hnh ch nht i vi my ch s dng
jaws (hnh 3.3) c hnh thnh t mi hng ca chm tia c chng chp ln
nhau to ra cc m hnh liu lng (cng ) phc hp (hnh 3.4).
32


Hnh 3.3: Hnh dng chm tia c to ra bi MLC (tri) v Jaw (phi)

Hnh 3.4: Bn liu lng phc hp
S khc nhau gia MLC-IMRT v JO-IMRT l MLC-IMRT chia cc trng
chiu thnh cc phn on c hnh dng bt k, cn JO-IMRT chia cc trng chiu
ra cc phn on hnh ch nht hoc hnh vung, nhng vi nhiu hnh ch nht
khc nhau cng bm st c hnh dng khi u. Trong lun vn ny, chng ti
nghin cu v k thut x tr s dng cc l ngm chuyn ng c lp (jaws).
33

3.2. Bi ton lp k hoch ngc trong k thut x tr IMRT
3.2.1. Bi ton lp k hoch xui v lp k hoch ngc
3.2.1.1. Bi ton k hoch xui
Vi k thut x tr 3D-CRT, ta phi thc hin qua cc bc:
- Thit lp trng chiu.
- S dng cc thit b ph tr.
- Tnh ton liu lng.
- nh gi k hoch.
Khi tin hnh nh gi k hoch, nu k hoch p ng c cc yu cu ca
bc s a ra ban u th k hoch c chp nhn, qu trnh lp k hoch s kt
thc. Nu k hoch cha p ng c yu cu ca bc s, ngi lp k hoch s
tip tc lm li theo cc bc trn.

Hnh 3.5: Bi ton k hoch xui
V th, ta c th ni, vic lp k hoch 3D-CRT nh mt bi ton xui.
34

3.2.1.2. Bi ton k hoch ngc
a. nh ngha bi ton k hoch ngc
tng v bi ton ngc ln u tin c a ra bi Brahme nm 1988 khi
ng a ra cu hi: Bit trc phn b liu mc tiu, lm sao iu chnh cc thng
s t c phn b liu ?.

Hnh 3.6: Bi ton lp k hoch ngc
K hoch ngc s dng thut ton ti u ha trn my tnh, xc nh cc
thng s tt nht ca chm tia a ra gii php cng gn d liu ra mong mun
cng tt. V phng din ton hc, vic ti to nh, phc hi nh, x l tn hiu v
qun l danh mc c th c xem nh qu trnh gii quyt mt bi ton ngc.
Chng ta c th ni rng bi ton ngc c hiu nh mt bi ton c p n
nhng cha c li gii.
V mt l thuyt, hon ton c th to c mt k hoch iu tr sao cho
100% liu lng c chiu vo khi u v 0% liu c chiu vo phn khe mnh
k bn-tc l phn khe mnh bn cnh hon ton khng chu liu bng cch a
dn vo cc trng s cho cc trng chiu.
35

Tuy nhin, iu ny trn thc t l khng th lm c, khi chiu mt bc x
vo mt khi u, cc vng ln cn s phi chu mt liu chiu nht nh. Liu chiu
vo phn khe mnh bn cnh l t hay nhiu ph thuc vo hng chiu chm tia
cng nh cc k thut che chn m k thut vin s dng trong qu trnh lp k
hoch x tr. Nh vy vic dng bi ton ngc gii quyt bi ton a 100%
liu vo khi u v 0% liu vo phn khe mnh bn cnh l khng kh thi. Do
phng php thc hin a ra c mt phng n tt nht trong trng hp
ny chnh l mt qu trnh ti u ha m mc tiu ca n chnh l a ra c mt
k hoch iu tr gn ng nht so vi yu cu ban u ca cc k thut vin, da
trn mt s cc ty chn mang tnh tha thun v liu vo phn khi u v phn khe
mnh xung quanh. Nh vy bi ton ngc cng gn ging nh bi ton thun
trong vic s dng mt qu trnh lp i lp li nhm tm ra mt phng n l ti u
nht, tuy nhin bi ton ngc phc tp hn so vi bi ton thun, cc bc thc
hin ca bi ton ngc c thc hin mt cch t ng v c s h tr ca my
tnh nn qu trnh thc hin nhanh hn rt nhiu so vi bi ton thun.
b. Cc thng s, mc tiu qu trnh ti u ha trong bi ton ngc
Trong tng v bi ton ngc, cc thng s gm: S lng chm tia,
hng chiu chm tia, nng lng chm tia v cng chm tia cn c ti u
to c phn b liu lng nh yu cu t ra ban u. Trong bn thng s trn,
s lng chm tia, hng chiu v nng lng chm tia c a vo trc khi
thc hin bi ton. Vic la chn s lng v hng chiu, nng lng chm tia
hon ton da trn c s nhng hiu bit ca cc k s vt l x tr v cu trc sinh
hc cng nh yu cu liu lng ban u cho mi c quan. Thng s duy nht c
ti u ha trong bi ton ngc chnh l bn phn b cng ca mi chm tia
c s dng.
Vy c th ni, mc tiu ca bi ton ngc ny l ti u phn b cng
chm tia thng qua vic chng chp cc hnh dng trng chiu khc nhau trong
qu trnh di chuyn cc l ngm. Da trn mc tiu ca bi ton ngc, c th c
hai cch tip cn gii bi ton ny nh sau:
36

Cch 1: Ti u phn b cng chm tia da trn cc chm tia n
v (pencil beam hay beamlet). Chm tia n v l nhng chm tia nh
c chia ra t chm tia ban u.
Cch 2: Ti u phn b cng chm tia da trn hnh dng cc
trng chiu c chng cht ln nhau.
Phng php ti u ha da trn chm tia n v bao gm hai bc:
Bc 1: Chia nh chm tia thnh nhiu chm tia n v. Trong bc ny,
trng s ca cc chm tia n v c ti u ha to nn bn phn b cng
cho mi chm tia.

Hnh 3.7: Ngun c chia thnh nhiu chm tia n v
Bc 2: T bn phn b cng ca mi chm tia, my tnh s tnh ton
thit lp chm tia thnh cc trng chiu lin tip theo mt trnh t nht nh
ca my gia tc da trn vic di chuyn v tr ca cc l ngm.
Vi phng php ny, ta gp mt s hn ch nht nh. Th nht l t bn
phn b cng ca mi chm tia, ta s tin hnh m cc trng chiu lin tip
theo mt trnh t nht nh da trn s di chuyn ca l ngm, nhng rt kh sau
khi chng chp cc trng chiu nh ny, ta t c bn cng chm tia
ging ht nh mong mun ban u. mt chm tia c phn b cng cng
chnh xc nh trong bn cng , th s ln chiu lin tip ca hng chm tia
phi cng ln. Th hai, t bn phn b chm tia, vic m ra cc trng chiu
37

khng th trnh khi xut hin cc trng chiu c kch thc nh. Vic ny s nh
hng ti s chnh xc ca vic tnh ton trong qu trnh lp k hoch cng nh
vic o c trc khi bnh nhn iu tr, hay iu tr bnh nhn. Do , trong mt
s trng hp, mc d ta c th tnh ton c bn phn b cng rt ti u,
nhng thc t li khng th thit lp cc ln chiu sao cho t c bn phn b
cng chnh xc nh th.
Phng php ti u phn b cng chm tia da trn hnh dng cc
trng chiu c chng cht ln nhau.
Khc vi phng php trn, phng php ti u ha da trn hnh dng v
m ca cc trng chiu hay cn gi l phng php ti u ha trc tip m
(direct aperture optimazation-DAO) s tin hnh ti u ha trc tip v tr cc l
ngm v trng s ca m do l to ra trong mi mt bc.
3.2.2. Quy trnh v cc m hnh ti u ha trong k thut IMRT
3.2.2.1. Quy trnh ti u ha k thut IMRT
V c bn, qu trnh ti u ha c thc hin nh s hnh 3.8. Thng
thng, trc khi tin hnh ti u ha, s lng chm tia, hng chiu chm tia v
nng lng chm tia c chn trc, cc yu cu ca bc s ban u c s dng
cho vic tnh ton trong hm mc tiu, nhm tm ra phng n tt nht.
hiu r hn bi ton, ta gi s c k hoch IMRT dng su chm tia. Nu
mi chm tia c chia thnh 100 chm tia n v v mi chm tia n v c 10
mc cng cho php s c 10
6
100 k hoch kh thi (nhiu hn rt nhiu so vi
k hoch 3D-CRT 6 chm tia).
i vi mt liu mong mun D
0
cho, nhim v ca k hoch ngc l tm
ra mt liu D trong tp cc liu kh thi (D) ging hoc sai khc t nht so vi D
0
. C
nhiu cch chn liu D. Mt cch tip cn thng c s dng ti u ha k
hoch l cc tiu ha sai khc gia D v D
0
theo mt hm bc 2.
Trong cc ng dng iu tr, ngi ta thng a ra mt h s quan trng r

