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Nh?ng v?n ?? c?p nh?t trong ch?n ?on v ?i?u tr? ngo?i khoa ung th? ph?i nguyn pht

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Nh?ng v?n ?? c?p nh?t trong ch?n ?on v ?i?u tr? ngo?i khoa ung th? ph?i nguyn pht ( issues update in diagnosis and surgical treatment primary lung cancer)

altPGS.TS ??ng Ng?c Hng; PGS.TS Ng V?n Hong Linh

I .??t v?n ??:

UTPQNP v?n cn l m?t b?nh n?ng . K?t qu? ?i?u tr? ni chung v ?i?u tr? ngo?i khoa ni ring cn h?n ch? . L do l:

+ Ch?n ?on s?m UTPQNP cn kh kh?n nn khi pht hi?n ???c th kho?ng 80% khng cn ch? ??nh m? (do b?nh nhn ??n mu?n , do th?y thu?c khng pht hi?n ???c).
+ Tiu chu?n vng ?? ch?n ?on UTPQNP l tm th?y ???c t? bo ung th?.Tin l??ng b?nh l?i ph? thu?c r?t nhi?u vox?p giai ?o?n (G?)v lo?i t? boung th?.

+ N?u x?p G? UTP cng chnh xc th ph??ng php ?i?u tr? ???c ch?n l?a cho ng??i b?nh cng hi?u qu? v tin l??ng v? s?ng cn cng c gi tr?.

V nh?ng l do trn, ?? gp ph?n nng cao ch?t l??ng ?i?u tr? v tin l??ng UTPQNP, chng ti xin trnh by t?ng h?p nh?ng nghin c?u c?a cc tc gi? n??c ngoi th?i gian g?n ?y.

II. V?n ?? xc ??nh giai ?o?n v ngh?a c?a n:

1. T? l? t? vong thay ??i r?t l?n theo t?ng giai ?o?n ung th?:

Theo cc tc gi?, t? l? t? vong sau 5 n?m cho t?ng giai ?o?n:

+ G? IA : 35%, IB : 60%.

+ G? IIA : 63%, IIB : 70%.

+ G? IIIA :85%, IIIB :95%.

2. H? th?ng x?p lo?i TNM:

. H? th?ng x?p lo?i TNM ???c Hi?p h?i ch?ng ung th? Hoa K? ( AJCC: American Joint Committee Cancer ) v T? ch?c ch?ng ung th? Qu?c t? (UICC: Union Internationale Contre le Cancer, 1997) ch?p nh?n t? 1986, n?m 1997 ? ???c xu?t b?n thnh s? tay, sau ? ???c c?p nh?t

??y ?? h?n vo 2006 ti b?n vo 2009 ( Xu?t b?n l?n th? 7 ):

T (Tumor),N (Node),M (Metastasis).

Cc tc gi? ? l?p thnh cc b?ng ng?n g?n ?? ti?n s? d?ng trong lm sng:

B?ng 1:

Giai ?o?n

Giai ?o?n T

Giai ?o?n N

Giai ?o?n M


Tis ( T?i ch? )


























T1, T2, T3




T1, T2, T3




B?t k? N



B?t k? T

B?t k? N



3. Xc ??nh N ( Node):

3.1. Xc ??nh T v M khng kh.V?i cc d?u hi?u lm sng,ch?pX.quang th??ng, ch?p c?t l?p vi tnh ( CT ), ch?p c?ng h??ng t? (MRI ), siu m ta c?ng c th? ch?n ?on ???c.Xc??nh N (Node) hi?n nay v?n l m?t kh kh?n, cc tc gi? ? ??a ra nh?ng nghin c?u v h??ng d?n sau:


Theo b?n ?? trn th 14 v? tr nhm h?ch lin quan ??n UTPNP:

*Nhm h?ch trung th?t trn:

1. H?ch trung th?t trn cng.

2. H?ch c?nh kh qu?n trn.

3.H?ch tr??c v sau kh qu?n.

4. H?ch c?nh kh qu?n d??i v h?ch c?nh t?nh m?ch Azygos.

Nhm h?ch ? ??ng m?ch ch?

