食管癌NCCN指南2009中文版.doc

Esophageal CancerNCCN 临床肿瘤指南食管癌V.1.2009Guidelines IndexNCCNEsophageal CancerStaging, Discussion, Referencesin Oncology v.1.2009Practice GuidelinesEsophageal Table of ContentsNCCN 食管癌指南成员* Jaffer A. Ajani, MD/Chair The University of TexasM. D. Anderson Cancer CenterJames S. Barthel, MD H. Lee Moffitt Cancer Center & Research Institute* Tanios Bekaii-Saab, MD Arthur G . James Cancer Hospital &Richard J. Solove Research Institute atThe Ohio State UniversityDavid J. Bentrem, MD Robert H. Lurie Comprehensive CancerCenter of Northwestern UniversityThomas A. DAmico, MD Duke Comprehensive Cancer CenterCharles S. Fuchs, MD, MPH Dana-Farber/Brigham and Womens CancerCenterHans Gerdes, MD Memorial Sloan-Kettering Cancer CenterJames A. Hayman, MD, MBA University of Michigan Comprehensive Cancer CenterLisa Hazard, MD Huntsman Cancer Institute at the University of UtahDavid H. Ilson, MD, PhD Memorial Sloan-Kettering Cancer CenterLawrence R. Kleinberg, MD The Sidney Kimmel Comprehensive CancerCenter at Johns HopkinsMary Frances McAleer, MD, PhD The University of TexasM. D. Anderson Cancer CenterNeal J. Meropol, MD Fox Chase Cancer CenterMary F. Mulcahy, MD Robert H. Lurie ComprehensiveCancer Center of Northwestern UniversityMark B. Orringer, MD University of Michigan Comprehensive Cancer Center* Raymond U. Osarogiagbon, MD St. Jude Childrens Research Hospital/ University of Tennessee Cancer InstituteJames A. Posey, MD University of Alabama at BirminghamComprehensive Cancer CenterAaron R. Sasson, MD UNMC Eppley Cancer Center atThe Nebraska Medical CenterContinueWalter J. Scott, MD Fox Chase Cancer CenterStephen Shibata, MD City of HopeVivian E. M. Strong, MD Memorial Sloan-Kettering Cancer CenterStephen G. Swisher, MD The University of TexasM. D. Anderson Cancer CenterMary Kay Washington, MD, PhD Vanderbilt-Ingram Cancer CenterChristopher Willett, MD Duke Comprehensive Cancer CenterDouglas E. Wood, MD Fred Hutchinson Cancer ResearchCenter/Seattle Cancer Care AllianceCameron D. Wright, MD Massachusetts General Hospital* Gary Yang, MD Roswell Park Cancer Institute Medical oncology Gastroenterology Surgery/Surgical oncology Internal medicine Radiotherapy/Radiation oncology Hematology/Hematology oncology Pathology* Writing committee memberVersion 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.Practice GuidelinesEsophageal Table of Contents目录NCCN 食管癌指南成员 指南更新内容汇总流程和评价（-）体 格 健 康 ，可 切 除的Tis, T1-T4, N0-1, NX 或IVA 期(ESOPH-2) 手术结果（ESOPH-3）身体情况不适合手术，不可切除的，或不选择手术（ESOPH-4） 分期 讨论参考随访，复发与姑息治疗（-5）临床试验:远处转移癌（ESOPH-6）联合治疗原则（- A）外科原则 (ESOPH-B)系统治疗原则(ESOPH-C)放疗原则 (ESOPH-D)NCCN认为对任何肿瘤病人的最佳治疗是参与临床试验。