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臺 北 榮 總 肺 癌 診 療 共 識 V.1.1 2014. 臺北榮總肺癌團隊 Revised on 2014/07/14. Multidisciplinary Team Taipei VGH Lung Cancer Panel Members TNM staging Taipei VGH supplement to TNM staging Table of stage grouping Evaluation and treatment Stage o (Tis)

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v 1 1 2014

臺 北 榮 總 肺 癌 診 療 共 識V.1.1 2014

臺北榮總肺癌團隊

Revised on 2014/07/14

slide2
Multidisciplinary Team

Taipei VGH Lung Cancer Panel Members

TNM staging

Taipei VGH supplement to TNM staging

Table of stage grouping

Evaluation and treatment

Stage o (Tis)

Stage I (T1ab-2a,N0) and Stage II (T1ab-2ab, N1; T2b, N0), and Stage IIB(T3, N0)

Stage IIB (T3 invasion, N0) and stage IIIA (T3-4,N1)

Stage IIIA (T1-3,N2) and Separate Pulmonary Nodules (stage IIB, IIIA, IV)

Stage IIIB (T1-3, N3)

Stage IIIB (T4 extension, N2-3) and Stage IV (M1a)(pleural or pericardial effusion)

Stage IV (M1b: solitary site)

Surveillance

Therapy for Recurrence and Metastases

Occult (Tx,N0,M0),Evaluation and Treatment

Second Lung Primary, Evaluation, and Treatment

Principles of Surgical Resection

Principles ofPathology

Principles of Radiation Therapy

- Recommended Radiation Doses

- Dose Volume Data for Radiation Pneumonitis

Principles of CCRT

Principles of Chemotherapy

-Non-Small Cell Lung Cancer

-Small Cell Lung Cancer

Adjuvant Chemotherapy

Neoadjuvant Chemotherapy

Clinical Trials for Advanced/ Metastatic NSCLC

Tracheal cancer

References

關於此臨床指引:肺癌的診療仍在發展階段,本指引主要在呈現目前肺癌診療的進展與共識,醫師應鼓勵病患參與臨床試驗

,使其有機會得到最好的治療。在本指引中的化療用藥建議是基於現有的臨床證據,和目前的衛生署或健保局規定無關。

臺 北 榮 總 肺 癌 診 療 共 識
slide3
癌委會

臺北榮總肺癌委員會暨肺癌多專科團隊組織架構

肺癌委員會暨肺癌多專科團隊

召集人:蔡俊明、許文虎副召集人:賴信良、吳玉琮

個案管理師:宋易珍、洪秀瑩、 廖嘉苗

非核心成員

核心成員

胸內

胸外

放射

病理

放療

核醫

藥劑部

骨科

營養

社工

slide4

臺北榮總肺癌多專科團隊核心人員

胸腔內科

李毓芹

蔡俊明

賴信良

陳育民

邱昭華

吳杰鴻

胸外

許文虎

吳玉琮

黃建勝

洪榮志

放射

許明輝

吳美翰

陳俊谷

周筱萍

病理

周德盈

葉奕成

放療

顏上惠

陳一瑋

藍耿立

胡育文

核醫

王世楨

林可瀚

胡蓮欣

slide5

NSCLC &SCLCTNM Staging

* MX has been removed by a general rule from UICC/AJCC.

summary of evaluation and treatment
Summary of Evaluation and Treatment
  • PFT: Necessary for all operable stages
  • PET (PET/CT) : recommend for all clinical stages, except
    • Non-operable stage IV
  • Mediastinoscopy: recommend for all clinical stages, except
    • Peripheral stage IA and non-operable stage IV p.s. N2 or N3 disease can be confirmed by methods including mediastinotomy, thoracoscopy, EBUS-FNA, EUS-FNA, CT-guided-FNA, supraclavicle LN biopsy
  • Brain MRI: recommend for all clinical stages, except
    • Stage IA (2A), Stage IB (2B)
  • Pre-operative diagnosis
    • It may not be necessary for those with high probability of malignancy and surgical resection is feasible. Intra-operative histological examination can be considered.
slide23