5. H?ch d??i ??ng m?ch ch? t?i c?a s? ch? - ph?.

6. H?ch c?nh ??ng m?ch ch? .

*Nhm h?ch trung th?t d??i:

7. H?ch d??i ng ba kh ph? qu?n .

8. H?ch c?nh th?c qu?n .

9. H?ch ? dy ch?ng ph?i .

*Nhm h?ch r?n ph?i v trong ph?i:

10. H?ch r?n ph?i .

11. H?ch lin thy ph?i .

12. H?ch thy ph?i .

13. H?ch phn thy ph?i .

14. H?ch d??i phn thy ph?i.

*H?ch trung th?t k hi?u l N2, bi?u th? b?ng cc ch? s? t? 1 ??n 9

*Nh?ng h?ch r?n ph?i v trong ph?i k hi?u l N1, bi?u th? b?ng cc ch? s? t? 10 ??n 14, v ??u n?m trong mng ph?i t?ng.

*Theo h? th?ng x?p lo?i hi?n nay, ???ng phn chia h?ch r?n ph?i N1 v h?ch trung th?t N2 l ???ng gi?i h?n c?a mng ph?i trung th?t.

3.2. ngh?a c? vi?c xc ??nh N2:

H?ch N1 l h?ch r?n ph?i v trong ph?i, nn khi ph?u thu?t ung th? ph?i khng kh kh?n ?? chng tavt h?ch.Kh kh?n l c xc ??nh ???c h?ch N2 hay khng? V ngh?a c?a n nh? th? nao? .

Theo tc gi?: Michael J. Weyant (2009); Raja M. Flores (2010):

-Di c?n c?a ung th? thy trn ph?i ph?i v tri vo trung th?t khi ? xc ??nh ???c c N2:


- Di c?n c?a ung th? thy gi?a v thy d??i ph?i ph?i v thy d??i ph?i tri vo trung th?t khi ? xc ??nh ???c c N2:


- Nh? v?y c ngh?a l:Khi ? c h?ch di c?n vo trung th?t (N2), n?u ung th? ? thy nao? ph?i nao? Th chng s? di c?n vo nhm h?ch no c?a trung th?t v t? l? di c?n l bao nhiu ph?n tr?m.

S? ?? ?nh s? h?ch:

S? ?? 1: S? ?? 2:


3.3. Xc ??nh N2 b?ng cc ph??ng php no?

Theo cc tc gi?, gi tr? c?a t?ng ph??ng php ???c ?nh gi d??i ?y:

3.3.1. X quang ng?c (T & N ):

+ V? tr u.

+ Bi?t kch th??c kh?i u, ?nh gi m?c ?? lan t?a c?a u theo ( T ).

+ Xc ??nh s? ph ??i c?a h?ch ( N ), nh?ng khng ch?c ch?n.

+ So snh v?i cc phim tr??c ?? ?nh gi s? ti?n tri?n c?a kh?i u.

+ C th? nh?n bi?t s? xm l?n c?a u vo thnh ng?c, trung th?t.

+ C th? xc ??nh Bng m? di c?n ph?i ??i bn, di c?n x??ng, no (kh chnh xc, ch? r ? G/? Mu?n).

+ Kh kh?n xc ??nh h?ch trung th?t (N2)

3.3.2. Ch?p c?t l?p ?i?n ton (CTScan):

- ??nh v? chnh xc kh?i u theo chi?u su.

- Lin quan v?i rnh lin thy.

- Nh?n bi?t s? ? kh trong ph?i gip phn bi?t tnh ch?t c tnh c?a kh?i u:

+ D?ng lnh tnh: B? t??ng ??i trn, vi ha, gi?i h?n r ( th?i gian nh ?i > 500 ngy).

+ c tnh: B? khng ??u, ?a cung, l?i lm, tia m?t tr?i, khng vi ha ( ti?n tri?n c?a kh?i u nhanh).

- CT scan xc ??nh ???c u di c?n h?ch trung th?t # 8% cho nh?ng h?ch 20 mm. M?t s? tc gi? ?nh gi CT scan: (JW Lewis ,1996; De Leyn P & cs, 2007):

+ ?? nh?y: 57% - 84,4%.

+ ?? chuyn: 52% - 81,1%.

+ Tin ?on d??ng: 56% - 68,7%.

+ Tin ?an m: 83% - 92,9%.

