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1、台 北 榮 總 肺 癌 診 療 共 識V.1.0 2009,台北榮總肺癌團隊 Revised on 2009/04/13 Released on 2009/05/04,台 北 榮 總 肺 癌 診 療 共 識,Multidisciplinary Team Taipei VGH Lung Cancer Panel Members TNM staging Taipei VGH supplement to TNM staging Table of stage grouping Evaluation and treatment Stage o (Tis) Stage I (T1-2,N0) and St
2、age II (T1-2, N1) Stage IIB (T3,N0) and stage IIIA (T3,N1) Stage IIIA (T1-3,N3) and stage IIIB (T4, N0-1) Stage IIIB (T1-3,N3) Stage IIIB (T4,N2-3) (T4: pleural effusion or pericardial effusion) Stage IV (M1: solitary site or disseminated) Surveillance Therapy for Recurrence and Metastases Occult (T
3、x,N0,M0),Evaluation and Treatment Second Lung Primary, Evaluation, and Treatment,Principles of Surgical Resection Principles of Pathology Principles of Radiation Therapy - Recommended Radiation Doses - Dose Volume Data for Radiation Pneumonitis Principles of CCRT Principles of Chemotherapy - Non-Sma
4、ll Cell Lung Cancer - Small Cell Lung Cancer Adjuvant Chemotherapy Neoadjuvant Chemotherapy Clinical Trials for Advanced/ Metastatic NSCLC Tracheal cancer References 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
5、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,Clifton F. Mountain, CHEST1997,Regional Lymph Node Classification for Lung Cancer Staging,- Extended mediastinosc
6、opy - Mediastinotomy - VATS,- EUS-FNA - VATS,- EBUS-TBNA - VATS (limited to 10 and 11),- Mediastinoscopy EUS-FNA EBUS-TBNA VATS,- Mediastinoscopy; EUS-FNA, EBUS-TBNA,N1=Ipisilateral hilar nodes N2=Subcarinal, ipisilateral mediastinal nodes N3=Contralateral hilar/ mediastinal, or supraclavicular or s
7、calene nodes,How to Approach,EUS: Endoscopic Ultrasound; EBUS: Endobronchoscopic ultrasound; FNA: Fine Needle Aspiration; TBNA: Transbronchoscopic Needle Aspiration; VATS: Video Assisted Thoracoscopic Surgery,Summary of Evaluation and Treatment,PFT: Necessary for all operable stages PET (PET/CT) : r
8、ecommend for all clinical stages, except Wet IIIB or stage IV with disseminate M1 Mediastinoscopy: recommend for all clinical stages, except Peripheral T1N0 Wet IIIB or stage IV with disseminate M1p.s. N2 or N3 disease can be confirmed by other methods including mediastinotomy, thoracoscopy, EBUS-FN
9、A, EUS-FNA, CT-guided-FNA, supraclavicle LN biopsy Brain MRI: recommend for all clinical stages, except Stage I Wet IIIB or stage IV with disseminate M1,正子掃描（PET/CT SCAN）：肺癌clinical stage 的pre-treament workup，至於安排時間點是在胸腔電腦斷層（chest-CT）後。 除非Chest CT或PET SCAN都無縱膈腔異常發現且主要病灶在週邊(peripheral IA lesion)可以不做縱
10、膈腔鏡外，否則縱膈腔鏡仍是評估縱膈腔淋巴結的gold standard Brain MRI取代brain CT建議在clinical stage II及stage III以上的病人安排。 術中病理檢查若有R1 (microscopic residual tumor) 或R2(macroscopic residual tumor)，應視實際情形考慮reresection /（+chemotherapy）或是chemoradiation /（+ chemotherapy）。,NSCL-1,From NCCN guideline, V.2.2009,NSCL-2,From NCCN guidelin
11、e, V.2.2009,NSCL-3,From NCCN guideline, V.2.2009,NSCL-4,From NCCN guideline, V.2.2009,NSCL-5,From NCCN guideline, V.2.2009,NSCL-6,From NCCN guideline, V.2.2009,NSCL-7,From NCCN guideline, V.2.2009,NSCL-8,From NCCN guideline, V.2.2009,NSCL-9,From NCCN guideline, V.2.2009,NSCL-10,From NCCN guideline,
12、V.2.2009,NSCL-11,From NCCN guideline, V.2.2009,NSCL-12,From NCCN guideline, V.2.2009,NSCL-13,Gefitinib or Erlotinib (if criteria met)z (2B),Gefitinib or Erlotinib (if criteria met)z (2B),(2B),(2B),Z Criteria for treatment with gefitinib (IPASS trial): Adenocarcinoma, non-smoker or light ex-smoker (q
13、uit 15yrs and 10 pack-years or fewer) No pre-existing idiopathic pulmonary fibrosisby evidence on chest CT,From NCCN guideline, V.2.2009,NSCL-14,From NCCN guideline, V.2.2009,NSCL-15,Or Gefitinib,Or Gefitinib,Gefitinib and Erlotinib in 2nd-line therapy : adenocarcinomaGefitnib in 3rd-line therapy: a
14、denocarcinoma; Erlotinib in 3rd-line therapy: NSCLC,From NCCN guideline, V.2.2009,PRINCIPLES OF SURGICAL RESECTION,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(physiologically feasible) ，應採取lobectomy或pneumonectomy。 如生理狀況受限制(physiologically compromised) ，應採局部切除(Limited rese
15、ction-segmentectomy or wedge resection) 。 在不違背標準腫瘤手術原則下，可採用VATS (Video- assisted thoracic surgery) 。,PRINCIPLES OF SURGICAL RESECTION,N1 determine the extent of invasion; establish the status of cancer involvement of surgical margins; determine the molecular abnormalities to predict for response to
16、EGFR- TKI 。 手術病理報告應該有WHO肺癌組織分類。 Pure bronchioloalveolar carcinoma (BAC)應無stroma、pleura與lymphatic spaces之侵犯。免疫染色: Non-mucinous BAC = TTF-1 (+) / CK7 (+) / CK20 (-); Mucinous BAC = 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: Epidermal Growth Factor Receptor TKI: Tyrosine Kinase Inhibitor TTF-1: Thyroid transcription factor-1,PRINCIPLES
