The American College of Chest Physicians (ACCP) guidelines for the diagnosis and treatment of lung cancer

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ACCP lung cancer diagnosis and treatment guide (Second Edition)SongNanjing General Hospital of Nanjing Military Area Command; School of medi

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ACCP lung cancer diagnosis and treatment guide (Second Edition)

Song

Nanjing General Hospital of Nanjing Military Area Command; School of medicine; Nanjing University

Lung cancer is the most common cancer and the most common cause of death. Aware of lung cancer in the population and importance with the development of evidence-based medicine as the basis for the diagnosis and treatment of disease in 2000, the American College of Chest Physicians (ACCP), through its health and science policy committee, commissioned the drafting of guidelines for the diagnosis and treatment of lung cancer with evidence-based. The aim is to help physicians achieve the best treatment goals at the time of the existing knowledge and ability. The January 2003 guidelines published in the supplement in the form of "chest" magazine. With the rapid pace of exploration and treatment of lung cancer diagnosis, ACCP commissioned a second version of the grass guide. This guide is the result of the joint efforts of nearly 100 volunteers and ACCP members. Guide on the basis of the first edition, added some new chapters, such as “ surgical pathology in the diagnosis of lung cancer &rdquo, ” “ bronchioloalveolar carcinoma; “ lung cancer adjuvant therapy and personalized oncology ” etc.. Many chapters have been extensively revised to cover the latest knowledge. For example, lung cancer screening, treatment of pulmonary nodules: when did it evolve into lung cancer? Conclusions: all of the chapters in this article refer to the relevant literature of the new life of the tracheal epithelium / early central lung cancer, palliative treatment, quality of life assessment, and hospice care for lung cancer patients. The recommendations recommended by the guidelines are marked with evidence-based medical evidence for clinicians and related professionals.

Diagnosis of lung cancer

1 screening for lung cancer

Early diagnosis of lung cancer is an important measure to improve the prognosis. Because most of the patients diagnosed with symptoms of lung cancer patients diagnosed at a late stage, has lost the chance of surgical treatment. Therefore, in order to improve the diagnosis rate of early lung cancer, the patients with early lung cancer were treated by screening. However, there is no clear evidence of evidence-based medicine that any screening method can improve the diagnostic rate of early lung cancer. Therefore, (1) low dose CT (LDCT) is not recommended as an early screening for lung cancer unless there is evidence of large-scale clinical trials (2C). LDCT is currently considered the most effective screening technique for lung cancer, but several clinical studies have suggested that there is insufficient evidence that LDCT can reduce lung cancer mortality. Considering the cost performance, LDCT screening may be useful for some “ high risk ” population. At present, there are at least 2 randomized clinical trials in progress, and it is expected that these findings will update our current knowledge and draw more valuable conclusions to guide clinical practice in the near future. (2) early screening for lung cancer (1A) is not recommended. Because chest radiography (CXR) is not as good as LDCT in terms of resolution and location, several previous studies clearly suggest that CXR cannot be used as a routine screening for lung cancer. (3) it is not recommended that single or continuous sputum cytology be used as an early screening method for lung cancer (1A).

Key points: there is no clear evidence of evidence-based medicine that any screening method can improve the early diagnosis of lung cancer and reduce mortality. Need to design better clinical trials and wait for further evidence of evidence-based medicine.

2 surgical pathological diagnosis of lung cancer

The diagnosis of lung cancer depends on cytological and histological examination of primary and metastatic lesions. The pathological diagnosis, clinical and imaging changes of lung cancer can provide correct staging, treatment and prognosis. Appropriate diagnostic techniques can improve diagnostic accuracy. The main recommendations are as follows: (1) pathological diagnosis of lung cancer, the report recommended learning type organization, tumor size and location, tumor grade, lymph node metastasis, pleural involvement, surgical resection and the edge of each station lymph node status and location (1B). (2) it is not recommended for screening for lung cancer in patients who are asymptomatic or with a history of cancer, and the use of simple or continuous sputum cell lines for screening is not of benefit (1A). Sputum cytology is widely used in the initial diagnosis of lung cancer because it is convenient, inexpensive and non-invasive. But not all lung cancer can be diagnosed by sputum cytology. The positive rate of sputum cytology was less than 20% in all clinical trials. (3) for pleural tumor, when unable to distinguish pleural adenocarcinoma and malignant pleural mesothelioma, recommended the use of histochemical and immunohistochemical analysis to increase the accuracy of diagnosis, if can be analyzed using other research such as ultra structure more complicated cases (1B). Malignant pleural mesothelioma of pleura and adenocarcinoma because of the similarity in clinical practice is often difficult to identify the clinical manifestations and the imaging and pathological differential diagnosis is often difficult, immunohistochemistry of pleural adenocarcinoma (CEA and EMA positive, and Calretinin negative), pleural mesothelioma (EMA, Calretinin positive, and CEA negative). Although there are still a part of the cases can not be diagnosed clearly, only to rely on the ultrastructural pathological examination. (4) for solid tumors in the lungs, when unable to distinguish between small cell lung cancer and non-small cell lung cancer, recommend the use of immunohistochemical analysis to increase the accuracy of diagnosis, if more complex cases can be used by other methods such as ultrastructural analysis (1B). Pathological diagnosis of small cell lung cancer and non-small cell lung cancer is not difficult. However, in some cases, especially in the differential diagnosis of neuroendocrine tumors and small cell lung cancer, there is a certain degree of difficulty. (5) in the case of adenocarcinoma of the gland, pure bronchioloalveolar carcinoma (BAC) or adenocarcinoma with BAC (1C) is recommended. Because of the difference of the clinical course, biological characteristics and prognosis of adenocarcinoma and BAC, it is helpful to choose the appropriate treatment plan for different cases and to analyze the prognosis accurately. (6) in order to distinguish between primary and metastatic lung cancer, it is recommended to improve the diagnostic accuracy by immunohistochemistry (1C). (7) to have pathological features and clinical staging of lung cancer patients, assessment of pathology and molecular markers are suitable for the record of the investigation, but is not recommended for routine treatment (1C); (8) to have pathological and clinical evaluation of lung cancer, judge whether there is occult lesions or micro metastasis, does not recommend the use of molecular biology techniques or pathological examination further, at the same time this check is not any clinical benefit (1C).

