肺癌的诊治指南精选课件.ppt

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1、关于肺癌的诊治指南第一页，本课件共有63页第二页，本课件共有63页肺癌的诊治指南肺癌的诊治指南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，本课件共有63页肺癌的诊断-临床诊断l病史采集和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（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专一性检查和组织细专一性检查和组织细胞病理学检查胞病理学检查l初步筛查初步筛查胸正

2、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，本课件共有63页肺癌的诊断-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）l肺癌疑诊检查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）积液细胞血检查第五页，本课件共有63页肺癌的诊断-临床诊断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：喉返神经受侵同侧膈肌麻痹：同侧膈神经受侵吞

3、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，本课件共有63页肺癌的诊断-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）腹腔脏器转移腹腔脏器转移：l肝：疼痛、

4、厌食、黄疸、腹水、肝源性低血糖l胰：胰腺炎表现、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，本课件共有63页肺癌的诊断-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周围神经

5、病变l癌性肌病等皮肤l皮肌炎l黑棘皮病等骨骼系统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l尿尿5羟吲哚乙酸定性羟吲哚乙酸定性第八页，本课件共有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特征第九页，本课件共有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特征第十页，本课件共有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特

6、征第十一页，本课件共有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特征第十二页，本课件共有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特征第十三页，本课件共有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特征第十四页，本课件共有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特征第十五页，本课件共有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特征第十六页，本课件共

7、有63页肺癌的诊断-组织病理学诊断lWHO肺癌组织学分类及临床病理特征肺癌组织学分类及临床病理特征第十七页，本课件共有63页肺癌的病期诊断-小细胞肺癌小细胞肺癌的分期小细胞肺癌的分期VA分期：美国荣总医院肺癌研究组年制定分期：美国荣总医院肺癌研究组年制定第十八页，本课件共有63页肺癌的病期诊断-非小细胞肺癌（1）l1997年非小细胞肺癌国际分期修订本中年非小细胞肺癌国际分期修订本中TNM的概念的概念第十九页，本课件共有63页肺癌的病期诊断-非小细胞肺癌（2）1997年非小细胞肺癌国际分期修订本中年非小细胞肺癌国际分期修订本中TNM的概念的概念第二十页，本课件共有63页肺癌的病期诊断-非小细胞肺

8、癌（3）1997年非小细胞肺癌国际分期修订本中年非小细胞肺癌国际分期修订本中TNM的概念的概念第二十一页，本课件共有63页肺癌的病期诊断-非小细胞肺癌(4)l1997年非小细胞肺癌国际分期修订本中年非小细胞肺癌国际分期修订本中TNM的概念的概念第二十二页，本课件共有63页肺癌的病期诊断-非小细胞肺癌(5)l1997年非小细胞肺癌国际分期修订本中年非小细胞肺癌国际分期修订本中TNM的概念的概念 注年公布的肺癌国际分期，在注年公布的肺癌国际分期，在T和和M定义上与年的定义上与年的分期基本一致，但有下述三点的修改：分期基本一致，但有下述三点的修改：l在原发肿瘤所在的叶内出现癌性卫星结节定义为在原发肿

9、瘤所在的叶内出现癌性卫星结节定义为T4；l在其他叶出现的癌性结节包括粟粒样病灶定义为在其他叶出现的癌性结节包括粟粒样病灶定义为M1；l心包积液的定义原则等同于胸腔积液。心包积液的定义原则等同于胸腔积液。第二十三页，本课件共有63页肺癌的病期诊断-非小细胞肺癌(6)1997年非小细胞肺癌国际分期修订本中年非小细胞肺癌国际分期修订本中TNM的概念的概念第二十四页，本课件共有63页肺癌的病期诊断-非小细胞肺癌(6)第二十五页，本课件共有63页小细胞肺癌的治疗原则和方法（1）小细胞肺癌的治疗方法第二十六页，本课件共有63页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

10、一第二十七页，本课件共有63页NCI guideline:Treatment of LD SCLClStandard treatment options:1.Combination chemotherapy with chest irradiation(with or without PCI given to patients with complete responses):lEC:etoposide+cisplatin+4500 cGy chest radiation therapy.2.Combination chemotherapy(with or without PCI in pat

11、ients with complete responses),especially in patients with impaired pulmonary function or poor performance status.3.Surgical resection followed by chemotherapy or chemotherapy plus chest radiation therapy(with or without PCI in patients with complete responses)for patients with stage I disease.第二十八页

12、，本课件共有63页NCI guideline:Treatment of ED SCLC(1)1.Combination chemotherapy with one of the following regimens with or without PCI given to patients with complete responses:The following regimens produce similar survival outcomes:CAV:cyclophosphamide+doxorubicin+vincristine.26,27 CAE:cyclophosphamide+d

13、oxorubicin+etoposide.28 EP or EC:etoposide+cisplatin or carboplatin.29,30 ICE:ifosfamide+carboplatin+etoposide.31 第二十九页，本课件共有63页NCI guideline:Treatment of ED SCLC(2)Other regimens appear to produce similar survival outcomes but have been studied less extensively or are in less common use,including:l

