肺癌-洪小南課件

肺癌-洪小南LUNGCANCER

Worldwideincidence**Incidenceper100,000population.Male 54.8Female 8.1Male 75.9Female 10.3Male 39.3Female 11.2Male 47.6Female 16.1Male 34.7Female 13.4Male 12.9Female 2.6Male 29.1Female 7.7Male 69.6Female 32.9Male 19.3Female 7.9Male 55.1Female 7.6EasternEuropeJapanAustraliaNewZealandChinaNorthernAfricaSouthernAfricaCentralAmericaWesternEuropeNorthAmericaTemperateSouthAmericaLUNGCANCER

5-yearsurvivalrates7%12%21%13%8%8%10%

14%14%EasternEuropeJapanAustraliaNewZealandChinaMiddleEast/

NorthernAfricaSub-SaharanAfricaLatinAmerica/

CaribbeanNorthwesternEuropeUSALUNGCANCER

Riskfactors—smokingSmokingcauses:80%oflungcancerdeathsinmen75%oflungcancerdeathsinwomen17%oflungcancercasesinnonsmokers28%ofallcancerdeaths35-yearoldmalewhosmokes25cigarettesperday:13%riskofdyingfromlungcancerbeforeage7510%riskofdyingfromcoronarydisease28%riskofdyingfromsmoking-relateddiseaseLUNGCANCER

ImpactofsmokingonriskCigarettes

smoked/dayRiskofdeveloping

lungcancer*Riskafter16years

ofsmokingcessation* 1-20 10.3-fold 1.6-fold 20 21.2-fold 4.0-fold*Datainwomen;riskcomparedtononsmokers.LUNGCANCER

LungcancercontrolHealthpolicySmoke-freeenvironmentsRestrictedadvertisingEducationalcurriculumEconomicincentivesCigarettetaxHealthinsurancediscountfornonsmokersMediacoverage/advocacySocietalstigmaassociatedwithsmokingLUNGCANCER

RiskfactorsotherthansmokingAsbestosRadon(fromminingorindoorexposure)Other“occupationalcarcinogens”Diet(vitaminsA,C,E,-carotenedeficiencies)Genetic/familialfactorsLUNGCANCER

Geneticabnormalities*Incancercelllines.Geneticabnormality NSCLC SCLCChromosome3p X X

deletionsp53genemutation X* XRbgeneabnormalities X X*myconcogenefamily X* XK-rasoncogene X

mutationLUNGCANCER

DiagnosisDiagnosisofsuspectedlungcancerChestX-rayfilm

CTscanPeripheraltumorCentraltumor

Options

Sputumcytology

Bronchoscopy

Percutaneousfine-needleaspiration

ThoracoscopyOptions

Percutaneousfine-needleaspiration

Bronchoscopy

Video-assistedthoracoscopy

LUNGCANCER

RadiographyLUNGCANCER

BronchoscopyLUNGCANCER

CTScanLUNGCANCER

MRILUNGCANCER

BonescintigraphyPET全稱：正電子發(fā)射計(jì)算機(jī)體層攝影（positron

emissioncomputedtomography,PET)代謝示蹤劑：18F-DG，葡萄糖類似物診斷原理：腫瘤及其轉(zhuǎn)移灶攝取18F-DG異常增加臨床應(yīng)用：腫瘤良惡性的鑒別腫瘤惡性程度的評價和分期治療效果的監(jiān)測與壞死和疤痕組織的鑒別PETCT-PET非小細(xì)胞肺癌的化療NON-SMALLCELLLUNGCANCER

Incidenceofmajorhistologictypes**Numbersdonotsumto100%because

ofdifferencesindiagnosticcriteria.18%40%Squamous

cellcarcinomaSmall-cellcarcinoma30%Adenocarcinoma15%OtherNON-SMALLCELLLUNGCANCER

Histologictypes

AdaptedfromRosenowandCarr.Smoker(%) Nonsmoker(%)

Smoker(%) Nonsmoker(%)

Male Female

38211723SquamousCellAdenocarcinomaLargeCellSmallCellBronchoalveolar

11056236522351327396810211SmokersvsnonsmokersNON-SMALLCELLLUNGCANCER

Signsandsymptomsatdiagnosis75404035255040302515154035351515CoughDyspneaChestPainHemoptysisPneumonitisWeightLossGeneralizedWeaknessAnorexiaFeverAnemiaFrequency(%)31%StageIII38%StageIV24%StageI7%StageIINON-SMALLCELLLUNGCANCER

