肺癌-洪小南课件

肺癌-洪小南LUNGCANCER

Worldwideincidence**Incidenceper100,000population.Male 54.8Female 8.1Male 75.9Female 10.3Male 39.3Female 11.2Male 47.6Female 16.1Male 34.7Female 13.4Male 12.9Female 2.6Male 29.1Female 7.7Male 69.6Female 32.9Male 19.3Female 7.9Male 55.1Female 7.6EasternEuropeJapanAustraliaNewZealandChinaNorthernAfricaSouthernAfricaCentralAmericaWesternEuropeNorthAmericaTemperateSouthAmericaLUNGCANCER

5-yearsurvivalrates7%12%21%13%8%8%10%

14%14%EasternEuropeJapanAustraliaNewZealandChinaMiddleEast/

NorthernAfricaSub-SaharanAfricaLatinAmerica/

CaribbeanNorthwesternEuropeUSALUNGCANCER

Riskfactors—smokingSmokingcauses:80%oflungcancerdeathsinmen75%oflungcancerdeathsinwomen17%oflungcancercasesinnonsmokers28%ofallcancerdeaths35-yearoldmalewhosmokes25cigarettesperday:13%riskofdyingfromlungcancerbeforeage7510%riskofdyingfromcoronarydisease28%riskofdyingfromsmoking-relateddiseaseLUNGCANCER

ImpactofsmokingonriskCigarettes

smoked/dayRiskofdeveloping

lungcancer*Riskafter16years

ofsmokingcessation* 1-20 10.3-fold 1.6-fold 20 21.2-fold 4.0-fold*Datainwomen;riskcomparedtononsmokers.LUNGCANCER

LungcancercontrolHealthpolicySmoke-freeenvironmentsRestrictedadvertisingEducationalcurriculumEconomicincentivesCigarettetaxHealthinsurancediscountfornonsmokersMediacoverage/advocacySocietalstigmaassociatedwithsmokingLUNGCANCER

RiskfactorsotherthansmokingAsbestosRadon(fromminingorindoorexposure)Other“occupationalcarcinogens”Diet(vitaminsA,C,E,-carotenedeficiencies)Genetic/familialfactorsLUNGCANCER

Geneticabnormalities*Incancercelllines.Geneticabnormality NSCLC SCLCChromosome3p X X

deletionsp53genemutation X* XRbgeneabnormalities X X*myconcogenefamily X* XK-rasoncogene X

mutationLUNGCANCER

DiagnosisDiagnosisofsuspectedlungcancerChestX-rayfilm

CTscanPeripheraltumorCentraltumor

Options

Sputumcytology

Bronchoscopy

Percutaneousfine-needleaspiration

ThoracoscopyOptions

Percutaneousfine-needleaspiration

Bronchoscopy

Video-assistedthoracoscopy

LUNGCANCER

RadiographyLUNGCANCER

BronchoscopyLUNGCANCER

CTScanLUNGCANCER

MRILUNGCANCER

BonescintigraphyPET全称：正电子发射计算机体层摄影（positron

emissioncomputedtomography,PET)代谢示踪剂：18F-DG，葡萄糖类似物诊断原理：肿瘤及其转移灶摄取18F-DG异常增加临床应用：肿瘤良恶性的鉴别肿瘤恶性程度的评价和分期治疗效果的监测与坏死和疤痕组织的鉴别PETCT-PET非小细胞肺癌的化疗NON-SMALLCELLLUNGCANCER

Incidenceofmajorhistologictypes**Numbersdonotsumto100%because

ofdifferencesindiagnosticcriteria.18%40%Squamous

cellcarcinomaSmall-cellcarcinoma30%Adenocarcinoma15%OtherNON-SMALLCELLLUNGCANCER

Histologictypes

AdaptedfromRosenowandCarr.Smoker(%) Nonsmoker(%)

Smoker(%) Nonsmoker(%)

Male Female

38211723SquamousCellAdenocarcinomaLargeCellSmallCellBronchoalveolar

11056236522351327396810211SmokersvsnonsmokersNON-SMALLCELLLUNGCANCER

Signsandsymptomsatdiagnosis75404035255040302515154035351515CoughDyspneaChestPainHemoptysisPneumonitisWeightLossGeneralizedWeaknessAnorexiaFeverAnemiaFrequency(%)31%StageIII38%StageIV24%StageI7%StageIINON-SMALLCELLLUNGCANCER

