Guidelines for lung cancer diagnosis and treatment (2011)I. overviewPrimary lung cancer is one of the most common malignant tumors in china.
Guidelines for lung cancer diagnosis and treatment (2011)
Primary lung cancer is one of the most common malignant tumors in china. 2010 health statistics show that in 2005, lung cancer mortality accounted for first of the mortality rate of malignant tumors in china. Department of thoracic surgery Henan Cancer Hospital Qin Jianjun
In order to further standardize the diagnosis and treatment of lung cancer in China, to improve the level of diagnosis and treatment of lung cancer in medical institutions, to improve the prognosis of patients with lung cancer, to ensure the quality of medical care and medical safety.
Two, diagnostic techniques and Applications
(a) high risk factors. There was a history of smoking and smoking index greater than 400 / year, high-risk occupational exposure history (such as exposure to asbestos) and family history of lung cancer, the age of people over the age of 45, is a high risk of lung cancer.
(two) clinical manifestations.
1 early lung cancer can not have obvious symptoms. When the disease develops to a certain extent, often the following symptoms:
(1) irritating cough.
(2) sputum with blood or blood sputum.
(3) chest pain.
Shortness of breath (5).
When respiratory symptoms for more than two weeks, the treatment does not reduce, especially irritating cough with blood, sputum, or the respiratory symptoms, the possibility of the existence of a high degree of vigilance to lung cancer.
2 when lung cancer invades the surrounding tissue or metastasis, the following symptoms can occur:
(1) tumor invasion of recurrent laryngeal nerve hoarseness.
(2) tumor invasion of superior vena cava, appear on face and neck edema and obstruction of superior vena cava syndrome.
(3) tumor of pleura caused by pleural effusion, often bloody effusion can cause shortness of breath.
(4) carcinoma involving the pleura and chest wall, can continue to cause severe chest pain.
(5) on the tip of lung cancer can invade and oppression in thoracic entrance organs, such as the first rib, subclavian artery and vein, brachial plexus, cervical sympathetic nerve, resulting in severe chest pain, upper extremity venous engorgement, edema, arm pain and upper limb movement disorder, on the same side, ptosis, pupil narrow, enophthalmos, no facial sweating of cervical sympathetic nerve syndrome.
(6) recent neurological symptoms and signs such as headache, nausea, dizziness, or unclear vision should be considered for the possibility of brain metastasis.
(7) for the fixed parts of the pain, plasma alkaline phosphatase or serum calcium should consider the possibility of bone metastasis.
(8) the right upper abdominal pain, hepatomegaly, alkaline phosphatase, aspartate aminotransferase, lactate dehydrogenase or elevated bilirubin should consider the possibility of liver metastasis.
(9) subcutaneous metastasis can be found in subcutaneous nodules.
(10) the transfer of blood to other organs may occur in the corresponding symptoms of organ metastasis.
(three) physical examination.
1 the majority of patients with lung cancer were not significantly associated with positive signs.
2 patients with unexplained pulmonary signs, Jiuzhibuyu, such as clubbing finger (toe), non migratory pulmonary joint pain, male breast hyperplasia, dark skin or dermatomyositis, ataxia, phlebitis and so on.
3 the clinical manifestations of patients with highly suspected lung cancer, physical examination found vocal cord paralysis, superior vena cava obstruction syndrome, Horner syndrome, Pancoast syndrome and other local invasion and metastasis of the possible.
4 clinical manifestations of highly suspected lung cancer patients with nodules, hepatomegaly, subcutaneous nodules, supraclavicular lymph nodes and distant metastasis may be found in physical examination tips.
(four) imaging examination.
1 chest X-ray: chest X-ray is an important means of early detection of lung cancer, but also one of the methods of postoperative follow-up.
2 chest CT examination: chest CT can further verify the location of the lesion and the scope of involvement, but also can be roughly distinguished between the benign and malignant, is an important means of diagnosis of lung cancer. Low dose spiral chest CT can effectively detect early lung cancer, and CT guided transthoracic lung biopsy is an important technique for obtaining cytological and histological diagnosis.
3.B type ultrasound: mainly used for the detection of abdominal organs and important abdominal lymph node metastasis, but also for double supraclavicular lymph node examination; lung lesions or chest wall lesions to the adjacent chest wall, can identify the solid and cystic and ultrasound guided biopsy; ultrasound is often used for the chest water extraction location.
4.MRI examination: MRI examination has certain value to the clinical stage of lung cancer, especially suitable for judging the spine, rib and brain metastasis.
5 bone scan: routine examination of bone metastasis in lung cancer. When the bone scan examination showed that the bone was suspicious, it could be used for MRI examination and verification.
6.PET-CT check: not recommended for routine use. The sensitivity and specificity of CT in the diagnosis of lung cancer with mediastinal lymph node metastasis were higher.
1 fiberoptic bronchoscopy: fiberoptic bronchoscopy is the most commonly used method for the diagnosis of lung cancer, including biopsy, biopsy, and bronchial lavage under direct vision. The above methods can improve the detection rate.
2 fiberoptic bronchoscopy guided transmural puncture mediastinal lymph node biopsy (TBNA) and ultrasound guided transmural fiber bronchoscopy lymph node biopsy (EBUS-TBNA): fiberoptic bronchoscopy guided transmural lymph help before the treatment of lung cancer TNM precise N2 staging staging biopsy. However, as a routine examination method, conditional hospital should be actively carried out. Conclusion N2 (N1) guided by fiber bronchoscope guided percutaneous puncture biopsy of lymph nodes (EBUS-TBNA) is a safe and reliable method for the accurate pathological diagnosis of lung cancer.
