台北荣总肺癌诊疗共识V10 2009.ppt

台北榮總肺癌診療共識v.1.02009,台北榮總肺癌團隊revisedon2009/04/13releasedon2009/05/04,台北榮總肺癌診療共識,multidisciplinaryteamtaipeivghlungcancerpanelmemberstnmstagingtaipeivghsupplementtotnmstagingtableofstagegroupingevaluationandtreatmentstageo(tis)stagei(t1-2,n0)andstageii(t1-2,n1)stageiib(t3,n0)andstageiiia(t3,n1)stageiiia(t1-3,n3)andstageiiib(t4,n0-1)stageiiib(t1-3,n3)stageiiib(t4,n2-3)(t4:pleuraleffusionorpericardialeffusion)stageiv(m1:solitarysiteordisseminated)surveillancetherapyforrecurrenceandmetastasesoccult(tx,n0,m0),evaluationandtreatmentsecondlungprimary,evaluation,andtreatment,principlesofsurgicalresectionprinciplesofpathologyprinciplesofradiationtherapy-recommendedradiationdoses-dosevolumedataforradiationpneumonitisprinciplesofccrtprinciplesofchemotherapy-non-smallcelllungcancer-smallcelllungcanceradjuvantchemotherapyneoadjuvantchemotherapyclinicaltrialsforadvanced/metastaticnsclctrachealcancerreferences關於此臨床指引：肺癌的診療仍在發展階段，本指引主要在呈現目前肺癌診療的進展與共識，醫師應鼓勵病患參與臨床試驗，使其有機會得到最好的治療。在本指引中的化療用藥建議是基於現有的臨床證據，和目前的衛生署或健保局規定無關。,癌委會,胸內,核心成員,召集人：蔡俊明、許文虎副召集人：賴信良、吳玉琮,肺癌委員會暨肺癌多專科團隊,非核心成員,胸外,放射,病理,骨科,核醫,社工,營養,放療,台北榮總肺癌委員會暨肺癌多專科團隊組織架構,藥劑部,個案管理師：宋易珍,台北榮總肺癌多專科團隊核心人員,胸腔內科,陳育民,賴信良,李毓芹,蔡俊明,胸外,吳玉琮,許文虎,放射,吳美翰,許明輝,病理,林可瀚,周德盈,放療,陳一瑋,顏上惠,邱昭華,陳俊谷,核醫,王世楨,nsclctnmstaging,lababede,o.etal.chest1999;115:233-235,cliftonf.mountain,chest1997,regionallymphnodeclassificationforlungcancerstaging,-extendedmediastinoscopy-mediastinotomy-vats,-eus-fna-vats,-ebus-tbna-vats(limitedto10and11),-mediastinoscopyeus-fnaebus-tbnavats,-mediastinoscopy;eus-fna,ebus-tbna,n1=ipisilateralhilarnodesn2=subcarinal,ipisilateralmediastinalnodesn3=contralateralhilar/mediastinal,orsupraclavicularorscalenenodes,howtoapproach,eus:endoscopicultrasound;ebus:endobronchoscopicultrasound;fna:fineneedleaspiration;tbna:transbronchoscopicneedleaspiration;vats:videoassistedthoracoscopicsurgery,summaryofevaluationandtreatment,pft:necessaryforalloperablestagespet(pet/ct):recommendforallclinicalstages,exceptwetiiiborstageivwithdisseminatem1mediastinoscopy:recommendforallclinicalstages,exceptperipheralt1n0wetiiiborstageivwithdisseminatem1p.s.n2orn3diseasecanbeconfirmedbyothermethodsincludingmediastinotomy,thoracoscopy,ebus-fna,eus-fna,ct-guided-fna,supraclaviclelnbiopsybrainmri:recommendforallclinicalstages,exceptstageiwetiiiborstageivwithdisseminatem1,正子掃描（pet/ctscan）：肺癌clinicalstage的pre-treamentworkup，至於安排時間點是在胸腔電腦斷層（chest-ct）後。除非chestct或petscan都無縱膈腔異常發現且主要病灶在週邊(peripheralialesion)可以不做縱膈腔鏡外，否則縱膈腔鏡仍是評估縱膈腔淋巴結的goldstandardbrainmri取代brainct建議在clinicalstageii及stageiii以上的病人安排。術中病理檢查若有r1(microscopicresidualtumor)或r2(macroscopicresidualtumor)，應視實際情形考慮reresection/（+chemotherapy）或是chemoradiation/（+chemotherapy）。