StagesatpresentationNON-SMALLCELLLUNGCANCER

PrognosticfactorsEarly-stagedisease(I,II,resectableStageIII)TumorsizePresence/absenceoflymphnodemetastasisHistologicsubtypeAdvanced-stagedisease(unresectableStageIIIandIV)PretreatmentstagePerformancestatusWeightlossGenderSerumlactatedehydrogenaseMetastaticsiteYearsNON-SMALLCELLLUNGCANCER

SurvivalbystageNON-SMALLCELLLUNGCANCER非小細(xì)胞肺癌治療的選擇：1.Ⅰ、Ⅱ期首選手術(shù)。Ⅰ期術(shù)后不進(jìn)行放療，其中T1N0有高危復(fù)發(fā)因素（細(xì)胞分化差、脈管有癌栓）可化療。T2N0術(shù)后應(yīng)輔助化療。

T1-2N1切緣陰性，有不良因素（不恰當(dāng)?shù)目v隔淋巴結(jié)切除，腫瘤累及淋巴結(jié)包膜外，肺門淋巴結(jié)多個陽性，切緣離腫瘤邊緣近）術(shù)后化療+/-放療。2.III期術(shù)后單純化療或放化療。

III期新輔助治療，序貫放化療或同步放化療

T4N0-1同側(cè)肺葉內(nèi)衛(wèi)星結(jié)節(jié)術(shù)后要輔助化療。3.一般情況好的予Ⅳ期予化療。放療可作為腦轉(zhuǎn)移。骨轉(zhuǎn)移。原發(fā)灶的姑息性治療。NON-SMALLCELLLUNGCANCERⅢ期非小細(xì)胞肺癌的綜合治療Ⅲ期病變是局部晚期病變。病變累及縱隔和/或鎖骨上淋巴結(jié)和/或侵犯縱隔內(nèi)主要臟器占非小細(xì)胞肺癌的31％－44％，ⅢA、ⅢB各一半Ⅲ期五年生存率15％－23％。ⅢB五年生存率6％－7%化療是Ⅲ期NSCLC的主要治療手段，與放療和/或手術(shù)綜合治療是目前標(biāo)準(zhǔn)治療。NON-SMALLCELLLUNGCANCER1、

綜合治療可改善預(yù)后，增加有效率，延長生存期。同時也增加不良反應(yīng)。2、

放化療同步治療療效優(yōu)于序貫治療，增加緩解率，略延長生存，但毒性增加，特別是放射性食管炎和貧血。3、

序貫化放療中化療可用常規(guī)劑量，毒副反應(yīng)可耐受?；暖熗街委煏r化療藥應(yīng)減量，例如NVB、15mg/m2/周，健擇300mg/m2/周。4、

治療時間的安排：序貫治療：常規(guī)劑量化療2療程休2周后放療。同步化放療通常在同一天開始兩種治療。5、

同步化放療中的化療通常含鉑的兩藥聯(lián)合方案。放療以每天1次的常規(guī)分割為宜。NON-SMALLCELLLUNGCANCER肺上鉤瘤（Pancoast’stumor）是特殊類型的Ⅲ期病變，占全部肺癌的2％－4％。病變位于肺炎，大多數(shù)是鱗癌。常有頸8、胸1神經(jīng)，第1、2肋骨破壞，但屬鄰近侵犯，與血道播散的骨轉(zhuǎn)移、神經(jīng)侵犯不同，標(biāo)準(zhǔn)治療是術(shù)前新輔助放療或新輔助放化療。目前更傾向同時放化療。術(shù)后五年生存率20％－30％，腫瘤能完全切除者五年生存率可達(dá)40％。Ⅳ期非小細(xì)胞肺癌的化療Ⅳ期非小細(xì)胞肺癌的預(yù)后與一般狀況密切相關(guān)。PS≤2，3－6月內(nèi)體重下降＜5%,經(jīng)化療可緩解癥狀，延長生存。一般情況差者應(yīng)予對癥支持治療。積極強(qiáng)烈的化療增加毒性，不改善生存。SCLC占所有肺癌的15%-20%。光鏡：細(xì)胞體積小，胞漿少，核大，核分裂多。電鏡：：有神經(jīng)內(nèi)分泌顆粒。臨床：生物學(xué)行為惡劣，生長迅速，早期遠(yuǎn)處轉(zhuǎn)移。診斷時LD30%-40%