3 mediastinoscopy: as an effective method for the diagnosis of lung cancer and the assessment of N staging, it is the gold standard for clinical evaluation of mediastinal lymph node status in lung cancer. Although CT, MRI, and PET-CT, which are used in clinic in recent years, can provide valuable evidence for the N staging of lung cancer before treatment, they still can not replace the diagnostic value of mediastinoscopy.
4: thoracoscopy thoracoscopy can accurately diagnosis and staging for lung cancer, by fiberoptic bronchoscopy and transthoracic lung biopsy puncture needle aspiration (TTNA) examination method to get early lung cancer pathological specimens, especially small pulmonary nodules underwent thoracoscopic resection of the lesions, which can diagnose. In the advanced stage of lung cancer, the biopsy of lymph nodes, pleura and pericardium can be performed under thoracoscopy, and the cytological examination of pleural effusion and pericardial effusion can provide reliable basis for the establishment of a comprehensive treatment plan.
(six) other inspection techniques.
1 sputum cytology: sputum cytology diagnosis of lung cancer is currently the simple non-invasive diagnostic method of diagnosis for three days left in the morning from deep cough sputum can be sputum cytology smears obtained cytology.
2 transthoracic needle aspiration biopsy of pulmonary masses (TTNA): TTNA can be carried out under the guidance of CT or B ultrasound, the sensitivity and specificity of the diagnosis of peripheral lung cancer are higher.
3 pleural puncture: when the pleural effusion is unclear, pleural puncture can be performed in order to further obtain cytological diagnosis and clear the stage of lung cancer.
4 pleural biopsy: pleural biopsy can improve the positive detection rate when no positive results were found.
5 superficial lymph node biopsy for pulmonary occupying lesions or have been diagnosed as lung cancer patients, if accompanied by superficial lymph nodes, should be a routine biopsy of superficial lymph nodes, to obtain the pathological diagnosis, staging of lung cancer further, guide clinical treatment.
(seven) blood biochemical examination.
1 blood biochemical examination: for primary lung cancer, there is no specific blood biochemical examination. Lung cancer patients plasma alkaline phosphatase or calcium rise is considered the possibility of bone metastasis, serum alkaline phosphatase and aspartate aminotransferase, lactate dehydrogenase or bilirubin rise is considered the possibility of liver metastasis.
2 blood tumor marker examination: there is no specific lung cancer biomarkers used in clinical diagnosis, it is not as a routine examination, but the conditions of the hospital can be at the discretion of the following examination, as a reference for the assessment of lung cancer:
(1) antigen (carcinoembryonic, CEA): serum CEA examination is mainly used to judge the prognosis of lung cancer and the monitoring of the treatment process.
(2) NSE (neurone specific enolase) is the preferred marker of small cell lung cancer for the diagnosis and treatment of small cell lung cancer.
(3) cytokeratin fragment (cytokeratin fragment, CYFRA21-1): a certain reference value for the diagnosis of lung squamous cell carcinoma.
(4) squamous cell carcinoma antigen (squarmous cell carcinoma, SCC): the value of lung squamous cell carcinoma in the treatment of monitoring and prognostic evaluation of a certain value (antigen).
(eight) histological diagnosis. Histopathological diagnosis is the basis for diagnosis and treatment of lung cancer. Biopsy diagnosed with lung cancer, should be standardized treatment. As a result of biopsy restriction, biopsy pathological diagnosis cannot be determined, or advise clinicians to repeat biopsy combined with imaging examination further selection of treatment programs, clinical and pathological diagnosis of joint consultation pathologists confirmed when necessary.
(nine) differential diagnosis of lung cancer.
1 benign tumor: a common pulmonary hamartoma, bronchopulmonary cyst, giant lymph node hyperplasia, inflammatory myofibroblastic tumor, sclerosing hemangioma, tuberculoma, arteriovenous fistula and pulmonary sequestration. These benign lesions have their own characteristics in the imaging examination, if it is not easy to distinguish with malignant tumors, surgical resection should be considered.
2 tuberculous lesions: lung disease is the most common and most easily confused with lung cancer lesions. It is easy to be misdiagnosed or delayed. For clinically difficult to identify lesions, sputum cytology, fiberoptic bronchoscopy, and other auxiliary examinations should be performed repeatedly until thoracotomy. Contraindications to radiation therapy (hereinafter referred to as radiation therapy) or chemical therapy (hereinafter referred to as chemotherapy) may be performed before the diagnosis of pathology or cytology. Positive tuberculin test cannot exclude as indicators of lung cancer.
3 pneumonia: approximately 1/4 of lung cancer occurs early in the form of pneumonia. On the slow onset, mild symptoms, anti-inflammatory treatment effect is not good or repeated in the same part of the pneumonia should be highly alert to the possibility of lung cancer.
4 other: including in the lungs of some rare, rare benign and malignant tumors, such as pulmonary fibroma, pulmonary lipoma, often difficult to identify before surgery.
Three, pathological evaluation
(a) standard for fixation of lung cancer specimens.
1 fixed liquid: recommend the use of 10% neutral formalin fixed, avoid the use of liquid containing heavy metals.
2 fixed amount: 10 times or more of the volume of the specimen.
3 fixed temperature: room temperature.
4 according to the location and state of the tumor when the specimen, there are two options:
(1) samples directly into the 10% neutral formalin fixed.
(2) injection of 10% neutral formalin fixed liquid enough from the bronchi when necessary, bronchial ligation or vise, fixed overnight.
5 fixed time: biopsy specimens: 6 hours, less than 48 hours; surgical specimens: 12 hours, less than 48 hours.
(two) material requirements.
1 biopsy specimens.
(1) check the number of clinical samples of biopsy specimens from biopsy specimens must be drawn.
(2) each wax block contains no more than 5 biopsy specimens.
(3) the specimen is wrapped in gauze or Soft Pervious paper to avoid loss.