C?ng theo nh?ng tc gi? trn, xc ??nh G? UTPNP b?ng CT Scan ch? c # 45,4% l cho k?t qu? ph h?p trong m?, #10,7% xc ??nh ???c di c?n gan, ph?i, th??ng th?n v # 12,5% cho x??ng, h?ch ? b?ng. ?i ??n k?t lu?n: CT Scan khng ?? kh? n?ng xc ??nh G/? TNM ( ??c bi?t l N) trong UTPNP.

3.3.3. Ch?p c?ng h??ng t?(MRI):

- C hi?u qu? t??ng ???ng CT Scan.

- Xc ??nh di c?n xa vo gan, th??ng th?n ngang nhau.

- Xc ??nh di c?n no: MRI h?n h?n CT Scan.

- Xc ??nh di c?n x??ng: MRI c?ng nh?y nh?ng khng b?ng X? hnh x??ng.

- Xc ??nh N kh kh?n v khng chnh xc.

3.3.4. Ch?p c?t l?p tn x? Positron (PET: Positron Emission Tomography):

- PET Scan v?i ??ng v? phng x? 18-fluorodeoxyglucose (FDG) k? thu?t m?i ?? ?nh gi G/? UTPQNP v nh?ng kh?i u c tnh khc. C kh? n?ng nh?n bi?t ???c nh?ng kh?i u, nh?ng h?ch di c?n s?m:

+ D? li?u ?em l?i c?a PET gip ch r?t l?n trong trong ch?n ?on UTPNP.

+ Khi kh?i u pht sng trn PET th 90 95% l ung th?.

+ N?u u < 10 mm v khng th?y trn PET th ch? kho?ng 5% c? h?i l c tnh.

+ ?? nh?y v ?? chuyn # 90%.

+ K?t h?p PET v?i CT Scan c ?? nh?y ngang b?ng v?i Ph?u Thu?t khi TB h?c c?a h?ch l c tnh do di c?n ( Eichfeld U v cs, 2005 ).

- Tuy nhin PET hi?n nay trn th? gi?i v trong n??c ch?a th?nh hnh v gi thnh c?a phim ch?p kh cao. PET c?ng khng ph?i l Tiu chu?n vng trong ch?n ?on ung th?.

3.3.4. N?i soi trung th?t(NSTT):

- NSTT v?n l m?t Tiu chu?n vng xc ??nh G/? h?ch trung th?t (Carlens E, 1959).

- ? M? hi?n nay v?n th?nh hnh.

- NSTT xc ??nh ???c cc nhm h?ch: 2R, 2L, 4R, 4L; h?ch tr??c KQ: 1, 3.

- Nh?ng h?ch khng th? sinh thi?t ???c: h?ch d??i ng ba KPQ: 7; h?ch TT d??i: 8, 9; h?ch ? c?a s? Ph? - Ch? v h?ch TT tr??c ? v? tr: 5, 6. (Landreneau RJ, 1993).

- ?? nh?y # 80 85%, theo Hammoud ZT, 1999: ?? nh?y # 43 57% v m tnh gi? # 5,5 8%.

- S? d? c m tnh gi? l v v? tr h?ch khng th? v?i t?i ???c b?ng NSTT ( Cc nhm h?ch 5, 6, 7, 8, 9 ).

3.3.5. N?i soi ph? qu?n(NSPQ):

NSPQ th?c hi?n STXTPQ an ton, t bi?n ch?ng:

- Dng th??ng xuyn ?? xc ??nh nh?ng h?ch d??i ng ba KPQ.

- Nh?ng h?ch c?nh KQ, ST c kh kh?n h?n do khng th? t?o ???c gc ?? ?? l?n gi?a thnh KPQ v kim ch?c.

- Kh? n?ng STXTPQ vo u kh kh?n h?n ( Ranes J.L, 2003; Tan B.B v cs, 2003 ).

- T? l? thnh cng # 90%, ?? nh?y 75%. Trong nhm h?ch N2, N3 t? l? m tnh gi? 25%.