NSCL-16

Therapy for recurrent and advanced NON-SQUAMOUS CELL CARCINOMA

Progression after EGFR-TKI

EGFR-TKI regardless of PSb

EGFR-TKI sensitive mutation (+)a

Chemotherapy (category 1)PS= 0-1 or Bevacizumab + chemotherapy (if criteria met)

PS= 2 Chemotherapy

PS= 3-4 Best supportive care

See NSCL-18

category 2B

CR/PR/SD

EGFR mutation testing

EGFR-TKI sensitive mutation (-)

PD

See NSCL-19

EGFR mutation status unknown

ALK mutation testing

ALK inhibitor

ALK mutation (+)

a Tumors with EGFR gene deletion at exon 19, mutation at L858R, L861Q and G719X are those usually sensitive to EGFR-TKI. b EGFR-TKI is the preferred choice, but chemotherapy can be used if TKI is contraindicated or chemotherapy is the patient’s preference.

slide24

NSCL-17

(See NSCL-19)

See NSCL-18

slide25

NSCL-18

Maintenance Therapy

First line Tx

Maintenance Tx

Pemetrexed or Erlotinib

NON-SQUAMOUS CELL CARCINOMA

CR/PR/SD

or

Regular follow-up

Disease progression

See NSCL-19

Erlotinib (category 2B)

SQUAMOUS CELL CARCINOMA

CR/PR/SD

or

Regular follow-up

a Tumors with EGFR gene deletion at exon 19, mutation at L858R, L861Q and G719X are those usually sensitive to EGFR-TKI. b EGFR-TKI is the preferred choice, but chemotherapy can be used if TKI is contraindicated or chemotherapy is the patient’s preference.

slide26

NSCL-19

Therapy for recurrent and advanced NON-SQUAMOUS CELL CARCINOMA

Therapy for recurrent and advanced SQUAMOUS CELL CARCINOMA

principles of pathological review
PRINCIPLES OF PATHOLOGICAL REVIEW

病理評估

病理評估的目的包括:

準確分類肺癌組織型態

依循AJCC建議確定所有分期參數,包括腫瘤大小、侵犯範圍(肋膜及支氣管)、手術切除邊緣適當性及淋巴結轉移評估

進一步確定腫瘤的特殊分子異常是預測使用tyrosine kinase inhibitors(TKI)治療的關鍵

手術病理報告應該有WHO肺癌組織分類。肺腺癌應使用最新發表之IASLC/ERS/ATS肺腺癌分類,強烈建議不使用細支氣管肺泡癌(bronchioloalveolar carcinoma,BAC)這個診斷。

NSCLC這個診斷應盡量避免使用,除非是已經過廣泛病理診斷檢查後仍無法分辨特別分化之病例。

高度建議盡可能獲得新鮮冷凍之腫瘤組織來進行分子分析,特別是在末期疾病。福馬林固定石臘包埋之腫瘤亦可用於多數分析。

在小標本應謹慎使用免疫及特殊染色,以儘量保存腫瘤組織用於分子檢測。使用一個鱗狀上皮癌的標記(例如p40)搭配一個腺癌的標記(例如TTF-1)的組合再加上黏液染色(mucicarmine) ,通常已足夠解決大部份診斷的問題。

principles of pathological review1
PRINCIPLES OF PATHOLOGICAL REVIEW

肺腺癌分類 (IASLC/ERS/ATS classification)

Preinvasive lesions

Atypical adenomatous hyperplasia

Adenocarcinoma in situ (AIS; formerly BAC)- <3cm nodule, lepidic growth

Minimally invasive adenocarcinoma (MIA)- <3cm nodule with <5mm invasion, predominantly lepidic growth

Invasive adneocarcinoma- lepidic predominant growth with >5mm of invasion; acinar, papillary, micropapillary or solid with mucin production

