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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

Non-Small Cell Lung Cancer非小细胞肺癌

NCCN Guidelines Version 4.2016  NCCN指南2016第4版


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).

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).

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).

The NCCN Panel also recommends that smoking cessation advice, counseling, and pharmacotherapy be provided to patients.

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.

Note that for some patients, diagnosis, staging, and surgical resection are done during the same operative procedure.

A multidisciplinary evaluation should be done before treatment.

Additional Pretreatment Evaluation治疗前的其他评估


As previously noted, evaluation of the mediastinal nodes is a key step in the further staging of the patient.

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.

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).

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.

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.

This strategy resulted in a 16% incidence of positive N2 nodes discovered only at the time of thoracotomy.

For identifying N2 disease, chest CT scans had sensitivity and specificity rates of 69% and 71%, respectively.

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.

When using CT scans, node positivity is based on the size of the lymph nodes.

Therefore, the CT scan will miss small metastases that do not result in node enlargement.

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.

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.

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.

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.

PET scans have been used to help evaluate the extent of disease and to provide more accurate staging.

The NCCN Panel reviewed the diagnostic performance of CT and PET scans.

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.

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.

Depending on the clinical scenario, a sensitivity of 40% to 65% and a specificity of 45% to 90% were reported.

Because they detect tumor physiology, as opposed to anatomy, PET scans may be more sensitive than CT scans.

Moreover, if postobstructive pneumonitis is present, there is little correlation between the size of the mediastinal lymph nodes and tumor involvement.

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%.

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%).

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.

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.

In patients with positive nodes on CT or PET, EBUS-TNBA can be used to clarify the results.

However, in patients with negative findings on EBUS-TNBA, conventional mediastinoscopy can be done to confirm the results.

Note that EBUS is also known as endosonography.

The routine use of bone scans (to exclude bone metastases) is not recommended.

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.

Patients with stage IB NSCLC are less likely to have brain metastases; therefore, brain MRI is only a category 2B recommendation in this setting.

If brain MRI cannot be done, then CT of the head with contrast is an option.

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).



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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