kim sot tm quan trng tng i ca cu trc . iu ny c th hin qua
phng trnh bc 2.
38

( ) ( )
2
c 0
n
1
F r D n D n
N
o
( =

(3.1)
Trong , r

l h s quan trng hay trng s quan trng ca cu trc , D

0
v
D
c
ln lt l liu ch nh v liu tnh ton. Vic ti u ha hm ny v bn cht l
mt php phn tch thng k bng phng php bnh phng ti thiu. Ngoi cng
thc (3.1), nhiu hm ti u khc cng c xut.
Hnh 3.8: Quy trnh ti u ha trong k thut IMRT
Vic xy dng cc hm ti u c vai tr rt quan trng i vi s thnh cng
ca iu tr IMRT v vic la chn phng n cui cng ph thuc vo c s l
thuyt ca m hnh. Mt hm c a ra nh gi mc ti u ca k hoch
v khi ti u ho hm ny ta s thu c cc thng s ti u. Trong vic lp k
hoch iu tr thng thng, hm ny ph thuc vo trng s chm tia, gc ca lc
nm, hng chm tia. Trong khi , IMRT l mt hm ca trng s cc chm tia
n v hoc l hm ca trng s cc hnh dng trng chiu ca tng chm tia.
Thit lp hng chiu v
nng lng cc chm tia
Xc nh cc tiu ch cn
t c
Cc bin khi to
iu chnh cc bin
Hm ti u
Dng ti u
Kt thc
Khng
C
39

thun tin, ngi ta chia cc phng php ti u ho thnh bn loi:
- Ti u ha theo liu.
- Ti u ha theo nhng hiu bit lm sng.
- Ti u ha theo liu ng nht tng ng (EUD).
- Ti u ha theo xc sut kim sot khi u hoc xc sut bin chng m lnh.
S khc bit c bn gia cc m hnh ny l cc i lng dng nh gi
k hoch ti u. Thc ra, mi m hnh k hoch ngc u c nhng u v khuyt
im ring.
3.2.2.2. Cc m hnh ti u ha
a. M hnh ti u ha theo liu
M hnh ti u ho theo liu lin quan n s phn b liu chnh xc hoc cc
bn liu lng-th tch (DVH) ca cc cu trc lin quan. Hm bc 2 trong
phng trnh (3.1) l mt v d ca m hnh ny. Hin nay phng php tip cn
da trn liu l phng php c s dng rng ri nht.
b. M hnh ti ha da trn hiu bit lm sng
Ngi ta mong mun a cc bin chng lm sng vo quy trnh ti u ha k
hoch iu tr. M hnh nh gi theo liu khng thc s phn nh ng n mi
quan h phi tuyn gia liu v phn ng ca khi u cng nh cc m bnh thng.
Trong thc t, s ph thuc ca cc bin chng lm sng vo liu ca mt cu trc
c th b suy bin theo ngha l mt bin chng lm sng c th c gy ra bi
mt lot cc bng phn phi liu hoc DVH. V d cc tuyn mang tai, bin chng
lm sng l nh nhau nu 15 Gy c gi n 67% th tch, 30 Gy cho 45% th tch,
hoc nu 45 Gy cho 24% th tch. Nu m hnh ti u ha theo liu c s dng
trong trng hp ny, kt qu cho ba k hoch khc nhau s khc nhau. khc
phc iu ny, ti u ho da trn lm sng gn y c pht trin bi Yang v
Xing [10]. Ni dung chnh ca phng php l d liu lm sng c s dng vo
vic ch nh qu trnh ti u ha. Trong phng php ny, cht lng mt k
hoch iu tr c o bng mt hm c xy dng t thc nghim, hm ny
khng ch ph thuc vo cc c tnh liu lng m cn vo c tnh liu lng-th
40

tch. i vi cc tuyn mang tai, v d: Ba DVH khc nhau c cp trn s
c ghi bi cng mt hm. Vic phn liu cui cng hoc DVHs ca cc tuyn s
c xc nh bng thut ton ti u vi vic xem xt cc yu cu i vi cc cu
trc khc. Nu mt trong ba cn phi c chn, ci to c s ghi nhn tt hn
cho cc cu trc lin quan s c u tin.
c. M hnh da trn liu ng nht tng ng EUD
Ti u ha ca phn b liu cng c th da trn EUD vi vic s dng h s
sinh hc. EUD l liu tng ng sinh hc (nhng phn b liu khc nhau nhng
gy ra cng 1 hiu ng sinh hc).

1
a
a
i
i
1
EUD D
N
| |
=
|
\ .

(3.2)
N l s voxels trong cu trc quan tm,
a
i
D l liu trong voxel th i, a l tham
s c trng cho khi u hoc cc m lnh.
Hm nh gi da trn EUD nh sau:

j
j
F f =
[
(3.3)
Trong , f
j
c th l:
+ Cho khi u:
T n
0
1
f
EUD
1
EUD
=
| |
+
|
\ .
(3.4)
+ Cho cc m lnh:
T n
0
1
f
EUD
1
EUD
=
| |
+
|
\ .
(3.5)
u im ca phng php ny l nhng cng thc rt n gin, cc cng thc
c th c p dng cho c hai t chc cn quan tm: Khi u v c quan nguy cp
(OAR), c t cc thng s hn so vi ti u da trn liu lng hoc cc h s sinh
hc. Kt qu ghi nhn cho thy vi vic ti u ha da trn EUD khi u c bao
tt hn v bo v tt hn cho c quan nguy cp.
41

d. M hnh sinh hc
M hnh ny c tnh n hiu ng sinh hc ca bc x i vi t bo. Hiu
ng sinh hc v cc thng s bc x c lin kt bi liu bc x thng qua vic s
dng hm p ng liu. Tuy nhin, mi quan h gia liu-bin chng khng n
thun l s tng quan 1-1. Cng mt bin chng sinh hc c th c to ra bi
nhiu s phn b liu, m thng s khng c ghi nhn nh nhau nu s dng
m hnh nh gi da trn liu lng. V nguyn tc, m hnh da trn c tnh
sinh hc thch hp nht cho vic nh gi mt k hoch x tr. Tuy nhin, hm p
ng liu ca cc cu trc khc nhau cha hon ton tha ng, c nhiu tranh ci
v cc m hnh cho vic tnh ton da trn ch s liu-phn ng cng nh vic s
dng chng trong ti u ha.
Mc tiu iu tr trong lp k hoch ngc da trn m hnh sinh hc thng
c xem nh l vic cc i ha xc sut kim sot khi u (TCP) trong khi gi xc
sut bin chng m lnh (NTCP) t mt mc liu chp nhn c. Nhng iu
kin vt l v liu v th tch liu thng c a ra m bo rng cc kt qu
t c ph hp vi chn on lm sng ca bc s.
3.3. M hnh ti u ha theo liu
Hm mc tiu trong m hnh ti u ha theo liu l mt cng thc ton hc,
n i din cho ch s nh gi mt k hoch a ra c gn ging vi yu cu ca
bc s hay khng, khi gi tr hm mc tiu cng nh tc l ta ang i ti mt k
hoch gn ng vi yu cu ca bc s. Trong qu trnh thc hin ti u ha, my
tnh lp li mt s ln tm ra phng n tt nht c th cho ti khi cc tiu ch
dng qu trnh lp c tha mn. Vic hiu chnh cc thng s trong qu trnh ti
u ha c t ng tnh ton da trn cc thut ton ti u ha khc nhau. iu
kin dng c xc nh khi s ln lp vt qu gii hn c ch nh ban u
hoc khng c ci tin ng k no c tm thy trong hm mc tiu. Khi qu trnh
ti u ha kt thc, k s lp k hoch nh gi k hoch ging nh trong bi ton
thun, h c th thay i mt s cc thng s ci thin cht lng ca k hoch
nu phn b liu l khng chp nhn c sau qu trnh ti u ha. Vic thay i
42

