《肺癌的诊治指南》PPT课件

肺癌的诊治指南,南京大学医学院附属南京鼓楼医院肿瘤内科乐翔,肺癌的诊治指南,肺癌的诊断肺癌的临床诊断肺癌的组织病理学诊断肺癌的病期诊断小细胞肺癌的病期诊断非小细胞肺癌的病期诊断肺癌的治疗小细胞肺癌的治疗方法和原则非小细胞肺癌的治疗方法和原则,肺癌的诊断-临床诊断,病史采集和完整体检肺癌肺内临床表现咳嗽（刺激性、持续性）咳痰（粘液痰、粘液性脓痰）咯血（痰中夹血、血痰、大咯血）胸闷气促（支气管狭窄、心胸腔积液、换气功能下降引起）哮鸣,专一性检查和组织细胞病理学检查初步筛查胸正侧位片血常规项痰细胞血检查,肺癌的诊断-临床诊断,肺癌局部侵润扩展的临床表现（1）胸疼（侵犯胸膜、肋骨、脊柱、大气管、食道）呼吸困难（上呼吸道狭窄-吸气性，呼吸面积减少-混合性，心包积液-心源性贫血，大咯血-血源性）胸腔积液（侵犯胸膜-周围型；淋巴引流受阻-中央型）,肺癌疑诊检查胸部螺旋CT增强扫描心包腔，胸腔积液超声定位（需要时）积液细胞血检查,肺癌的诊断-临床诊断,肺癌局部侵润扩展的临床表现（2）声音嘶哑：喉返神经受侵同侧膈肌麻痹：同侧膈神经受侵吞咽困难；食道受压心包填塞，心律失常：心包心脏受侵上腔静脉综合症：上纵隔淋巴结受侵Pancoast综合症：肺尖部肿瘤侵润肩背部剧疼：局部肌肉神经受侵腋窝肌肉萎缩：局部肌肉神经受侵同侧Horner症：侵犯颈交感神经和臂从神经,肺癌疑诊检查支气管镜检查，细胞学检查纵隔镜检查（需要时）组织学检查，免疫组化检查,肺癌的诊断-临床诊断,肺癌远处转移的临床表现体表淋巴结肿大（锁骨上淋巴结、前斜角肌区脂肪垫、腋下淋巴结、皮下结节）脑转移（颅高压-头疼、呕吐、视物不清；局灶性癫痫、偏瘫、失语、脑膜刺激症）腹腔脏器转移：肝：疼痛、厌食、黄疸、腹水、肝源性低血糖胰：胰腺炎表现、阻塞性黄疸、高血糖肾上腺、腹膜后淋巴结：一般无症状肾：肾积水，血尿骨；脊柱转移：疼痛，截瘫，大小便失禁肢体骨：疼痛，骨折,肺癌病期诊断浅表淋病结活检或穿刺腹部螺旋CT增强扫描或B超声波脊柱、MRI肢体骨、X摄片或CT、MRI肝肾功能、电解质骨髓细胞血或活检检查、腰椎穿刺ECT骨扫描，PET,肺癌的诊断-临床诊断,肺癌的副综合症（SCLC多见）内分泌系统Cushing综合征抗利尿激素分泌异常综合症高钙血症（肺鳞癌多见）男性乳腺发育类癌综合症神经肌肉系统小脑皮质变性周围神经病变癌性肌病等皮肤皮肌炎黑棘皮病等骨骼系统肺源性骨关节病（肺腺癌多见）,相应检查鉴别诊断24h17-羟皮质醇20mg24h尿钠200mg血钙波动在增高的20%左右尿5羟吲哚乙酸定性,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的病期诊断-小细胞肺癌,小细胞肺癌的分期VA分期：美国荣总医院肺癌研究组年制定,肺癌的病期诊断-非小细胞肺癌（1）,1997年非小细胞肺癌国际分期修订本中TNM的概念,肺癌的病期诊断-非小细胞肺癌（2）,1997年非小细胞肺癌国际分期修订本中TNM的概念,肺癌的病期诊断-非小细胞肺癌（3）,1997年非小细胞肺癌国际分期修订本中TNM的概念,肺癌的病期诊断-非小细胞肺癌(4),1997年非小细胞肺癌国际分期修订本中TNM的概念,肺癌的病期诊断-非小细胞肺癌(5),1997年非小细胞肺癌国际分期修订本中TNM的概念注年公布的肺癌国际分期，在T和M定义上与年的分期基本一致，但有下述三点的修改：在原发肿瘤所在的叶内出现癌性卫星结节定义为T4；在其他叶出现的癌性结节包括粟粒样病灶定义为M1；心包积液的定义原则等同于胸腔积液。,肺癌的病期诊断-非小细胞肺癌(6),1997年非小细胞肺癌国际分期修订本中TNM的概念,肺癌的病期诊断-非小细胞肺癌(6),小细胞肺癌的治疗原则和方法（1）,小细胞肺癌的治疗方法,小细胞肺癌的治疗原则和方法（2）,小细胞肺癌的治疗原则和效果+同时；序贯；/选择其一,NCIguideline:TreatmentofLDSCLC,Standardtreatmentoptions:1.Combinationchemotherapywithchestirradiation(withorwithoutPCIgiventopatientswithcompleteresponses):EC:etoposide+cisplatin+4500cGychestradiationtherapy.2.Combinationchemotherapy(withorwithoutPCIinpatientswithcompleteresponses),especiallyinpatientswithimpairedpulmonaryfunctionorpoorperformancestatus.3.Surgicalresectionfollowedbychemotherapyorchemotherapypluschestradiationtherapy(withorwithoutPCIinpatientswithcompleteresponses)forpatientswithstageIdisease.,NCIguideline:TreatmentofEDSCLC(1),CombinationchemotherapywithoneofthefollowingregimenswithorwithoutPCIgiventopatientswithcompleteresponses:Thefollowingregimensproducesimilarsurvivaloutcomes:CAV:cyclophosphamide+doxorubicin+vincristine.26,27CAE:cyclophosphamide+doxorubicin+etoposide.28EPorEC:etoposide+cisplatinorcarboplatin.29,30ICE:ifosfamide+carboplatin+etoposide.31,NCIguideline:TreatmentofEDSCLC(2),Otherregimensappeartoproducesimilarsurvivaloutcomesbuthavebeenstudiedlessextensivelyorareinlesscommonuse,including:Cyclophosphamide+doxorubicin+etoposide+vincristine.32CEV:cyclophosphamide+etoposide+vincristine.33Single-agentetoposide.21PET:cisplatin+etoposide+paclitaxel.34,NCIguideline:TreatmentofEDSCLC(3),2.Radiationtherapytositesofmetastaticdiseaseunlikelytobeimmediatelypalliatedbychemotherapy,especiallybrain,epidural,andbonemetastases.,NCIguideline:TreatmentofEDSCLC(4),3.Identificationofeffectivenewagentsisdifficultinpatientswhohavepreviouslybeentreatedwithstandardchemotherapybecauseresponseratestoagents,evenofknownefficacy,areknowntobelowerthaninpreviouslyuntreatedpatients.Thissituationledtothesuggestionthatpatientswithextensivediseasewhoaremedicallystablebetreatedwithnewagentsunderevaluation,withprovisionsforearlychangetostandardcombinationtherapyifthereisnoresponse.35Suchastrategyhasbeenshowntobefeasible,withsurvivalcomparabletosurvivalwithinitialstandardtherapy,aslongasthepatientswithextensivediseasearecarefullychosen.36-38Avarietyofotherstrategieshavebeenproposed,dependingontheactivityofthenewagentinothertumors,inpreclinicalsmallcelllungcancermodels,ortheactivityofdruganalogs.39Activesingleagentsundergoingfurtherevaluationincludepaclitaxelandtopotecan.40,41,非小细胞肺癌的治疗原则和方法（1）,非小细胞肺癌的治疗方法,非小细胞肺癌的治疗原则和方法（2）,非小细胞肺癌的治疗原则和疗效注：+同时；序贯；/选择其中之一,非小细胞肺癌的治疗原则和方法（3）,非小细胞肺癌的治疗原则和疗效注：+同时；序贯；/选择其中之一,非小细胞肺癌的治疗原则和方法（4）,非小细胞肺癌的治疗原则和疗效,注：+同时；序贯；/选择其中之一,NCIGuidelineofNSCLCTreatmentofoccultlungcancer(Tx,N0,M0),Inoccultlungcancer,adiagnosticevaluationoftenincludeschestx-rayandselectivebronchoscopywithclosefollow-up(e.g.,computedtomographicscan),whenneeded,todefinethesiteandnatureoftheprimarytumor;tumorsdiscoveredinthisfashionaregenerallyearlystageandcurablebysurgery.Afterdiscoveryoftheprimarytumor,treatmentisdeterminedbyestablishingthestageofthepatientstumor.Therapyisidenticaltothatrecommendedforothernon-smallcelllungcancerpatientswithsimilarstagedisease.,NCIGuidelineofNSCLCTreatmentofstage0(Tis,N0,M0),Standardtreatmentoptions:Surgicalresectionusingtheleastextensivetechniquepossible(segmentectomyorwedgeresection)topreservemaximumnormalpulmonarytissuesincethesepatientsareathighriskforsecondlungcancers.Endoscopicphotodynamictherapy.2,3,NCIGuidelineofNSCLCTreatmentofstage(T1-2,N0,M0),Standardtreatmentoptions:Lobectomyorsegmental,wedge,orsleeveresectionasappropriate.Radiationtherapywithcurativeintent(forpotentiallyresectablepatientswhohavemedicalcontraindicationstosurgery).Clinicaltrialsofadjuvantchemotherapyfollowingresection.14,15Adjuvantchemopreventiontrials.12,13,16Endoscopicphotodynamictherapy(underclinicalevaluationinhighlyselectedT1,N0,M0patients).17,NCIGuidelineofNSCLCTreatmentofstage(T1-2N1M0,T3N0M0,),Standardtreatmentoptions:Lobectomy;pneumonectomy;orsegmental,wedge,orsleeveresectionasappropriate.Radiationtherapywithcurativeintent(forpotentiallyoperablepatientswhohavemedicalcontraindicationstosurgery).Clinicaltrialsofadjuvantchemotherapywithorwithoutothermodalitiesfollowingcurativesurgery.10Clinicaltrialsofradiationtherapyfollowingcurativesurgery.10,NCIGuidelineofNSCLCTreatmentofstageA(T1-3N2M0,T3N1M0,),Standardtreatmentoptions:Surgeryaloneinoperablepatientswithoutbulkylymphadenopathy.22-24Radiationtherapyalone,forpatientswhoarenotsuitableforneoadjuvantchemotherapyplussurgery.1,2Chemotherapycombinedwithothermodalities.4-6,12,NCIGuidelineofNSCLCTreatmentofstageA(T1-3N2M0,T3N1M0,),Superiorsulcustumor(T3,N0orN1,M0)Standardtreatmentoptions:Radiationtherapyandsurgery.Radiationtherapyalone.Surgeryalone(selectedcases).Chemotherapycombinedwithothermodalities.Clinicaltrialsofcombinedmodalitytherapy.Concurrentchemotherapyandradiationtherapyfollowedbysurgerymayprovidethebestoutcome,particularlyforpatientswithT4,N0orN1disease.26Levelofevidence:3iiiDi,NCIGuidelineofNSCLCTreatmentofstageA(T1-3N2M0,T3N1M0,),Chestwalltumor(T3,N0orN1,M0)Standardtreatmentoptions:Surgery.24,27Surgeryandradiationtherapy.Radiationtherapyalone.Chemotherapycombinedwithothermodalities.,NCIGuidelineofNSCLCTreatmentofstageB(anyTN3M0,T4anyNM0,),Standardtreatmentoptions:Radiationtherapyalone.7Chemotherapycombinedwithradiationtherapy.1-3,9Chemotherapyandconcurrentradiationtherapyfollowedbyresection.13,14Chemotherapyalone.,NCIGuidelineofNSCLCTreatmentofstage(anyT,anyN,M1,),Standardtreatmentoptions:(1)1.External-beamradiationtherapy,primarilyforpalliativereliefoflocalsymptomatictumorgrowth.2.Chemotherapy.Thefollowingregimensareassociatedwithsimilarsurvivaloutcomes:Cisplatinplusvinblastineplusmitomycin.14Cisplatinplusvinorelbine.3,15Cisplatinpluspaclitaxel.6,9Cisplatinplusdocetaxel.9,16Cisplatinplusgemcitabine.9,17Carboplatinpluspaclitaxel.5,9,15,NCIGuidelineofNSCLCTreatmentofstage(anyT,anyN,M1,),Standardtreatmentoptions:(2)3.Clinicaltrialsevaluatingtheroleofnewchemotherapyregimensandothersystemicagents.Initialresultssuggestnewernon-platinum-basedchemotherapyregimensmayproduceresponseandsurvivalresultssimilartothoseproducedbystandardplatinum-basedregimens.18Furthertrialscomparingplatinum-andnon-platinum-basedregimensareong