2 surgical specimens.
(1) partial resection of the lung (lung resection and wedge resection).
Removal of surgical sutures or metal nails.
The size of the specimen and the surface of the pleura were recorded.
Vertical incision was used to remove the lung parenchyma, and to describe the size of the mass, the incision (with / without hemorrhage / necrosis / void formation) and the relationship between the pleura and lung parenchyma and the distance between the edge and the edge of the mass.
According to the location and size of the lesions of 1-4 tissue, tumor tissue cutting and pleural tumors, and lung parenchyma margin.
The cut non tumor lung tissue.
(2) lobectomy and pneumonectomy specimens.
To examine the five basic structures of the lung: airway, lung parenchyma, pleura, blood vessels and lymph nodes. The size of the lung was measured.
Bronchial resection margin, vascular resection margin and pleural margin.
The whole lung resection specimens to find hilar lymph nodes.
According to the location and status of the tumor specimens were received, there are two options: one is to use the scissors along the longitudinal axis to open the main bronchi and their branches all the plane cut in pulmonary tissue can best be exposed the relationship between lesions and surrounding lung tissue structure. The two is the main bronchus into the Faure Marin specimens, every 0.5-1.0cm incision, the cut should be frontal plane, perpendicular to the hilum.
The description of tumor size and edge (with / without bleeding / necrosis / cavity formation), in the lobar and segmental position within the relationship, and the extent of the lesion and bronchial (focal or transfer) and the adequacy of resection. Depending on the size of the tumor, the location of the occurrence, the scope of the full extraction (conventional 4), and cut to show the relationship between the tumor and the surrounding lung tissue (conventional 2).
The cut non tumor lung tissue.
(3) lymph nodes.
It is recommended that surgeons use Cancer (American Joint Committee on, AJCC) in the staging system of regional lymph node grouping (N) to group the nodes. N2 lymph nodes usually separate and accurate inspection packet by the surgeon, it should be reported separately the lymph node. N2 lymph nodes often associated with lung resection specimens should be distinguished according to the specific site. The lymph nodes in the soft tissue of the lung and the lung parenchyma were found along the bronchus. All the lymph nodes were needed to be collected and recorded. All visible negative lymph nodes should be complete submission, the naked eye positive lymph nodes can cut part inspection.
(4) recommended size of tissue block: not more than 2 cm X1.5 cm x0.3cm.
3 after the specimen processing principles and retention time.
(1) preservation of the remaining specimens. From the remaining tissue preservation in fixed standard solution, and always maintain full fixed liquid volume and the concentration of formaldehyde, avoid dry specimens or because of insufficient or fixed liquid concentration decreased from decaying tissue; for in the pathological diagnosis report issued after receiving the feedback information of clinical specimens or supplementary materials review.
(2) the time limit for the disposal of the remaining samples. Recommendations in the report issued by pathological diagnosis after 1 months, has not received the clinical feedback information, does not occur due to outside the hospital consultation opinions for review case, at the discretion of the hospital.
4 pathological types.
(1) type of lung cancer: general direct description of the location of the tumor, the tumor from the carina length record.
(2) the histological type of lung cancer: a histological classification of lung cancer (WHO), with reference to the 2004 Edition (Annex 1).
5 pathology report.
(1) pathological reports and requirements of biopsy specimens.
The basic information and submission of patient information.
For intraepithelial neoplasia (dysplasia), grading report.
If there is cancer, the histological type.
(2) pathological reports and requirements of surgical specimens.
The basic information and submission of patient information.
The general situation: measuring the size of the lung, describe other incidental structure; description of tumor and lung, lung and (or) the relationship between the main airway and pleural tumor; from the bronchial margin and that from the other necessary margin distance (i.e. the soft tissue of the chest wall hilar vessels); tumor the size, whether there is a satellite nodule; description of non tumor lung tissue.
The diagnosis report contents: one is the site of the tumor: the tumor was located in the lung, which side lobes, if possible, the lung specific segment. Two is the type of surgery: pulmonary resection, lobectomy, pulmonary resection, including partial lung resection. Three is the histological type, including the following aspects: histological grading, margin histologic evaluation, pleural involvement, lymphatic vascular invasion, perineural invasion, lymph node metastasis.
The main differential diagnosis of immunohistochemical: squamous cell carcinoma, CK5/6, CK14 key screening 34 beta E12 and p63; lung cancer screening CK7 and TTF-l; neuroendocrine carcinoma of the lung CK18, AE1/AE3, CD56 screening, CgA, NSE and Syn.
The need of optional medication and prognosis related test items: HER2, VEGF, p53, p170, Top2A, PCNA, Ki-67.
The complete pathological report is based on the fact that the clinician fills out a detailed list of pathological diagnoses, describes the results of the surgery and related clinical findings and clearly identifies the lymph nodes. The mutual communication, trust and cooperation between clinicians and pathologists are the basis for establishing correct staging and guiding clinical treatment.
Four, lung cancer staging
(1) non-small cell lung cancer.
At present, non small cell lung cancer TNM staging by the International Association for the study of lung cancer (IASLC) 2009 7th edition staging criteria (IASLC 2009).
1 Definitions of T, N and M in TNM staging of lung cancer.
(1) primary tumor (T).
TX: primary tumor can not be evaluated, or sputum, bronchial lavage fluid to find cancer cells but no visible imaging or bronchoscopy.
T0: no evidence of primary tumor.
Tis: carcinoma in situ.
T1: the maximum tumor diameter less than 3cm, surrounded by lung or pleura surrounded, bronchoscopic tumor invasion beyond the bronchus (without involving the main bronchus).
T1a: maximum tumor diameter less than or equal to 2cm.
T1b: the maximum diameter of the tumor > 2cm and less than or equal to 3cm.