Invasive adenocarcinoma variants- mucinous adenocarcinomas, colloid, fetal and enteric morphologies

principles of pathological review2
PRINCIPLES OF PATHOLOGICAL REVIEW

免疫組織化學染色

免疫染色可幫助鑑別原發性肺癌分類或轉移肺腺癌,區別腺癌及惡性間皮細胞癌,決定腫瘤之神經內分泌分化。

原發性肺腺癌

TTF-1對區分原發或轉移肺腺癌很重要。大部分(70-100%)原發肺腺癌(nonmucinous)TTF-1為陽性,轉移腺癌(甲狀腺癌除外)為陰性反應。

Napsin A於>80%的肺腺癌表現,可用於輔助TTF-1。

Mucicarmine, p40, p63, CK5/6, CK34βE12可用於分辨肺腺癌及鱗狀細胞癌

使用一個鱗狀上皮癌的標記(例如p40)搭配一個腺癌的標記(例如TTF-1)再加上黏液染色(mucicarmine)的組合可用於進一步分類診斷為NSCLC-NOS的小標本。

神經內分泌分化

CD56, chromogranin及synaptophysin可用於辨識神經內分泌分化。

惡性間皮細胞癌vs.肺腺癌

建議使用兩個已知的間皮細胞癌免疫陽性抗體及兩個已知的腺癌免疫陽性抗體來做鑑別。

間皮細胞癌的免疫陽性抗體:WT-1, calretinin, D2-40, HMBE-1, cytokeratin 5/6

肺腺癌的免疫陽性抗體:CEA, B72.3, Ber-EP4, MOC31, CD15, TTF-1

principles of pathological review3
PRINCIPLES OF PATHOLOGICAL REVIEW

肺癌之分子病理診斷

  • EGFR and KRAS
    • EGFR 突變與TKI治療之反應相關;如TKI 對exon 21 mutation (L858R)與exon 19 deletion之腫瘤治療效果良好。
    • EGFR與KRAS突變在肺癌病人中互不相存
    • 腺癌EGFR突變的盛行率在西方人為10%,而在亞洲病人高達50%,且在非吸菸者、女性及非黏液腫瘤有較高EGFR突變頻率。最常見的突變位置在exon 21 (L858R)及exon 19 deletions。
    • TKI治療抗藥性與KRAS突變及EGFR的第二位點突變(如T790M)有關
  • ALK
    • ALK基因轉位可發生於一小群的肺癌病人,特別是年輕、不吸菸以及較末期的腺癌病人。 ALK抑制劑對這群病人有相當好的治療效果。
    • 多數ALK基因轉位與EGFR突變互不相存。
    • ALK基因轉位的分子診斷標準是fluorescence in situ hybridization (FISH),已被美國FDA認可。其他的診斷方法包括免疫染色以及PCR。
principles of pathological review4
PRINCIPLES OF PATHOLOGICAL REVIEW

小細胞癌

  • 小細胞癌(SCLC)是一種惡性上皮腫瘤,由極少細胞質、不清楚的細胞邊緣、細緻顆粒狀的核染色質及沒有或不明顯的核仁的小細胞所組成。這些細胞呈圓形、橢圓或梭狀,且核相嵌現象明顯。高達30%SCLC病人解剖時發現部分NSCLC分化,此現象較常於先前接受過治療的病人檢體上發現,暗示肺癌的形成來自能夠有不同分化的多潛能幹細胞。
  • 小細胞癌多數(95%)原發自肺,少數則來自肺外器官,二者有類似之臨床和生物特性,極易廣泛轉移。
  • 幾乎所有SCLCs免疫染色keratin、epithelial membrane antigen (EMA)及thyroid transcrption factor-1 (TTF-1)呈陽性。多數SCLC亦表現神經內分泌分化,CD56、synaptophysin、chromogranin A或neuron-specific enolase (NSE)呈陽性免疫染色。
slide33
肺癌之手術治療原則