参与临床试验是特别推荐的。最佳支持原则（ESOPH-E）指南索引打印指南Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.Practice GuidelinesEsophageal Table of Contents指南更新内容汇总Summary of changes in the 1.2009 version of the Esophageal Cancer guidelines from the 1.2008 version include:(ESOPH-1): Workup:Fourth Bullet: “SMA-12” was changed to “chemistry profile”.Fifth Bullet: Changed to “Chest/abdominal CT with contrast” (Also for ESOPH-2)Tenth Bullet: “PET/CT scan” was changed to “PET/CT (preferred) or PET scan.” (Also for ESOPH-2) Fourth Column, Top Branch: The panel added the Stage “Tis” after “Medically fit, resectable.”(ESOPH-2): “Discussion of patient in a multidiscplinary conference is desirable” was changed to “Multidisciplinary evaluation preferred”. The panel added a new column that denotes the following Stages and their recommendations:Tis or T1aT1b, N0, NXT1b, N1 or T2-T4, N0-1, NX or Stage IVA Footnotes “j” and “k” are new to the page.(ESOPH-3): Node negative; Adenocarcinoma: The panel added a new pathway for “Tis”. Under Postoperative Treatment for “Adenocarcinoma distal esophagus, GE junction”: The panel added “ECF if received preoperatively(category 1)”.(ESOPH-4): New pathway was added for “Tis or T1a”. Under Primary Treatment; Second Row: “50.4 Gy of RT.” was changed to 50-50.4 of RT.” The Best Supportive Care box recommendations were removed from the page. (ALSO for ESOPH-6)(ESOPH-5): Follow-up:Third Bullet: “Chest x-ray as indicated” was changed to “Imaging as clinically indicated”.Fifth Bullet: “Radiology and endoscopy as clinically indicated.” was changed to “Endoscopy, as clinically indicated.” withcorresponding new footnote “v” regarding Tis or T1a patients who undergo EMR.Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.UPDATES1 of 2Practice GuidelinesEsophageal Table of Contents指南更新内容汇总-继续(ESOPH-A): Principles of Multidisciplinary Team Approach Page Title: “Principles of Combined Modality Therapy” was changed to “Principles of Multidisciplinary Team Approach”. First Bullet: “Frequent meetings.are useful” was changed to “Frequent meetings.are encouraged”. Eighth Bullet: “.multidisciplinary meeting is a method.” was changed to “.multidisciplinary meeting is highly encouraged”.