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1、肺癌肺癌(fi i)(fi i)(fi i)(fi i)的诊治指南的诊治指南 南京大学医学院附属南京鼓楼医院(yyun)肿瘤内科乐翔第一页，共六十三页。肺癌的诊治指南第二页，共六十三页。肺癌的诊治指南肺癌的诊治肺癌的诊治(zhnzh)(zhnzh)(zhnzh)(zhnzh)指南指南l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l小细胞肺癌的病期诊断l非小细胞肺癌的病期诊断l肺癌的治疗(zhlio)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第三页，共六十三页。肺癌的诊治指南肺癌的诊断(zhndun)(zhndun)-临床诊断(zhndun)(zhndun)l病史采集和
2、完整体检病史采集和完整体检l肺癌肺内临床表现肺癌肺内临床表现咳嗽(ksu)（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l专一性检查专一性检查(jinch)(jinch)和和组织细胞病理学检查组织细胞病理学检查(jinch)(jinch)l初步筛查初步筛查胸正侧位片胸正侧位片血常规项血常规项痰细胞血检查痰细胞血检查 第四页，共六十三页。肺癌的诊治指南肺癌(fi i)(fi i)的诊断-临床诊断l肺癌局部侵润扩展的临肺癌局部侵润扩展的临床表现（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
3、道狭窄(xizhi)-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）l肺癌疑诊检查肺癌疑诊检查胸部螺旋CT增强(zngqing)扫描心包腔，胸腔积液超声定位（需要时）积液细胞血检查第五页，共六十三页。肺癌的诊治指南肺癌的诊断(zhndun)(zhndun)-临床诊断(zhndun)(zhndun)l肺癌局部侵润扩展的临床表现（肺癌局部侵润扩展的临床表现（2）声音嘶哑：喉返神经(shnjng)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
4、症：肺尖部肿瘤侵润l肩背部剧疼：局部肌肉神经受侵l腋窝肌肉萎缩：局部肌肉神经受侵l同侧Horner症：侵犯颈交感神经和臂从神经l肺癌(fii)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，免疫组化检查第六页，共六十三页。肺癌的诊治指南肺癌(fi i)(fi i)的诊断-临床诊断l肺癌远处转移的临床表现肺癌远处转移的临床表现体表淋巴结肿大体表淋巴结肿大（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）腹腔腹腔(fqing)脏器转移脏器转移：l肝：疼痛、厌食、黄疸、腹水、肝源性低血糖l胰：胰腺炎
5、表现、阻塞性黄疸、高血糖l肾上腺、腹膜后淋巴结：一般无症状l肾：肾积水，血尿骨骨；l脊柱转移：疼痛，截瘫，大小便失禁l肢体骨：疼痛，骨折l肺癌病期诊断肺癌病期诊断浅表淋病结活检或穿刺腹部螺旋(luxun)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第七页，共六十三页。肺癌的诊治指南肺癌(fi i)(fi i)的诊断-临床诊断l肺癌的副综合症（肺癌的副综合症（SCLC多见多见）内分泌系统lCushing综合征l抗利尿激素分泌异常综合症l高钙血症（肺鳞癌多见）l男性乳腺发育l类癌综合症神经肌肉系统l小脑皮质变性l周
6、围神经病变l癌性肌病等皮肤l皮肌炎l黑棘皮病等骨骼(gg)系统l肺源性骨关节病（肺腺癌多见）l相应检查鉴别诊断相应检查鉴别诊断l24h17-羟皮质醇羟皮质醇20mgl24h尿钠尿钠200mgl血钙波动在增高的血钙波动在增高的20%左右左右(zuyu)l尿尿5羟吲哚乙酸定性羟吲哚乙酸定性第八页，共六十三页。肺癌的诊治指南肺癌的诊断(zhndun)(zhndun)-组织病理学诊断(zhndun)(zhndun)lWHO肺癌组织学分类及临床病理肺癌组织学分类及临床病理(bngl)(bngl)特特征征1981年分类年分类1999年分类年分类临床病理特征临床病理特征良性良性不典型增生原位癌 侵袭前病变、
7、原位癌鳞状细胞间变不典型腺瘤样增生弥漫性特发性肺神经 内分泌细胞增生 第九页，共六十三页。肺癌的诊治指南肺癌(fi i)(fi i)的诊断-组织病理学诊断lWHO肺癌组织学分类肺癌组织学分类(fn li)(fn li)及临床病理特及临床病理特征征1981年分类年分类1999年分类年分类临床病理特征临床病理特征恶性恶性鳞状细胞癌变异型梭形细胞癌、鳞状细胞癌变异型乳头状透明细胞小细胞基底细胞样（ 免 疫 组 化CYFRA21/SCC）主要发生在段支气管，其次在叶支气管，因此约2/3为中央型肺癌癌侵犯支气管粘膜，易脱落，故痰中容易找到癌细胞而被早期发现肿瘤向管腔生长，使支气管狭窄，甚至阻塞，导致肺不
8、张，脂质性肺炎、支气管肺炎或肺脓肿周围型鳞癌常可发生癌灶中心广泛凝固性坏死，可有空洞形成按癌细胞分化程度可分为分化好、中度分化和分化差三级第十页，共六十三页。肺癌的诊治指南肺癌的诊断(zhndun)(zhndun)-组织病理学诊断(zhndun)(zhndun)lWHO肺癌肺癌(fi i)(fi i)组织学分类及临床病理特组织学分类及临床病理特征征1981年分类年分类 1999年分类年分类临床病理特征临床病理特征小细胞癌燕麦细胞癌中间细胞型复合性燕麦细胞癌小细胞癌、变异型复合性小细胞癌（ 免 疫 组 化NSE）主要发生在主支气管和叶支气管，约70%病例表现为肺门周围肿块肿瘤生长迅速和广泛转移。
