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1、肺癌的诊治指南,肺癌的诊治指南,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 小细胞肺癌的病期诊断 非小细胞肺癌的病期诊断 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,肺癌的诊断-临床诊断,病史采集和完整体检 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,专一性检查和组织细胞病理学检查 初步筛查 胸正侧位片 血常规项 痰细胞血检查,肺癌的诊断-临床诊断,肺癌局部侵润扩展的临床表现（1） 胸疼（侵犯胸膜、肋骨、脊柱、大气管、食道） 呼吸
2、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）,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,肺癌的诊断-临床诊断,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 肩背部剧疼： 局部肌肉神经受侵 腋窝肌肉萎缩：局部肌肉神经受侵 同侧Horner症： 侵犯颈交感神经和臂从神经,肺癌疑诊检查 支气管
3、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,肺癌的诊断-临床诊断,肺癌远处转移的临床表现 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（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： 肝：疼痛、厌食、黄疸、腹水、肝源性低血糖 胰：胰腺炎表现、阻塞性黄疸、高血糖 肾上腺、腹膜后淋巴结：一般无症状 肾：肾积水，血尿 骨； 脊柱转移：疼痛，截瘫，大小便失禁 肢体骨： 疼痛，骨折,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
4、髓细胞血或活检检查、 腰椎穿刺 ECT骨扫描，PET,肺癌的诊断-临床诊断,肺癌的副综合症（SCLC多见） 内分泌系统 Cushing综合征 抗利尿激素分泌异常综合症 高钙血症（肺鳞癌多见） 男性乳腺发育 类癌综合症 神经肌肉系统 小脑皮质变性 周围神经病变 癌性肌病等 皮肤 皮肌炎 黑棘皮病等 骨骼系统 肺源性骨关节病（肺腺癌多见）,相应检查鉴别诊断 24h17-羟皮质醇20mg 24h尿钠200mg 血钙波动在增高的20%左右 尿5羟吲哚乙酸定性,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织
5、病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的诊断-组织病理学诊断,WHO肺癌组织学分类及临床病理特征,肺癌的病期诊断-小细胞肺癌,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,肺癌的病期诊断-非小细胞肺癌（1）,1997年非小细胞肺癌国际分期修订本中TNM的
6、概念,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TNM的概念,肺癌的病期诊断-非小细胞肺癌（3）,1997年非小细胞肺癌国际分期修订本中TNM的概念,肺癌的病期诊断-非小细胞肺癌(4),1997年非小细胞肺癌国际分期修订本中TNM的概念,肺癌的病期诊断-非小细胞肺癌(5),1997年非小细胞肺癌国际分期修订本中TNM的概念 注年公布的肺癌国际分期，在T和M定义上与年的分期基本一致，但有下述三点的修改： 在原发肿瘤所在的叶内出现癌性卫星结节定义为T4； 在其他叶出现的癌性结节包括粟粒样病灶定义为M1； 心包积液的定义原则等同于胸腔积液。,肺癌的病期诊断-非小细胞肺
7、癌(6),1997年非小细胞肺癌国际分期修订本中TNM的概念,肺癌的病期诊断-非小细胞肺癌(6),小细胞肺癌的治疗原则和方法（1）,小细胞肺癌的治疗方法,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；/选择其一,NCI guideline:Treatment of LD SCLC,Standard treatment options: 1.Combination chemotherapy with chest irradiation (with or without PCI given to patients with complete responses): E
8、C: etoposide + cisplatin + 4500 cGy chest radiation therapy. 2.Combination chemotherapy (with or without PCI in patients with complete responses), especially in patients with impaired pulmonary function or poor performance status. 3.Surgical resection followed by chemotherapy or chemotherapy plus ch
9、est radiation therapy (with or without PCI in patients with complete responses) for patients with stage I disease.,NCI guideline:Treatment of ED SCLC (1),Combination chemotherapy with one of the following regimens with or without PCI given to patients with complete responses: The following regimens
10、produce similar survival outcomes: CAV: cyclophosphamide + doxorubicin + vincristine.26,27 CAE: cyclophosphamide + doxorubicin + etoposide.28 EP or EC: etoposide + cisplatin or carboplatin.29,30 ICE: ifosfamide + carboplatin + etoposide.31,NCI guideline:Treatment of ED SCLC (2),Other regimens appear
11、 to produce similar survival outcomes but have been studied less extensively or are in less common use, including: Cyclophosphamide + doxorubicin + etoposide + vincristine.32 CEV: cyclophosphamide + etoposide + vincristine.33 Single-agent etoposide.21 PET: cisplatin + etoposide + paclitaxel.34,NCI g
12、uideline:Treatment of ED SCLC (3),2. Radiation therapy to sites of metastatic disease unlikely to be immediately palliated by chemotherapy, especially brain, epidural, and bone metastases.,NCI guideline:Treatment of ED SCLC (4),3. Identification of effective new agents is difficult in patients who h
13、ave previously been treated with standard chemotherapy because response rates to agents, even of known efficacy, are 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
14、under evaluation, with provisions for early change to standard combination therapy if there is no response.35 Such a 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
15、 variety of other strategies have been proposed, depending on the activity of the new agent in other tumors, in preclinical small cell lung cancer models, or the activity of drug analogs.39 Active single agents undergoing further evaluation include paclitaxel and topotecan.40,41,非小细胞肺癌的治疗原则和方法（1）,非小