Key points: surgical pathology of lung cancer diagnosis emphasis on surgical margin with each station lymph node; risk populations for asymptomatic or cancer history, does not recommend the use of simple or continuous sputum cell line test to screen for lung cancer; fully affirmed the immunohistochemistry in the differential diagnosis of pleural mesothelioma and adenocarcinoma (SCLC and NSCLC, primary lung cancer and metastatic carcinoma) in value, while emphasizing the clinical significance of BAC and BAC associated with the differentiation of simple glandular cancer.

3 treatment of patients with pulmonary nodules - when nodules develop into lung cancer

The diagnosis of pulmonary nodules is often quite difficult in clinical practice, second edition of the guide to focus on and put forward the following suggestions: first detailed for each of solitary pulmonary nodules (SPN) patients, clinicians recommend assessment on malignant possibility before examination according to clinical experience or effective way; ((1C) 2) for each chest radiographic findings of solitary pulmonary nodules in patients with obvious, recommended to review patients before the chest and other imaging data (1C); (3) for imaging showed an increase in the patients with pulmonary solitary nodules, unless special contraindications recommended histologic diagnosis method (1C); (4) the imaging findings of solitary pulmonary nodules in patients with stable for more than 2 years, unless the chest CT showed ground glass opacity (GGO), it is not recommended to do further Diagnostic assessment, but for GGO patients can consider long-term follow-up once a year (2C); (5) for solitary pulmonary nodules of calcification are benign features of clear, is not recommended for further diagnostic examination (1C); (6) for chest imaging of visible indefinite the SPN recommended CT examination, especially the TLC scanning lesions (1C); (7) regarding the nature of chest CT visible indefinite SPN, recommended review of patients before control of chest imaging data (1C); (8) for chest imaging normal renal function of visible matter uncertain SPN, recommended the use of enhanced CT scan (1C); (9) for moderate malignancy (5%-60%) and the diameter of the measurement for the 8-10mm properties of uncertain SPN, recommend the use of FDG-PET scanning to determine the nature of nodules (1B); (10) for highly malignant The possibility of (>60%) and 1cm in diameter) and no evidence of metastatic disease in patients, should further evaluate the situation before treatment for mediastinal tumors (Yu Yuanfa 1B); (3) for clinical treatment for stage IA lung cancer, to assess mediastinal and pulmonary PET examination stage to consider (2C); at the same time for clinical treatment for stage IB-IIIB lung cancer, if conditions permit, the feasible PET evaluation of mediastinal and pulmonary stage (1B); (4) check for FDG-PET positive mediastinal lymph nodes before surgical resection of primary lesions, should be taken to mediastinal lymph node samples further evaluation (1B); chest MRI examination should not be used as a routine means of mediastinal staging, but can be applied to the patients with suspected plexus metastasis of superior vena cava or arm (1B); (5 ) for confirmed or suspect lung cancer patients, according to the patient's history and symptoms (such as weight loss >10 pounds, muscle pain, headache, severe weakness etc.) and signs (lymph nodes >1cm, superior vena cava syndrome) to analyze and judge whether there is a local and distant metastasis (1B (6); the abnormal clinical findings) of patients should be conducted outside the chest imaging examination for the corresponding parts of the symptoms should be corresponding to the special examination (such as head CT/MRI examination with systemic PET scan or bone scan and abdominal CT examination) (1B); (7) for IIIA and IIIB patients, should be routine the chest outside the conventional imaging (such as head CT/MRI examination with systemic PET scan or bone scan and abdominal CT examination) (2C); (8) unless the histological evidence or clinical and imaging clear evidence of Biao Mingyuan Metastasis, and the imaging findings of patients with distant metastases are not excluded from the potentially curative treatment (1B).

Invasive mediastinal staging: for no distant metastasis NSCLC, clear mediastinal lymph node metastasis is the key factors to determine the treatment, although there are some guiding significance of non-invasive examination, but in most cases of invasive lung cancer mediastinal staging is necessary: (1) the metastases in the mediastinum (no patients distant metastasis), available CT inspection and evaluation of mediastinal lymph node staging, without the need for invasive (2C); (2) for a single lymph node enlargement (no distant metastasis) were recommended for invasive examination, regardless of the results of the PET examination (1B); many invasive (mediastinoscopy. EUS-NA, TBNA, EBUS-NA, TTNA) can be used to assess mediastinal lymph node N2, N3 (1B); fine needle aspiration cytology (EUS-NA, TBNA, EBUS-NA, TTNA) for the patients with benign lesions should be further longitudinal By bronchoscopy, regardless of the results of the PET examination (1C); (3) for mediastinal imaging (by CT), normal central lung cancer or N1 mediastinal lymph nodes (without metastasis), recommended for invasive examination, regardless of the results of the PET examination (1C); (4) for central lung cancer or type N1 mediastinal lymph nodes (without metastasis) were recommended for invasive check. In general, suggestions for mediastinoscopy, but if mediastinoscopy was negative, can be considered EUS-NA, EBUS-NA examination (2C); (5) for clinical staging of peripheral lung cancer I stage, and PET findings of mediastinal lymph node positive (no distant metastasis), recommended for invasive check. General recommendations for mediastinoscopy, but if mediastinoscopy was negative, can be considered EUS-NA, EBUS-NA (1C); PET examination of mediastinal lymph nodes were negative, without the need for invasive mediastinal lymph node staging (1C); (6) to the left upper lobe lung cancer, previously recommended for mediastinal lymph nodes check if the other node, station of mediastinal lymph nodes were not enlarged, recommended for invasive evaluation of the staging mass assessment of pulmonary artery lymph node (2C) window.

Key points: for NSCLC clinical staging (non invasive), non-invasive examination guidelines emphasize that a comprehensive and systematic (intrathoracic and extrathoracic) to correct staging of the importance of the PET diagnostic value in staging evaluation. It also emphasizes the importance of the staging of mediastinal invasion in most patients, and some diagnostic techniques such as mediastinoscopy, EUS-NA, TBNA, EBUS-NA, TTNA, etc..