T2: tumor size or scope in accordance with any one of the following: the maximum diameter of the tumor > 3cm; but not more than 7cm; in the main bronchus, but more than 2cm from the carina; involving the pleura; extended to the hilum of lung atelectasis or obstructive pneumonia, but does not involve the whole lung.
T2a: the maximum tumor diameter less than 5cm, and in accordance with any of the following points: the maximum diameter of the tumor > 3cm; involving the main bronchus, but more than 2cm from the carina; involving the pleura; extended to the hilum of lung atelectasis or obstructive pneumonia, but does not involve the whole lung.
T2b: the maximum diameter of the tumor > 5cm and less than or equal to 7cm.
T3: any size of the tumor has a direct violation of the structure of the chest wall (including lung tumor), diaphragm, mediastinal pleura, pericardium; or tumor located away from the main bronchial carina within 2cm, but not involving the carina; or pulmonary atelectasis or obstructive pneumonia. The largest diameter of the tumor was > 7cm; single or multiple satellite foci with the same lobe of the primary tumor.
T4: any size of the tumor has a direct violation of the following structure: mediastinum, heart and great vessels, trachea, esophagus, recurrent laryngeal nerve, vertebral and carina; or the primary leaves of different single or multiple lesions.
(2) regional lymph nodes (N).
NX: regional lymph nodes cannot be assessed.
N0: no regional lymph node metastasis.
N1: metastasis to the ipsilateral bronchial lymph nodes and (or) ipsilateral hilar lymph nodes, and pulmonary lymph nodes, including the direct invasion of the primary tumor.
N2: transfer to the ipsilateral mediastinal and (or) subcarinal lymph node.
N3: transferred to the contralateral mediastinum, contralateral hilar lymph nodes, ipsilateral or contralateral scalene muscles or supraclavicular lymph nodes.
(3) distant metastasis (M).
MX: distant metastasis cannot be assessed.
M0: no distant metastasis.
M1: distant metastasis.
M1a: pleural dissemination (including malignant pleural effusion, malignant pericardial effusion, pleural metastasis nodules); metastatic nodules of side lobe.
M1b: extra thoracic metastasis.
Pleural effusion (or pericardial effusion) in most patients with lung cancer is caused by a tumor. But if the pleural effusion (or pericardial effusion cytology) repeatedly failed to find the cancer cells in pleural effusion (or pericardial effusion) and non ischemic or non exudative, clinical judgment of the pleural effusion (or pericardial effusion) and unrelated tumors, this type of pleural effusion (or pericardial effusion) does not affect the stage.
2 TNM staging of lung cancer (IASLC, 2009).
TNM staging of lung cancer (IASLC 2009)
Stealth lung cancer
Tx, N0, M0
Tis, N0, M0
T1a, B, N0, M0
T2a, N0, M0
T1a, B, N1, M0
T2a, N1, M0
T2b, N0, M0
T2, N1, M0
T3, N0, M0
T1, N2, M0
T2, N2, M0
T3, N1, M0
T3, N2, M0
T4, N0, M0
T4, N1, M0
T4, N2, M0
Any T, N3, M0
Any T, any N, M1a, B
(two) small cell lung cancer. Small cell lung cancer staging: for staging limited and extensive stage by non operative patients for surgery were treated by the International Association for the study of lung cancer (IASLC) staging standard 2009 seventh edition.
(I) treatment principle. We should take comprehensive treatment principle, namely: according to the patient's body condition, typology of cytology, pathology of tumor, invasion and scope (clinical stage) and the trend of development, take a multidisciplinary treatment model (MDT), planning and reasonable application of surgery, chemotherapy, radiotherapy and targeted therapy, to the purpose of controlling tumor radical or the maximum extent, improve the cure rate, improve the quality of life of patients, prolong the survival time of the patients to. At present, the treatment of lung cancer is mainly treated by surgery, radiotherapy and drug treatment.
(two) surgical treatment.
1 principles of surgical treatment.
Surgical resection is the main treatment of lung cancer, but also the only way to cure lung cancer. Lung cancer surgery is divided into radical surgery and palliative surgery, should strive for radical resection. In order to achieve the best and complete resection of the tumor, reduce tumor metastasis and recurrence, and the final pathological TNM stage, to guide the postoperative comprehensive treatment. The following surgical principles should be observed for resectable lung cancer:
(1) a comprehensive treatment plan and the necessary imaging examinations (clinical staging) should be completed prior to non emergency surgery. To fully evaluate the possibility of surgical resection and to develop an operation plan.
(2) complete resection of the tumor and regional lymph nodes as far as possible, as far as possible to retain functional healthy lung tissue.
(3) video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical technique which has been developed rapidly in recent years. It is suitable for patients with stage I lung cancer.
(4) if the physical condition of patients, should be treated with anatomic lung resection (lobectomy, bronchial sleeve lobectomy or pneumonectomy). If the condition of the body is not allowed, the surgical resection should be performed: pulmonary resection (first choice) or wedge resection, or VATS operation.
(5) except for the complete resection of the primary lesion, complete resection (R0) should be performed routinely in the hilar and mediastinal lymph nodes (N1 and N2 lymph nodes). At least 3 mediastinal drainage area (N2 station) lymph node sampling or lymph node clearance, as far as possible to ensure the complete removal of lymph nodes. It is suggested that the right thoracic clearance range is 2R, 3a, 3P, 4R, 7-9 group of lymph nodes and surrounding soft tissue, and the clearance of left chest is: 4L, 5-9 lymph nodes and surrounding soft tissues.
(6) the pulmonary vein and pulmonary artery were treated sequentially.
(7) sleeve lobectomy in rapid pathological examination margin (including bronchial and pulmonary artery or vein stump) negative cases, as far as possible to retain more lung function (including bronchial and pulmonary vessels), postoperative patients quality of life than pneumonectomy patients.