16、细胞肺癌的治疗方法,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,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,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,NCI Guideline of NSCLC Treatment of occult lung cancer (Tx,N0,M0),In occult lung cancer, a diagnostic evaluation often includes chest
17、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, treatment is determined
18、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.,NCI Guideline of NSCLC Treatment of stage 0 (Tis,N0,M0),Standard treatment options: Surgical resection using the least extensive techniq
19、ue possible (segmentectomy or wedge resection) to preserve maximum normal pulmonary tissue since these patients are at high risk for second lung cancers. Endoscopic photodynamic therapy.2,3,NCI Guideline of NSCLC Treatment of stage (T1-2,N0,M0),Standard treatment options: Lobectomy or segmental, wed
20、ge, or sleeve resection as appropriate. Radiation therapy with curative intent (for potentially resectable patients who have medical contraindications to surgery). Clinical trials of adjuvant chemotherapy following resection.14,15 Adjuvant chemoprevention trials.12,13,16 Endoscopic photodynamic ther
21、apy (under clinical evaluation in highly selected T1, N0, M0 patients).17,NCI Guideline of NSCLC Treatment of stage (T1-2N1M0,T3N0M0,),Standard treatment options: Lobectomy; pneumonectomy; or segmental, wedge, or sleeve resection as appropriate. Radiation therapy with curative intent (for potentiall
22、y operable patients who have medical contraindications to surgery). Clinical trials of adjuvant chemotherapy with or without other modalities following curative surgery.10 Clinical trials of radiation therapy following curative surgery.10,NCI Guideline of NSCLC Treatment of stage A (T1-3N2M0,T3N1M0,
23、),Standard treatment options: Surgery alone in operable patients without bulky lymphadenopathy.22-24 Radiation therapy alone, for patients who are not suitable for neoadjuvant chemotherapy plus surgery.1,2 Chemotherapy combined with other modalities.4-6,12,NCI Guideline of NSCLC Treatment of stage A
24、 (T1-3N2M0,T3N1M0,),Superior sulcus tumor (T3, N0 or N1, M0) Standard treatment options: Radiation therapy and surgery. Radiation therapy alone. Surgery alone (selected cases). Chemotherapy combined with other modalities. Clinical trials of combined modality therapy. Concurrent chemotherapy and radi
25、ation therapy followed by surgery may provide the best outcome, particularly for patients with T4, N0 or N1 disease.26 Level of evidence: 3iiiDi,NCI Guideline of NSCLC Treatment of stage A (T1-3N2M0,T3N1M0,),Chest wall tumor (T3, N0 or N1, M0) Standard treatment options: Surgery.24,27 Surgery and ra
26、diation therapy. Radiation therapy alone. Chemotherapy combined with other modalities.,NCI Guideline of NSCLC Treatment of stage B (anyTN3M0,T4anyNM0,),Standard treatment options: Radiation therapy alone.7 Chemotherapy combined with radiation therapy.1-3,9 Chemotherapy and concurrent radiation thera
27、py followed by resection.13,14 Chemotherapy alone.,NCI Guideline of NSCLC Treatment 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 w
28、ith similar survival outcomes: Cisplatin plus vinblastine plus mitomycin.14 Cisplatin plus vinorelbine.3,15 Cisplatin plus paclitaxel.6,9 Cisplatin plus docetaxel.9,16 Cisplatin plus gemcitabine.9,17 Carboplatin plus paclitaxel.5,9,15,NCI Guideline of NSCLC Treatment of stage (anyT,anyN,M1,),Standar
29、d 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 produced by standard platinum-based regimens.18 Fu
30、rther 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,NCI Guideline of NSCLC Treatment of recurrent NSCLC,St
31、andard 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: Cisplatin plus vinblastine plus mitomycin.16 Cisplatin plus vinorelbine.17 Cisplatin plus
32、 paclitaxel.18,19 Cisplatin plus gemcitabine.19,20 Carboplatin plus paclitaxel.19,21,22 Cisplatin plus docetaxel.19,NCI Guideline of NSCLC Treatment of recurrent NSCLC,Standard 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),