9、纵隔累及、远处转移常见小细胞癌为分化差的神经内分泌癌，而不是未分化癌的小细胞型第十一页，共六十三页。肺癌的诊治指南肺癌的诊断(zhndun)(zhndun)-组织病理学诊断(zhndun)(zhndun)lWHO肺癌肺癌(fi i)(fi i)组织学分类及临床病理特组织学分类及临床病理特征征1981年分类年分类1999年分类年分类临床病理特征临床病理特征腺癌腺泡性癌乳头状癌细支气管肺泡癌实性腺癌伴有黏液形成腺 癌 （ 免 疫 组 化 CEA/Ca125）腺泡癌乳头状癌细支气管肺泡癌非黏液性癌黏液性癌混合性黏液及非黏液性或不确定性实性腺癌伴有黏液形成腺癌伴混合性亚型变异型高分化的胎儿型腺癌黏液性
10、（胶样）腺癌黏液性囊腺癌印戒细胞腺癌透明细胞腺癌以周围型肿块多见腺癌有数种变型，分化好的胎儿性腺癌预后非常好第十二页，共六十三页。肺癌的诊治指南肺癌(fi i)(fi i)的诊断-组织病理学诊断lWHO肺癌组织学分类肺癌组织学分类(fn li)(fn li)及临床病理特及临床病理特征征1981年分类年分类1999年分类年分类临床病理特征临床病理特征大细胞癌变异型巨细胞癌透明细胞癌大细胞癌变异型大细胞神经内分泌癌复合型大细胞神经内分泌癌基底细胞样癌淋巴上皮癌样癌透明细胞癌具有横纹肌样表型的大细胞癌细胞体积较大、核大核仁显著、胞质丰富的恶性上皮性肿瘤，无鳞癌、小细胞癌或腺癌特点高度恶性，多发生在段
11、支气管或叶支气管，大多数症状与肿瘤局部作用有关，少数患者可出现副瘤综合征肿瘤体积较大，中央坏死常见，但空洞形成不常见第十三页，共六十三页。肺癌的诊治指南肺癌(fi i)(fi i)的诊断-组织病理学诊断lWHO肺癌肺癌(fi i)(fi i)组织学分类及临床病理特组织学分类及临床病理特征征1981年分类年分类1999年分类年分类临床病理特征临床病理特征腺鳞癌腺鳞癌必须存在确凿无疑的鳞状分化（角化或细胞间桥）和腺样分化（腺泡、小管或乳头结构），其中任何一种成分必须超过5%第十四页，共六十三页。肺癌的诊治指南肺癌(fi i)(fi i)的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理肺癌组织
12、学分类及临床病理(bngl)(bngl)特特征征1981年分类年分类1999年分类年分类临床病理特征临床病理特征具有多形性、肉瘤样或肉瘤成分的癌具有梭形和（或）巨细胞的癌多形性癌梭形细胞癌巨细胞癌癌肉瘤肺母细胞瘤其他癌肉瘤是由恶性上皮和间充质两种成分混合而成的肿瘤，其中间充质成分必须为特殊的异源性组织癌肉瘤是由恶性胚胎性腺体（类似宫内膜样腺体）和恶性母细胞性间质组成的肿瘤第十五页，共六十三页。肺癌的诊治指南肺癌(fi i)(fi i)的诊断-组织病理学诊断lWHO肺癌组织学分类及临床肺癌组织学分类及临床(ln chun)(ln chun)病理病理特征特征1981年分类年分类 1999年分类年分
13、类临床病理特征临床病理特征类癌类癌典型类癌非典型类癌起源于支气管和细支气管粘膜上皮神经内分泌细胞。较少见，恶性程度低典型类癌和非典型类癌在区域淋巴结和远处转移率以及无瘤存活率有显著差别。微瘤性类癌是一种直径序贯；/选择其一局限期广泛期治疗原则C+RPCI/N0C+RSC+BRMHCRCRCR1(脑、脊柱、骨局部)C+BRM化疗反应率中位生存期2年生存率5年生存率RR/CR80%/50-60%12-15M15-20%7%65-70%/10-20%8-12M5%序贯；/选择其中之一分期综合治疗方法综合治疗方法5年生存率年生存率（%）隐匿癌观察或化学预防0S0/L100100AT1S17565BT2
14、侵及脏层胸膜 S155T2跨叶侵犯S2T2侵及主支气管 S3T2不能承受手术 R0第四十七页，共六十三页。肺癌的诊治指南非小细胞(xbo)(xbo)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(tngsh)；序贯；/选择其中之一分期综合治疗方法综合治疗方法5年生存率年生存率（%）AT1N1S15040BT2N1S1-3C235-50T3S4C235T3R1+C1S4C2；R1S4C2最差AT1-2N2C1S1-3；C1+R1S1-3C2；S1-3C2R25030T3N1R1+C1/R1S1-3C2；S4C235T3N2C1R1S1-3C2；S4C25第四十八页，共六十三页。
15、肺癌的诊治指南非小细胞肺癌的治疗原则(yunz)(yunz)和方法（4）非小细胞(xbo)肺癌的治疗原则和疗效分期综合治疗方法综合治疗方法5年生存率年生存率（%）BT4N0-2S3C2；C1/R1S3C2 1510T4N3C3+R35-10M1单器官 C3+R3/C3R3；BSC5R3；BSC注：+同时(tngsh)；序贯；/选择其中之一第四十九页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of occult lung cancer (Tx,N0,M0) In occult lung cancer, a diagnostic evaluatio
16、n often includes chest x-ray and selective bronchoscopy with close follow-up (e.g., computed tomographic scan), when needed, to define the site and nature of the primary tumor; tumors discovered in this fashion are generally early stage and curable by surgery. After discovery of the primary tumor, t
17、reatment is determined by establishing the stage of the patients tumor. Therapy is identical to that recommended for other non-small cell lung cancer patients with similar stage disease. 第五十页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of stage 0 (Tis,N0,M0)Standard treatment options: 1.Surgical r