(8) in patients with recurrent or solitary pulmonary metastasis after complete resection of lung cancer at the age of 6 months, with the exception of distant metastasis, recurrence of the lung or resection of the lung metastasis were excluded.
(9) the heart lung function and body condition assessment can not accept surgical patients by I and II, could be diverted via radical radiotherapy, radiofrequency ablation therapy and drug treatment.
2 surgical indications.
(1) I, II and III stage a (T3N1-2M0; T1-2N2M0; T4N0-1M0 complete resection) in non small cell lung cancer and small cell lung cancer (T1-2N0 ~ 1M0).
(2) effective stage N2 non-small cell lung cancer after neoadjuvant therapy (chemotherapy or chemotherapy plus radiotherapy).
(3) Part III B stage non small cell lung cancer (T4N0-1M0), such as the invasion of the superior vena cava, the adjacent large vessels, the atrium, the carina, and the like, can completely remove the tumor.
(4) stage IV non small cell lung cancer, with a single contralateral lung metastasis, a single brain or adrenal metastasis.
(5) the clinical suspicion of pulmonary nodules in patients with lung cancer, which can not be qualitatively diagnosed by various examinations, may be considered in surgical exploration.
3 surgical contraindication
(1) the state of the body can not tolerate surgery, heart, lung, liver, kidney and other important organ function can not tolerate the operation.
(2) the most clear diagnosis of stage, most III stage B and stage a non-small cell lung cancer staging, and later than stage T1-2N0-1M0 non-small cell lung cancer.
(three) radiotherapy. Radiotherapy for lung cancer includes radical radiotherapy, palliative radiotherapy, adjuvant radiotherapy and prophylactic radiotherapy.
1 principles of radiotherapy.
(1) of radical radiotherapy for KPS score (Karnofsky score more than 70 points in Appendix 2) patients, including for locally advanced or iatrogenic / early and personal factors of inoperable non-small cell lung cancer, unresectable non-small cell lung cancer, and the limited stage small cell lung cancer.
(2) palliative radiotherapy for the treatment of advanced lung cancer primary and metastatic lesions. For non small cell lung cancer patients with single brain metastases can be treated with whole brain radiotherapy.
(3) in patients with positive pN2 after radiotherapy, adjuvant radiotherapy was used to encourage patients to participate in clinical studies.
(4) postoperative radiotherapy design should refer to the patient's surgical pathology and surgical records.
(5) prophylactic radiotherapy is effective for whole body radiotherapy in patients with small cell lung cancer.
(6) radiotherapy combined with chemotherapy is usually used for the treatment of lung cancer. Because of the difference of staging, treatment and the general situation of patients, the concurrent chemotherapy and radiotherapy can be selected by the combined regimen. Suggestions for radiotherapy and chemotherapy for EP and paclitaxel containing regimens.
(7) received chemotherapy patients, the potential toxicity will increase, before treatment should inform patients of radiotherapy; design and implementation, should pay attention to the protection of the lung, heart, esophagus and spinal cord; the treatment process should be as much as possible to avoid adverse reactions caused by improper handling of unplanned interruption of radiotherapy.
(8) the use of advanced radiotherapy techniques such as three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) is recommended.
(9) patients who received radiotherapy or chemotherapy should be adequately monitored and supported during treatment.
2 indications for radiotherapy for non-small cell lung cancer (NSCLC).
Radiotherapy can be used due to health reasons not the surgical treatment of patients with early NSCLC radical treatment, preoperative and postoperative adjuvant therapy for locally advanced unresectable lesions, and the treatment of patients with locally advanced incurable patients with important palliative treatment.
Radiation therapy is one of the effective means of local control of I in patients with stage NSCLC who cannot undergo surgery. In patients with NSCLC who underwent surgical treatment, if surgical resection margins were negative and mediastinal lymph node positive (pN2), in addition to routine postoperative adjuvant chemotherapy, it was recommended that postoperative radiotherapy. For patients with pN2 positive margins, it is recommended that patients be treated with concurrent chemoradiotherapy after resection of the tumor. For patients with positive margins, radiotherapy should be initiated as soon as possible.
For patients with stage NSCLC II-III who cannot undergo surgery due to physical causes, conformal radiotherapy combined with concurrent chemotherapy should be given if physical conditions permit. In patients with a promising cure, the reduction in the duration of treatment or the reduction of treatment dose was minimized by the use of a more appropriate radiotherapy plan and a more aggressive supportive treatment when receiving radiotherapy or concurrent chemoradiotherapy.
For patients with stage NSCLC IV with extensive metastasis, some patients may receive radiation therapy for primary and metastatic lesions in order to achieve palliative care.
Indication of radiotherapy for 3 small cell lung cancer (SCLC).
Limited stage SCLC after chemotherapy after some patients can achieve complete remission, but if not combined with radiotherapy, the risk of intrathoracic recurrence is very high, with radiotherapy can not only decrease the local recurrence rate, but also significantly reduced the risk of death.
In a wide range of patients with SCLC, distant metastases treated with chemotherapy plus chest radiotherapy may also improve the tumor control rate and prolong survival.
If the condition permits, small cell lung cancer radiotherapy should be started as soon as possible, can be considered and chemotherapy simultaneously. If the lesion is too large, the risk of lung injury caused by radiation therapy is too high, you can also consider the use of 2-3 cycles of chemotherapy, and then start radiotherapy as soon as possible.
4 prophylactic brain irradiation.
Patients with limited stage small cell lung cancer, in the chest lesions after treatment to achieve complete remission is recommended with prophylactic cranial irradiation. Prevention of brain metastases in patients with small cell lung cancer may also be associated with the use of prophylactic cranial irradiation in the treatment of extensive stage small cell lung cancer.