cc thng s ny bao gm iu chnh cc iu kin trong qu trnh ti u ha, v
hm mc tiu, thay i hng chiu chm tia, chnh sa li ng khoanh vng ca
khi u v vng bo v. Mt s h thng lp k hoch iu tr cho php dng qu
trnh ti u ha iu chnh cc iu kin lin quan ti hm mc tiu trong qu
trnh ti u, v khi ng li qu trnh ti u ngay lp tc bi v khi ma trn v
liu phn b cho cc chm tia n v khng phi tnh ton li. Nu thay i v
hng chiu chm tia th cn phi c mt qu trnh ti u ha mi, bi v lc ny
hng chiu thay i lm cho ma trn phn b liu ca cc chm tia n v b
thay i v phi tnh ton li. Vic hiu chnh cc thng s tip theo ph thuc
nhiu vo trnh hiu bit ca ngi lp k hoch v k thut s dng ca bi ton
ngc ny. H cn phi hiu r v mi quan h khi iu chnh cc thng s ti kt
qu phn b liu lng khi s dng bi ton ngc hiu chnh cc thng s mt
cch hp l nht.
3.3.1. Hm mc tiu
3.3.1.1. Cng thc ton hc
Bi ton ngc trong x tr chnh l mt qu trnh ti u ha tm ra mt
phn b liu tt nht cho bnh nhn trong qu trnh iu tr.
Trong m hnh bi ton ngc ti u ha theo liu, thng s ti u ha
chnh l trng s ca cc chm tia n v v bn cng bc x ca mi chm
tia. N tng ng vi vic tm gi tr nh nht ca hm s f(x) trong x l
vector trng s ca chm tia n v.
( )
x 0
min f x
>
}
(3.6)
f(x) chnh l mt hm s i din cho cht lng ca k hoch thu c, v n
c gi l objective function hay hm mc tiu. Hm mc tiu c xy dng
da trn phn b liu lng ban u v c s dng so snh gia cc k hoch
iu tr vi nhau, nhm tm ra mt k hoch tt nht. iu kin x > 0 l v my gia
tc khng th pht ra mt liu lng m, hay ni cch khc bnh nhn khng th
nhn c mt liu lng m.
43

Trong x tr nh CT c chp khi bnh nhn ti iu tr, v c s dng
chnh hnh dung v gii phu cc c ca bnh nhn v c s dng tnh ton
liu trong qu trnh tnh ton liu phn b cho bnh nhn. Thng tin v mt
electron trn nh CT c dng tnh ton liu trong c tnh ti s khng ng
u v vt cht ca cc m. Thm vo ngi ta c th s dng kt hp nh CT
vi cc loi nh nh MRI, SPET, SPECT tng tnh chnh xc khi khoanh vng
khi u v cc b phn khe mnh khc. Tp cc ta ca bnh nhn trong qu
trnh chp nh CT c a vo h thng lp k hoch x tr (TPS) t xy dng
nn m hnh 3D ca bnh nhn. tnh ton liu lng, TPS chia nh bnh nhn
thnh nhiu hnh khi lp phng nh gi l voxel.

Hnh 3.9: Chm tia v c th bnh nhn c chia thnh nhiu phn nh
S lng cc voxel trong mt c quan c th ph thuc vo kch thc c
quan v kch thc ca voxel. Trong thut ton ny, cc voxel c nh cc ch
s i=0, 1, 2, n. Bn phn b cng ca mi chm tia c chia thnh cc
hnh ch nht hoc hnh vung nh gi l im nh (pixel) vi ch s l j=0, 1,
2, m. Cc pixel i din cho mt ct ca cc chm tia n v vi mt phng i
qua im cch trc chnh ca chm tia 100 cm v vung gc vi trc chnh ca
chm tia (isocenter plane). S lng cc pixel ph thuc vo kch thc ca cc c
quan v s lng chm tia c s dng.
44

Gi
ij
A l liu nhn c ca mt voxels th i t mt chm tia n v c trng
s
j
w . Khi tng liu nhn c ca voxels i c tnh bng tng liu lng ca
cc chm tia n v vi cc trng s tng ng chiu ti n.
m
i ij j
j 1
D A w
=
=

(3.7)
y
j
w chnh l h s ca bn phn b cng tng ng vi chm tia
n v th j.
Nu s dng ma trn v vector th s phn b liu cho mt vng c quan
tm c tnh: D Aw = . Trong m hnh ti u theo liu, hm mc tiu l mt hm
ca phn b liu thc s D v phn b liu mong mun D
0
c ngi lp k hoch
a vo da theo yu cu ca bc s.
0
OF = f(D, D ) (3.8)
Khi cng thc (3.6) c vit li nh sau:
min f(Aw, D
0
) (3.9)
Kch thc khng gian ti u ca bi ton (3.9) ph thuc vo s lng voxel
ly ban u v s lng hoc kch thc ca chm tia n v.
3.3.1.2. C s xy dng hm mc tiu
V mt ton hc, mc tiu ca qu trnh ti u ha theo liu l tm gi tr nh
nht ca hm mc tiu. V vy, vic a ra mt cng thc ton hc dng so snh,
nh gi cc k hoch vi nhau l rt quan trng. Mt k hoch iu tr thng
c nh gi bng vic so snh ng DVH hoc ng ng liu (isodose line).
Hm mc tiu nn bao gm c hai cch trn c th so snh, nh gi cc k
hoch vi nhau mt cch chnh xc nht. Tuy nhin mt s yu cu chng hn nh
s phn b ng ng liu lin quan n cc cu trc gii phu ca bnh nhn nn
rt kh so snh mt cch nh lng. V vy ngi ta a vo cc ch tiu liu-th
tch v liu ng nht tng ng (EUD) thay th.
Vic lp hm mc tiu ph thuc vo cc tiu ch nh gi k hoch thng
c s dng. Cc tiu ch khc nhau s yu cu nhng hnh thc khc nhau ca
45

hm mc tiu. Vic xy dng hm mc tiu c th chia thnh hai loi da trn bn
cht ca cc tiu chun:
- Xy dng hm mc tiu da trn c s vt l, bao gm mc tiu v liu lng.
- Xy dng hm mc tiu da trn c s sinh hc.
Trong phn tip theo, chng ti s trnh by r hn v s khc nhau gia tiu
chun sinh hc v vt l, v hm mc tiu c xy dng da vo chng nh th
no? Trong hm mc tiu, cc tiu chun ny c th l cc iu kin hay cc mc
tiu c th. Trong thc t chng c thit lp da trn vic thit lp mc u
tin ca cc mc tiu.
3.3.2. Mc tiu v liu lng
Mt tiu chun quan trng cho mt k hoch x tr l s phn b liu cho khi
u. V d, theo khuyn co ca ICRU, liu vo khi u phi nm trong khong 95%
ti 107% tng liu ch nh. Vi cc c quan khc nhau th gii hn khong liu ny
cng khc nhau. Khi lp k hoch cho bnh nhn cn phi t c cc yu cu ny.
V vy ton b cc im bn trong th tch c chiu nhn c liu chiu
ln hn hay nh hn khong gi tr qui nh th u b a vo tnh ti cht
lng ca k hoch x tr khi dng so snh vi cc k hoch khc thng qua
cng thc sau.
T
N
2
T i
i 1
OF (D D)
=
=

(3.10)
Trong (D
i
-D)
2
dng tnh ton s sai khc gia liu nhn c v liu
c yu cu ban u ti im th i trong vng quan tm. Trong thc t khng th
c c mt phn b liu m trn mi im u nhn c liu lng nh ch
nh ban u, gi tr nh nht v ln nht thng c dng thay th cho phn
b liu ca mt b phn ang c quan tm, tc l phn b liu by gi khng th
c ch ra bng ch mt gi tr m n s nm trong mt khong gi tr t gi tr nh
nht ti gi tr ln nht. Ton b cc im trong vng ang quan tm, nu gi tr
liu lng ca n nh hn gi tr D
min
s b a vo tnh ton s sai khc. Tng t
nh vy ton b cc im trong vng quan tm c liu ln hn gi tr D
max
cng b
46

a vo tnh gi tr cho s sai khc so vi gi tr ch nh ban u. Khi hm mc
tiu cho khi u c tnh ton nh sau:
T
N
2 2
T i min min i i max i max
i=1
1
OF = u(D -D ) .H(D -D )+w(D -D ) .H(D -D )
N

(3.11)
Trong : - H l hm bc nhy: {
1 if x>0
0 if x 0
H(x)
s
=

- u v w l cc trng s tng ng vi trng hp liu nh hn D
min

v liu ln hn D
max
.
- D
i
l liu nhn c ti voxels th i.