3.3.6. Sinh thi?t xuyn thnh ng?c (STXTN) d??i h??ng d?n c?a ch?p c?t l?p vi tnh (CLVT) :

Sinh thi?t xuyn thnh ng?c l m?t trong cc bi?n php l?y b?nh ph?m ch?n ?on. ? n??c ta k? thu?t STXTN ht b?ng kim nh? ? ???c ti?n hnh t? nh?ng n?m 1980 d?a trn phim ph?i th?ng-nghing. Khi xu?t hi?n my ch?p c?t l?p vi tnh, m?t s? n?i ? s? d?ng ?? h??ng d?n sinh thi?t ph?i ht b?ng kim nh? . Tuy nhin, b?nh ph?m th??ng ch? cho php lm xt nghi?m t? bo h?c. G?n ?y c m?t s? tc gi? trong n??c th?c hi?n k? thu?t sinh thi?t b?ng kim Tru cut. Trong k? thu?t ny b?nh ph?m l?y ???c l m?nh sinh thi?t c?t. Nh? v?y, ngoi xt nghi?m t? bo h?c cn c th? xt nghi?m m b?nh h?c, ?y l xt nghi?m r?t quan tr?ng cho vi?c ?nh gi t?n th??ng, ??c bi?t l phn lo?i tp ung th?. Tuy nhin STXTN v?n cn nhi?u h?n ch? v c nh?ng ch? ??nh, ch?ng ch? ??nh c?a n:

- Kch th??c h?ch TT ph?i > 1,5 cm.

*?? nh?y # 90%, m tnh gi? t? 20 50%.

*Kh?i u ? ph?i ch?c sinh thi?t d? h?n v c ?? nh?y cao h?n.

*Ngy nay ?ng d?ng nhi?u v PP ? c kim ch?c ST chuyn d?ng v c PP nhu?m b?nh ph?m m?i ( LIU).

- Ch? ??nh:

+ C kh?i u ? ph?i v trung th?t. Cc t?n th??ng nhi?m trng ph?i ch?a r c?n nguyn, km hay khng ?p ?ng ?i?u tr? ban ??u.

+ ?? phn bi?t cc t?n th??ng gi? u ph?i, nh?ng tr??ng h?p trn d?ch khu tr, d?ch rnh lin thy, u mng ph?i, b?nh l vng TT.

+ STXTN xc ??nh c TB UT di c?n vo h?ch TT chnh xc > 90%. Kho?ng 10% trn kh mng ph?i ph?i ??t d?n l?u.

+ Tr??ng h?p nghi c tnh, nh?ng khng c ch? ??nh ph?u thu?t, n?u khng ST th khng c c? s? ch?n ?on.

- Ch?ng ch? ??nh:

+ Ch?ng ch? ??nh tuy?t ??i khi nghi ng? nang sn, u mu.

+ Ch?ng ch? ??nh c?a ph?u thu?t.

+ BN c r?i lo?n ?ng mu, khng h?p tc, ch?c n?ng HH h?n ch?, kh ph? th?ng n?ng, t?ng AL?MP n?ng, ? PT c?t ph?i.

3.3.7. N?i soi ph? qu?n d??i h??ng d?n c?a Siu m sinh thi?t h?ch Lympho Trung th?t:

- Cerfolio R.J (2007) NC trong 3 n?m ( 2003 2006) v?i 288 BN c 112 BN c h?ch N2 t?i h?ch s? 5, 6. Tc gi? k?t lu?n:

+ S ch?c ST qua NSTQ ST h?ch N2 t?i h?ch s? 5, 6 khng chnh xc b?ng PTNSLN.

+ K? thu?t ny th??ng dng xc ??nh h?ch Dy ch?ng ph?i d??i, d??i ng ba KPQ.

+ Nh?ng h?ch ? pha tr??c bn KQ th??ng kh l?y m?u, nh?ng r?t th??ng g?p trong UTP.

+ ?? nh?y # 90%, m tnh gi? 23%.

3.3.8. Ph?u thu?t n?i soi l?ng ng?c v?i tr? gip c?a Video(Video assisted thoracic surgery) xc ??nh G/? UTPQNP l m?t h??ng ?i m?i gp ph?n quan tr?ng trong ch?n ?on v ?i?u tr? UTPQNP:

*PTNSLN sinh thi?t kh?i u ph?i ngo?i bin m cc ph??ng ti?n ch?n ?on khc khng xc ??nh ???c:

- Kh? n?ng ST ???c UTP ??t t?i 91,43%, th?t b?i l 8,57%.