應當由通過專科認證並且以肺癌手術為主要執業項目的胸腔外科醫生來決定腫瘤可否以手術切除。

手術切除(包括楔形切除術)優於腫瘤消融術 (射頻消融、微波消融、冷凍療法、立體定向放療)。每一位考慮行根治性局部治療的患者在接受評估時,都應諮詢胸腔腫瘤外科醫生的意見。手術切除高風險患者考慮以立體定位放射治療時,建議由包含放射腫瘤醫師之多專科團隊評估之。

slide34
肺癌之手術治療原則

在任何非緊急治療前,應完成完整治療計畫的制訂和必要的影像學檢查。

胸腔外科醫生應積極參加針對肺癌患者的多專科團隊討論和會議 (如多專科綜合治療門診和/或腫瘤委員會)。

slide35
肺癌之手術治療原則
  • 對於大多數非小細胞肺癌患者,解剖性肺切除術為首選。
  • 亞肺葉切除術(肺節切除和楔形切除)應當達到肺實質切緣大於等於2 公分或者大於等於結節的大小。 除非技術不可行性,術中在不顯著增加手術風險的情況下,應對Nl和N2淋巴結進行取樣活檢。肺節切除術(首選)或者楔形切除術基於下列原因可適用於部分特定患者:
    • 肺功能不佳(poor pulmonary reserve)或者因其他嚴重合併症而不能接受肺葉切除術
    • 周圍型結節≤2 cm,並至少符合以下標準中的一項:
      • 組織學類型為純粹之原位型腺癌 (AIS)
      • CT檢查顯示結節≥50%表現為毛玻璃樣
      • 影像學隨診檢查證實腫瘤倍增時間較長(≥400天)
slide36
肺癌之手術治療原則

如患者無解剖學和手術方面的禁忌症,只要不違反腫瘤治療標準和胸腔手術切除原則,電視輔助胸腔鏡外科手術(VATS)是一個可接受的合理選擇

在高個案量醫學中心(high volume centers)並具有相當的胸腔鏡外科手術經驗,選擇某些病人施行胸腔鏡肺葉切除可以改善短期結果(疼痛,住院天數,回復正常功能時間)而不會危及癌症預後

如解剖位置合適且能夠做到切緣(resection margin)陰性,保留肺組織的解剖性切除術(袖狀切除術)優於全肺切除術。

slide37
肺癌之手術治療原則

T3 (擴展) 及T4 局部侵犯腫瘤需要總括性(En-Bloc)切除所有腫瘤涉及之組織構造,以達到切緣陰性為目的。 如果外科醫師或醫學中心無法確定可否完整切除,可考慮取得其他高個案量醫學中心之外科第二意見 。

外科及病理的聯繫(Surgical pathologic correlation)對於評估顯然接近(apparent close)或陽性切緣非常重要 ,因為這些並不一定代表真正的切緣或代表真正會局部復發的區域(例如當隆凸下淋巴結分開廓清時,主支氣管或間支氣管的內面,或當沒有附著主動脈時鄰近主動脈的肋膜切緣) 。

slide38
肺癌之手術治療原則

N1和N2淋巴結切除並標明位置(最少對3個N2站的淋巴結進行取樣或行完全淋巴結清除術)

IIIA期 (N2)患者在接受切除術時應行正規的同側縱隔淋巴結清除術

完整切除需求手術切緣陰性、系統性淋巴擴清或取樣、 無包膜外淋巴結腫瘤擴展( extracapsular nodal extension of tumor)、及最高位縱膈腔淋巴結為陰性。如果切緣陽性、包膜外淋巴結腫瘤擴展、無法移除的陽性淋巴結、或陽性肋膜或心包膜積液,則定義為非完整切除。完整切除歸類為R0 ,病理顯微鏡檢陽性為R1 ,肉眼可見殘餘腫瘤則為R2 。

slide39
肺癌之手術治療原則

術後病理分期為II期或以上的患者應當轉診至胸腔腫瘤內科進行評估。

IB期患者可考慮轉診至胸腔腫瘤內科,IIIA期患者可考慮轉診至放射腫瘤科。

local tumor ablation cryoablation rfa microwave
Local tumor ablation (Cryoablation/RFA/Microwave)

Medically inoperable

Node negative or node covered by radiotherapy

Tumor Size < 4 cm

ECOG <= 1

slide41
射頻腫瘤消融術(RFA)

http://www.jaapa.com/rfa-is-an-effective-alternative-to-lobectomy-for-lung-cancer/article/123906/