Hnh 3.10: t iu kin cho bi ton ngc
Hnh 3.10 l biu din hm mc tiu v liu lng trong phn mm Prowess
panther cho cc th tch cn chiu x v cc c quan cn bo v. V d, liu ch nh
l 70 Gy th mc tiu v liu lng bt buc ngi lp k hoch phi t liu ti
thiu 95% tng liu ch nh v khng vt qu 107%. Tc l khng c di
66,50 Gy v khng c vt qu 74,90 Gy.
47

Vi cc vng cu trc cn bo v, ch nhng im nm trong vng c quan
cn bo v nhn liu ln hn gii hn liu cho php D
OAR
c a vo tnh ton
s sai khc. Do , hm mc tiu cho cc phn cn bo v xung quanh nh sau:
OAR
N
2
OAR i OAR i OAR
i 1
OAR
1
OF (D -D ) .H(D D )
N
=
=

(3.12)
Trong D
OAR
l phn liu gii hn c ch nh cho phn th tch cn bo
v ang xt.
3.3.3. Mc tiu liu lng-th tch
Vi cc c quan ni tip nh ty sng th hm mc tiu da trn liu lng-
th tch c p dng i vi gi tr liu ti a. i vi cc c quan song song nh
gan, phi, thn, cc tiu chun v liu ti a trn n t quan trng hn so vi cc
c quan ni tip. V d 1/3 th tch phi c th nhn liu nhiu nht l 45 cGy, 2/3
th tch nhn liu nhiu nht l 30 cGy, v ton b th tch phi ch c th nhn liu
nhiu nht l 17,5 cGy. Vi mc tiu liu-th tch, ngi dng t do hn trong vic
a ra cc tiu ch ca mnh cho k hoch x tr mong mun. Cc tiu ch v liu ti
thiu v liu ti a c th d dng nh ngha bng vic s dng tiu chun liu-th
tch. V d, trong trng hp liu ti a l X Gy, ta c th nh ngha da trn mc
tiu liu th tch l: 0% th tch nhn liu X Gy. Hoc liu ti thiu l Y Gy, s
c nh ngha l 100% th tch nhn liu Y Gy. Trong thc t, tiu chun liu-th
tch chim mt s lng ln s tiu chun hu ch cho cc yu cu khi lp k hoch.
Mc tiu liu-th tch ca cc th tch cn bo v thng c nh ngha l
V(D>D
1
) < V
1
: Tc l th tch V nhn c liu D ln hn D
1
phi nh hn th tch
V
1
. T th DVH biu din phn b liu lng theo th tch nh hnh 3.11-a bn
di ta c D
2
l liu trung bnh m th tch V
1
nhn c: D
2
= D(V
1
), tc l D
2
l
liu lng c xc nh thng qua hm D(V
1
). Nu D
2
<D
1
th iu kin ca chng
ta c tha mn. Nu D
2
>D
1
th ton b nhng im c D
2
>D
1
s c a vo
tnh ton s sai khc so vi yu cu v liu lng ban u. Cng thc ton hc ca
hm mc tiu cho s sai khc ny c tnh nh sau:
48

OAR
N
2
OAR i 1 i 1 2 1
i 1
OAR
1
OF (D -D ) .H(D D ).H(D D )
N
=
=

(3.13)
Ngc li, mc tiu liu-th tch cho phn khi u thng c nh ngha nh
sau: V(D>D
1
)>V
1
: Tc l th tch V nhn c liu D ln hn D
1
phi ln hn th
tch V
1
(hnh 3.11-b). Hm mc tiu cho trng hp ny c nh ngha nh sau:
T
N
2
T i 1 1 i i 2
i 1
T
1
OF (D -D ) .H(D D ).H(D D )
N
=
=

(3.14)

Hnh 3.11: th mc tiu liu-th tch
3.3.4. Mc tiu v EUD
Niemierko (1997) nh ngha liu ng nht tng ng EUD ca mt
phn b liu trong khi u l liu ng nht vo khi u cn thit tiu dit cng
mt s lng t bo trong khi u.
Hai nm sau, Niemierko (1999) m rng khi nim EUD p dng cho
cc c quan cn bo v. Mt cch tng qut, EUD l mt hm n gin ca phn b
liu vt l, c kh nng c s dng trong vic nh gi s phn b liu khng
ng nht trong x tr 3D-CRT hoc IMRT.
Ta c cng thc ca EUD nh sau:
1
a
a
i
i 1
1
EUD D
N
=
| |
=
|
\ .

(3.15)
49

Trong , D
i
l liu lng ti voxels th i. N l s lng cc voxels trong vng
cu trc gii phu ang quan tm. ngha ca a l khi u hoc l m lnh bnh
thng, v n c xc nh bng thc nghim thng qua s so snh k hoch iu
tr vi kt qu lm sng. Thng thng, gi tr ca a l dng i vi cc vng m
bnh thng v cc t chc cn bo v. Gi tr ca a l m i vi khi u.
T phng trnh (3.15), ta c th thy.
- Nu a = 1, EUD tr thnh liu trung bnh.
- Nu a = , EUD tr thnh liu cc i.
- Nu a = -, EUD tr thnh liu cc tiu.
Wu (2002) v cc cng s xut cng thc hm mc tiu da trn EUD
nh sau [8].
T n
0
1
OF ln
EUD
1
EUD
| |
|
|
=
|
| |
+
|
|
\ .
\ .

(3.16)
OAR n
0
1
OF ln
EUD
1
EUD
| |
|
|
=
|
| |
|
+
|
|
\ .
\ .

(3.17)
Trong , EUD
0
l gii hn liu mong mun nu liu a ra l khng ng
nht. Vi vng khi u, EUD phi ln hn gi tr EUD
0
c xc nh trc, gi tr
ny ph thuc vo bn cht ca t bo ung th trong khi u. Do , hm mc tiu s
gn tin v gi tr 0 khi gi tr ca EUD
0
/ EUD nh hn 1 v mc tiu EUD l m
bo an ton. Mt k hoch vi EUD
0
/ EUD ln hn 1 s c a vo tnh s sai
khc theo phng trnh (3.16) v mc tiu EUD b vi phm. Ngc li, i vi
cc vng cn bo v, EUD c yu cu nh hn so vi mt gi tr EUD
0
xc nh
trc ph thuc vo c quan cn bo v. Do , k hoch s a vo tnh ton s
sai khc nh phng trnh (3.17) trong trng hp EUD
0
< EUD.
50

3.3.5. H s quan trng (importance factor)
Mc ch ca qu trnh ti u ha trong lp k hoch x tr l thu c s cn
i gia khi u v vng cn bo v. Do , hm mc tiu cui cng thng l s
kt hp ca cc hm mc tiu ring r cho tng c quan. Cch kt hp hm mc
tiu ph bin nht t cc c quan khc nhau l da trn h s quan trng ca c
quan , hay cn gi l trng s ca c quan .
N M
n m
n T m OAR
n=1 m=1
OF= w .OF w .OF +


(3.18)
Tuy nhin, mt c quan c th c nhiu iu kin, khi , cng thc trn c
vit li nh sau:
N I M J
ni mj
ni T mj OAR
n=1 i=1 m 1 j=1
OF= w .OF w .OF
=
| |
| |
+
|
|
\ .
\ .