StagesatpresentationNON-SMALLCELLLUNGCANCER

PrognosticfactorsEarly-stagedisease(I,II,resectableStageIII)TumorsizePresence/absenceoflymphnodemetastasisHistologicsubtypeAdvanced-stagedisease(unresectableStageIIIandIV)PretreatmentstagePerformancestatusWeightlossGenderSerumlactatedehydrogenaseMetastaticsiteYearsNON-SMALLCELLLUNGCANCER

SurvivalbystageNON-SMALLCELLLUNGCANCER非小细胞肺癌治疗的选择：1.Ⅰ、Ⅱ期首选手术。Ⅰ期术后不进行放疗，其中T1N0有高危复发因素（细胞分化差、脉管有癌栓）可化疗。T2N0术后应辅助化疗。

T1-2N1切缘阴性，有不良因素（不恰当的纵隔淋巴结切除，肿瘤累及淋巴结包膜外，肺门淋巴结多个阳性，切缘离肿瘤边缘近）术后化疗+/-放疗。2.III期术后单纯化疗或放化疗。

III期新辅助治疗，序贯放化疗或同步放化疗

T4N0-1同侧肺叶内卫星结节术后要辅助化疗。3.一般情况好的予Ⅳ期予化疗。放疗可作为脑转移。骨转移。原发灶的姑息性治疗。NON-SMALLCELLLUNGCANCERⅢ期非小细胞肺癌的综合治疗Ⅲ期病变是局部晚期病变。病变累及纵隔和/或锁骨上淋巴结和/或侵犯纵隔内主要脏器占非小细胞肺癌的31％－44％，ⅢA、ⅢB各一半Ⅲ期五年生存率15％－23％。ⅢB五年生存率6％－7%化疗是Ⅲ期NSCLC的主要治疗手段，与放疗和/或手术综合治疗是目前标准治疗。NON-SMALLCELLLUNGCANCER1、

综合治疗可改善预后，增加有效率，延长生存期。同时也增加不良反应。2、

放化疗同步治疗疗效优于序贯治疗，增加缓解率，略延长生存，但毒性增加，特别是放射性食管炎和贫血。3、

序贯化放疗中化疗可用常规剂量，毒副反应可耐受。化放疗同步治疗时化疗药应减量，例如NVB、15mg/m2/周，健择300mg/m2/周。4、

治疗时间的安排：序贯治疗：常规剂量化疗2疗程休2周后放疗。同步化放疗通常在同一天开始两种治疗。5、

同步化放疗中的化疗通常含铂的两药联合方案。放疗以每天1次的常规分割为宜。NON-SMALLCELLLUNGCANCER肺上钩瘤（Pancoast’stumor）是特殊类型的Ⅲ期病变，占全部肺癌的2％－4％。病变位于肺炎，大多数是鳞癌。常有颈8、胸1神经，第1、2肋骨破坏，但属邻近侵犯，与血道播散的骨转移、神经侵犯不同，标准治疗是术前新辅助放疗或新辅助放化疗。目前更倾向同时放化疗。术后五年生存率20％－30％，肿瘤能完全切除者五年生存率可达40％。Ⅳ期非小细胞肺癌的化疗Ⅳ期非小细胞肺癌的预后与一般状况密切相关。PS≤2，3－6月内体重下降＜5%,经化疗可缓解症状，延长生存。一般情况差者应予对症支持治疗。积极强烈的化疗增加毒性，不改善生存。SCLC占所有肺癌的15%-20%。光镜：细胞体积小，胞浆少，核大，核分裂多。电镜：：有神经内分泌颗粒。临床：生物学行为恶劣，生长迅速，早期远处转移。诊断时LD30%-40%