8 bronchial intraepithelial neoplasia / early central airway lung cancer

Most lung cancers are diagnosed at advanced stage with a 5 year survival rate of less than 15%. Early diagnosis and treatment is an important strategy to improve the survival and prognosis of lung cancer. Because of the limitation of the white light bronchoscope, the development of fluorescent bronchoscopy in recent years has significantly improved the diagnostic rate of early lung cancer. Follow the guidelines for the development of new technology, put forward the following recommendations: (1) for severe atypical hyperplasia, carcinoma in situ, sputum cytology find cancer cells but the chest imaging examination is recommended for patients with negative standard white light bronchoscopy, if conditions allow feasible fluorescence bronchoscopy (1B); (2) for endovascular treatment the recommended treatment for carcinoma in situ, fluorescence bronchoscopy guided (2C); (3) for carcinoma in situ known as severe dysplasia or central airway, check the recommended every 3-6 months for standard white light bronchoscopy as follow. If conditions permit feasible fluorescence bronchoscopy (2C); (4) there is no surgery of superficial squamous cell carcinoma syndrome, recommended for photodynamic therapy, electrocautery, cryotherapy, brachytherapy, is not recommended for Nd: Nd: YAG laser therapy, because of its high risk (1C).

Key points: guidelines recommend the use of fluorescent bronchoscopy in the diagnosis of bronchial intraepithelial neoplasia / early central airway lung cancer.

Two, the treatment of non-small cell lung cancer (NSCLC)

Treatment of stage 1.I and II NSCLC

I and II belong to only 25-30%NSCLC patients at diagnosis, surgical treatment is the main method for the treatment of early lung cancer, postoperative adjuvant therapy is necessary for some of these patients: (1) for I and II NSCLC, and no operative contraindications were recommended for surgical resection (1A); recommended by the evaluation of patients with lung cancer in Department of thoracic surgery physicians, even if patients are considered only for non operative treatment such as percutaneous ablation or stereotactic radiotherapy (1A); (3) for treatment of operation of the traditional I and II NSCLC, recommended a wide range of lobectomy or resection without lobular resection (wedge resection or lung surgery) (1A); to be able to tolerate surgery, due to the decline in lung function associated with other diseases or cannot tolerate lobectomy or a wide range of surgical resection of I and II NSCLC, recommended for lobular pulmonary resection without medical treatment Treatment (1B); (4) for undergoing thoracoscopic resection (resection of pulmonary lobe or segment of I) NSCLC patients by video-assisted thoracic surgery experienced surgical operation is an acceptable option (1B); (5) for the surgical treatment of I and II NSCLC. Recommended for mediastinal lymph node resection during surgery system and sample, in order to more accurate pathological staging (1B); (6) the central or localized to the complete resection of the patients with advanced NSCLC, recommended for sleeve resection and pneumonectomy, because sleeve resection can achieve the same the objective of complete resection (1B); to complete removal of N1 (II) NSCLC were recommended for sleeve resection and pneumonectomy. Because the sleeve resection can also achieve the objective of complete resection (1B); (7) for patients with IA stage NSCLC complete surgical resection, adjuvant chemotherapy is not recommended as routine clinical trials (1A); IB NSCLC for patients with complete surgical resection, adjuvant chemotherapy is not recommended for routine (1B); (8) for II NSCLC and PS complete surgical resection in patients with good scores, recommend adjuvant chemotherapy for platinum based (1A); (9) patients with I or II NSCLC for inoperable or not willing to recommend surgery, underwent radical hyperfractionated radiotherapy (1B); and for patients with stage IA or IB NSCLC complete surgical resection, postoperative radiation therapy could reduce the survival, it is not recommended to use (1B); for completely resected stage II NSCLC, it is not clear in postoperative radiotherapy can reduce local recurrence The survival benefit, therefore, is not recommended for postoperative radiotherapy (1B).

Key points: lobectomy or a wide range of treatment of I stage II, NSCLC recommended resection without lobular resection (resection or wedge lung surgery), and can tolerate the operation, due to the decline in lung function associated with other diseases or cannot tolerate lobectomy or a wide range of surgical resection for stage I and stage II NSCLC, recommended for lobular pulmonary resection without medical treatment, recommended for mediastinal lymph node resection during surgery system and sample, in order to more accurate pathological staging. For patients with stage IA NSCLC complete surgical resection, adjuvant chemotherapy is not recommended as routine clinical trials; for patients with IB stage NSCLC complete surgical resection, and is not recommended for routine adjuvant chemotherapy for stage II; NSCLC and PS complete surgical resection in patients with good scores, recommend adjuvant chemotherapy for platinum based the.

Treatment of stage NSCLC 2.IIIA

IIIA NSCLC is a group of patients with heterogeneity, for the treatment of this group of patients should be carefully selected according to the specific circumstances, multidisciplinary treatment is the main treatment for these patients: (1) the hidden after surgery found that the N2 (IIIA2), if can complete resection and mediastinal lymph node a primary focus, recommended primary lesion resection and mediastinal lymph node dissection (2C); NSCLC surgery for the recommended mediastinal lymph node dissection system and sample (1B); (2): adjuvant chemotherapy after surgery for discovery of the hidden N2 (IIIA1-2) patients and a good PS score, adjuvant chemotherapy is recommended for platinum based (1A); (3) radiotherapy after surgery: the hidden found N2 (IIIA2), in the adjuvant chemotherapy after radiotherapy after surgery should be considered to reduce the local complex Send (2C); (4) adjuvant chemotherapy after surgery found: for the implicit N2 (IIIA2), is not recommended for concurrent chemoradiotherapy after surgery, except for clinical trials (IB); (5) for the preoperative stage N2 (IIIA3) were recommended to evaluate the multi subjects in the treatment before (including Department of thoracic surgery physicians) (IC); induction chemotherapy is not recommended before surgery, except in a clinical trial (IC). Pulmonary resection is not recommended for patients who have been treated with chemoradiation as a clinical trial. For such patients should be limited to lobectomy. For after induction chemotherapy, can pneumonectomy patients, it is not recommended for lung resection, radiotherapy and continue for the full dose (IB), for these patients is not recommended for adjuvant therapy after primary tumor resection, except for clinical trials. (IC); (6) to clear before the operation of N2 disease (IIIA3), do not recommend surgery alone (1A); suggestions to platinum based combined chemoradiotherapy as initial therapy (1B); (7) the surgical viewpoint: before surgery for N2 disease diagnosed with non small cell lung cancer (IIIA3), excision of lesions not only recommended (1A); if not completely resection, postoperative radiotherapy to suggest that platinum based (1C); (8) for large N2 disease (IIIA4) and PS scores of patients with good, does not recommend the use of radiotherapy alone, push the recommended use of combined chemotherapy and radiotherapy with platinum based, with mild weight loss in patients with concurrent chemotherapy than sequential chemotherapy are recommended (1A).