14、Cyclophosphamide+doxorubicin+etoposide+vincristine.32 lCEV:cyclophosphamide+etoposide+vincristine.33 lSingle-agent etoposide.21 lPET:cisplatin+etoposide+paclitaxel.34第三十页，本课件共有63页NCI guideline:Treatment of ED SCLC(3)2.Radiation therapy to sites of metastatic disease unlikely to be immediately pallia

15、ted by chemotherapy,especially brain,epidural,and bone metastases.第三十一页，本课件共有63页NCI guideline:Treatment of ED SCLC(4)3.Identification of effective new agents is difficult in patients who have previously been treated with standard chemotherapy because response rates to agents,even of known efficacy,a

16、re known to be lower than in previously untreated patients.This situation led to the suggestion that patients with extensive disease who are medically stable be treated with new agents under evaluation,with provisions for early change to standard combination therapy if there is no response.35 Such a

17、 strategy has been shown to be feasible,with survival comparable to survival with initial standard therapy,as long as the patients with extensive disease are carefully chosen.36-38 A variety of other strategies have been proposed,depending on the activity of the new agent in other tumors,in preclini

18、cal small cell lung cancer models,or the activity of drug analogs.39 Active single agents undergoing further evaluation include paclitaxel and topotecan.40,41 第三十二页，本课件共有63页非小细胞肺癌的治疗原则和方法（1）l非小细胞肺癌的治疗方法第三十三页，本课件共有63页第三十四页，本课件共有63页第三十五页，本课件共有63页第三十六页，本课件共有63页第三十七页，本课件共有63页第三十八页，本课件共有63页第三十九页，本课件共有63页

19、第四十页，本课件共有63页第四十一页，本课件共有63页第四十二页，本课件共有63页第四十三页，本课件共有63页第四十四页，本课件共有63页第四十五页，本课件共有63页第四十六页，本课件共有63页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；/选择其中之一第四十七页，本课件共有63页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；/选择其中之一第四十八页，本课件共有63页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；/选择其中之一第四十九页，本课件共有63页NCI Guideline of NSC

20、LC Treatment of occult lung cancer(Tx,N0,M0)In occult lung cancer,a diagnostic evaluation 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 ge

21、nerally early stage and curable by surgery.After discovery of the primary tumor,treatment 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，本课件共有63页NCI Guideline of NSCL

22、C Treatment of stage 0(Tis,N0,M0)Standard treatment options:1.Surgical resection 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

23、,3 第五十一页，本课件共有63页NCI Guideline of NSCLC Treatment of stage (T1-2,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 t

24、rials of adjuvant chemotherapy following resection.14,15 4.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，本课件共有63页NCI Guideline of NSCLC Treatment of stage (T1-2N1M0,T3N0M0,)Standard treatment option

25、s:1.Lobectomy;pneumonectomy;or 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 s

26、urgery.10 4.Clinical trials of radiation therapy following curative surgery.10第五十三页，本课件共有63页NCI Guideline of NSCLC Treatment of stage A(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

27、not suitable for neoadjuvant chemotherapy plus surgery.1,2 3.Chemotherapy combined with other modalities.4-6,12第五十四页，本课件共有63页NCI Guideline of NSCLC Treatment of stage A(T1-3N2M0,T3N1M0,)Superior sulcus tumor(T3,N0 or N1,M0)Standard treatment options:1.Radiation therapy and surgery.2.Radiation therap

28、y 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 N1 disease.26 Level of evidence:

29、3iiiDi 第五十五页，本课件共有63页NCI Guideline of NSCLC Treatment of stage A(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 with other modalities.第五十六页，本课件共有63页NCI Guideline of NSCLC Tr

30、eatment 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 resection.13,14 4.Chemotherapy alone.第五十七页，本课件共有63页NCI Guideline of NSCLC T

31、reatment of stage (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 associated with similar survival outcomes:lCisplatin plus vinblastine plus mitomycin.14 lCispla

32、tin 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，本课件共有63页NCI Guideline of NSCLC Treatment of stage (anyT,anyN,M1,)anyT,anyN,M1,)Standard treatment options:(2)3.Clinical trials evaluating

33、 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 produced by standard platinum-based regimens.18 Further trials comparing platinum-and non-platinum-based

34、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，本课件共有63页NCI Guideline of NSCLC Treatment of recurrent NSCLCStandard treatment options:(1)1.Palliative radiat

35、ion therapy.2.Chemotherapy alone.For patients who have not received prior chemotherapy,the following regimens are associated with similar survival outcomes:lCisplatin plus vinblastine plus mitomycin.16 lCisplatin plus vinorelbine.17 lCisplatin plus paclitaxel.18,19 lCisplatin plus gemcitabine.19,20

36、lCarboplatin plus paclitaxel.19,21,22 lCisplatin plus docetaxel.19 第六十页，本课件共有63页NCI Guideline of NSCLC Treatment of recurrent NSCLCStandard treatment options:(2)3.Surgical resection 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，本课件共有63页第六十二页，本课件共有63页感感谢谢大大家家观观看看第六十三页，本课件共有63页