Rather than make prophylactic cranial irradiation for small cell lung cancer patients and doctors should be fully discussed, according to each patient's condition determined.
Palliative radiotherapy for 5 patients with advanced lung cancer.
The main purpose of palliative radiotherapy for patients with advanced lung cancer is to solve the local compression symptoms caused by primary or metastatic lesions, the pain caused by bone metastasis, and the neurological symptoms caused by brain metastasis. For such patients, the use of low fractionated irradiation can be considered, so that patients can be more easily treated, but also more quickly relieve symptoms.
6 treatment effect.
Evaluation of therapeutic efficacy of radiotherapy based on WHO solid tumor efficacy evaluation criteria (Annex 3) or RECIST efficacy evaluation criteria (Annex 4).
Conventional radiotherapy techniques should be used to protect the lungs, heart, esophagus and spinal cord in order to avoid severe radiation damage to the vital organs of the body. RTOG standard for acute radiation induced lung injury (Annex 5).
(four) drug therapy for lung cancer. Drug therapy for lung cancer includes chemotherapy and molecular targeted drug therapy (EGFR-TKI). Chemotherapy is divided into palliative chemotherapy, adjuvant chemotherapy and neoadjuvant chemotherapy, we should strictly grasp the clinical indications, and under the guidance of the doctor of oncology. Chemotherapy should fully consider the patient's physical condition, physical condition, adverse reactions, quality of life and patients' wishes, to avoid excessive treatment or inadequate treatment. The efficacy of chemotherapy should be evaluated in a timely manner, closely monitored and controlled, and the drug and / or dose should be adjusted as appropriate.
The indications for chemotherapy: a PS score of 2 or less (Annex 6, ZPS score, 5 points), the function of important organs can tolerate chemotherapy, chemotherapy for SCLC PS score can be relaxed to 3. Encourage patients to participate in clinical trials.
1 drug therapy for advanced NSCLC.
(1) first-line drug therapy.
Platinum containing two drug regimen is the standard first-line treatment; EGFR mutation patients, the choice of targeted drug therapy; conditional, on the basis of chemotherapy can be combined with anti angiogenic drugs. Currently available chemotherapy drugs see Annex 7. For first-line treatment of patients with disease control (CR+PR+SD), the condition can choose to maintain treatment.
(2) second-line drug therapy. Second-line treatment options include docetaxel, pemetrexed and targeted drug EGFR-TKI.
(3) treatment with three wires. Optional EGFR-TKI or enter clinical trials.
2 surgical treatment of unresectable NSCLC.
Radiotherapy and chemotherapy combined with radiotherapy or chemotherapy may be selected according to the specific circumstances. Synchronous recommended treatment for chemotherapy etoposide / cisplatin or carboplatin (EP/EC) and paclitaxel or docetaxel / cisplatin. Sequential treatment of chemotherapeutic drugs with first-line treatment.
Perioperative adjuvant therapy of 3.NSCLC.
Complete resection of stage NSCLC II-III, platinum containing two drug regimens recommended adjuvant chemotherapy 3-4 cycles. Adjuvant chemotherapy began after the patient's physical condition returned to normal, usually in 3-4 weeks after the start of surgery.
Neoadjuvant chemotherapy: neoadjuvant chemotherapy with two cycles of platinum containing drugs and a period of 2 cycles for resectable stage NSCLC III. Timely evaluation of efficacy, and pay attention to determine adverse reactions, to avoid increased surgical complications. Surgery is usually performed at 2-4 weeks after chemotherapy. Postoperative adjuvant therapy should be based on preoperative staging and neoadjuvant chemotherapy efficacy, the effective continuation of the original scheme or according to the patient's tolerance adjustment, invalid should replace the program.
4 small cell lung cancer (SCLC) drug therapy.
Treatment of limited stage small cell lung cancer (stage II-III) combined with radiotherapy and chemotherapy. Recommended chemotherapy regimen EP or EC program.
Comprehensive treatment of extensive stage small cell lung cancer (stage IV). Chemotherapy recommended by EP, EC or topotecan plus cisplatin (IP) or irinotecan (IC).
Second line protocol recommended topotecan. Encourage patients to participate in clinical trials of new drugs.
5 principles of lung cancer chemotherapy.
(1) patients with lung cancer of KPS < 60 or ECOG > 2 should not be treated with chemotherapy.
(2) white blood cells less than 3 x 109/L, less than 1.5 * 109/L, platelet less than 6 * 1010/L, less than 2 * 1012/L red blood cells, hemoglobin less than 20% of patients with lung cancer in principle should not be chemotherapy.
(3) the liver and kidney function of the patients with lung cancer were abnormal, the laboratory indexes were more than the normal value of 2 times, or had serious complications and infection, fever, bleeding tendency should not be chemotherapy.
(4) in the course of chemotherapy, withdrawal or replacement should be considered in the following situations:
After 2 cycles of treatment of disease progression, or in the rest period in the chemotherapy cycle deteriorated again, should stop the original plan, choose appropriate alternatives; adverse reaction of chemotherapy to 3-4, a clear threat to the lives of patients, should be discontinued, the next treatment to switch to other programs; the serious complications, should stop drug next time, when treatment is to switch to other programs.
(5) the standardization and individualization of treatment should be emphasized. Must master the basic requirements of chemotherapy. In addition to the routine application of antiemetic drugs, in addition to platinum drugs carboplatin hydration and diuresis. Two times a week after chemotherapy, blood routine examination.
(6) the curative effect of chemotherapy was evaluated according to the standard of curative effect evaluation of WHO solid tumor or the evaluation standard of RECIST.
(five) staging of non-small cell lung cancer.