Key points: IIIA NSCLC recommended multidisciplinary treatment for operable stage IIIA (N2) NSCLC recommended a complete surgical resection of the primary lesion and mediastinal lymph node dissection, postoperative adjuvant PS score in patients with a good recommendation for platinum based chemotherapy; postoperative radiotherapy should be assisted to reduce local recurrence. Clinical trials are recommended.

3 phase NSCLC treatment of IIIB

About 10-15% of lung cancer patients diagnosed clearly belong to stage IIIB. In the course of disease, age, and risk of IIIB NSCLC treatment depends on the factors, PS status and degree of weight loss: (1) in the selection of a clinical T4N0-1 non-small cell lung cancer patients, because of the satellite in the same lobe tumor nodules, involving the carina, invasion of the superior vena cava, so before the operation, including suggestions for a cardiothoracic surgery, lung surgery expert, multidisciplinary expert group evaluation, to determine whether the patients for surgery. If N2 is involved, surgery is not recommended (1C); (2) for IIIB patients due to N3 disease, neoadjuvant chemotherapy or treatment (induction) chemotherapy after surgery is not recommended (1C); (3) for malignant pleural effusion, PS is 1 or 0, a slight weight loss (≤ 5%) for patients with stage IIIB disease, suggesting platinum based combination chemotherapy (1A); (4) IIIB patients with a PS score of 2 or associated with significant weight loss (> 10%) of the patients, only after careful weighing before considering radiotherapy (1C); (5) the PS score of 0 or 1 and a slight weight loss (≤ 5%) IIIB patients with synchronous radiotherapy is feasible (1A); (6) can be combined with thoracic radiotherapy chemotherapy and the most effective and ideal number of chemotherapy cycles, it is not clear Chu, so is still unable to recommend an ideal combination chemotherapy scheme (2C); (7) for stage IIIB non-small cell lung cancer, suggest that conventional radiotherapy plus chemotherapy (1B); (8) for patients with stage IIIB disease, such as PS state difference, but not too widely to cure the purpose or chest disease symptoms caused by very serious, can the palliative radiotherapy. The segmentation method should take full account of the physician's judgment and patient needs (1A).

Key points: by IIIB NSCLC patients in the same lobe in satellite tumor nodules of multidisciplinary experts to assess whether surgical treatment, if N2 is not recommended in surgical treatment. Surgical treatment of N3 disease after neoadjuvant chemotherapy or chemoradiotherapy is not recommended. For patients with PS (0-1), platinum based combination chemotherapy is recommended for concurrent chemoradiotherapy. For PS chemotherapy 2 patients should be weighed carefully chosen.

4 stage IV non small cell lung cancer treatment

It is estimated that about 40% of lung cancer patients are diagnosed at a definite stage of IV, and it is clear that chemotherapy can improve survival and remission in patients with good PS status, but the effect of chemotherapy on patients with poor PS score is uncertain. With the publication of new clinical trial results, the guidelines were updated on the basis of 2003: (1) for PS patients with good IV status, it is recommended that the combination of the two drugs chemotherapy. Do not recommend three kinds of cytotoxic chemotherapy, because it does not bring the improved survival benefits, and may only toxicity (1A); (2) PS in the choice of a good state of stage IV non-small cell lung cancer patients (non metastatic squamous cell carcinoma, no brain and no hemoptysis) clinical research found: Bevacizumab and carboplatin, paclitaxel can improve the survival rate. In these patients, bevacizumab plus carboplatin and paclitaxel can be used as a treatment method (1A); (3) for the elderly (≥ 70 to 79 years) of stage IV non-small cell lung cancer patients, it is recommended to use a single drug chemotherapy (1A), but if the patient is good and no significant PS state complications can be considered the two drugs combined with chemotherapy (1B); (4) for non-small cell lung cancer for more than 80 years of age stage IV patients, chemotherapy benefit is not clear, is not good according to the specific circumstances of the individual (2C); (5) for patients with a PS score of 2. To establish a foundation in remission chemotherapy suggest a clear response rate and the symptoms (1B); in the treatment strategy, is not what the specific proposals to carboplatin based two drug regimen than a drug improved survival in a phase III clinical trials (2C) (; 6) recommended the use of FACT-L or EORTC QLQ-C30 questionnaire to measure the patient's quality of life, because it is a significant prognostic factor for survival (1A); appropriate education about the pros and cons of chemotherapy for stage IV patients at the same time, this will make the process of making choice in the treatment of patients in the decision to participate positively (1C).

Key points: for the PS phase of patients with good phase IV, the proposed combination of two drug regimens chemotherapy, chemotherapy is not recommended for the three cytotoxic drugs. In the choice of the PS good state of stage IV non-small cell lung cancer patients (non metastatic squamous cell carcinoma, no brain and no hemoptysis), bevacizumab plus carboplatin and paclitaxel can be used as a treatment method. For patients with stage IV (≥ 70 to 79 years), single drug chemotherapy is recommended. The benefits of chemotherapy in patients older than 80 years of age IV are still uncertain. For patients with a PS score of 2, the recommended chemotherapy should be based on a clear response rate and remission of symptoms.