,nscl-1,fromnccnguideline,v.2.2009,nscl-2,fromnccnguideline,v.2.2009,nscl-3,fromnccnguideline,v.2.2009,nscl-4,fromnccnguideline,v.2.2009,nscl-5,fromnccnguideline,v.2.2009,nscl-6,fromnccnguideline,v.2.2009,nscl-7,fromnccnguideline,v.2.2009,nscl-8,fromnccnguideline,v.2.2009,nscl-9,fromnccnguideline,v.2.2009,nscl-10,fromnccnguideline,v.2.2009,nscl-11,fromnccnguideline,v.2.2009,nscl-12,fromnccnguideline,v.2.2009,nscl-13,gefitiniborerlotinib(ifcriteriamet)z(2b),gefitiniborerlotinib(ifcriteriamet)z(2b),(2b),(2b),zcriteriafortreatmentwithgefitinib(ipasstrial):adenocarcinoma,non-smokerorlightex-smoker(quit15yrsand10pack-yearsorfewer)nopre-existingidiopathicpulmonaryfibrosisbyevidenceonchestct,fromnccnguideline,v.2.2009,nscl-14,fromnccnguideline,v.2.2009,nscl-15,orgefitinib,orgefitinib,gefitinibanderlotinibin2nd-linetherapy:adenocarcinomagefitnibin3rd-linetherapy:adenocarcinoma;erlotinibin3rd-linetherapy:nsclc,fromnccnguideline,v.2.2009,principlesofsurgicalresection,非緊急狀況下，術前所需影像學檢查應完備。是否可切除(resectablility)之決定建議應由有經驗之胸腔外科醫師來決定。如生理狀況許可(physiologicallyfeasible)，應採取lobectomy或pneumonectomy。如生理狀況受限制(physiologicallycompromised)，應採局部切除(limitedresection-segmentectomyorwedgeresection)。在不違背標準腫瘤手術原則下，可採用vats(video-assistedthoracicsurgery)。,principlesofsurgicalresection,n1determinetheextentofinvasion;establishthestatusofcancerinvolvementofsurgicalmargins;determinethemolecularabnormalitiestopredictforresponsetoegfr-tki。手術病理報告應該有who肺癌組織分類。purebronchioloalveolarcarcinoma(bac)應無stroma、pleura與lymphaticspaces之侵犯。免疫染色:non-mucinousbac=ttf-1(+)/ck7(+)/ck20(-);mucinousbac=ttf-1(-)/ck7(+)/ck20(+)。免疫染色可幫助鑑別原發或轉移肺腺癌，區別腺癌及惡性間皮細胞癌，決定腫瘤之神經內分泌分化。egfr:epidermalgrowthfactorreceptortki:tyrosinekinaseinhibitorttf-1:thyroidtranscriptionfactor-1,principlesofpathologicalreview,ttf-1對區分原發或轉移肺腺癌很重要。大部分原發肺腺癌ttf-1為陽性，轉移腺癌(甲狀腺癌除外)為陰性反應。primarylungadenocarcinoma:ttf-1(+)/ck7(+)/ck20(-)/cdx-2(-)metastaticcolorectalcarcinoma:ttf-1(-)/ck7(-)/ck20(+)/cdx-2(+)egfrmutation之有無與tki治療之反應相關；如tki對exon19deletion之腫瘤治療效果良好。k-ras與吸煙相關；k-ras與egfrmutation為mutuallyexclusive；有k-rasmutation對tki治療效果不佳。小細胞癌多數(95%)原發自肺，少數則來自肺外器官，二者有類似之臨床和生物特性，極易廣泛轉移。小細胞癌細胞通常keratin及至少一種之neuroendocrinedifferentiationmarkers(cd56,synaptophysin或chromogranina)呈陽性免疫染色。,3dconformaltechnique,按2009年nccnguideline的精神，其所建議的放射治療已非傳統二次元定位的方式，而是因應放射治療技術的進步，以電腦斷層評估腫瘤的位置、體積和淋巴結引流的三次元定位方式，來決定照射的角度、劑量和範圍。美國nccn所建議的放射照射劑量並不完全適用於國人，本共識以依國內病人狀況要做適度的調整。,recommendedradiationdosesfornsclc(modifieddosesfordomesticpatients),dosevolumedataforradiationpneumonitis(modifiedfordomesticpatients),mld-meanlungdose,lp:percentageoflungthatreceivedradiation(gy),同步化學併放射治療(ccrt)原則,nsclcdose:upto60-66gy/1.8-2gy/daylimitedsclc1.年齡小於等於70歲，ps：01，接受ccrtdose：5060gy/1.8gy/day排程：放療自開始持續做至5060gy，而化學治療自開始先做三個療程後休息，須重新評估病患治療反應，之後再依實際情形安排接續的治療。