腫瘤內插入電極針,交流電被導入電極後經由人體流向貼在大腿的墊片再離開人體,射頻的能量在電極針非絕緣體部分釋放出來,導致腫瘤插針部位經由離子激化(ion agitation)產生熱量的形式,造成腫瘤局部組織的凝固性壞死(coagulation necrosis)。

slide43
按2012年NCCN guideline的精神,其所建議的放射治療已非傳統二次元定位的方式,而是因應放射治療技術的進步,以電腦斷層評估腫瘤的位置、體積和淋巴結引流,來決定照射的角度、劑量和範圍,技術包括三度空間順形治療(3D conformal radiotherapy,3DCRT),強度調控放射治療(intensity-modulated radiotherapy,IMRT),動態式弧形放射治療 (Volumetric Modulated Arc Therapy,VMAT),影像導引斷層式治療(Tomotherapy)

美國NCCN所建議的放射照射劑量並不完全適用於國人,本共識以依國內病人狀況要做適度的調整 。

recommended dose volume limit for lung
Recommended Dose/Volume Limit for Lung

QUANTEC = Quantitative Analysis of Normal Tissue Effects in the Clinic

V20 = % of whole lung receiving ≥ 20 Gy

MLD = Mean Lung Dose

  • QUANTEC is recommended by NCCN guideline
  • For conventional fractionation, definitive RT:
    • V20 ≦ 30–35% and MLD ≦ 20–23 Gy to limit the risk of radiation pneumonitis to ≦ 20%
    • Limiting the dose to the central airways to ≦ 80 Gy to reduce the risk of bronchial stricture
  • Reference : Radiation dose-volume effects in the lung. Int J Radiat Oncol Biol Phys. 2010 Mar 1;76(3 Suppl):S70-6.
radiation therapy for small cell lung cancer
Radiation Therapy for Small Cell Lung Cancer

◎Limited SCLC

1.年齡小於等於70歲,PS:0~1,接受CCRT DOSE:56~70 Gy/2Gy/day

排程:放療自開始持續做至 56~70 Gy,而化學治療自開始先做三個療程後休

息,須重新評估病患治療反應,之後再依實際情形安排接續的治療。

如有PR/CR持續化學治療

2.年齡大於70歲,PS:0~1,採用接續性化放療(sequential chemoradiotherapy)

DOSE:50~60 Gy/1.8Gy/day

排程:連續的三個療程的化學治療後休息,在二週內重新評估

如有PR/CR加做胸腔的放療及三個療程的化學治療

3.如有PD接受第二線化療。

◎Prophylactic cranial irradiation (PCI)

1. Limited or extensive stage,CR 或 PR after initial treatment 且PS:0~1,可考慮加做PCI

DOSE: 30Gy/ 2Gy/ day x15 fractionsor

25Gy/2.5Gy/day x10 fractions

slide49
◎NSCLC Dose: up to 60-66Gy/1.8-2Gy/day

◎Limited SCLC

1.年齡小於等於70歲,PS:0~1,接受CCRT DOSE:50~60 Gy/1.8Gy/day

排程:放療自開始持續做至50~60 Gy,而化學治療自開始先做三個療程後休

息,須重新評估病患治療反應,之後再依實際情形安排接續的治療。

如有CR加做预防性全腦放射治療 (prophylactic cranial irradiation, PCI)

DOSE: 30Gy/ 2Gy/ day x15 fractions(一天一次共十五次)

如有PR持續化學治療,但不做PCI

2.年齡大於70歲,PS:0~1,採用接續性化放療(sequential chemoradiotherapy)

DOSE:50~60 Gy/1.8Gy/day

排程:連續的三個療程的化學治療後休息,在二週內重新評估

如有CR加做PCI, DOSE: 30Gy/ 2Gy/ day x15 fractions(一天一次共十五次)