(3.19)
Trong :
-
n
T
OF v
m
OAR
OF l cc hm mc tiu tng ng cho khi u th n v c quan
cn bo v th m.
-
ni
w ,
mj
w ln lt l trng s ca yu cu th i i vi th tch khi u th n,
v yu cu th j ca th tch cn bo v th m.
Vic a ra cc trng s ny gip ngi lp k hoch c th chnh sa k
hoch ci thin cht lng t c. Nhng mc tiu no yu cu cn phi t
c ln, th trng s a ra cho mc tiu cng ln. Nhng mc tiu t quan
trng hn s c trng s thp hn. Nu k hoch khng c chp nhn sau qu
trnh ti u ha IMRT, ta c th thay i li trng s hoc cc mc tiu t c
k hoch mong mun [8].
3.4. Thut ton ti u ha trc tip m (DAO)
Trong bi ton ngc c trnh by trn, cc chm tia c chia nh
thnh nhiu chm tia n v, liu lng tng ng ca cc chm tia n v ny
c tnh ton trc khi qu trnh ti u ha din ra. Trong qu trnh ti u ha, cc
k hoch khc nhau c to ra trong qu trnh di chuyn cc l ngm, cht lng
ca tng k hoch thu c s c lu gi li da trn cc yu cu ch nh ban
51

u. Sau khi kt thc qu trnh ti u ha, da vo v tr cc l ngm di chuyn
trong qu trnh ti u ha, n to nn mt bn phn b cng chm tia. V tr
ca cc l ngm tng ng vi cc ln m trng chiu lin tip ca ngm v c
gi l tng phn on trng chiu (segment) [3].

Hnh 3.12: Quy trnh thut ton DAO
Thut ton DAO l thut ton m t chi tit cch thc di chuyn ca cc l
ngm trong sut qu trnh ti u ha. ng thi, thut ton ny s la chn kt qu
ti u nht thng qua vic nh gi hm mc tiu. K hoch no c gi tr hm mc
tiu thp nht s c chn.
Thut ton DAO c trin khai da trn cc thng s u vo ca bi ton
ngc. N yu cu ba thng s u vo: S lng chm tia, nng lng chm tia v
hng chiu cc chm tia. Ba thng s ny s c ngi lp k hoch thit lp
trc tin ph thuc vo kinh nghim v s hiu bit lm sng. Hnh 3.12 m t
tin trnh ca thut ton DAO. Ban u cc l ngm c m ra sao cho n m kht
vi hnh dng khi u, qu trnh ti u s c bt u bng vic tnh ton hm mc
tiu t v tr ban u ca cc l ngm [8].
Trng chiu
khi to
Thay i hnh dng
trng chiu

khi to
Tnh ton liu
Hm mc tiu
Dng qu trnh
ti u

khi to
Kt thc
Khng
C
52


Hnh 3.13: Bc u tin trong qu trnh ti u
Sau thut ton s duyt qua tt c cc gi tr ca cc bin ca n, cc bin
y gm: m ca trng chiu v trng s ca m . Trng s ca mt
trng chiu y c th hiu l thi gian hay s ln m ca trng chiu .
Trong qu trnh ti u ha, cc l ngm c chn v di chuyn mt cch ngu
nhin, t to nn cc hnh dng trng chiu khc nhau. Cc l ngm c
la chn di chuyn ngu nhin theo hm phn b Gaussian, cn khong cch mi
ln di chuyn ca l ngm c la chn c xc nh theo cng thc:
( )
step
succ 0
n / T
1 A 1 e

o = +

(3.20)
y, A l m ca trng chiu ti thi im bt u ti u ha, n
succ
l s
ln di chuyn ngm to ra c k hoch c gi tr hm mc tiu nh hn gi tr
nh nht hin thi ca n (tc l to c ra k hoch tt hn),
step
0
T phn nh s cho
php di chuyn l ngm mt khong nhiu hay t, khi qu trnh ti u cng gn ti
gi tr ti u th gi tr
step
0
T ny cng nh. Khi n
succ
th 1. trnh trng
hp cc phn on trng chiu c kch thc qu nh, ngi ta thng chn gii
53

hn ti thiu cho m ca cc phn on trng chiu trc khi tin hnh ti u
ha. Do , sau khi tnh ton c khong dch chuyn ngu nhin ca l ngm bt
k no , thut ton s tnh c kch thc ca segement sau khi dch chuyn v
so snh vi m ti thiu cho php (v d 3x3 cm
2
). Nu m ca phn on
trng chiu nh hn m ti thiu, th thut ton s t ng la chn ngu
nhin li mt l ngm bt k, v tnh ton dch chuyn ngu nhin cho l ngm
. Nu m ca phn on trng chiu ln hn hoc bng m ti thiu
cho php, th thut ton s chuyn sang bc tip theo l tnh gi tr hm mc tiu.
Sau khi di chuyn v tr l ngm, hm mc tiu OF c tnh ton li, v tr l
ngm va di chuyn ti c chp nhn nu nh gi tr hm mc tiu OF l gim
dn. Ngc li, nu gi tr hm mc tiu khng gim th v tr mi ca l ngm
c chp nhn vi xc sut P c tnh theo cng thc sau:
prob
0
1/ T
succ
1
P B
(n 1)
=
+

(3.21)
y B l xc sut ti thi im bt u ti u ha, n
succ
v T
0
pro
c ngha
ging vi cng thc tnh khong di chuyn ca l ngm bn trn. Khi n
succ
th
P0.

Hnh 3.14: Cc tiu a phng v cc tiu ton cc

54

Vic chp nhn v tr ca l ngm vi xc sut P nhm mc ch vt qua
c cc trng hp m hm mc tiu ang t trng thi cc tiu a phng (min
local) hi vng tm c gi tr cc tiu ton cc (min global) trong cc ln di
chuyn v tr l ngm tip theo (hnh 3.14).
Kt thc qu trnh ti u ha, chng ta thu c k hoch m gi tr hm mc
tiu l nh nht, hay ni cch khc, k hoch thu c l k hoch c biu phn
b liu lng gn ging nht so vi yu cu t ra ban u. Khi bn phn b
cng chm tia cng c ti u v n c to thnh nh vic chng chp cc
trng chiu lin tip vi m khc nhau c to ra trong qu trnh ti u ha
(hnh 3.15).

Hnh 3.15: Cc phn on trng chiu (segment) v bn cng
55

CHNG 4
NG DNG K THUT X TR JO-IMRT V KT QU O
THC NGHIM TI BNH VIN A KHOA NG NAI
Trong chng ny, chng ti tin hnh lp k hoch x tr trn phn mm
Prowess panther cho bnh nhn bng k thut x tr JO-IMRT so snh vi k
thut x tr 3D-CRT. Da trn kt qu thu c, chng ti thy rng k thut x tr
JO-IMRT cho kt qu tt hn hn so vi k thut x tr thng thng (3D-CRT).
ng thi, chng ti cng tin hnh o thc nghim ti khoa Y hc Ht nhn, bnh
vin a khoa ng Nai nh gi sai s gia liu tnh ton c da trn phn
mm Prowess panther vi liu o thc nghim thu c cho cc k hoch x tr
c thit lp bng phng php JO-IMRT. Nu kt qu thu c c sai s nh hn
5% l chp nhn c, nu kt qu sai s ln hn 5% l khng chp nhn c
(theo tiu chun ca IAEA).
4.1. Trang thit b cn thit trin khai k thut x tr JO-IMRT
c th trin khai k thut x tr iu bin cng ch bng cc ngm
chuyn ng (JO-IMRT) cn phi c cc trang thit b sau :
- My gia tc x tr vi h thng cc ngm c lp (independent jaws).
- My m phng ct lp (CT-SIM).
- H thng phn mm lp k hoch thc hin c JO-IMRT.
- H thng thit b dng kim tra cht lng k hoch iu tr (QA):
Phantom, my o liu, u d, ...
4.2. Quy trnh k thut x tr iu bin cng (JO-IMRT)
Bc u tin trong quy trnh k thut IMRT l vic s dng cc dng c
c nh bnh nhn. Vic nh v v c nh bnh nhn ngy cng quan trng v v tr
v t th ca bnh nhn lin quan n s chnh lch liu lng ngay trong th tch
khi u v gia th tch khi u vi cc t chc nguy cp lin k.
Bc tip theo l chp CT m phng vi phng tin c nh, sau chuyn
ton b hnh nh CT m phng vo my tnh lp k hoch x tr (hnh 4.1).
56


Hnh 4.1: Quy trnh k thut x tr JO-IMRT
4.2.1. Lp k hoch x tr JO-IMRT vi phn mm Prowess panther
Nm 2006, John Nguyen, nh pht minh ngi M gc Vit, a ra k
thut IMRT c th thc hin c vi my gia tc khng c MLC bng vic s
dng h thng cc ngm chuyn ng c lp, chnh l k thut JO-IMRT. Pht
minh ny c cp bng sng ch ti M vo nm 2006 [6].
Cng ging nh lp k hoch x tr thng thng, u phi qua cc bc nh:
Xc nh th tch khi u (bia): GTV, CTV, PTV, v th tch cc c quan cn c
bo v, cng vi s hiu bit r rng v liu ch nh cho khi u v liu gii hn
chu ng cho php i vi cc c quan. im khc nhau gia lp k hoch x tr
thng thng v lp k hoch IMRT th hin ch thit lp trng chiu v qu
trnh ti u ha k hoch. Tu tng v tr khi u so vi cc c quan cn c bo v,
xc nh s trng chiu vi cc gc chiu khc nhau, mi trng chiu c th t 5-
9 phn on trng chiu (segments). V d: Vi ung th vm, chng ti s dng 7
trng chiu: 72
0
, 100
0
, 155
0
, 180
0
, 210
0
, 265
0
, 300
0
. Mi trng chiu chia lm 7
C nh bnh nhn
Chp CT m phng
Lp k hoch JO-IMRT
o liu kim tra (QA)
Tin hnh iu tr
57

phn on trng chiu. Vy tng cng c 49 phn on trng chiu trong mt k
hoch IMRT cho trng hp ny. Vi my gia tc ca chng ti, c th s dng
c 2 mc nng lng 6 MV v 15 MV khi lm IMRT.