- Cho ch?n ?on phn bi?t nhanh gi?a u lnh v c ( km theo sinh thi?t t?c th).

- PTNSLN xc ??nh chnh xc 100% tnh tr?ng c?a khoang mng ph?i: d?ch mng ph?i, tnh tr?ng mng ph?i t?ng, mng ph?i thnh, ??c bi?t l n?t v? tinh trong khoang mng ph?i.

* PTNSLN xc ??nh G/? UTPQNP:

- ?nh gi chnh xc m?c ?? ti?n tri?n, xm l?n c?a u nguyn pht ra mng ph?i t?ng (T2 4) m m?t s? ph??ng ti?n ch?n ?on khc khng xc ??nh ???c.

- Gip ST chnh xc t? 76,9 88,9% h?ch r?n ph?i v ST chnh xc t? 78,6 85,7% h?ch TT m lm sng v CT Scan khng ch?n ?on ???c, qua ? ?nh gi di c?n h?ch N1, N2 chnh xc h?n.

- Gip xc ??nh chnh xc 100% cc t?n th??ng nh? di c?n mng ph?i thnh, mng ph?i t?ng m cc ph??ng ti?n ch?n ?on hnh ?nh khng th? nhn th?y ???c,qua ? h?n ch? m? ng?c cho nh?ng BN khng c ch? ??nh ph?u thu?t.

Nh? v?y:Trong 8 ph??ng php xc ??nh giai ?o?n v tp TB UTPQNP th ph??ng phpPh?u thu?t n?i soi l?ng ng?c v?i tr? gip c?a Video (Video assisted thoracic surgery) l ?u ?i?m h?n c? m?t h??ng ?i m?i gp ph?n quan tr?ng trong ch?n ?on v ?i?u tr? UTPQNP.Ph??ng php ny hi?n nay c tnh kh? thi ? Vi?t Nam v h?u h?t cc c? s? ph?u thu?t trong c? n??c ??u ???c trang b? my ph?u thu?t n?i soi.

IV. Ch? ??nh ?i?u tr? ngo?i khoa UTPQNP:

?? ch? ??nh ?i?u tr? UTPQNP, cc tc gi? ??u th?ng nh?t d?a vo:

- Tp m b?nh h?c.
- Giai ?o?n ung th?.

- ?nh gi ch?c n?ng c?a b?nh nhn.

1. Tp m b?nh h?c:

Hi?n nay ??u th?ng nh?t ch? ??nh ph?u thu?t UTPQNP tp t? bo l?n. Tp t? bo nh? ch?ng ch? ??nh ph?u thu?t v lo?i ny:

- Tin l??ng x?u.

- ? g?n ph? qu?n l?n.

- Lan r?ng trong trung th?t.

- S?m di c?n r?ng trong l?ng ng?c.

  1. Giai ?o?n ung th?:

UTPQNP tp t? bo l?n [Non- Small Cell Lung Cancer (NSCLC)]:


(Giai ?o?n)


(M t?)

Treatment Options

(Chi?n thu?t ?i?u tr?)

I a : T1 No Mo

I b : T2 No Mo

Tumor of any size is found only in the lung

(kh?i u b?t k? kch th??c, ch? khu tr ? ph?i )

Surgery (Ph?u thu?t)

II a : T1 N1 Mo

II b : T2 N1 Mo

T3 No Mo

Tumor has spread to lymph nodes associated

with the lung

(Kh?i u ? pht tri?n lan r?ng ??n h?ch Lympho trong ph?i)

Surgery (Ph?u thu?t)

III a :

T3 N1 Mo

T1,2,3 N3 Mo

Tumor has spread to the lymph nodes in the tracheal area, including chest wall and

diaphragm (Kh?i u pht tri?n r?ng t?i h?ch Lympho khu v?c kh qu?n, g?m c? thnh ng?c v c? honh)


followed by radiation

or surgery

(?i?u tr? ho ch?t

sau x? tr? ho?c sau

ph?u thu?t)

III b :

T1,2,3 N3 Mo

T4 N B?t k? Mo

Tumor has spread to the lymph nodes on the opposite lung or in the neck (Kh?i u pht tri?n

lan r?ng t?i h?ch ? ph?i ??i bn ho?c h?ch vng c?)

Combination of chemotherapy and radiation (K?t h?p ho tr? v x? tr?)