如有PR加做胸腔的放療及三個療程的化學治療,但不做PCI

3.如有PD接受第二線化療。

同步化學併放射治療(CCRT)原則
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同步化學併放射治療(CCRT)原則
  • Principles of chemotherapy regimen
    • Chemotherapy at systemic doses results in superior outcome but at the cost of an increased toxicity.
    • Platinum-based regimen is preferred
    • Reference regimens with combination of platinum
      • Etoposide
      • Vinorelbine or Vinblastine
    • Alternative regimens with combination of platinum
      • Paclitaxel
      • Docetaxel
      • Pemetrexed
    • High-risk drugs for CCRT
      • Gemcitabine
      • EGFR-TKI (gefitinib, erlotinib)
      • Bevacizumab
      • Doxorubicin
slide51
◎第一線

- Gemcitabine (GC-G)G (1000-1250mg/m2) + Cisplatin (60-75mg/m2), Q3-4W.

- Vinorelbine (NC-N)Vinorelbine (25-30 mg/m2 i.v. or 60-80 mg/m2 p.o.) + Cisplatin (60-75 mg/m2), Q3-4W.

- Paclitaxel (TaC or TaC-Ta-Ta)1.Paclitaxel (160-175 mg/m2) + Cisplatin (60- 75 mg/m2), Q3W.2.Paclitaxel (60-80 mg/m2)-D1,8,15 + Cisplatin (60-75 mg/m2) -D1, Q4W.

- Docetaxel (TC or TC-T)1. Docetaxel (60-75 mg/m2)-D1 + Cisplatin (60-75 mg/m2)-D1, Q3W.2. Docetaxel (30-35 mg/m2)-D1,8 + Cisplatin (60-75 mg/m2)- D1,Q3W.

- Pemetrexed (AC)Pemetrexed (500mg/m2) + Cisplatin (60-75mg/m2), Q3W.

-Gefitinib 250 mg, QD. (ifEGFR sensitizing mutation(+) )

-Erlotinib 150 mg, QD. (if EGFR sensitizing mutation(+) )

-Afatinib 40 mg, QD. (if EGFR sensitizing mutation(+) )

-Crizotinib 250 mg, BID. (ALK gene rearrangement(+) )

※備註:

1. Elderly or poor performance status:cisplatin omited

2. Cisplatin 若改成 Carboplatin, 劑量為 (CCr+25) x AUC, AUC = 4-6

3. Bevacizumab 7.5 mg/kg 可與 chemotherapy 並用於第一線治療, 但限於non-squamous cell carcinoma, no hemoptysis4. Pemetrexate/cisplatin用於第一線治療以及 pemetrexate用於第二線

治療都僅限於non-squamous cell carcinoma

◎第二線

- Docetaxel

1. Docetaxel (60 - 75mg/m2)-D1, Q3W.

2. Docetaxel (30 - 35mg/m2)-D1,8, Q3W.

- Pemetrexed(500mg/m2)-D1,Q3W.

-Gefitinib 250 mg, QD. (if Adeno)

- Erlotinib 150 mg, QD. (if Adeno)

◎第三線

- Erlotinib 150 mg, QD. (if NSCLC)

肺癌化學治療用藥準則 – 非小細胞肺癌

* 病患若參加本院 IRB 同意之臨床試驗,則依該臨床試驗之治療計畫進行

slide52
肺癌化學治療用藥準則 – 小細胞肺癌 ( 臨床試驗病例除外 )

◎ Standard regimens (PVP):

1.  Cisplatin (60-75 mg/m2)+ VP-16 (60-80 mg/m2) D1,2,3/ Q3W

2.  Carboplatin (AUC=5)D1 + VP-16 (60-80 mg/m2) D1,2,3/ Q3W

◎ Relapsed regimens:

1. Ifosfamide 1000 mg/m2 D1-3 + oral VP16 50 mg D1-10/ Q3W

2. Topotecan 1.5 mg/m2 D1-3 + epirubicin 30 mg/m2 D1/ Q3W

chemotherapy regimens for adjuvant therapy platintinum based
Chemotherapy Regimens for Adjuvant Therapy-platintinum based

( Indication: pathological stage II and IIIA )