Hnh 4.2: Cc trng chiu: 72
0
, 100
0
, 155
0
, 180
0
, 210
0
, 265
0
, 300
0

Sau khi chn hng chiu, mc nng lng, s phn on trng chiu, tng
liu, s ngy iu tr, ...my tnh s tin hnh ti u ha k hoch IMRT da trn
cc iu kin t vo cho khi u v cc c quan cn bo v.
Nh cp chng 3, chng ta c cc hm mc tiu v liu lng, mc
tiu v liu-th tch, mc tiu v liu ng nht tng ng. th biu din cc
hm mc tiu ny c th hin trong phn mm Prowess panther hnh 4.3.
Mc tiu v liu lng gm: Points less than, Points greater than (cc ng
thng ng trong hnh 4.3) .
Hm mc tiu Points less than dng hn ch nhng im c liu lng
nh hn mt gi tr D cho trc. Khi , nhng im c liu nh hn D s c
a vo tnh ton s sai khc trong hm mc tiu.
Hm mc tiu Points greater than dng hn ch nhng im c liu
lng ln hn mt gi tr D cho trc. Khi , nhng im c liu ln hn D s
c a vo tnh ton s sai khc trong hm mc tiu.
58

Mc tiu v liu-th tch gm: DVH below, DVH above (biu tng hnh trn c
hai mi tn trong hnh 4.3).
Hm mc tiu DVH above dng a ra iu kin l th tch V nhn liu
D > D
1
phi nh hn th tch V
1
cho trc. Nu trong vng th tch V, c im no
c liu D > D
1
th s c a vo tnh ton s sai khc trong hm mc tiu.
Hm mc tiu DVH below dng a ra iu kin l th tch V nhn liu
D > D
1
phi ln hn th tch V
1
cho trc. Nu trong vng th tch V, c im no
c liu D < D
1
th s c a vo tnh ton s sai khc trong hm mc tiu.

Hnh 4.3: Biu din cc hm mc tiu trong phn mm Prowess panther
Mc tiu v liu ng nht tng ng EUD.
-EUD less than.
-EUD greater than.
59

Phn mm Prowwess panther vi thut ton DAO s tin hnh hng chc
nghn php th vi cc thng s trn. Trong qu trnh ti u ho ng DVH c
th hin lin tc khi ta thay i cc iu kin (constrain), trng s (importance
factor), khi thy ng DVH tt, c th tm dng v lu k hoch li. So snh cc
DVH vi nhau v vi 3D-CRT, ly k hoch c DVH tt nht (hnh 4.4, hnh 4.5).

Hnh 4.4: ng DVH thay i khi iu chnh trng s ca PTV
Nu qu trnh ti u ha c chp nhn th lc my tnh s tin hnh tnh
ton liu chi tit cho khi u v cc c quan. Di y l biu liu lng-th tch
(DVH) ca k hoch. Da vo ng DVH chng ta tin hnh nh gi k hoch.
Nu k hoch p ng c yu cu th qu trnh ti u kt thc.

Hnh 4.5: ng DVH ca k hoch cui cng

60

4.2.2. Quy trnh o liu kim tra cht lng (QA) cho JO-IMRT
Khi mt k hoch ti u ho c hon thin th ton b thng tin s c
chuyn n phn tnh ton cc chuyn ng ca cc cc ngm (jaw). Ngha l v tr
ca tng jaw s ph thuc vo yu cu ca phn b liu lng. Vic kim tra liu
lng trc iu tr c th dng ba phng php: Dng bung ion ho, dng film,
hoc dng m trn cc detector bn dn so snh vi nhng g tnh ton trong
quy trnh lp k hoch. Vi phng php o liu s dng bung ion ha, cc im
o kim tra phi l nhng im nm vng c chnh lch thp v phn b liu
lng. Nu kt qu tnh ton v o sai khc trong khong 5% th k hoch JO-
IMRT c chp nhn v c th iu tr cho bnh nhn.
4.2.2.1. Cc thit b s dng trong qu trnh o

Hnh 4.6: Phantom u v bung ion ha Farmer Chamber FC65-P
Vic o c tin hnh bi h thng o liu c chnh xc cao do IAEA
cung cp, h thng bao gm nhiu thit b nh: Thit b m phng c th ngi c
h s m tng ng gi l phantom (hnh 4.6), my o liu Dose 1 (hnh 4.7),
kt hp vi u o l bung ion ha Farmer Chamber FC65-P.
61


Hnh 4.7: Thit b o liu Dose 1
Cc thit b ny c kt ni theo s :
Hnh 4.8: S h o kim tra cht lng
4.2.2.2. Quy trnh kim tra cht lng cho JO-IMRT
Bc 1: Chp CT m phng cho phantom u (hnh 4.6).
Bc 2: Lp k hoch QA JO-IMRT trn phantom.
S dng chc nng to k hoch QA JO-IMRT ca phn mm Prowess
panther chuyn ton b thng s nh: Hng chiu, nng lng, cc phn on
trng chiu, ... trong k hoch ca bnh nhn cn kim tra sang k hoch QA JO-
IMRT.
Bc 3: Tnh ton liu ti cc im trn phantom.
Sau khi tnh ton liu cho k hoch QA-IMRT, da trn phn b ca cc
ng ng liu, cc im tnh ton liu nm vng c chnh lch thp v phn
b liu lng.
My o liu
Dose 1
Bung ion ha
FC 65-P
Phantom
Cable
62


Hnh 4.9: V tr cc im o liu trong k hoch QA JO-IMRT
Bc 4: o h s hiu chnh my (Calibration: K).
- Thit lp khong cch t ngun n b b mt phantom (SSD): 100 cm.
- Thit lp u d su liu cc i d
max
=1,6 cm.
- Thit lp thn my (gantry) v 0
0
, trng chiu 10x10 cm, nng lng 6 MV.
- Cho my pht 100 MU v ghi nhn kt qu o c trn my Dose 1: D
k
.
- H s K c nh ngha nh sau:
( )
k
D
cGy
K
MU
100
= (4.1)
63


Hnh 4.10: Thit lp plastic phantom o h s hiu chnh my
Bc 5: Thit lp phantom, tin hnh pht tia v ghi nhn gi tr o c.
- S dng h thng laser m phng, thit lp phantom trn bn iu tr sao cho
trc ca chm tia i qua im cn o.
- t u d FC65 vo phantom, thit lp cc thng s trn Dose 1: Chn loi
u d, t in p, o bc x phng nn, ...
- Tin hnh pht tia trn phantom c thit lp: Thi gian pht tia trung
bnh cho mt im cn o l 20-30 pht.
- Ghi nhn cc gi tr o hin th trn my o liu Dose 1 tnh ton sai s.
Bc 6: Tnh ton sai s.
Sai s gia liu tnh ton v liu o c tnh theo cng thc sau.
( )
cal Musured
Musured
D .K D .100%
Saiso
D

= (4.2)
D
Musured
: Liu o c t thc t c hin th trn Dose 1.
D
cal
: Liu tnh ton ti im kho st.
64

Trong phn mm Prowess panther, liu hin th ti im l tng liu ca c
qu trnh iu tr. V th D
cal
=tng liu iu tr/s ngy iu tr.
V d: Hnh 4.11 hin th liu tnh ton trn phn mm ti ta (0; -1,2; 0) l
6695,64 (cGy).
Vy liu tnh ton ti im kho st ny l: D
cal
=6695,65/35=191,30 (cGy).

