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1、小细胞肺癌的分期、影像学表现和治疗 Small Cell Lung Carcinoma: Staging, Imaging, and Treatment Considerations 罗桂媛,2015.6.15 上海市东方医院南院影像科,10/7/2018,介绍Introduction,2004 WHO 将肺癌分为两个主要组织学类型: 非小细胞肺癌 和小细胞肺癌 。SCLC 占肺癌总数的 13%-15%，是最常见的原发性肺神经内分泌肿瘤 。 The 2004 World Health Organization (WHO) classification scheme divides lung c
2、ancer into two major histologic categories: nonsmall cell lung carcinoma (non-SCLC) and SCLC，SCLCs account for 13%15% of all lung cancers and are the most common primary pulmonary neuroendocrine neoplasm。 在所有组织类型中，小细胞肺癌的发病与吸烟关系最为密切，大约95%的小细胞肺癌患者有吸烟史。 and of all the histologic subtypes of lung cancer
3、, SCLC has the strongest association with cigarette smoking.,10/7/2018,介绍Introduction,小细胞肺癌特点是肿瘤细胞倍增时间短，增殖指数高，比非小细胞肺癌更具侵略性，并有早期广泛转移的倾向。SCLC is more aggressive than non-SCLC and is characterized by a rapid doubling time, high growth fraction (the ratio of proliferating cells to total cells), and grea
4、ter propensity for early development of widespread metastases,10/7/2018,介绍Introduction,美国老年委员会肺癌研究小组(VALSG) 制定的分期系统将小细胞肺癌分为局限期和广泛期。不过现在已经被修订的TNM分期方法所代替。 SCLC is usually categorized according to a modified version of the Veterans Administration Lung Cancer Study Group (VALSG) staging system as either
5、 limited-stage SCLC (LS-SCLC) or extensive-stage SCLC (ESSCLC).,10/7/2018,介绍Introduction,准确的分期对小细胞肺癌患者的治疗有指导性意义，放疗和化疗联合治疗对局限期小细胞肺癌是有效果的，其中一小部分患者能长期存活。 Accurate staging of patients with SCLC helps guide individual treatment strategies, since patients with LS-SCLC are candidates for curative-intent ch
6、emotherapy radiation therapy, a small percentage of whom experience long-term survival.,10/7/2018,介绍Introduction,在本文献中，我们主要是复习小细胞肺癌的病理及它的发展，并讨论CT 和 PET -CT 对患者疾病的分期和评价。In this article, we review the pathophysiology and natural history of SCLC and discuss the role of computed tomography (CT) and 2-fl
7、uorine-18fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET)/CT in the evaluation and staging of patients with the disease.,10/7/2018,肺神经内分泌肿瘤的分类 Classification of Pulmonary Neuroendocrine Neoplasms,WHO将肺神经内分泌肿瘤分为3个病理等级 以及4个分类： 低度恶性：典型类癌肿瘤； 中间级肿瘤：不典型类癌； 高度恶性肿瘤：包括大细胞神经内分泌肿瘤以及小细胞肺癌。 在这篇文
8、章，我们专注于小细胞肺癌。 The 2004 WHO tumor classification scheme includes four major types of pulmonary neuroendocrine tumors, which are grouped into three histologic grades. Low-grade malignant neoplasms include typical carcinoid tumor, intermediate-grade neoplasms include atypical carcinoids, and high-grade
9、 neoplasms include large cell neuroendocrine tumor and SCLC . In this article, however, we focus on SCLC,10/7/2018,流行病学和临床特点Epidemiologic and Clinical Features,95%以上的高级别的神经内分泌肿瘤起源于肺，而肺外疾病：鼻咽部、 胃肠道和泌尿生殖道等器官的肿瘤极为少见。 More than 95% of high-grade neuroendocrine carcinomas originate in the lung, whereas e
10、xtrapulmonary tumors involving organs such as the nasopharynx, gastrointestinal tract, and genitourinary tract are exceptionally rare, with a prevalence of 0.1%0.4% in the United States,10/7/2018,流行病学和临床特点Epidemiologic and Clinical Features,据美国的流行病学资料显示小细胞肺癌的患病率在 20 世纪 80 年代达到顶峰，之后一直在下降，此后，在过去的 30 年
11、从17%-20%降至 13%-15%。原因有很多，例如降低吸烟率，增加过滤的香烟的使用，以及对小细胞肺癌的病理标准所做的更改。小细胞肺癌好发年龄在 60 和 70岁之间。男女比例2.6:1。 The prevalence of SCLC in the United States peaked in the 1980s and has been declining since that time, decreasing from 17%20% to 13%15% over the past 30 years (4,12). Several factors may, at least in par
12、t, be responsible for this decline, such as a decrease in smoking rates, increased use of filtered cigarettes, and changes that have been made to the pathologic criteria for SCLC。SCLC typically affects patients between the ages of 60 and 70 years, SCLC has historically been seen more frequently in m
13、en than in women by a ratio of 2.6:1。,10/7/2018,流行病学和临床特点Epidemiologic and Clinical Features,最常见的临床症状包括咳嗽、 胸痛、 咯血、 呼吸困难，通常会伴有一些全身性疾病，比如体重下降，疲劳和厌食等症状。 The most common signs and symptoms reported at the time of presentation include cough, chest pain, hemoptysis, and dyspnea. Because patients typically
14、 have systemic disease at the time of diagnosis, symptoms such as weight loss, fatigue, and anorexia are often present.,10/7/2018,流行病学和临床特点Epidemiologic and Clinical Features,侵袭性的肿瘤或晚期的患者会有特定的临床症状。例如，大约10%的患者伴有上腔静脉综合征相关的症状。侵犯食管及纵隔结构 (如，喉返神经和气管) 会导致吞咽困难和声音嘶哑，另外肺外转移性疾病可表现为骨痛、 皮肤瘙痒、 黄疸、 癫痫发作、 精神失常，和/或共
15、济失调 。Patients with invasive or advanced disease may present with specific symptoms. For instance, 10% of patients report symptoms related to superior vena cava syndrome (9,13). Invasion of the esophagus and mediastinal structures (eg, the recurrent laryngeal nerve and trachea) can result in dysphagi
16、a and hoarseness, respectively Extrapulmonary metastatic disease can manifest as bone pain, pruritus, jaundice, seizures, changes in mental status, and/or ataxia (9,13).,10/7/2018,组织学和病理特点Histologic and Gross Pathologic Features,小细胞肺癌的确诊通过核心活检或细针穿刺活检。在光学显微镜，小细胞肺癌细胞呈蓝色圆形、 椭圆形，或纺锤状，细胞胞浆稀少，边界模糊不清，细颗粒细胞
17、核的染色质，核缺失或，核仁不明显(图 1a)，对于肺的神经内分泌肿瘤，小细胞肺癌具有最高的有丝分裂率，并且广泛坏死。The diagnosis of SCLC may be established by examining tissue obtained at fine-needle aspiration biopsy or core biopsy. At light microscopy, SCLC is characterized by small blue round, oval, or spindle-shaped cells with scant cytoplasm, ill-def
18、ined borders, finely granular nuclear chromatin, and absent or inconspicuous nucleoli (Fig 1a) (2,6). Of the pulmonary neuroendocrine tumors, SCLC has the highest mitotic rate (10 mitoses per 10 high-power fields; median, 80 mitoses per 10 high-power fields), and extensive necrosis is typically present.,