Comprehensive treatment of 1 stage I non small cell lung cancer.
(1) the preferred surgical treatment, including lobectomy plus hilar and mediastinal lymph node dissection, the thoracic surgery or VATS.
(2) patients with poor pulmonary function may be considered for anatomic pulmonary or wedge resection plus hilar and mediastinal lymph node dissection.
(3) patients with completely resected stage IA lung cancer are not suitable for postoperative adjuvant chemotherapy.
(4) patients with completely resected stage IB are not recommended for routine postoperative adjuvant chemotherapy.
(5) the first stage of lung cancer with positive margins is recommended for reoperation. For any other reason who cannot be re operated, chemotherapy and radiotherapy are recommended.
Comprehensive treatment of 2 stage non small cell lung cancer.
(1) the preferred surgical treatment, including lobectomy and double lobectomy or pneumonectomy plus hilar and mediastinal lymph node dissection.
(2) patients with poor pulmonary function may be treated with anatomic pulmonary section or wedge resection plus hilar and mediastinal lymph node dissection.
(3) postoperative adjuvant chemotherapy in patients with complete resection of stage II non small cell lung cancer.
(4) the whole chest wall resection should be performed when the tumor invades the parietal pleura or chest wall. The resection range was at least 2cm of the upper and lower edge of the rib, which was at least close to the lesion, and the length of the resection should be at least 5cm.
(5) secondary lung cancer with positive margins is recommended for reoperation, and for any patient who cannot be re operated for any reason, postoperative chemotherapy and radiotherapy are recommended.
Comprehensive treatment of 3 stage III non-small cell lung cancer.
Locally advanced non-small cell lung cancer (TNM) is stage III lung cancer. Comprehensive treatment is the best choice for the treatment of III non-small cell lung cancer. Locally advanced NSCLC can be divided into two categories: resectable and non resectable. Which:
(1) resectable locally advanced non small cell lung cancer:
T3N1 patients with NSCLC, the first choice of surgical treatment, postoperative adjuvant chemotherapy.
Surgical resection of stage N2 lung cancer is controversial. Imaging examination showed that single group of mediastinal lymph nodes, or two groups of mediastinal lymph nodes but no fusion estimated complete resection, recommended preoperative mediastinoscopy, diagnosis after neoadjuvant chemotherapy, and surgical treatment.
In some cases of T4N0-1: a): the same satellite nodules lung lobe in the new stage, such as the lung cancer T3 stage, surgical resection is the first choice, also can choose the preoperative neoadjuvant chemotherapy, adjuvant chemotherapy. B may be the first choice of neoadjuvant chemotherapy in the treatment of other resectable stage T4N0-1 non-small cell lung cancer. For complete resection, postoperative adjuvant chemotherapy is considered. If the margin is positive, postoperative radiotherapy and platinum containing chemotherapy.
The treatment of lung tumor: some patients suggest first concurrent chemotherapy and then surgery plus adjuvant chemotherapy. For inoperable lung tumor, radiotherapy plus chemotherapy.
(2) resection of locally advanced non small cell lung cancer:
Imaging examination showed a mass shadow in the mediastinum and a positive non small cell lung cancer.
Most T4 and N3 non-small cell lung cancer.
Patients with T4N2-3.
The pleural metastasis nodules, malignant pleural effusion and malignant pericardial effusion patients, new stages have been classified as M1, are not suitable for surgical resection. Some cases may be treated with thoracoscopic pleural biopsy or pleural fixation.
4 treatment of stage IV non-small cell lung cancer.
Before the start of the treatment of lung cancer, it is suggested to obtain the tumor tissue to detect the mutation of epidermal growth factor receptor (EGFR), and to formulate the corresponding treatment strategy according to the EGFR mutation.
Systemic therapy is the main method for the treatment of stage IV lung cancer, and the aim is to improve the quality of life and prolong life.
(1) the treatment of solitary metastasis of lung cancer.
The solitary brain metastasis and the lung lesions are resectable non small cell lung cancer, the brain lesions can be resected or stereotactic radiotherapy, the primary lesions of the breast according to the principle of staging treatment.
The solitary adrenal metastasis and lung lesions may be resected for non small cell lung cancer, and the adrenal lesions may be treated by surgical resection.
The contralateral lung or other ipsilateral lung lobe nodule, respectively according to the two primary tumor staging their treatment.
(2) systemic therapy for stage IV lung cancer.
The EGFR sensitive mutation stage IV non-small cell lung cancer, recommended gefitinib or erlotinib as first-line therapy.
For EGFR wild-type or mutation of unknown stage IV non-small cell lung cancer, if the functional status score of PS=0 to 1, should be started as soon as possible with platinum containing systemic chemotherapy of the two drugs. For patients who are not suitable for platinum treatment, non platinum two drugs combined with chemotherapy may be considered.
Patients with advanced non-small cell lung cancer (PS=2) should be treated with single agent chemotherapy, but there is no evidence to support the use of cytotoxic chemotherapy in patients with PS> 2.
The current evidence does not support the age factor as the choice of chemotherapy regimen for the.
The failure of first-line chemotherapy for non-small cell lung cancer, recommended docetaxel, pemetrexed as second-line chemotherapy and gefitinib or erlotinib for Nie second-line or three line oral treatment.
The score was PS> 2 stage IV non-small cell lung cancer, may only use the best supporting treatment.
On the basis of systemic treatment, the appropriate local treatment can be used to improve symptoms and improve quality of life.
(six) staging of small cell lung cancer.
Phase SCLC 1.I. Surgery + adjuvant chemotherapy (EP/EC 4-6 cycle).
Phase SCLC 2.II-III: combination of radiotherapy and chemotherapy.
(1) optional sequential or synchronous.
