肺癌ppt课件

肺癌中山大学附属第一医院呼吸内科周燕斌流行病学epidemiology美国癌症死亡率(1992-1996)01020304050607080直肠癌胰腺癌肺癌前列腺癌乳腺癌卵巢癌男女死亡率100,000人/每年Riesetal1999美国肺癌发病率和死亡率(1973-1996)1050100Incidence-malesMortality-malesIncidence-femalesMortality-femalesRateper100,000people(logscale)19747678808284868890929496Yearofdiagnosis/deathRiesetal1999肺癌发生率：病理类型、性别、种族(1973-1996)6010194-685-71973-5男性黑人男性白人女性黑人女性白人Yearofdiagnosis鳞癌腺癌大细胞癌小细胞癌94-685-773-5Rateper100,000people(logscale)94-685-773-594-685-773-5Wingoetal1999肺癌的流行病学特点–90-92年肺癌占恶性肿瘤死因第1位的省市:上海:43.53/10万天津:38.86辽宁:32.07黑龙江:29.06吉林:28.06云南:23.07北京:22.25内蒙古:22.04肺癌的流行病学特点全国上海广东051015202530354045全国上海广东72--7490--92解剖和病理AnatomyandPathology肺癌的分类学按部位分:–中央型–周围型按生物学分:–小细胞肺癌:(15-20%)–非小细胞肺癌:(80-85%)鳞癌腺癌大细胞癌腺鳞癌其它肺癌病理类型鳞癌0.30-0.35腺癌0.35-0.40大细胞癌0.10小细胞癌0.20-0.25症状和诊断SymptomsandDiagnosis肺癌的症状学发生发展表现–肺癌形成无症状–累及小支气管咳嗽–累及粘膜微血管血痰–侵及胸膜胸壁胸闷胸痛–阻塞支气管气促发热–胸膜播散胸水非特异性症状:食欲不振体重下降肺癌的症状学外侵和转移症状–上腔静脉综合征–Horner’sSyndrome–Pancoast’sSyndrome肺癌伴随症状:–肺性骨关节病–类癌综合征–男性乳房发育肺癌的主要症状和体征020406080100咯血纳差疼痛咳嗽呼吸困难患者(%)Hollenetal1999Transthoracicneedleaspiration(TTNA)ofanon-smallcellPancoasttumor肺癌的诊断学几个需要遵循的原则–警惕经治未愈的呼吸道症状–注意少见的肺外表现–从常规到复杂从无创到有创–重视获取病理学诊断细胞学,组织学非小细胞肺癌的诊断PhysicalexaminationDetectsignsVisualizeandsamplemediasturiallymphnodesDetectposition,size,numberoftumorsDetectchestwallinvasionmediastinallymphodenopathydistantmetastasesLymphnodestagingDetectchangesinhormoneproduction,andhematologicalmanifestationsoflungcancerPreciselocationoftumorobtainbiopsyChestX-rayCTscanPETscanLaboratoryanalysisBronchoscopyMediastinoscopyFNACytologyNCCNGuidelines2000诊断（Diagnosis）1、CXR，CT，包括胸部、肝和肾上腺B2、对肺周围型病变经皮肺穿刺是合适的，但非强制性，特别是既往胸片检查无病变者。B3、CT提示纵隔淋巴结1cm（短径）应行纵隔镜检，前纵隔切开活检或穿刺。BBTSGuidelinesThorax2001,5689-108非小细胞肺癌X线胸片非小细胞肺癌CT扫描纵隔镜检查分期和预后stagingandprognosticationMountain1997非小细胞肺癌分期DiseaseEarlyLocalizedAdvancedStage0IAIBIIAIIBIIIAIIIBIVTNMTISN0M0(carcinomainsitu)T1N0M0T2N0M0T1N1M0T2N1M0T3N0M0T3N1M0T1-3N2M0T4,AnyN,M0AnyT,N3,M0AnyT,AnyN,M1非小细胞肺癌分期Stage0StageIAStageIIBStageIIIBStageIVLymphnodesMainbronchusContralaterallymphnodeMetastasistodistantorgansInvasionofchestwall非小细胞肺癌：临床分期与预后1year3years5years0102030405060708090100IAIBIIAT2N1M0IVIIBIIIAIIIBClinicalstageatpresentationSurvival(%)Mountain1997T3N0M0T3N1M0T1-3N2M0T4N3Probabilityofsurvivalaccordingtoclinicalstage非小细胞肺癌:其他影响预后因素可手术(0-IIIA期)肺部症状肿瘤的最大径erbB-2,p53过表达血管侵犯肿瘤血管形成Harpole1995非小细胞肺癌:其他影响预后因素不可手术(IIIB-IV期)PS评分年龄和性别体重下降转移灶LDH,AKP（碱性磷酸酶）,血钙，血红蛋白含铂化疗方案Albainetal1991治疗Treatment肺癌治疗思维决策先进行肺癌的生物学分类–小细胞肺癌–非小细胞肺癌再根据资料作肺癌的分期决定肺癌