Special problems in 5.NSCLC therapy

For some special cases and type NSCLC (such as Pancoast cancer, the same lung lobe satellite nodule, solitary brain or adrenal metastasis) need to recognize and deal with the special: (1) Pancoast for cancer patients is recommended to obtain histological diagnosis before the beginning of treatment (1C); (2) for Pancoast cancer and is considering radical surgery, recommended a thoracic entrance and brachial plexus MRI not to exclude the vascular structure or outer epidural resection of tumor invasion (1C); (3) Pancoast for cancer and affect the subclavian artery and spinal surgery patients, suggestions only in some specialized center (2C); (4) for Pancoast cancer and is considering therapeutic resection, recommend mediastinal tumor staging and invasive extrathoracic imaging Check the CT/MRI (or PET of the head or CT of the body or the scan of the skeletal system). The involvement of mediastinal nodules and / or metastatic disease represents a contraindication for surgical resection (1C); (5) for resection of possible metastasis of Pancoast cancer patients (PS state), recommended before surgery and radiotherapy and chemotherapy resection (1B); (6) for ongoing cancer patients surgical resection of Pancoast, recommended must try our best to ensure complete resection surgery (1A); lung resection should include (instead of not anatomically wedge resection) resection and involvement of chest wall structure (1C); (7) whether or not complete surgical resection, postoperative radiation therapy is not recommended. Because of the lack of evidence to improve the survival rate (2C); (8) but not for transfer and PS status of patients with good unresectable, recommended concurrent chemoradiotherapy (1C); (9) for Pancoast cancer and not up to To cure patients, recommended for palliative radiotherapy (1B); (10) to achieve the clinical classification of T4N0.1M0, considering the curative resection of non-small cell lung cancer patients, recommend invasive mediastinal tumor staging and extrathoracic imaging (CT plus CT/MRI plus bone head or body PET or abdominal scan). Mediastinal lymph node involvement and / or metastatic disease represents a contraindication of surgery excision (1C) surgery; only in some of the conditions of the medical center (1C); (11) or suspected diagnosis of lung cancer and the same lung lobe satellite nodules were not recommended, the satellite nodules further diagnostic (1B); only primary lung cancer should be evaluated for pleural metastasis, of mediastinal lymph node status was determined. Can not change because of the existence of satellite lesions (1C); (12) non-small cell lung cancer patients in the same lobe and a satellite lesions (no mediastinal or distant metastasis), recommended by lobectomy to lung cancer resection (1B); (13) there are two synchronous primary non small cell lung cancer resection patients considered cured, recommended traumatic mediastinal tumor staging and chest imaging (head CT/MRI plus or PET or CT plus systemic abdominal skeletal system scan). Mediastinal lymph node involvement and / or metastatic disease represent surgical contraindications (1C); (14) there are two primary non-small cell lung cancer patients of suspected, recommended a complete extrathoracic examination, to exclude the two metastatic lung lesions is possible (1C); (15) second of cancer doubt before surgery, and surgery found in second lesions of patients in another lobe, recommend enough lung tissue retention and not involving N2 nodules in two patients, resection of cancer (1C); (16) for being considered surgical resection (two primary lesions) in patients with non-small cell lung cancer, tumor staging and recommended traumatic mediastinal pleural imaging (head CT/MRI plus or PET or CT plus systemic abdominal skeletal system scan). The involvement of mediastinal nodules and / or metastatic disease represent a contraindication of surgery resection (1C); (17) solitary brain metastases of non-small cell lung cancer patients, in consideration of the pulmonary I or stage II primary tumor resection, traumatic mediastinal tumor staging is recommended and chest imaging (head CT/MRI plus or PET or CT plus systemic abdominal skeletal system scan). The involvement of mediastinal nodules and / or metastatic disease represent a contraindication of surgery resection (1C); if there is no other site of metastases, for a resectable N0.1 of primary non-small cell lung cancer patients with solitary metastasis of the brain, suggest that surgical resection or resection and stereotactic radiosurgery (at the same time, resection of the primary tumor) (1C); the primary tumor was completely resected primary non-small cell lung cancer, metastasis of solitary brain, suggest that surgical resection or resection and stereotactic radiosurgery (1B); (18) patients had solitary metastases of curative resection the brain, for the transfer rate of benefits in survival and recurrence of brain, although there are some contradictions and shortcomings of the data. But that whole brain radiation therapy adjuvant (2B); (19) to have been the solitary brain metastases and primary tumor resection patients, can consider adjuvant chemotherapy (2C); (20) for solitary gland metastasis of non-small cell lung cancer of the kidney the patient should be considered for the purpose of surgical resection to cure, recommended for traumatic mediastinal tumor staging and chest imaging (head CT/MRI plus or PET or CT plus systemic abdominal skeletal system scan). The involvement of mediastinal nodules and / or metastatic disease represent a contraindication of surgery resection (1C); in the absence of metastasis of other cases, resection of metastases is recommended by the primary tumor and the solitary adrenal (1C); (21) if the disease free survival of more than 6 months and the primary focus of non-small cell lung cancer has been completely removed, he did not transfer and complete resection of primary non-small cell lung cancer patients, recommended isolated adrenal metastases resection (1C); (22) invasion of the chest wall in patients with non-small cell lung cancer, is considering a radical surgical resection, suggestions for mediastinal invasion stage, chest

Key points: a guide to NSCLC some special circumstances (such as Pancoast and type of cancer, the same lung lobe satellite nodule, solitary brain or adrenal metastasis) were discussed and suggested. To assess the condition of Pancoast recommendations for cancer before surgery, resection of possible metastasis of Pancoast carcinoma patients (PS state), recommended before surgery and radiotherapy for resection and chemotherapy; but not metastasis and PS good patients of unresectable and recommended concurrent chemoradiotherapy. Concurrent chemoradiotherapy is recommended for patients who cannot be surgically removed, but have not been transferred to the PS. For patients with Pancoast cancer who cannot be cured, palliative radiotherapy is recommended. NSCLC patients in the same lobe and a satellite lesions (no mediastinal or distant metastasis), recommended by lobectomy to resection of lung cancer. For solitary brain metastases, no other metastasis sites, a resectable N0.1 primary NSCLC patients, surgical resection is recommended or resection of brain lesions in stereotactic radiosurgery (simultaneous resection of the primary tumor). For patients with solitary adrenal metastases from non-small cell lung cancer; primary and solitary adrenal metastases.