(2) sequential therapy is recommended for the treatment of synchronization and radiotherapy after 2 cycles of induction chemotherapy.
(3) recommended prophylactic brain irradiation (PCI) in patients who have been treated with standard therapy.
3.IV phase SCLC: chemotherapy based comprehensive treatment in order to improve the quality of life.
Recommended EP/EC, IP, IC. Standardized treatment for patients with disease recurrence within 3 months is recommended for clinical trials. 3-6 months of recurrence were recommended topotecan, irinotecan and gemcitabine or paclitaxel treatment. 6 months after the disease can choose the initial treatment options.
Six, diagnosis and treatment process and follow-up
(a) lung cancer diagnosis and treatment process.
The general process of diagnosis and treatment of lung cancer is shown in Appendix 8.
For patients with new onset of lung cancer should establish a complete medical records and related data files, regular follow-up after treatment and inspection. Specific examination methods include history, physical examination, blood tests, imaging, endoscopy, etc., in order to monitor disease recurrence or treatment related adverse reactions, assessment of quality of life, etc.. The frequency of follow-up was 2 to 6 months after treatment, followed up every 6 months from 2 to 5 years, followed up once every 5 years.
Appendix: histological type of lung cancer in 1.2004 WHO
2 Karnofsky score (KPS, percentile)
3 WHO solid tumor efficacy evaluation criteria
4 RECIST efficacy evaluation criteria
5 RTOG classification criteria for acute radiation-induced lung injury
6 Zubrod-ECOG-WHO score (ZPS, 5)
7 commonly used NSCLC first-line chemotherapy program
8 lung cancer diagnosis and treatment process
Histological types of WHO lung cancer in 2004
squamous cell carcinoma
Squamous cell carcinoma, papillary subtype
Squamous cell carcinoma, clear cell subtype
Squamous cell carcinoma, small cell subtype
Squamous cell carcinoma, basal cell subtype
small cell carcinoma
Small cell carcinoma
Bronchioloalveolar carcinoma, non mucinous
Bronchioloalveolar carcinoma. mucinous
Bronchioloalveolar carcinoma, mucinous and non mucinous mixed or uncertain
Solid adenocarcinoma with mucin production
Mucinous (colloid) adenocarcinoma
Signet ring cell carcinoma
Clear cell adenocarcinoma
Large cell carcinoma
Large cell neuroendocrine carcinoma
Complex large cell neuroendocrine carcinoma
Basal cell carcinoma
Lymphoepithelioma like carcinoma
Clear cell carcinoma
Large cell carcinoma with rhabdoid phenotype
Spindle cell carcinoma
Giant cell carcinoma
Adenoid cystic carcinoma
Epithelial myoepithelial carcinoma
Squamous cell carcinoma in situ
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia
Karnofsky score (KPS, percentile)
Health condition is normal, no obvious symptoms and signs and complaints.
Able to work normally, with mild symptoms and signs.
To engage in normal activities, with symptoms or signs.
Life can take care of itself, but can not maintain normal life or work.
Most of life can take care of themselves, but occasionally need to help others, can not engage in normal work.
Most of the life can not take care of themselves, often treatment and care.
Life can not take care of themselves, the need for specialist treatment and care.
Life completely lost self-care ability, need hospitalization and active support therapy.
The condition is serious, must receive the support treatment.
Her condition deteriorated sharply, approaching death.
WHO solid tumor efficacy evaluation criteria
1 complete remission (CR): tumors completely disappeared over a period of 1 months.
The 2 part of the remission (PR): the maximum diameter of the tumor and the maximum vertical diameter of the product reduced by up to 50%, no increase in other lesions, continued for more than 1 months.
3 stable disease (SD): the lesions present product reduced less than 50%, increase of not more than 25%, lasting more than 1 months.
4 disease progression (PD): lesions present product increased more than 25%.
RECIST evaluation criteria
Evaluation of target lesions:
Complete remission (CR): all target lesions disappeared.
Partial remission (PR): the maximum length of the target lesion was reduced by 30% compared with baseline.
Lesion progression (PD): the sum of the longest diameter of the target lesion and the maximum length of the target lesion recorded after the start of treatment increased by 20%, or one or more new lesions.
Lesion stabilization (SD): between partial remission and disease progression.
Evaluation of non target lesions:
Complete remission (CR): all non target lesions disappeared and tumor markers returned to normal.
Incomplete remission / stability (IR/SD): the presence of one or more non target lesions and / or tumor markers consistently above normal.
Progression of the lesion (PD): the emergence of one or more new lesions and / or the presence of non target lesions.
The evaluation of the best overall efficacy: the minimum measured from the beginning of treatment to disease progression or recurrence. Usually, the best curative effect of the patient is classified by lesion measurement and confirmation.
RTOG classification criteria for acute radiation-induced lung injury
Level 0: no change.
1 grade: mild cough or dyspnea exertion.
Level 2: continuous cough need to cough anesthetic drugs / slightly activity that is difficult to breathe, but no breathing difficulties during the break.
Grade 3: severe cough, respiratory failure due to narcotic cough, or dyspnea at rest / clinical or radiographic evidence of acute radiation pneumonitis / intermittent oxygen inhalation or may require steroid therapy.
Grade 4: severe respiratory insufficiency / continuous oxygen inhalation or assisted ventilation.
Level 5: fatal.
(ZPS, 5 points)
Light symptoms, self-care, can engage in light physical activity.
Can bear the symptoms of cancer, self-care, but not more than 50% days in bed.
Severe symptoms of tumor, bed time more than 50% during the day, but also get up to stand, part of life self-care.
Ill completely bedridden.
Commonly used NSCLC first-line chemotherapy program
Time and cycle
Q21d * 4
Q21d * 4
One thousand two hundred and fifty
Q21d * 4
Q21d * 4