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转载 非小细胞肺癌治疗前临床评估NCCN指南2016V4

张品良 副主任医师 山东省肿瘤医院 呼吸肿瘤内科
2016-09-19 131人已读
张品良 副主任医师
山东省肿瘤医院

Non-Small Cell Lung Cancer非小细胞肺癌

NCCN Guidelines Version 4.2016  NCCN指南2016第4版

Discussion讨论

Treatment Approaches治疗手段山东省肿瘤医院呼吸肿瘤内科张品良

Clinical Evaluation临床评价

As previously described, low-dose CT screening is now recommended for asymptomatic select patients who are at high risk for lung cancer (see the NCCN Guidelines for Non-Small Cell Lung Cancer and for Lung Cancer Screening, available at NCCN.org). 如前所述,对于无症状选择性的肺癌高危患者目前推荐低剂量CT筛查(见非小细胞肺癌肺癌筛查NCCN指南,可在NCCN.org获得)。

Low-dose CT screening may find lung nodules that are suspicious for cancer; the workup and evaluation of these lung nodules is described in the NSCLC algorithm (see Diagnostic Evaluation of Lung Nodules in this Discussion and see Principles of Diagnostic Evaluation in the NCCN Guidelines for Non-Small Cell Lung Cancer).
低剂量CT筛查可发现可疑恶性肿瘤的肺结节;这些肺结节的检查与评估在NSCLC工作步骤中描述(见本讨论中肺结节的诊断评估和非小细胞肺癌NCCN指南中的诊断评估原则)。

After patients are confirmed to have NSCLC based on a pathologic diagnosis, a clinical evaluation needs to be done (see the NCCN Guidelines for Non-Small Cell Lung Cancer).
在患者病理确诊为NSCLC后,需要进行临床评估(见非小细胞肺癌NCCN指南)。

In patients with symptoms, the clinical stage is initially determined from disease history (ie, cough, dyspnea, chest pain, weight loss) and physical examination together with a limited battery of tests (see Evaluation and Clinical Stage in the NCCN Guidelines for Non-Small Cell Lung Cancer).
在有症状的患者中,从病史(如,咳嗽、呼吸困难、胸痛、体重下降)和体格检查以及有限的系列检测数据初步确定临床分期(见非小细胞肺癌NCCN指南中的评估与临床分期)。

The NCCN Panel also recommends that smoking cessation advice, counseling, and pharmacotherapy be provided to patients.
NCCN小组还建议劝告患者戒烟、提供咨询服务和药物治疗。

After the clinical stage is determined, the patient is assigned to one of the pathways that are defined by the stage, specific subdivision of the particular stage, and location of the tumor.
在确定临床分期后,将患者分配到根据分期、特定分期的具体细分期以及肿瘤部位所确定的路径中。

Note that for some patients, diagnosis, staging, and surgical resection are done during the same operative procedure.
注意,对于诊断、分期相同的患者,采取相同的手术过程手术切除。

A multidisciplinary evaluation should be done before treatment.
治疗前应进行多学科评价。

Additional Pretreatment Evaluation治疗前的其他评估

Mediastinoscopy纵隔镜检查

As previously noted, evaluation of the mediastinal nodes is a key step in the further staging of the patient.
正如先前所指出的那样,纵隔淋巴结的评估是患者进一步分期中的一个关键步骤。

FDG PET/CT scans can be used as an initial assessment of the hilar and mediastinal nodes (ie, the presence of N1, N2, or N3, which are key determinants of stage II and stage III disease); however, CT scans have known limitations for evaluating the extent of lymph node involvement in lung cancer (see Mediastinoscopy and Other Imaging Studies in this Discussion).
FDG PET/CT扫描可作为肺门与纵隔淋巴结的初步评估(即存在N1、N2还是N3,这是决定II期和III期疾病的关键);然而,已知CT扫描评价肺癌淋巴结受累程度具有局限性(见本讨论中的纵隔镜检查和其他影像学检查)。

Mediastinoscopy is the gold standard for evaluating mediastinal nodes.
纵隔镜检查是评估纵隔淋巴结的金标准。

Thus, mediastinoscopy is encouraged as part of the initial evaluation, particularly if the results of imaging are not conclusive and the probability of mediastinal involvement is high (based on tumor size and location).
因此,鼓励纵隔镜检查作为初步评估,尤其是如果成像结果不能确定且纵隔受累的概率高(根据肿瘤的大小和位置)。

Therefore, mediastinoscopy is appropriate for patients with T2 to T3 lesions even if the FDG PET/CT scan does not suggest mediastinal node involvement.
因此,对于T2到T3病变的患者即使FDG PET/CT扫描没有提示纵隔淋巴结受累纵隔镜检查也是合适的。