6 bronchial alveolar cell carcinoma

In 1999, WHO published a new classification system for lung cancer to define the definition of NSCLC (BAC), and therefore, according to the new definition, BAC accounted for only 5%. Although the incidence rate of BAC is low, but this type of lung cancer because of the unique pathological and imaging features of molecular targeted therapy for unique reaction, it will be BAC listed separately to discuss: (1) proposed to retain the use of the word BAC, which can meet the lung cancer lung cancer classification system of WHO (1B) (revised; 2) suspected BAC patients, recommended for surgical biopsy tissue pathological diagnosis (1C); to not surgical biopsy patients, pathological types of bronchoalveolar cell carcinoma diagnosis should be corresponding obtained by transbronchial or core needle biopsy, and CT scans showed that completely frosted glass like change, or pneumonia performance (1C); (3) the CT scan showed ground glass opacity or real variable (BAC) pneumonia patients, the PET scan is usually false negative, so suggestions for false negative The PET scan results for other diagnostic examination to exclude the existence of lung cancer (1C); (4) with suspected BAC patients, if CT showed complete hair hyalinization, surgery and pathology of bronchioloalveolar carcinoma cells alone, no evidence of invasion and surgical margin clean, small lobe resection may be more appropriate (1B); (5) the PS score and BAC in patients with unresectable, recommend the use of standard chemotherapy. The use of first-line drugs targeting the epidermal growth factor receptor should be reserved for patients with poor physical performance or clinical trials (2C).

Key points: for the BAC should try to clear and consistent with the pathological diagnosis, surgery for patients suspected of BAC, if CT showed complete gross hyalinization, surgery and pathology of bronchioloalveolar carcinoma cells alone, no evidence of invasion and surgical margin clean, lobular resection is feasible. For patients with good BAC score and unresectable PS, standard chemotherapy is recommended. First-line use of epidermal growth factor receptor targeting drugs should be reserved for patients with poor physical fitness scores or to participate in clinical trials.

Three, the treatment of small cell lung cancer

2005 statistics show that small cell lung cancer (SCLC) in patients with lung cancer in the United States accounted for 13-20%, the key problem of SCLC in the processing of guidelines (such as PET, SCLC in the staging of chemotherapy significance and surgical treatment etc.) the suggestion is as follows: (1) small cell lung cancer staging routine examination including medical history, physical examination, blood cell counts, chemotherapy group, thoracic and abdominal CT scan, CT scan or chest with whole liver and adrenal glands, head CT or MRI and bone scan (1B); (2) PET scanning is not recommended for routine staging of non-small cell lung cancer (2B); (3) extensive patients must accept the 4-6 cycle (not more than 6 cycles) with cisplatin or carboplatin based combination chemotherapy, cisplatin combined with etoposide or irinotecan (1B); after chemotherapy, if patients of chest lesions achieved complete remission and intrathoracic lesions or completely Partial remission should provide consolidation radiotherapy (2C); (4) clinical trial is not recommended unless, given maintenance treatment for partial or complete remission or limitation in patients with extensive stage (1B); (5) small cell lung cancer relapsed or resistant patients should be given further chemotherapy (1B); (6) the PS score good (ECOG 0 or 1), elderly patients with organ function perfect should be given to platinum based chemotherapy (1A); (7) the poor prognosis factors: poor PS scores, or with serious medical illness still recommend chemotherapy (2C); (8) unless given to participate in clinical trials no significant increase dose induction or maintenance treatment of extensive stage or limited stage small cell lung cancer (1A); (9) limited stage small cell lung cancer should be combined with radiotherapy and chemotherapy. Doctors and patients need radiotherapy of tumor medicine oncologists discuss common combination therapy (1A); the PS score and if the condition allows, limitation of patients should be given concurrent chemoradiation therapy (1C); to accept radiotherapy and chemotherapy for early patients should undergo accelerated division of radiotherapy combined with platinum based chemotherapy (1B); (10) limited stage small cell lung cancer resection patients achieved complete remission or stage I patients should be treated with prophylactic cranial irradiation (1C); extensive patients after complete remission should be given prophylactic cranial irradiation (1C); (11) and small cell lung cancer patients in stage I patients can undergo radical surgery that should be invasive mediastinal staging, chest imaging (head CT/MRI, abdominal CT plus bone scan) and platinum based chemotherapy (1A); for the I period has underwent radical surgery Patients were advised to receive platinum based adjuvant chemotherapy (2C); (12) patients with histologically small cell lung cancer and non-small cell lung cancer were treated with small cell lung cancer. All small cell lung cancer treatment measures can be used for such patients (2C).

Key points: extensive stage SCLC patients must accept the 4-6 cycle (no more than 6 cycles) with platinum based chemotherapy, platinum can be combined with etoposide or irinotecan; after chemotherapy, if patients with thoracic lesions achieved complete remission and intrathoracic lesions complete or partial remission should provide chest consolidation radiotherapy. There is no point in increasing dose induction or maintenance therapy for patients with extensive or limited stage small cell lung cancer. If the PS score and condition permit, patients with localized stage should be treated with concurrent chemoradiotherapy. Patients with limited stage small cell lung cancer should be given prophylactic cranial irradiation in patients with complete remission or I stage resection; prophylactic cranial irradiation should be given to patients with extensive stage remission.

Four, complementary treatment and integration of lung cancer

Complementary therapy refers to treatment means and methods of routine treatment added, complementary / integrated treatment is a new concept for malignant tumor therapy combined with mainstream treatments and other complementary therapies and supplementary means, can control the symptoms, improve the quality of life and improve the curative effect. ACCP first published guidelines for complementary therapies in patients with lung cancer. Guide for objective evaluation and analysis to put forward the following suggestions on these treatment methods: (1) suggested that all patients have to consider the use of complementary and alternative treatment (1C); (2) suggested that all lung cancer patients can make a qualified expert on the advantages and disadvantages of supplementary treatment, given the openness, evidence-based, patient centered instruction (1C); (3) in patients with lung cancer, mental model is recommended as a multidisciplinary approach to reduce anxiety, mood swings, or chronic pain (1B); (4) with anxiety or pain in patients with lung cancer, the tumor and massage therapist training to massage treatment recommendations as part of a multidisciplinary treatment (1C); (5) the deep or severe compression is not recommended for tumors or near anatomical distorted parts (such as postoperative change), and is not recommended for bleeding The tendency of patients (2C); (6) of patients with lung cancer, treatment is not recommended based on the application of biological field (1C); (7) recommend acupuncture as a complementary treatment, especially when it is difficult to control pain or side effects (such as causing neuropathy or other treatments obviously when mouth parched and tongue scorched (1A)); when nausea and vomiting caused by chemotherapy is difficult to control, suggestions for acupuncture treatment (1B); electrical stimulation wristband is not recommended for control of nausea and vomiting caused by chemotherapy (1B); (8) when using other methods, is not recommended for patients with lung cancer to stop smoking, try acupuncture to help quit smoking (2C); (9) lung cancer patients have symptoms caused by chemotherapy such as dyspnea, fatigue, neuropathy, or pain after thoracotomy, recommended try acupuncture treatment (2C); but the bleeding tendency of patients, suggest that qualified doctors caution. With acupuncture (1C); (10) recommendations for dietary supplements, especially herbs, to evaluate their side effects and potential interactions with other drugs. These may be associated with other drugs (such as drug drug interactions), should not be in the chemotherapy and radiotherapy, or preoperative use at the same time (1B); (11) against the tumor treatment response or no decrease in efficacy in patients with lung cancer, only in the context of clinical trials to recommend the use of plant medicine (1C) suggest that patients; avoid “ replacement therapy ” promoted to mainstream treatment (1A).