18、esection using the least extensive technique possible (segmentectomy or wedge resection) to preserve maximum normal pulmonary tissue since these patients are at high risk for second lung cancers. 2.Endoscopic photodynamic therapy.2,3 第五十一页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of stage (T1-2
19、,N0,M0)Standard treatment options: 1.Lobectomy or segmental, wedge, or sleeve resection as appropriate. 2.Radiation therapy with curative intent (for potentially resectable patients who have medical contraindications to surgery). 3.Clinical trials of adjuvant chemotherapy following resection.14,15 4
20、.Adjuvant chemoprevention trials.12,13,16 5.Endoscopic photodynamic therapy (under clinical evaluation in highly selected T1, N0, M0 patients).17 第五十二页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of stage (T1-2N1M0,T3N0M0,T1-2N1M0,T3N0M0,)Standard treatment options: 1.Lobectomy; pneumonectomy; or
21、segmental, wedge, or sleeve resection as appropriate. 2.Radiation therapy with curative intent (for potentially operable patients who have medical contraindications to surgery). 3.Clinical trials of adjuvant chemotherapy with or without other modalities following curative surgery.10 4.Clinical trial
22、s of radiation therapy following curative surgery.10第五十三页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of stage A (T1-3N2M0,T3N1M0,T1-3N2M0,T3N1M0,)Standard treatment options: 1.Surgery alone in operable patients without bulky lymphadenopathy.22-24 2.Radiation therapy alone, for patients who are no
23、t suitable for neoadjuvant chemotherapy plus surgery.1,2 3.Chemotherapy combined with other modalities.4-6,12第五十四页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of stage A (T1-3N2M0,T3N1M0,T1-3N2M0,T3N1M0,)Superior sulcus tumor (T3, N0 or N1, M0)Standard treatment options: 1.Radiation therapy and su
24、rgery. 2.Radiation therapy alone. 3.Surgery alone (selected cases). 4.Chemotherapy combined with other modalities. 5.Clinical trials of combined modality therapy. Concurrent chemotherapy and radiation therapy followed by surgery may provide the best outcome, particularly for patients with T4, N0 or
25、N1 disease.26 Level of evidence: 3iiiDi 第五十五页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of stage A (T1-3N2M0,T3N1M0,T1-3N2M0,T3N1M0,)Chest wall tumor (T3, N0 or N1, M0)Standard treatment options: 1.Surgery.24,27 2.Surgery and radiation therapy. 3.Radiation therapy alone. 4.Chemotherapy combined