Mediastinoscopy may also be appropriate to confirm mediastinal node involvement in patients with a positive FDG PET/CT scan.
在FDG PET/CT扫描阳性患者中,纵隔镜检查还适于证实纵隔淋巴结受累。

In patients with solid tumors less than 1 cm or for nonsolid tumors (ie, GGOs) less than 3 cm, pathologic mediastinal lymph node evaluation is not required if the nodes are FDG-PET/CT negative.
在小于1cm的实体瘤或小于3cm的非实性肿瘤(即磨玻璃结节)患者中,如果FDG-PET/CT淋巴结阴性,纵隔淋巴结病理学评估不是必需的。

In patients with peripheral T2a, central T1ab, or T2 lesions with negative FDG PET/CT scans, the risk for mediastinal lymph node involvement is higher and mediastinoscopy and/or EUS-FNA and EBUS-TBNA are recommended (see Other Imaging Studies in this Discussion and the NCCN Guidelines for Non-Small Cell Lung Cancer).
在FDG PET/CT扫描阴性的周围型T2a、中心型T1ab或T2病变患者中,纵隔淋巴结转移的风险较高,建议纵隔镜检查和/或EUS-FNA和EBUS-TBNA(见本讨论与非小细胞肺癌NCCN指南中的其他影像学检查)。

Dillemans et al have reported a selective mediastinoscopy strategy, proceeding straight to thoracotomy without mediastinoscopy for T1 peripheral tumors without enlarged mediastinal lymph nodes on preoperative CT.
Dillemans等已报道选择性纵隔镜检查策略,对于术前CT无纵隔淋巴结肿大的周围型T1肿瘤进行直接开胸而不需纵隔镜检查。

This strategy resulted in a 16% incidence of positive N2 nodes discovered only at the time of thoracotomy.
该策略的结果是在开胸时仅发现16%的N2淋巴结阳性率。

For identifying N2 disease, chest CT scans had sensitivity and specificity rates of 69% and 71%, respectively.
对于N2的识别,胸部CT扫描的敏感性和特异性分别为69%和71%。

However, using both the chest CT scan plus mediastinoscopy was significantly more accurate (89% vs. 71%) than using the chest CT scan alone for identifying N2 disease.
然而,对于确定N2疾病,胸部CT扫描加纵隔镜检查两者均使用比单独使用胸部CT扫描显著更准确(89%对71%)。

When using CT scans, node positivity is based on the size of the lymph nodes.
当使用CT扫描时,淋巴结阳性是根据淋巴结的大小。

Therefore, the CT scan will miss small metastases that do not result in node enlargement.
因此,CT扫描会漏掉淋巴结未肿大的小转移灶。

To address this issue, Arita et al specifically examined lung cancer metastases to normal size mediastinal lymph nodes in 90 patients and found an incidence of 16% (14/90) false-negative chest CT scans with histologic identification of occult N2 or N3 disease.
为解决这个问题,Arita等在90例患者中专门研究了肺癌转移到正常大小的纵隔淋巴结,发现病理隐匿性N2或N3疾病胸部CT扫描假阴性率为16%(14/90)。

Bronchoscopy is used in diagnosis and local staging of both central and peripheral lung lesions and is recommended for pretreatment evaluation of stage I to IIIA tumors.
在中心型和周围型肺病变的诊断和局部分期中支气管镜均可使用并推荐用于I-IIIA期肿瘤的治疗前评估。

However, in patients who present with a solitary pulmonary nodule where the suspicion of malignancy is high, surgical resection without prior invasive testing may be reasonable.
然而,在表现为孤立性肺结节、高度怀疑恶性肿瘤的患者中,术前不进行侵袭性检查可能是合理的。

Other Imaging Studies其他影像学检查

As previously mentioned, CT scans have known limitations for evaluating the extent of lymph node involvement in lung cancer.
如前所述,已知CT扫描评价肺癌淋巴结受累范围具有局限性。

PET scans have been used to help evaluate the extent of disease and to provide more accurate staging.
PET扫描已用于帮助评估病变范围并提供更准确的分期。

The NCCN Panel reviewed the diagnostic performance of CT and PET scans.
NCCN小组审查了PET与CT扫描的诊断性能。

The NCCN Panel believes that PET scans can play a role in the evaluation and more accurate staging of NSCLC, for example, in identifying stage I (peripheral and central T1–2, N0), stage II, stage III, and stage IV diseases.
NCCN专家组认为,PET扫描可以在NSCLC更准确的分期评估,如I期(外周和中心型T1-2N0)、II期、III期和IV期疾病的确定中发挥作用。

However, FDG PET/CT is even more sensitive and is recommended by NCCN.
但是,FDG PET/CT更敏感,因此被NCCN推荐。