如有cr加做预防性全腦放射治療(prophylacticcranialirradiation,pci)dose：30gy/2gy/dayx15fractions(一天一次共十五次）如有pr持續化學治療，但不做pci2.年齡大於70歲，ps：01，採用接續性化放療(sequentialchemoradiotherapy)dose：5060gy/1.8gy/day排程：連續的三個療程的化學治療後休息，在二週內重新評估如有cr加做pci,dose：30gy/2gy/dayx15fractions(一天一次共十五次）如有pr加做胸腔的放療及三個療程的化學治療，但不做pci3.如有pd接受第二線化療。,肺癌化學治療用藥準則非小細胞肺癌,第一線-gemcitabine(gc-g)g(1000-1250mg/m2)+cisplatin(60-75mg/m2),q3-4w.-vinorelbine(nc-n)vinorelbine(25-30mg/m2i.v.or60-80mg/m2p.o.)+cisplatin(60-75mg/m2),q3-4w.-paclitaxel(tacortac-ta-ta)1.paclitaxel(160-175mg/m2)-d1+cisplatin(60-75mg/m2)-d1,q3w.2.paclitaxel(60-80mg/m2)-d1,8,15+cisplatin(60-75mg/m2)-d1,q4w.-docetaxel(tcortc-t)1.docetaxel(60-75mg/m2)-d1+cisplatin(60-75mg/m2)-d1,q3w.2.docetaxel(30-35mg/m2)-d1,8+cisplatin(60-75mg/m2)-d1,q3w.備註:1.elderlyorpoorperformancestatus：cisplatinomited2.cisplatin若改成carboplatin,劑量為(ccr+25)xauc,auc=4-63.bevacizumab7.5mg/kg可與gemcitabine/cisplatin或paclitaxel/carboplatin可並用於第一線化學治療(2b)4.gefitinib可用於第一線治療,ifadenocarcinoma,non-smokerorlightex-smoker(quit15yrsand10pack-yearsorfewer)andnopre-existingidiopathicpulmonaryfibrosisbyevidenceonchestct(2b)5.pemetrexate/cisplatin可用於第一線化學治療innon-squamous(2b),第二線-docetaxel1.docetaxel(60-75mg/m2)-d1,q3w.2.docetaxel(30-35mg/m2)-d1,8,q3w.-pemetrexed(500mg/m2)-d1,q3w.-gefitinib250mg,qd.(ifadeno)-erlotinib150mg,qd.(ifadeno)第三線-gefitinib250mg,qd.(ifadeno)-erlotinib150mg,qd(ifnsclc),*病患若參加本院irb同意之臨床試驗，則依該臨床試驗之治療計畫進行,肺癌化學治療用藥準則小細胞肺癌（臨床試驗病例除外）,standardregimens(pvp):1.cisplatin(60-75mg/m2)+vp-16(60-80mg/m2)d1,2,3/q3w2.carboplatin(auc=5)d1+vp-16(60-80mg/m2)d1,2,3/q3wrelapsedregimens:1.ifosfamide1000mg/m2d1-3+oralvp1650mgd1-10/q3w2.topotecan1.5mg/m2d1-3+epirubicin30mg/m2d1/q3w,chemotherapyregimensforadjuvanttherapy-cisplatinbase,chemotherapyregimensforadjuvanttherapy-alternative,cisplatin若改成carboplatin,劑量為(ccr+25)xauc,auc=4-6,*palitaxel+carboplatinregimenshowednosurvivalbenefitinstageibpatients,staging,proposedtnmclassificationandstagingforprimarytrachealcarcinoma*,primarytrachealcancer,*ref:paolomacchiarini,lancetoncol2006;7:8391,honcologist1997;2;245-253,b,primarytrachealcancer,medicallyfitforsurgery,resectable,primarytreatment,surgery,adjunctive/adjuvanttreatment,radiation,completeresection(r0):50gyovertumorbedandadjacentmediastinumincompleteresectionwithresidualmarginr1:r2:60gyovertumorbedand50gyoveradjacentmediastinum,a,amedicallyabletotoleratemajorthoracicsurgerycr0=nocanceratresectionmargins,r1=microscopicresidualcancer,r2=macroscopicresidualcancer,trach-1,c,c,primarytrachealcancer,medicalunfitforsurgery,orunresectable,orsurgerynotelectedandpatientmedicallyabletotoleratechemotherapy,medicalunfitforsurgeryandpatientunabletotoleratechemotherapy,rt,60gy+concurrentchemotherapy(cis