的治疗方案治疗结束安排随防计划非小细胞肺癌：治疗概况肿瘤局限手术肿瘤范围较大化疗,放疗(手术)晚期肿瘤化疗PDQGuidelines非小细胞肺癌的治疗：0期肺叶，肺段切除术，或楔形切除术根治性化疗（有手术禁忌者）内镜下光动力学治疗(疗效待评估)PDQGuidelines非小细胞肺癌的治疗：I期和II期肺叶切除术或肺切除术根治性化疗（有手术禁忌者）辅助化疗辅助放疗新辅助化疗PDQGuidelinesI期非小细胞肺癌:手术Locoregionalrecurrencerate(perperson-year)Locoregionalrecurrencerate(%ofpatients)01020304050Segmen-tectomy(n=68)Lobectomy(n=105)00.00.010.020.030.040.050.060.070.080.090.10Limitedresection(n=122)Lobectomy(n=125)p=0.008WarrenandFaber1994GinsbergandRubinstein1995p0.05I期和II期非小细胞肺癌:放疗Dosoretzetal199201020304050607080Overall65Gray60GrayT1T2T3RadiationdoseDisease-freesurvival(%)非小细胞肺癌的治疗：III期单纯手术治疗(部分IIIA期患者)术后放疗化疗+放疗单纯放疗单纯化疗(IIIB期伴恶性胸腔积液）PDQGuidelinesIII期非小细胞肺癌:手术联合其他治疗StudyPassetal1992Rothetal1994Roselletal1994RegimensSurgerypluschemotherapy(n=13)Surgeryplusradiotherapy(n=14)Surgerypluschemotherapy(n=28)Surgeryalone(n=32)Surgeryplusradiotherapypluschemotherapy(n=30)Surgeryplusradiotherapy(n=30)Mediansurvival(months)28.715.66411268pvalue0.0950.0080.001I-IIIB期非小细胞肺癌:CHART0102030405060701-year2-yearConventionalradiotherapy(n=225)CHART(n=338)Survival(%patients)Saundersetal1997p=0.004III期非小细胞肺癌:联合放、化疗NSCLCCollaborativeGroup19950.00.51.01.52.0RadiotherapypluschemotherapybetterRadiotherapy(control)betterBuenosAiresBrusselsFLCSG2EssenSLCSGCEBI138WSLCRG/FIPerugiaCALGB8433EORTC08842SWOG8300aSWOG8300bSubtotalp=0.005IV期非小细胞肺癌的治疗化疗（含铂方案）,有生存获益新一代化疗药物外放射治疗(姑息治疗)内镜下激光治疗或近距离化疗（解除气道阻塞）PDQGuidelinesIV期非小细胞肺癌:联合化疗05101520253035PVpPVpmPVePVeMiFOMi/CAPResponserate(%)p0.001acrosstreatments012345678910PVpPVpmPVePVeMiFOMi/CAPMediansurvival(months)p=0.61acrosstreatmentsWeicketal1991IV期非小细胞肺癌:新一代化疗药物Paclitaxel,vinorelbine,docetaxelGemcitabine,topotecan,irinotecan单药疗效优于顺铂联合化疗：在研Jassem1999晚期非小细胞肺癌的联合化疗:近年的随机试验(1)StudyLeChevalieretal1994Bonomietal1996Crinoetal1998Belanietal1998Cardenaletal1999RegimensVindesine/cisplatinVinorelbine/cisplatinEtoposide/cisplatinPaclitaxel(135)/cisplatinPaclitaxel(250)/cisplatin/G-CSFMitomycin/ifosfamide/cisplatinGemcitabine/cisplatinEtoposide/cisplatinPaclitaxel/cisplatinEtoposide/cisplatinGemcitabine/cisplatinMediansurvival(months)7.69.5*7.69.5*9.9*9.68.68.27.77.28.71-yearsurvival(%)2837323739343337322632Tumorresponse(%)1930*12*27*32*2638*1423*21.940.6**p0.05Gandaraetal1999晚期非小细胞肺癌的联合化疗:近年的随机试验(2)StudyKellyetal1999Schilleretal2000RegimensVinorelbine(25)/cisplatin(100)Paclitaxel(225)/carboplatin(AUC6)Paclitaxel(135)/cisplatin(75)Gemcitabine(1000)/cisplatin(100)Docetaxel(75)/cisplatin(75)Paclitaxel(225)/carboplatin(AUC6)M