The NCCN Panel assessed studies that examined the sensitivity and specificity of chest CT scans for mediastinal lymph node staging.
NCCN小组评估研究了胸部CT扫描对纵隔淋巴结分期的敏感性和特异性。

Depending on the clinical scenario, a sensitivity of 40% to 65% and a specificity of 45% to 90% were reported.
取决于临床情况,报告的敏感性为40%-65%、特异性为45%-90%。

Because they detect tumor physiology, as opposed to anatomy, PET scans may be more sensitive than CT scans.
因为其检测肿瘤生理学,而非解剖学,因此PET扫描可能比CT扫描更敏感。

Moreover, if postobstructive pneumonitis is present, there is little correlation between the size of the mediastinal lymph nodes and tumor involvement.
此外,如果存在阻塞性肺炎,纵隔淋巴结大小与肿瘤浸润之间几乎没有相关性。

Chin et al found that PET, when used to stage the mediastinal nodes, was 78% sensitive and 81% specific with a negative predictive value of 89%.
Chin等发现,当PET用于纵隔淋巴结的分期时,敏感性是78%,特异性是81%,阴性预测值为89%。

Kernstine et al compared PET scan to CT scan for identifying N2 and N3 disease in NSCLC.
Kernstine等对PET扫描与CT扫描用于识别NSCLC N2和N3疾病进行了比较。

The PET scan was found to be more sensitive than the CT scan in identifying mediastinal node disease (70% vs. 65%).
认为在识别纵隔淋巴结病变方面PET扫描比CT扫描更敏感(70%对65%)。

FDG PET/CT has been shown to be useful in restaging patients after adjuvant therapy.
已证明FDG PET/CT在辅助治疗后患者的再分期方面是有用的。

When patients with early-stage disease are accurately staged using FDG PET/CT, inappropriate surgery is avoided.
当早期患者使用FDG PET/CT准确分期时,可避免不适当的手术。

However, positive FDG PET/CT scan findings for distant disease need pathologic or other radiologic confirmation (eg, MRI of bone).
然而,对于FDG PET/CT扫描发现的阳性远隔病变需要病理或其他影像学(如,骨MRI)确认。

If the FDG PET/CT scan is positive in the mediastinum, the lymph node status needs pathologic confirmation.
如果FDG PET/CT扫描纵隔淋巴结阳性,该淋巴结情况需要病理学证实。

Transesophageal EUS-FNA and EBUS-TBNA have proven useful to stage patients or to diagnose mediastinal lesions; these techniques can be used instead of invasive staging procedures in select patients.
已经证明经食道EUS-FNA和EBUS-TBNA对于患者分期或诊断纵隔病变是有用的;在选择的患者中这些技术可以用来代替侵袭性分期程序。 

When compared with CT and PET, EBUS-TBNA has a high sensitivity and specificity for staging mediastinal and hilar lymph nodes in patients with lung cancer.
与CT和PET相比,EBUS-TBNA对肺癌患者的纵隔及肺门淋巴结分期具有高敏感性和特异性。

In patients with positive nodes on CT or PET, EBUS-TNBA can be used to clarify the results.
CT或PET淋巴结阳性患者,可以用EBUS-TNBA来澄清结果。

However, in patients with negative findings on EBUS-TNBA, conventional mediastinoscopy can be done to confirm the results.
然而,在EBUS-TNBA结果阴性的患者中,可进行常规纵隔镜检查以证实该结果。

Note that EBUS is also known as endosonography.
注意,EBUS亦称为腔内超声检查。

The routine use of bone scans (to exclude bone metastases) is not recommended.
不推荐常规使用骨扫描(排除骨转移)。

Brain MRI (with contrast), to rule out asymptomatic brain metastases, is recommended for patients with stage II, III, and IV disease to rule out metastatic disease if aggressive combined-modality therapy is being considered.
对于II、III和IV期疾病患者,如果考虑积极的联合治疗,为了排除无症状脑转移,建议脑MRI(对比剂)以排除转移性疾病。

Patients with stage IB NSCLC are less likely to have brain metastases; therefore, brain MRI is only a category 2B recommendation in this setting.
IB期NSCLC患者不太可能有脑转移;因此,在这种情况下脑MRI只是2B类推荐。

If brain MRI cannot be done, then CT of the head with contrast is an option.
如果不能做脑MRI,则头部加强CT是一个选择。

Note that PET scans are not recommended for assessing the presence of brain metastases (see the NCCN Guidelines for Central Nervous System Cancers, available at NCCN.org).
注意,不推荐PET扫描用于评估脑转移的存在(见中枢神经系统癌症NCCN指南,可在NCCN.org获取)。

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张品良 副主任医师

山东省肿瘤医院 呼吸肿瘤内科

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