26、with other modalities.第五十六页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of stage B (anyTN3M0,T4anyNM0,)anyTN3M0,T4anyNM0,)Standard treatment options: 1.Radiation therapy alone.7 2.Chemotherapy combined with radiation therapy.1-3,9 3.Chemotherapy and concurrent radiation therapy followed by resecti
27、on.13,14 4.Chemotherapy alone. 第五十七页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of stage (anyT,anyN,M1,)anyT,anyN,M1,)Standard treatment options: (1)1. External-beam radiation therapy, primarily for palliative relief of local symptomatic tumor growth. 2. Chemotherapy. The following regimens are a
28、ssociated with similar survival outcomes: lCisplatin plus vinblastine plus mitomycin.14 lCisplatin plus vinorelbine.3,15 lCisplatin plus paclitaxel.6,9 lCisplatin plus docetaxel.9,16 lCisplatin plus gemcitabine.9,17 lCarboplatin plus paclitaxel.5,9,15 第五十八页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatm
29、ent of stage (anyT,anyN,M1,)anyT,anyN,M1,)Standard treatment options: (2)3. Clinical trials evaluating the role of new chemotherapy regimens and other systemic agents. Initial results suggest newer non-platinum-based chemotherapy regimens may produce response and survival results similar to those pr
30、oduced by standard platinum-based regimens.18 Further trials comparing platinum- and non-platinum-based regimens are ongoing. Information about ongoing clinical trials is available from the NCI Cancer.gov Web site. 4. Endobronchial laser therapy and/or brachytherapy for obstructing lesions.11第五十九页，共
31、六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of recurrent NSCLCStandard treatment options: (1)1. Palliative radiation therapy. 2. Chemotherapy alone. For patients who have not received prior chemotherapy, the following regimens are associated with similar survival outcomes: lCisplatin plus vinblasti
32、ne plus mitomycin.16 lCisplatin plus vinorelbine.17 lCisplatin plus paclitaxel.18,19 lCisplatin plus gemcitabine.19,20 lCarboplatin plus paclitaxel.19,21,22 lCisplatin plus docetaxel.19 第六十页，共六十三页。肺癌的诊治指南NCI Guideline of NSCLC Treatment of recurrent NSCLCStandard treatment options: (2)3. Surgical re
33、section of isolated cerebral metastasis (highly selected patients).6 4. Laser therapy or interstitial radiation therapy for endobronchial lesions.23 5. Stereotactic radiosurgery (highly selected patients).3,5 Changes to This Summary (09/29/2003)第六十一页，共六十三页。肺癌的诊治指南第六十二页，共六十三页。肺癌的诊治指南内容(nirng)总结肺癌的诊治指南。腋窝肌肉萎缩：局部肌肉神经受侵。支气管镜检查(jinch)，细胞学检查(jinch)。纵隔镜检查(jinch)（需要时）组织学检查(jinch)，免疫组化检查(jinch)。具有多形性、肉瘤样或肉瘤成分的癌。影像学上，肺门阴影可以由最大的肺门和叶淋巴结共同构成。S3：袖状切除+纵隔淋巴结切除。C3+R3/C3R3。Chemotherapy alone.第六十三页，共六十三页。肺癌的诊治指南