Hnh 4.11: Liu tnh ton v liu o c ti im kho st.
Sai s trong v d ny l:
( ) 191,30.0,966 179,1 .100%
Saiso 3,18%
179,1

= = vi K=0,966.
4.3. Kt qu lp k hoch x tr JO-IMRT v kt qu QA
4.3.1. Trng hp 1: Bnh nhn Nguyn Th M., K vm. Ch nh x tr iu bin
cng vi tng liu ch nh: GTV v hch c thp: 70 Gy; CTV: 50 Gy; phn
liu: 2 Gy/ngy (hnh 4.12).
Trong trng hp ny, chng ti s dng 7 trng chiu: 72
0
, 100
0
, 155
0
,
180
0
, 210
0
, 265
0
, 300
0
v mi trng chiu c 7 phn on trng chiu (segment).
Thi gian tin hnh lp k hoch x tr JO-IMRT trn phn mm Prowess panther
mt khong 3-5 gi. Liu lng phn b ti GTV, CTV c nh gi da trn
tng lt ct CT v biu liu lng-th tch (DVH).
65


Hnh 4.12: Hnh nh lt ct CT c xc nh GTV, CTV
Chng ti tin hnh nh gi, so snh k hoch x tr 3D-CRT v JO-IMRT
da trn hnh 4.13 v hnh 4.14.

Hnh 4.13: So snh k hoch x tr JO-IMRT v 3D-CRT
ng ng liu gia k hoch x tr JO-IMRT (hnh 4.13-tri) bao st th tch cn tia
hn so vi 3D-CRT (phi), ng thi trnh c thn no, ty sng, ...
66


Hnh 4.14: So snh 2 DVH: JO-IMRT (nt t) v 3D-CRT (nt lin)
Trn hnh 4.14 ta nhn thy, ng nt t mu xanh ca ty sng trong k hoch
JO-IMRT thp hn nhiu so vi k hoch 3D-CRT (nt lin: cao hn). Tc l ty sng
nhn c liu thp hn trong k hoch JO-IMRT. Th tch GTV (mu vng) v CTV
(mu ) ca k hoch JO-IMRT th cao hn so vi k hoch 3D-CRT. Tc l th tch
khi u nhn c liu cao hn i vi k thut JO-IMRT (bng 4.1).
Bng 4.1: Kt qu so snh liu hp th gia 2 k hoch JO-IMRT v 3D-CRT
Cc vng th tch
Liu hp th (Gy)
JO-IMRT 3D-CRT
CTV 62,32 59,13
GTV 73,73 71,61
Ty sng 43,58 61,48
Thn no 18,26 25,45
Nhn xt: Liu bc x ti khi u l gn tng ng nhau, trong khi liu
ti cc c quan lnh k thut JO-IMRT thp hn nhiu so vi k thut 3D-CRT.
67

Vy JO- IMRT l mt k thut x tr hin i, c nhiu u vit so vi 3D-CRT, tp
trung cao nht liu tia x ti th tch cn iu tr, ng thi gim thiu v bo tn
c cc c quan nhy cm xung quanh.
Sau khi tin hnh nh gi k hoch, chng ti tin hnh kim tra sai s trc
khi iu tr thc t cho bnh nhn. Cc kt qu sai s u nh hn 5% (bng 4.2).
Bng 4.2: Sai s gia liu tnh v liu o ca bnh nhn Nguyn Th M
ung th vm ti bnh vin a khoa ng Nai
im o
Tng Liu
tnh ton(cGy)
S ngy
(ngy)
H s K
Liu tnh
(cGy)
Liu o
(cGy)
Sai s
(%)
im 1 6695,64 35 0,966 184,80 179,1 3,18
im 2 6574,26 35 0,966 181,45 177 2,51
im 3 6510,32 35 0,966 179,68 172,2 4,35
im 4 6534,59 35 0,966 180,35 172,4 4,61
im 5 6589,54 35 0,966 181,87 179,4 1,38
(Kt qu chi tit v v tr ta cc im: im 1,im 2, im 3, im 4, im 5
xem chi tit trong ph lc 1).
Nhn xt: Khi tin hnh o thc nghim kho st sai s gia liu tnh ton
bng phn mm so vi liu o c ti bnh vin a khoa ng Nai. Vi kt qu
bc u, tht ng khch l cho chng ti tin hnh k thut ny v cc sai s cc
cc im kho st u nh hn 5% (t 1,38%-4,61%). Cc sai s ny c th chp
nhn c.
Mc d cc thit b, cng nh phng php o ca chng ti u ging vi hai
bnh vin ln ti H Ni: Bnh vin K v bnh vin Bch Mai nhng kt qu sai s
ca chng ti vn cao hn so vi hai bnh vin ny (bng 4.3, bng 4.4). iu ny
c th l gii l do chng ti khng o trn cng mt bnh nhn v cc im o
khng hon ton ging nhau (mc d u da trn nguyn tc chn cc im o l
cc im c s chnh lch thp v phn b liu lng, nhng ta o khc nhau).
Hn na, cc kt qu sai s cng cn ph thuc vo kinh nghim ca ngi o.
68

Bng 4.3: Sai s gia liu tnh v liu o ca bnh nhn ung th vm
ti bnh vin K-H Ni [3]
im o
Ta
(cm)
Liu tnh
(cGy)
Liu o
(cGy)
Sai s
(%)
im 1 0,00; 2,75; 2,30 219,41 214,80 2,10
im 2 0,00; 2,75; 5,00 202,94 197,4 2,70
im 3 3,00; 2,75; 2,30 203,59 201,30 1,12
im 4 -2,00; 2,75; 2,30 208,60 207,40 0,50
Bng 4.4: Sai s gia liu tnh v liu o ti bnh vin Bch Mai-H Ni [6]
Loi bnh
ung th
Sai s ti cc im o
Isocenter
(tm)
Tm chm tia
trn/di
u d
Tm chm
tia bn
tri u d
Tm chm
tia bn
phi u d
Ung th u-c 1 -1.4% -1,9% 1,8% -0,7%
Ung th u-c 2 -0.6% -1,9% 1,1% 0,6%
Ung th gan -3,0% -3,1% -3,1% -3,1%
Ung th v 2,84% 2,13% 3,68% 1,96%
Ung th no 0,15% 0,39% 0,41% 0,5%
Nhn xt: Bnh vin K v bnh vin Bch Mai l hai bnh vin u tin trong
c nc ng dng k thut x tr JO-IMRT. Cc kt qu sai s ca hai bnh vin
ny u nh hn 5%. Bn cnh , bnh vin Bch Mai cng trin khai k thut
ny i vi hu ht cc loi ung th nh: Ung thu gan, ung th v, ung th li vi
cc sai s u nm trong gii hn cho php (bng 4.4).
4.3.2. Trng hp 2: Bnh nhn Trn Vn H, K vm. Ch nh x tr iu bin
cng vi tng liu ch nh: CVT1: 63 Gy; CTV2: 55Gy; 2,25 Gy/ngy.
Trong trng hp ny chng ti s dng 7 trng chiu: 90
0
, 120
0
, 150
0
, 180
0
,
210
0
, 240
0
, 270
0
. Mi trng chiu gm 7 phn on trng chiu. Di y l kt
qu chng ti nhn c:
69


Hnh 4.15: ng isodose k hoch JO-IMRT bao st khi u hn 3D-CRT
Nhn xt: ng ng liu mu xanh trong k hoch JO-IMRT un cong
trch thn no. Trong khi , ng ng liu ny k hoch 3D-CRT i qua
thn no.