Chemotherapy Regimens for Adjuvant Therapy-non platintinum based

( Indication: Adeno, pT2 and tumor size > 3 cm )

Chemotherapy Regimens for Adjuvant Therapy- Alternative

Cisplatin 若改成 Carboplatin, 劑量為 (CCr+25) x AUC, AUC = 4-6

*Palitaxel+carboplatin regimen showed survival benefit in stage IB, > 4 cm

staging

Primary Tracheal Cancer

Staging

Proposed TNM classification and staging for primary tracheal carcinoma*

*Ref: Paolo Macchiarini, Lancet Oncol 2006; 7: 83–91

primary tracheal cancer
Primary Tracheal Cancer

WORKUP

CLINICAL STAGE

ADDITIONAL EVALUATION (as clinically indicated)

Medical fit for surgery, resectable

See Primary Treatment (TRACH-1 )

a

Medical unfit for surgery, or unresectable, or surgery not elected and patient medically able to tolerate chemotherapy

  • Multidisciplinary evaluation is encouraged
  • PET/CT scan
  • Consider 3D-CT reconstruction (multi-planar reconstruction, volume rendering technique, minimal intensity projector)

b

See Primary Treatment (TRACH-2 )

  • H&P
  • CBC, platelet
  • Chemistry profile
  • Smoking cessation counseling
  • PFT
  • Chest CT scan
  • Bronchoscopy
  • Brain MRI

Stage I-III, IVA

Medical unfit for surgery and patient unable to tolerate chemotherapy

See Primary Treatment (TRACH-2 )

Stage IVB

Metastatic cancer

See Primary Treatment (TRACH-3)

a Medically able to tolerate major thoracic surgery b Unresctable tumor: greater than 50% of tracheal length involved by tumor, “frozen”mediastinum, poor general condition of patient, distant metastases in squamous cell carcinoma; Oncologist 1997;2;245-253

slide58

Primary Tracheal Cancer

PRIMARY TREATMENT

ADJUNCTIVE/ADJUVANT TREATMENT

Radiation

c

  • Complete resection (R0):

50Gy over tumor bed and adjacent mediastinum

  • Incomplete resection with residual margin

R1:

R2:

>60Gy over tumor bed and 50Gy over adjacent

mediastinum

Medically fit for surgery, resectable

c

a

Surgery

a Medically able to tolerate major thoracic surgery c R0=No cancer at resection margins, R1=Microscopic residual cancer, R2=Macroscopic residual cancer

TRACH-1

slide59

Primary Tracheal Cancer

PRIMARY TREATMENT

Medical unfit for surgery, or unresectable, or surgery not elected and patient medically able to tolerate chemotherapy

RT, 60Gy + concurrent chemotherapy (Cisplatin-based) (preferred) or Best supportive care

b

Best Supportive Care

  • Obstruction: stent, laser, photodynamic therapy, RT (external 30-50Gy or brachytherapy)
  • Pain control: RT and/or medications
  • Nutrition

Medical unfit for surgery and patient unable to tolerate chemotherapy

RT 60-66Gy or Best supportive care

b Unresctable tumor: greater than 50% of tracheal length involved by tumor, “frozen”mediastinum, poor general condition of patient, distant metastases in squamous cell carcinoma; Oncologist 1997;2;245-253

TRACH-2

slide60

Primary Tracheal Cancer

SALVAGE THERPAY

Karnofsky performance score > 60 or ECOG performance score≦2

RT, 60Gy + concurrent chemotherapy (Cisplatin-based) (preferred) or Chemotherapy or Best supportive care

Stage IVB

Metastatic cancer

Best Supportive Care

  • Obstruction: stent, laser, photodynamic therapy, RT (external 30-50Gy or brachytherapy)
  • Pain control: RT and/or medications
  • Nutrition

Karnofsky performance score ≦ 60 or ECOG performance score≧3

Best supportive care

TRACH-3

slide61
臺 北 榮 總 肺 癌 診 療 共 識

主要依據- 1.NCCN v4 2014

本治療指引將每年檢討修訂一次預定下次修訂日期: 2015年07月