ED60%-70%

SMALLCELLLUNGCANCER

IncidenceofhistologictypesMixedsmallcell/

largecellcarcinoma

4-6%Combinedsmall

cellcarcinoma

<1%Puresmallcell

carcinoma

>90%SMALLCELLLUNGCANCER

SymptomsPrimarytumorCoughDyspneaWheezingHemoptysisChestpainPostobstructivepneumonitisRegionalmetastasesSuperiorvenacavasyndromeHoarsenessDysphagiaDistantmetastasesBonepainCNSsymptoms(headache,doublevision).SMALLCELLLUNGCANCER

DifferentiatingsignsfromNSCLCMorecommoninSCLCHilarandmediastinaladenopathyAtelectasisPneumonitis LesscommoninSCLCPeripherallocationPleuraleffusionChestwallinvovementSMALLCELLLUNGCANCER

StagingLimiteddiseaseDiseaseconfinedtoonehemithoraxandregionallymphnodes:hilar,ipsilateral,andcontralateralmediastinal;supraclavicular(controversial)Ipsilateralpleuraleffusion(contoversial)ExtensivediseaseAnydiseasebeyondlimiteddiseasesitesSMALLCELLLUNGCANCER

Stageandextrathoracicdiseasesites

atpresentation

PercentagewithFindingFinalstage

Limited 30%-40%

Extensive 60%-70%Bone 19%-38%Liver 17%-34%Bonemarrow 17%-23%Brain 0%-14%Lymphnodes 7%-25%Softtissue 3%-11%SMALLCELLLUNGCANCER

EvaluationofdiseaseextentMinimumEvaluationHistoryandphysicalexaminationChestradiograph±CTLiverfunctiontestsandexamination±liverscanBonepainandalkalinephosphatase±bonescanNeurologichistoryandexamination±brainCTPlateletcountorleukoerythroblasticperipheralbloodsmearSMALLCELLLUNGCANCER

Evaluationofdiseaseextent(cont’d)EvaluationforStageDependentTherapyHistoryandphysicalexaminationChestradiograph±CT±fiberopticbronchoscopyLiverfunctiontestsandliverscan±liverbiopsyBonescanBonemarrowaspiration±BrainCTEvaluationforSurgicalResection(inadditiontoabove)FiberopticbronchoscopyChestCTandmediastinoscopySMALLCELLLUNGCANCER

PrognosticfactorsStagePerformancestatusGenderAgeHistologicalsubclassificationBonemarrowmetastasesLivermetastasesCNSinvolvementBloodbiochemistry,

especiallylactatedehydrogenaseSMALLCELLLUNGCANCER

Survivalbystage

MedianSurvival– MedianSurvival– 5-YearSurvival

UntreatedPatients TreatedPatients (%)

(wk) (mo)Limiteddisease 12 14-20 10%-20%Extensivedisease 5 8-12 3%-5%常见转移部位：骨19%-38%肝脏17%-34%骨髓17%-23%脑0-14%淋巴结7%-25%软组织3-11%胰腺，肾上腺，肾脏内分泌器官转移倾向：甲状腺8%，垂体15%，睾丸7%，甲旁腺1%中枢神经系统：脑，硬膜外，脑脊膜腔，尸检多处转移：73%有效单药ADM30%CTX39-40%HN240-44%MTX30%HMM30%Vp-1637-45%VCR35-42%CBP50%VM-2619-65%IFO24-71%VDS25-32%DDP16%Taxol34-41%Docetaxel28%CPT-11复治47%Topotecan39%,复治25%Gem26%联合化疗疗效：三药优于二药优于单药，超过四药增加毒性。RRCRMS2YSLD80-90%50-60%12-20M15-40%ED60-80%15-20%7-11M少联合化疗方案EPVp-1680mg/m2d1-5DDP20mg/m2d1-5Q3WRR60-90%CR:LD20-45%ED10-25%MS:LD12MED10M联合化疗方案2.ECVp-16100mg/m2d1-3CBPAUC5Q3WLD:RR:85%,CR:37%ED:RR:68%,CR:19%MS:LD12.5MED11.8M毒性较EP小联合化疗方案3.CAVCTX800mg/m2d1ADM40-50mg/m2d1VCR2mgd1Q3WRR50-70%.CR:LD40-60%ED10-15%MS:LD12-15MED8-10M联合化疗方案4.TECTAX