Hnh 4.16: So snh 2 DVH: JO-IMRT (nt lin) v 3D-CRT (nt t)
Nhn xt: Liu hp th ti khi u tng ng nhau, nhng liu ti cc c
quan trong k hoch JO-IMRT (ng nt lin) thp hn k hoch 3D-CRT v trong
k hoch JO-IMRT cc ng ng liu bao st khi u hn. iu ny c ngha l
cng ca cc chm tia ti c iu bin.
Tip theo, chng ti tin hnh o thc t kim tra sai s gia liu tnh ton
v liu o c trn thc t. Bng 4.5 l kt qu chng ti o c.
70

Bng 4.5: Sai s gia liu tnh v liu o ca bnh nhn Trn Vn H
ung th vm ti bnh vin a khoa ng Nai
im o
Tng liu
tnhton
(cGy)
S ngy H s K
Liu tnh
(cGy)
Liu o
(cGy)
Sai s
(%)
im 1 7143,50 35 0,9979 203,67 203,1 0,28
im 2 6609,83 35 0,9979 188,46 185,5 1,59
im 3 6907,55 35 0,9979 196,94 191,2 3,00
im 4 6718,50 35 0,9979 191,55 189,9 0,87
im 5 7151,83 35 0,9979 203,91 199,9 2,01
(Kt qu chi tit v v tr ta cc im: im 1,im 2, im 3, im 4, im 5
xem chi tit trong ph lc 2).
Nhn xt: Kt qu sai s u nh hn 5%. Sai s ca bnh nhn ny nh hn
sai s ca bnh nhn trong trng hp th nht l do chng ti rt ra c nhiu
kinh nghim thc t trong vic chn v tr cc im cn o (chn cc im nm trn
ng ng liu 95%) v cch thit lp phantom u trong qu trnh m phng
sai s l t nht (xc nh trc v tr ca u d trc khi m phng).
4.4. Kt lun
Da trn kt qu ca vic lp k hoch x tr vi k thut iu bin cng
JO-IMRT so snh vi k thut x tr thng thng 3D-CRT, khng nh rng vi k
thut JO-IMRT to ra s phn b liu ti u ti cc th tch bia v gim liu cho
cc c quan lnh. Cc kt qu sai s tuy c cao hn so vi cc bnh vin ln nhng
cc sai s ny u nh hn 5%. y l kt qu bc u trong vic nghin cu
nhm trin khai k thut JO-IMRT ti bnh vin a khoa ng Nai trong thi gian
sp ti. iu ny c bit c ngha c v kinh t v y t. V hin nay, k thut ny
mi ch c ng dng ti bnh vin Bch Mai v bnh vin K.
71

KT LUN
Mc ch ca lun vn l: Nghin cu v ng dng k thut x tr iu bin
cng JO-IMRT.
Trong lun vn ny, chng ti thc hin c cc cng vic sau:
1. Tm hiu v nguyn l v bn cht ca phng php x tr iu bin cng
chm tia.
2. Tm hiu c quy trnh v cc m hnh ti u ha trong k thut x tr
iu bin cng chm tia. C th, tm hiu m hnh ti u ha theo liu
lng bc x, v xc nh c cng thc ton hc cho hm mc tiu ca
m hnh ny.
3. S dng phn mm lp k hoch x tr Prowess panther lp cc k hoch
vi hai phng php khc nhau: 3D-CRT, JO-IMRT cho bnh nhn ung th
vm. Sau , chng ti a ra c s so snh, nh gi cc k hoch
c lp da trn k thut x tr JO-IMRT vi k thut x tr 3D-CRT.
4. Tin hnh o c thc nghim ti bnh vin a khoa ng Nai, kim tra
chnh xc ca kt qu tnh ton c trn phn mm Prowess panther
khi s dng k thut x tr JO-IMRT. T nhng kt qu o thc nghim
khng nh tnh chnh xc ca phng php x tr JO-IMRT cng nh m
hnh ti u ha theo liu.
Vic s dng k thut x tr IMRT, s gip thi gian iu tr c gim ngn
bi khng mt cng tho lp ph kin nh lc nm, khi che chn ch, khng to ra
cc electron v photon tn x t cc ph kin ny, do s gim c hin tng
chy da i vi bnh nhn x tr. Hn na, vi k thut JO-IMRT, my gia tc cng
khng cn phi trang b MLC. iu ny rt c ngha v iu kin mi trng
Vit Nam rt kh c th s dng MLC mt cch hiu qu. Vi k thut ny, thi
gian iu tr gim i mt na so vi iu tr thng thng, to cm gic thoi mi
cho bnh nhn khi iu tr.
72

KIN NGH
Vi nhng kt qu bc u trong vic nghin cu v ng k thut x tr
iu bin cng JO-IMRT ti bnh vin a khoa ng Nai. Do thi gian c hn
cng nh kh nng ca bn thn cn hn ch, nn vic tm hiu ch dng li mc
tng quan, c bn v mt l thuyt v ng dng cho mt loi ung th vm.
Trong tng lai, chng ti s tip tc ng dng k thut x tr JO-IMRT cho cc
loi ung th khc v tin hnh kim tra k hoch trc iu tr bng film k
hoch tng thm chnh xc trong iu tr. Sau khi c c cc kt qu kh quan,
chng ti s tin hnh iu tr thc t cho bnh nhn ung th vm ti bnh vin a
khoa ng Nai.
73

TI LIU THAM KHO
Ting Vit
[1] Phan S An, Trn nh H (2011), X tr ung th, H Ni
[2] Nuyn Xun C (2011), C s vt l v nhng tin b v k thut x tr ung
th, Nh xut bn Y hc, H Ni.
[3] Nuyn Xun C, Nguyn Anh Tun (2007), Bc u trin khai k thut x tr
iu bin liu lng bng my gia tc vi h jaws-only ti bnh vin K, H
Ni.
[4] Nguyn B c (2003), Thc hnh x tr ung th, Nh xut bn Y hc, H Ni.
[5] Mai Trng Khoa, Nuyn Xun C (2012), Mt s tin b v k thut x tr ung
th v ng dng lm sng, Nh xut bn y hc, H Ni.
[6] Mai Trng Khoa, Trn nh H (2009), ng dng k thut x tr iu bin liu
trong iu tr ung th ti bnh vin Bch Mai, H Ni.
[7] Chu Vn To (2004), An ton bc x ion ha, Nh xut bn HQG TP H Ch
Minh, TP H Ch Minh.
Ting Anh
[8] Arno J. Mundt, John C. Roeske, (2005), Intensity modulated radiation
therapy-a clinical perspective, BC Decker Inc, The United States of America.
[9] Nguyn Thi Bnh (2008), Method of IMRT optimization of shallow tumor
cases where the PTV extends into the build up region, University of
Cambridge.
[10] C. Yu, Christopher J. Amies (2008), Planing and delivery of intensity
modulated radiation therapy, Medical physics, Vo. 35, No 12.
[11] Dai J R and Hu Y M (1999), Intensity-modulation radiotherapy using
independent collimators: an algorithm study, Med.Phys, Vo. 26.
74

[12] Earl M A, Shepard D M, Naqvi S, Li X A and Yu C X (2003), Inverse
planning for intensity-modulated arc therapy using direct aperture
optimization, Phys. Med. Biol, Vo.48, 107589.
[13] Kestin L L, Sharpe M B, Franzier R C (2000), Intensity modulation to
improve dose uniformity with tangential breast radiotherapy: Initial clinical
experience, Radiat. Oncol. Biol. Phys, Vo. 48, 155968.
[14] M.A.Earl, D.M.Shepard (2002), Direct aperture optimization: A turnkey
solution for step-and-shoot IMRT, Medical physics, Vo. 29, No 6, 21201-
1595.
[15] M. A. Earl, D. M. Shepard (2007), Jaws only IMRT using direct aperture
optimization, Medical physics, Vo. 34, No 1, 21201-1595.
[16] www.radiologyinfo.org, Intensity Modulated Radiation Therapy.
[17] www.mayoclinic.org, Intensity Modulated Radiation Therapy.
[18] www.medicalphysics.org, IMRT For Head And Neck Cancer.

75

PH LC
Ph lc 1: Kt qu o liu kim tra ca bnh nhn Nguyn Th M

Hnh p1.1: o liu ti v tr 1
X l kt qu o v tnh sai s:
- Tng liu hin th trong phn mm Prowess panther l 6695,64 (cGy).
V vy, liu tnh ton D
cal
=(6695,64/35)K=(6695,64/35)x0,966=184,80 cGy.
- Liu o c hin th trn my Dose 1 l 179,1 cGy.
- Sai s tnh theo cng thc (4.1): saiso= (184,80-179,1)/ 179,1x100=3,18%.
76


Hnh p1.2: o liu ti v tr 2


Hnh p1.3: o liu ti v tr 3
77


Hnh p1.4: o liu ti v tr 4

Hnh p1.5: o liu ti v tr 5
78

Ph lc 2: Kt qu o liu kim tra ca bnh nhn Trn Vn H

Hnh p2.1: V tr o liu ti 5 im