Key points: it is recommended that all patients with lung cancer should be given special consideration in the use of complementary and alternative therapies. In patients with lung cancer, physical and mental models are recommended as a multidisciplinary approach to reduce anxiety, mood swings, or chronic pain. Acupuncture is recommended as a complementary treatment to relieve symptoms. Recommended use of botanical drugs in clinical trials. &ldquo should be avoided; replacement therapy for ” promotion as mainstream therapy.

Five. The follow-up and investigation of patients with lung cancer after radical treatment

Only about 20% of patients with lung cancer after diagnosis to radical radical treatment, investigation and follow-up after treatment to improve the prognosis of critical illness monitoring, many institutions and academic organizations (such as NCCN, ASCO etc.) are proposed for lung cancer follow-up, the ACCP guidelines suggest: (1) the radical treatment of lung cancer patients. A radical treatment of the complications of follow-up should be performed by appropriate specialists, at least 3-6 months, at the end of the patients should be re evaluated by a multidisciplinary cancer treatment group design appropriate monitoring program to monitor recurrence and / or secondary tumor (2C); (2) the radical treatment of lung cancer, and PS pulmonary function in patients with good advice, were followed up every 6 months, including history, physical examination and imaging examination (chest X-ray or chest CT), lasted for 2 years, after a year Time. All patients should inform the symptom identification, if found signs of deterioration, should promptly contact the doctor (1C); (3) under ideal conditions, through the investigation and identification of primary lung cancer recurrence and / or secondary tumor progression requires a multidisciplinary team. If possible, the diagnosis of primary lung cancer and radical treatment doctors should be as health consultation, supervision of the investigation process (2C); (4) blood tests, PET scans, sputum cytology, tumor markers and fluorescence bronchoscopy is not currently recommended for the survey (2C); (5) smoking lung cancer patients strongly encourage them to quit, and given medication and behavioral therapy, including the follow-up period (1A).

Key points: monitoring of recurrence and / or secondary tumors by appropriate surveillance procedures designed by a multidisciplinary oncology team. Radical treatment of lung cancer patients, PS status and lung function in patients with good, it is recommended to carry out a follow-up every 6 months for a period of 2 years, after a year.

Six, palliative treatment of lung cancer

Palliative care is an important part of the treatment of lung cancer, palliative treatment can improve the quality of life of patients and improve the survival of patients with lung cancer, guide common symptoms and complications (such as pain, cough and dyspnea) palliative treatment for evidence-based evaluation and recommendations: (1) all lung cancer patients and their families must be is that pain can effectively alleviate the safety. All patients must be regular inquiries pain, can use the pain of self report and a major source of simple rating scale as the assessment (1A); (2) of all the patients, individualized drug therapy was used for pain control. Regular medication, proper treatment of pain. To assess the effect of pain management in during the period of treatment (1A); (3) of all the patients with mild to moderate pain, just started using paracetamol or non steroidal anti-inflammatory drugs for pain control, to ensure that the use of these drugs without contraindications. When the pain is severe or aggravated is the use of opioid analgesics (1B); (4) to any patient, if they can expect to use opioids, does not recommend the use of pethidine. It is a short duration of action and metabolite normeperidine toxicity, can cause central nervous excitement, irritability, restlessness and seizures (1B); (5) of those patients not rely solely on the analgesic drugs to analgesia, adjuvant drug such as tricyclic antidepressants, anti epileptic drugs and sedation the medicine can often increase the analgesic effect (1C); (6) of all the patients, oral administration is convenient and economic. For patients with lung cancer who are unable to take oral analgesics, rectal or skin administration is recommended. The intramuscular analgesia drug can cause pain, inconvenience and absorption is not reliable, it is not recommended to use (1C); (7) to accept all papaverine patients receiving treatment, taking into account the constipation is a common adverse reaction, shall take preventive measures and to regularly check (1B); (8) encourage all patients stay and as far as possible to do self check. As far as possible to avoid long-term activities (1B); (9) the pain and muscle tension or spasm associated with skin irritation, recommended (hot and cold), acupuncture and psychological nursing method to relieve pain, idyllic lifestyle can be included in the treatment plan when the pain, but can not replace the analgesic therapy (1C); (10) for advanced lung cancer patients, palliative radiotherapy can control pain. Recommended palliative chemotherapy to control pain and other symptoms, even if it has no obvious effect on survival (1B); (11) the standard scheme of pain reaction is not obvious in lung cancer patients, it is necessary to introduce them to see the special pain clinic or doctor (1C); (12) of all complained of dyspnea lung cancer patients, recommended to evaluate all the possible causes, such as large airway obstruction, pleural effusion, pulmonary embolism or with COPD exacerbation and congestive heart failure. If the cause is clear, should be given appropriate treatment (1C); (13) to no treatment of etiology of dyspnea in patients with lung cancer, recommended papaverine drugs, also recommend other treatment methods such as oxygen therapy, bronchodilators and corticosteroids (1C); all of the symptoms of dyspnea lung cancer patients, recommended given the non drug and non invasive treatment, such as patient and family education, breathing control, relaxation techniques, walking exercise and mental support (2C); (14) influence on the life of cough lung disease, recommended to evaluate the causes of treatment (1B); if there is no treatment of the etiology, the recommended drugs given papaverine cough (1B); (15) the pain caused by bone metastases of lung cancer patients, radiotherapy is recommended to control pain, for pain control. The effect of a single dose of 8Gy radiotherapy, radiotherapy and graded higher doses are the same (1A); high dose fractionated radiotherapy can get longer pain relief, reduce the frequency of treatment, and bone related events is also receiving a single dose of radiotherapy patients (1A); (16) for patients with lung cancer the obvious pain of bone metastasis, radiotherapy combined with bisphosphonates is recommended for pain relief (1A); such as the pain caused by bone metastasis, without obvious analgesic, radiotherapy and bisphosphonate reaction, recommended radiopharmaceutical for pain relief (1B); if a clear transfer of bone and / or bearing bone and isolated line the change of bone melting (above the invasion to the cortex 50%) and life expectancy of more than 4 weeks, the recommended surgical fixation in order to reduce the risk of fractures. You can use intramedullary nailing, especially for femoral or humerus (1C); (17) for symptomatic brain metastases, while recommended in the 6 week of treatment (including surgery or radiation therapy) for 16mg/ days of dexamethasone, symptom control after rapid reduction or intermittent administration (1B (18);) for solitary brain metastasis of non-small cell lung cancer patients, if carefully check out other distant metastases and mediastinal lymph node metastasis, should be considered for primary lung cancer radical resection (1C); (19) for solitary brain metastasis N0, 1 patients with non small cell lung cancer, such as no other distant metastasis and primary tumor resection, surgical resection or radiotherapy should focus on surgical resection of brain metastases (primary tumor resection). After the removal of an isolated brain metastasis, the whole brain radiotherapy (1B) should be continued. (20) the T1 weighted phase MRI examination of the entire spine is necessary for patients with new onset back pain. Do not recommend such as X-ray, ECT and CT (1C); check for not paralyzed can walk with spinal epidural metastases in patients with lung cancer, should be immediately given high doses of dexamethasone and radiotherapy (1B); (21) if the X-ray findings showed that vertebral compression, should consult the Department of Neurosurgery consultation, if possible, for spinal epidural compression PS state can transfer patients should immediately underwent surgical treatment, followed by radiotherapy (1A); (22) for massive hemoptysis in patients with lung cancer, bronchoscopy with clear bleeding site is necessary, the following should be endovascular treatment, such as argon laser treatment and coagulation, electrocoagulation (1C); (23) for symptomatic malignant pleural effusion in patients with lung cancer, pleural puncture and drainage to relieve symptoms as the first step of treatment is necessary (1C); (24) for thoracic drainage after recurrence Lung cancer patients, closed thoracic drainage and decortication is necessary (1B); (25) for suspected symptoms of superior vena cava obstruction is caused by lung cancer patients in the treatment given before should first clear histological or cytological diagnosis (1C); for SCLC, recommended for