ED60%-70%

SMALLCELLLUNGCANCER

IncidenceofhistologictypesMixedsmallcell/

largecellcarcinoma

4-6%Combinedsmall

cellcarcinoma

<1%Puresmallcell

carcinoma

>90%SMALLCELLLUNGCANCER

SymptomsPrimarytumorCoughDyspneaWheezingHemoptysisChestpainPostobstructivepneumonitisRegionalmetastasesSuperiorvenacavasyndromeHoarsenessDysphagiaDistantmetastasesBonepainCNSsymptoms(headache,doublevision).SMALLCELLLUNGCANCER

DifferentiatingsignsfromNSCLCMorecommoninSCLCHilarandmediastinaladenopathyAtelectasisPneumonitis LesscommoninSCLCPeripherallocationPleuraleffusionChestwallinvovementSMALLCELLLUNGCANCER

StagingLimiteddiseaseDiseaseconfinedtoonehemithoraxandregionallymphnodes:hilar,ipsilateral,andcontralateralmediastinal;supraclavicular(controversial)Ipsilateralpleuraleffusion(contoversial)ExtensivediseaseAnydiseasebeyondlimiteddiseasesitesSMALLCELLLUNGCANCER

Stageandextrathoracicdiseasesites

atpresentation

PercentagewithFindingFinalstage

Limited 30%-40%

Extensive 60%-70%Bone 19%-38%Liver 17%-34%Bonemarrow 17%-23%Brain 0%-14%Lymphnodes 7%-25%Softtissue 3%-11%SMALLCELLLUNGCANCER

EvaluationofdiseaseextentMinimumEvaluationHistoryandphysicalexaminationChestradiograph±CTLiverfunctiontestsandexamination±liverscanBonepainandalkalinephosphatase±bonescanNeurologichistoryandexamination±brainCTPlateletcountorleukoerythroblasticperipheralbloodsmearSMALLCELLLUNGCANCER

Evaluationofdiseaseextent(cont’d)EvaluationforStageDependentTherapyHistoryandphysicalexaminationChestradiograph±CT±fiberopticbronchoscopyLiverfunctiontestsandliverscan±liverbiopsyBonescanBonemarrowaspiration±BrainCTEvaluationforSurgicalResection(inadditiontoabove)FiberopticbronchoscopyChestCTandmediastinoscopySMALLCELLLUNGCANCER

PrognosticfactorsStagePerformancestatusGenderAgeHistologicalsubclassificationBonemarrowmetastasesLivermetastasesCNSinvolvementBloodbiochemistry,

especiallylactatedehydrogenaseSMALLCELLLUNGCANCER

Survivalbystage

MedianSurvival– MedianSurvival– 5-YearSurvival

UntreatedPatients TreatedPatients (%)

(wk) (mo)Limiteddisease 12 14-20 10%-20%Extensivedisease 5 8-12 3%-5%常見轉(zhuǎn)移部位：骨19%-38%肝臟17%-34%骨髓17%-23%腦0-14%淋巴結(jié)7%-25%軟組織3-11%胰腺，腎上腺，腎臟內(nèi)分泌器官轉(zhuǎn)移傾向：甲狀腺8%，垂體15%，睪丸7%，甲旁腺1%中樞神經(jīng)系統(tǒng)：腦，硬膜外，腦脊膜腔，尸檢多處轉(zhuǎn)移：73%有效單藥ADM30%CTX39-40%HN240-44%MTX30%HMM30%Vp-1637-45%VCR35-42%CBP50%VM-2619-65%IFO24-71%VDS25-32%DDP16%Taxol34-41%Docetaxel28%CPT-11復(fù)治47%Topotecan39%,復(fù)治25%Gem26%聯(lián)合化療療效：三藥優(yōu)于二藥優(yōu)于單藥，超過四藥增加毒性。RRCRMS2YSLD80-90%50-60%12-20M15-40%ED60-80%15-20%7-11M少聯(lián)合化療方案EPVp-1680mg/m2d1-5DDP20mg/m2d1-5Q3WRR60-90%CR:LD20-45%ED10-25%MS:LD12MED10M聯(lián)合化療方案2.ECVp-16100mg/m2d1-3CBPAUC5Q3WLD:RR:85%,CR:37%ED:RR:68%,CR:19%MS:LD12.5MED11.8M毒性較EP小聯(lián)合化療方案3.CAVCTX800mg/m2d1ADM40-50mg/m2d1VCR2mgd1Q3WRR50-70%.CR:LD40-60%ED10-15%MS:LD12-15MED8-10M聯(lián)合化療方案4.TECTAX