(ESOPH-B 1 of 3): Principles of Surgery Fifth Bullet: A new first arrow bullet was added regarding “Tis or T1a” tumors as well as corresponding references.(ESOPH-B 2 of 3): Principles of Surgery Last bullet was revised to include endoscopic mucosal resection, other ablative techniques, and experienced endoscopists.(ESOPH-C): Principles of Systemic Therapy “Docetaxel plus cisplatin (category 2B)” was added under Preoperative Chemoradiation and Definitive chemoradiation. After “Oxaliplatin plus fluoropyrimidine (5-FU or capecitabine),” the panel added a new footnote that states “Leucovorin or levoleucovorin is indicated with certain infusional 5-FU based regimens.” (This is for Preoperative chemoradiation, Definitive chemoradiation, and Metastatic or Locally advanced cancer) Metastatic or Locally advanced: “Paclitaxel-based regimen (category 2B)” was added.(ESOPH-D): Principles of Radiation Therapy Blocking: “.heart (1/3 of heart 40 GY.)” changed to “.heart (1/3 of heart 50 GY).”(ESOPH-E): Principles of Best Supportive Care “Principles of Best Supportive Care” is a new page that provides specific recommendations for esophageal cancer best supportive care throughout the guidelines. The new page replaces the “Best Supportive Care” box that was on pages ESOPH-4 and ESOPH-6.Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.UPDATES2 of 2Practice GuidelinesEsophageal Table of Contents流程临床分期附加表现(根据临床表现)体格健康, b可切除 c,dSee Primary 病史及体格检查 吞钡（可选） 如有可能，用食管胃十二指肠内窥镜检查整个上消化道 全血细胞计数和生化检查 胸腹部增强扫描 如肿瘤位于隆突水平或以上，且无远处转移（）证据，行支气管镜检查如无远处转移证据，行内窥镜超声检查，如发现淋巴结，行细针穿刺活检 如无远处转移证据且肿瘤位于贲门处，可选用腹腔镜检查通过活检证实可疑远处转移癌 如无远处转移证据，行扫描（推荐）或 PET 扫描， 期（局限性 癌肿） IVB期远处转移癌 鼓励多学科评价 (腹腔阳性病变者必须应用) 营养状态评价(术前营养支持可考虑鼻饲或J管 不推荐PEG) 如果计划用结肠替代食管或作旁路，行钡剂灌肠或结肠镜检查 如用结肠代食管，行动脉造影（可选择）Tis, T1T4, e N0-1, NX, 或 IVA期 d,f体格情况不适合手术, 不可切除的 T4, g 不可切除的 IVA期 h 或 病人可耐受放化疗而不选择手术不可手术且病人不能耐受放化疗远处转移癌Treatment(ESOPH-2)参见主要治疗 (ESOPH-4)参见主要治疗 (ESOPH-4)参见姑息治疗 (ESOPH-6)a癌肿位于贲门部者，腹腔淋巴结受累仍可考虑综合治疗b身体情况可以耐受腹部和或胸部手术。c对颈段食管癌而言，放化疗更为适宜。.d参见外科原则（ESOPH-B).e可切除的：胸膜、心包或膈肌受累；即使有区域淋巴结转移，-也是可切除的。f可切除的：可切除腹腔淋巴结，无腹腔动脉、主动脉或其它器官受累及。g不可切除的：主动脉、气管、心脏、大血管受侵、食管气管瘘。h不可切除的：不可切除腹腔淋巴结，累及腹腔动脉、主动脉或其它器官。Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.ESOPH-1Practice GuidelinesEsophageal Table of Contents体格健康, b 可切除 Tis，T1T4, e N0-1, NX, 或IVA d,f首选多学科评估i分期Tis 或T1aT1b, N0, NX主要治疗内镜下粘膜切除术(EMR) j 或消融 j,k 或食管切除术 d食管切除术 c,d,l,m(对T1b 期优先)食管末端腺癌及胃-食管交界处癌行术前化疗n附加/辅助治疗手术参见食管切除术后手术结果(ESOPH-3)T1b, N1根治性放化疗 n,o观察/姑息手术 (可选)食管切除术d,l或 T2-T4,N0-1,NX 或IVA期术前放化疗 n,o: RT, 50-50.4 Gy+ 同步化疗 增强CT扫描 PET/CT(推荐) 或 PET 扫描 (证据级别 2B) 上消化道内窥镜 p(可选)无病变证据仅局部病变持续存在无远处转移不可切除或远处转移(推荐)或观察 (证据级别 2B) 食管切除术 d,l如果可切除(推荐)或姑息治疗, 包括化疗 n姑息化疗 n和/或最佳支持治疗 q参见食管切除术后手术结果(ESOPH-3)b身体情况可以耐受腹部和或胸部手术.c 对颈段食管癌而言，放化疗更为适宜.d 参见外科原则（-B）。e 可切除的：胸膜、心包或膈肌受累；即使有区域淋巴结转移，-也是可切除的.f 可切除的：可切除腹腔淋巴结，无腹腔动脉、主动脉或其它器官受累及.i 参见多学科协作治疗 (ESOPH-A).j 可能应用于 Tis 或T1a, 定义为肿瘤侵犯粘膜, 但不侵犯粘膜下层.Note: All recommendations are category 2A unless otherwise indicated.k消融可以通过各种技术实现，包括光动力治疗，应用光敏剂（如photophrin）。l经膈或经胸或微创，推荐胃重建。m术后营养支持一般推荐采用空肠造口。n参见系统治疗原则（-）。o参见放疗原则（-）。p评估周，内镜活检及刷检。q 参见最佳支持治疗(ESOPH-E).Follow-upClinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.(See ESOPH-5)Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.ESOPH-2Practice GuidelinesEsophageal Table of Contents食管切除术后结果/临床病理发现腺癌TisT1, N0T2, N0术后治疗观察观察观察 或选择合适的病人 u放化疗 n,o,t(氟嘧啶为主) 淋巴结阴性T3, N0 s放化疗 n,o,t(氟嘧啶为主) tR0切除 rR1 切除 r淋巴结阳性鳞癌上中段食管癌下段食管癌、贲门癌观察观察或放化疗 n,o,t(氟嘧啶为主) (证据级别2B) 放化疗 n,o,t(氟嘧啶为主)或ECF 如果接受手术前(证据级别 1)放化疗 n,o,t(氟嘧啶为主)R2 切除 rN参见系统治疗原则 (ESOPH-C).o 参加放疗原则(ESOPH-D).r切缘没有癌，镜下癌残留，肉眼可见癌残留或。s观察未见贲门肿瘤。.t术前未接受放化疗，术后可接受放化疗。放化疗 n,o,t(氟嘧啶为主) 或姑息治疗 (参见ESOPH-6)u用于风险高的病人，如组织学低分化、淋巴管受侵、神经血管受侵或年轻患者。限于低位食管或贲门癌患者。Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.Follow-up(See ESOPH-5)Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.ESOPH-3Practice GuidelinesEsophageal Table of Contents主要治疗Tis 或 T1aEMR 或其他烧灼技术 或最佳支持治疗 q身体情况不适合手术, 不可切除的 T4, g 不可切除的IVA期 h或病人可耐受化疗而不愿意手术50-50.4 Gy of RT + 同期化疗(氟嘧啶为主) (推荐) n,o或 化疗 n 或最佳支持治疗 q身体情况不适合手术且病人不能耐受化疗最佳支持治疗 qg不可切除的：主动脉、气管、心脏、大血管受侵、食管气管瘘。h不可切除的：不可切除腹腔淋巴结，累及腹腔动脉、主动脉或其它器官。n 参见系统治疗原则(ESOPH-C).o 参见放疗原则(ESOPH-D).q 参见最佳支持治疗(ESOPH-E).Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.ESOPH-4Practice GuidelinesEsophageal Table of Contents随访复发姑息治疗 如无症状: 病史和体格检查 每四个月一次，持续一年，然后没六个月一次，持续两年，以后每年一次 根据临床需要查血生化和全血细胞计数 根据临床需要行影像学检查 对临床有表现的吻合口狭窄行内窥镜检查 v 营养咨询仅局部复发: 既往行手术而未行放化疗可切除 d 且身体可耐受手术食管复发: (既往行放化疗而未行手术治疗)不可切除 d 或身体情况不可手术同期放化疗 n,o (氟嘧啶为主) 推荐和/或最佳支持治疗 q或手术或化疗 n姑息手术 d复发参见姑息治疗(ESOPH-6)复发, 参见姑息治疗 (ESOPH-6)参见姑息治疗 (ESOPH-6)d 参见手术原则 (ESOPH-B).