Key points: it is recommended that all patients with lung cancer can effectively and safely relieve pain. Individualized drug therapy should be used to control pain. Palliative radiotherapy can control pain in patients with advanced lung cancer. Palliative chemotherapy is recommended to control pain and other symptoms. For patients with metastatic bone pain, a combination of bisphosphonates and local radiotherapy is recommended to relieve pain. Stent implantation can be used as a treatment for the treatment of superior vena cava obstruction, tracheoesophageal fistula, or broncho esophageal fistula.

Seven. Palliative care consultation, quality of life assessment and hospice care for patients with lung cancer

Palliative treatment, quality of life evaluation consultation should be throughout the whole course of treatment in patients with lung cancer patients until death: (1) for all advanced lung cancer patients (and their families), recommended palliative care as part of a treatment plan, including those who tried to cure the patient or life prolonging treatment (1C); (2) for patients with advanced lung cancer, palliative care and hospice care should be recommended by a palliative care team (1C); (3) for patients with advanced lung cancer, recommended by the responsible health care team regularly use the standard simple questionnaire of illness, health related quality of life scores (1B (4); the patient died of lung cancer) recommend clinicians in keeping after contact with their family or friends (1C); (5) of lung cancer patients, and actively participate in the following activities contribute to the sadness Emotional catharsis: expected inform patients and their families within weeks of death; hospice patients will advance to inform the family; give the hospice effective, key for mentally, physically and caring in action (1C); (6) to maintain a healthy lifestyle of nursing staff recommend clinicians to encourage patients with lung cancer during the dying during the period of nursing and funeral (1C); (7) recommend hospice patients with lung cancer from the angle of behavior culture understanding of death and sorrow (1C).

Key points: palliative care is recommended as part of the treatment plan for all patients with advanced lung cancer. It is recommended that the health care team regularly use standardized, simple and convenient questionnaires to assess the health-related quality of life. And emphasizes the importance of spiritual and humanistic care.

Eight, chemoprevention of lung cancer

Chemoprevention of tumors is the use of special drugs to reverse, suppress and prevent the occurrence of tumors. On the prevention of lung cancer, both the general population and high risk population and lung cancer patients, so far has not yet confirmed the significant effect on the prevention of any kind of drugs and methods on the occurrence and development of lung cancer: (1) the smoking history of more than 20 pack years or suffering from lung cancer, do not recommend adding carotene as β lung cancer grade one or two or three grade prevention drugs (1A); (2) the risk factors of lung cancer and lung cancer individuals do not recommend taking vitamin E, retinoids, N acetylcysteine, aspirin as a lung cancer, two or three (1A); drug prevention is not recommended budesonide, cyclooxygenase 2 (COX-2) inhibitor 5-, cyclooxygenase inhibitors, prostaglandin analogs as lung cancer grade one, grade two or three level of drug prevention, from clinical trials concluded that good design ( 2C); does not recommend the use of oltipraz (schistosomicide) as drugs for lung cancer in first grade, grade two or three grade prevention; (1B) does not recommend the use of selenium and anise brain as drugs for lung cancer in first grade, grade two or three grade prevention (1B); there was no enough evidence to recommend any of a single or combination of drugs for lung cancer in first grade, grade two or three grade prevention drugs (1B).

Key points: it has not been proved that any kind of drugs and methods have obvious preventive effect on the occurrence and development of lung cancer.

Main references

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