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原创 小细胞肺癌NCCN指南2017第二版讨论(第四部分)

张品良 副主任医师 山东省肿瘤医院 呼吸肿瘤内科
2016-10-18 179人已读
张品良 副主任医师
山东省肿瘤医院

Small Cell Lung Cancer 小细胞肺癌

NCCN Guidelines Version 2.2017
NCCN指南2017第2版山东省肿瘤医院呼吸肿瘤内科张品良

Discussion
讨论

Surgical Resection of Stage I SCLC
I期小细胞肺癌的手术切除

The Principles of Surgical Resection for SCLC are described in the NCCN algorithm; studies supporting these recommendations are described in this section. Briefly, the NCCN Guidelines state that surgery should only be considered for patients with stage I (T1–2, N0) SCLC in whom mediastinal staging has confirmed that mediastinal lymph nodes are not involved. Data show that patients with clinically staged disease in excess of T1–2,N0 do not benefit from surgery. Note that only 5% of patients with SCLC have true stage I SCLC. The Lung Cancer Study Group conducted the only prospective randomized trial evaluating the role of surgery in SCLC. Patients with limited-stage disease, excluding those with solitary peripheral nodules, received 5 cycles of chemotherapy with CAV; those showing a response to chemotherapy were randomly assigned to undergo resection plus thoracic radiotherapy or thoracic radiotherapy alone. The overall survival rates of patients on the 2 arms were equivalent, suggesting no benefit to surgery in this setting. However, only 19% of enrolled patients had clinical stage I (T1–2, N0, M0) disease.
在NCCN工作步骤中描述了小细胞肺癌手术切除的原则;在这一章节中描述了支持这些建议的研究。简而言之,NCCN指南指出,手术应该仅仅考虑用于纵隔分期证实的纵隔淋巴结未累及的I期(T1–2N0)小细胞肺癌患者。数据显示,疾病临床分期超出T1–2N0的患者,手术不能获益。值得注意的是,只有5%的小细胞肺癌患者为真正的I期。肺癌研究小组实施了唯一一项前瞻性随机试验评估手术在小细胞肺癌中地位。排除孤立性周围性肺结节的局限期患者,接受了5周期的CAV化疗化疗有效的患者随机分配至接受切除术加胸部放疗或单纯胸部放疗。两组患者的总生存率相同,这表明在这种情况下手术未受益。然而,只有19%的入组患者为临床I期(T1–2N0M0)。

Most data regarding the benefit of surgery are from retrospective reviews. These studies report favorable 5-year survival rates of 40% to 60% in patients with stage I disease. In most series, survival rates decline significantly in patients with more advanced disease, leading to the general recommendation that surgery should only be considered in those with stage I disease. Interpretation of these results is limited by the selection bias inherent in retrospective reviews and by the variable use of chemotherapy and radiotherapy.
几乎所有的有关手术获益的数据均来自回顾分析。这些研究报告的I期患者良好的5年生存率为40%-60%。在大多数群组中,更晚期疾病患者的生存率下降显著,因此一般建议,只有在I期情况下才考虑手术。这些结果的解释是在回顾性研究中受固有的选择偏差限制,并且化疗和放疗的使用也是多种多样。

Analyses of the SEER database also suggest that surgery may be appropriate for some patients with localized disease. However, these studies are limited by the lack of information on chemotherapy use in the database. In addition, comparison of the survival of surgical patients to all those who did not undergo surgery is inherently flawed by selection bias. Ultimately, the role of surgery in SCLC will not be fully defined until results are available from trials comparing surgery plus adjuvant chemotherapy to concurrent chemoradiotherapy in patients who are rigorously staged.
SEER数据库分析也表明,对于某些局限期患者手术可能是恰当的。然而,数据库中的这些研究受缺乏化疗使用信息的限制。此外,比较手术患者与所有未手术患者生存研究固有的缺陷是选择偏倚。总之,手术在小细胞肺癌中的作用尚未十分明确,除非是可得到在严格分期的患者中比较手术加辅助化疗与同步放化疗试验的结果。

NCCN Guidelines
NCCN 指南

In all patients with clinical stage I (T1–2, N0) SCLC who are being considered for surgical resection, occult nodal disease should be ruled out through mediastinal staging before resection. If resection is performed, the NCCN Panel favors lobectomy and does not feel that segmental or wedge resections are appropriate for patients with SCLC. After complete resection, adjuvant chemotherapy or chemoradiation is recommended. Adjuvant chemotherapy alone is recommended for patients without nodal metastases, whereas concurrent chemotherapy and postoperative mediastinal radiotherapy are recommended for patients with nodal metastases (see Adjuvant Treatment in the NCCN Guidelines for SCLC). Although panel members agree that postoperative mediastinal radiotherapy is recommended in this setting, it should be based on the extent of nodal sampling/dissection and extent of nodal positivity; however, there are no data to support this recommendation. PCI should be considered after adjuvant therapy in select patients, because it can improve survival (see Prophylactic Cranial Irradiation in this Discussion and Adjuvant Treatment in the NCCN Guidelines for SCLC). For the 2017 update, the NCCN Panel added new recommendations for response assessment after adjuvant therapy. Response assessment using CT with contrast of the chest, liver, and adrenal gland should occur only after completion of initial therapy for patients with limited-stage disease; repeating scans during therapy is not recommended.
在考虑手术切除的所有临床Ⅰ期(T1–2N0)小细胞肺癌患者中,均应在切除前通过纵隔分期排除隐匿性淋巴结病变。对于小细胞肺癌患者,如果进行切除,NCCN小组支持肺叶切除术而不是段或楔形切除。建议在完全切除术后辅助化疗或放化疗。对于无淋巴结转移的患者,建议单纯辅助化疗,而对于淋巴结转移的患者建议同步化疗加术后纵隔放疗(见小细胞肺癌NCCN指南中的辅助治疗)。虽然小组成员同意在这种情况下建议术后纵隔放疗,但是应该基于广泛的淋巴结采样/解剖和广泛的淋巴结阳性;不过,没有数据支持该建议。在选择性患者中辅助治疗后应考虑预防性脑照射(PCI),因为可改善生存(见本讨论中的预防性脑照射和小细胞肺癌NCCN指南中的辅助治疗)。2017更新,NCCN小组增加了辅助治疗后疗效评价新建议。对于局限期患者,应该只有在初始治疗完成后才使用胸部、肝脏和肾上腺强化CT进行疗效评估;不建议在治疗过程中重复扫描。

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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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