远处转移癌n 参见系统治疗原则(ESOPH-C). o 参见放疗原则(ESOPH-D). q参见最佳支持治疗(ESOPH-E).v Tis或T1期接受EMR或其他烧灼治疗的患者，必须每3个月行内镜检查，持续1年，之后每年一次。Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.ESOPH-5Practice GuidelinesEsophageal Table of Contents姑息治疗Karnofsky 评分60 %orECOG 评分 2化疗 n,w和/或最佳支持治疗 q远处转移癌Karnofsky 评分 60 %orECOG 评分3最佳支持治疗qn 参见系统治疗原则 (ESOPH-C).q 参见最佳支持治疗原则(ESOPH-E).w进一步治疗须根据连续个疗程后病人的身体状态和临床有效率。Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.ESOPH-6Practice GuidelinesEsophageal Table of Contents多学科协作治疗胃、食管癌原则级证据支持联合治疗模式有益于局限性胃、食管癌病人。专家小组坚信，任何关注这部分病人的各个学科作出的单一治疗的决定都遭受挫败。具备下列因素，局限性胃食管癌联合治疗模式可得到理想的推广： 相关机构和来自各个学科的个体，在规律的基础上，致力于对病人详细数据的联合考查。常规会议（次周或次周）是鼓励的。 每次会议，应鼓励相关学科参加，包括肿瘤外科学，肿瘤内科学，胃肠外科学，肿瘤放射学，放射学，病理学。除此之外，营养服务、社会工作者、护士和其他支持这一原则的人员的参加也是必要的。 充分分期完成后，所有长期治疗策略均可得到开展，但是，理论上优先于可给予的任何治疗方法。 对于作出完整的治疗方案，联合考查病人的实际医疗数据比阅读文献报道更有用。 由多学科小组为个别病人作出一致建议的简要资料是有用的。 由多学科小组制定的建议可供特定病人的主要治疗小组的医师咨询。 入选病人治疗效果的回顾，对于整个治疗小组是另一个有益的教育方法。 多学科会议过程中，周期性组织相关文献的回顾，对整个治疗小组是非常鼓励的。Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.Version 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.ESOPH-APractice GuidelinesEsophageal Table of Contents外科原则 (1 of 3) 在手术之前，对所有病人都应该评估其生理状况能否接受食管切除。 1 在手术之前应该根据内镜超声、胸腹部和-进行临床分期，以评估可切除性（推荐）。 接受食管切除手术的病人应该是生理状况较适宜，癌肿较局限可切除，位于胸段食管（距会厌超过）与腹内段的食管。 颈段食管癌或胸段食管癌距会厌不超过者，应接受根治性放化疗。 可切除的胸段食管癌（距会厌超过）或贲门癌：Tis 或 T1a, 定义为肿瘤侵犯粘膜但不侵犯粘膜下层, 可考虑EMR, 其他烧灼技术, 或在有经验的中心行食管切除术. 位于粘膜下层或更深的肿瘤需手术治疗. 2,3,4,5,6,7-，肿瘤可切除，即使有区域淋巴结转移（），肿瘤仅累及心包、胸膜或膈肌者是可切除的。可切除的期：病变位于低位食管，腹腔淋巴结可切除且腹腔动脉、主动脉或其它器官未被累及。 不可切除的食管癌:，肿瘤累及心脏、大血管、气管或临近器官，包括肝脏、胰腺、肺和脾脏，是不可切除的。不可切除的期：癌肿位于低位食管，腹腔淋巴结不可切除且腹腔动脉、主动脉或其它器官包括肝脏、胰腺、肺和脾脏被累及。不可切除的期：远处转移或非区域淋巴结转移。 手术方式取决于外科医生的经验和习惯以及病人的意愿。Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.下页继续ESOPH-BVersion 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.(1 of 3)Practice GuidelinesEsophageal Table of Contents手术原则 (2 of 3) 胸段食管癌或贲门癌（距会厌超过）可选择的手术方式：:右侧或左侧开胸，胸部或颈部吻合经膈肌裂孔，颈部吻合微创，颈部或胸部吻合8 可选择的食管替代器官:胃（推荐）结肠小段空肠长段空肠微血管吻合，费用过高（激烈争议） 可接受的淋巴结清扫: 9标准扩大 (En-Bloc)应该切除至少个淋巴结以得到充分的淋巴结分期。术前放化疗后的最适度淋巴结数目是未知的。在根治性放化疗后出现食管局部可切除的复发病灶的病人，如果没有远处转移，可以考虑姑息性手术治疗10 食管切除术、内镜下粘膜切除术、其他烧灼技术应该在高水平的医疗中心由有经验的医师进行。11,12Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.参考文献见下页ESOPH-BVersion 1.2009, 08/07/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.(2 of 3)Practice GuidelinesEsophageal Table of Contents外科原则 (3 of 3)参考文献1 Steyerberg EW, Neville BA, Kopper LB, Lemmens VE, et al. Su