IV :

T B?t k? N B?t k? M1

Tumor has spread beyond the chest

(Kh?i u ? lan ra ngoi ng?c)

Chemotherapy and/or palliative

(maintenance) care

(Ho tr? ho?c

gi?m ?au)

3. ?nh gi ch?c n?ng c?a b?nh nhn:

?nh gi:

- PFT ( pulmonary function test) : ( FVC ( forced vital capacity) and FEV1 ( forced expiratory volume in one second) Dung tch s?ng th? g?ng s?c (FVC) v Th? tch th? ra g?ng s?c trong giy ??u tin (FEV1)

+ FEV1 and DLCO ( carbon monoxide diffusion in the lung).

- Ventilation and perfusion scans (scan thng kh v t??i mu).

- Cardiopulmonary exercise testing (VO2max) (Test tim ph?i g?ng s?c).

- Arterial blood gas sampling (Sa02)(?o kh mu ??ng m?ch).

- ?nh gi theo ch? s? Karnofski (IK).

Nh? v?y ch? ??nh m? ???c tm t?t nh? sau:

-UTPQNP tp t? bo l?n [Non- Small Cell Lung Cancer (NSCLC)].

- Giai ?o?n: I,II, v IIIA.

- IK > 70%.

- Cc xt nghi?m c?n lm sng cho php.

Ph??ng php ph?u thu?t:

- C?t phn thy, c?t thy ph?i ho?c c?t b? m?t l ph?i + L?y b? h?ch di c?n theo giai ?o?n b?nh .


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19. Michael J. Weyant, Raja M. Flores.VATS MEdiastinal Nodal Dissection .www.ctsnet.orgPublication Date: 6-Sep-2005 .Last Modified: 26-Oct-2005.


H?i ngh? tim m?ch chuyn ?? " lc ??ng m?ch ch? v vim n?i tm m?c nhi?m khu?n"

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Ngy 13 thng 6 n?m 2013 , t?i b?nh vi?n h?u ngh? Vi?t ??c ? tt? ch?c h?i kh?o ph?u thu?t tim m?ch chuyn ?? lc ??ng m?ch ch? v vim n?i tm m?c nhi?m khu?n, ??n tham gia h?i ngh? g?m cc chuyn gia hng ??u c? n??c v? ph?u thu?t tim m?ch ??t bi?t c s? tham gia chuyn gia Baldev S. Sekhon, M.D., FACS v? ph?u thu?t tim ng??i l?n v ??ng m?ch ch? (?n ??).


PGS Nguy?n Ti?n Quy?t c m?t v ?nh gi cao vi?c t? ch?c h?i ngh? ny v pht bi?u t?i h?i ngh? v? t?m quan trong vi?c c?p nh?t lin t?c ki?n th?c tin ti?n c?a th? gi?i trong ?i?u tr? ph?u thu?t t?i Vi?t nam ni chung v Vi?t ??c ni chung, ??t bi?t tnh chuyn mn ha su, nh? nh?ng c?p nh?t v? l?nh v?c ?i?u tr? v ph?u thu?t m b?nh vi?n Vi?t ??c ? c nh?ng l?nh v?c ngang t?m th? gi?i v khu v?c ???c b?n b qu?c t? ?nh gi cao.


H?i ngh? ? nghe 05 bi bo co v xem trnh di?n ph?u thu?t live surgery mang tnh ?o t?o c?p nh?t v nghin c?u t?ng k?t th?c ti?n chuyn ?? v? ph?u thu?t lc ??ng m?ch ch?, vim n?i tm m?ch nhi?m khu?n c?a cc chuyn gia trong v ngoi n??c, nhi?u tham lu?n ? ???c trao ??i t?i h?i ngh? r?t si n?i v h?u ch, V?i cc k?t qu? ph?u thu?t b?nh l lc ??ng m?ch ch? v vim n?i tm m?c nhi?m khu?n trong n??c ???c cc chuyn gia ?nh gi r?t cao v ?n t??ng.



??a ch? T?p ch Tim m?ch v Y h?c Tr?c tuy?n h?u ch

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Cc ?? ti bo co h?i ngh? tim m?ch v l?ng ng?c l?n th? III (Hu? 2010)

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L'intervention de Ross: reste-t-elle une option universelle?
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