非小细胞肺癌NCCN2017V5 初始治疗 多发性肺癌

Discussion讨论

Initial Therapy 初始治疗

Multiple Lung Cancers 多发性肺癌山东省肿瘤医院呼吸肿瘤内科张品良

Patients with a history of lung cancer or those with biopsy-proven synchronous lesions may be suspected of having multiple lung cancers (see Clinical Presentation in the NCCN Guidelines for NSCLC). It is important to determine whether the multiple lung cancers are metastases or separate lung primaries (synchronous or metachronous), because most multiple lung tumors are metastases. Therefore, it is essential to determine the histology of the lung tumor (see Principles of Pathologic Review in the NCCN Guidelines for NSCLC). Infection and other benign diseases also need to be ruled out (eg, inflammatory granulomas). Although criteria have been established for diagnosing multiple lung cancers, no definitive method has been established before treatment. The Martini and Melamed criteria are often used to diagnose multiple lung cancers as follows: 1) the histologies are different; or 2) the histologies are the same but there is no lymph node involvement and no extrathoracic metastases. 有肺癌病史或活检证实的同期病变患者可怀疑有多发性肺癌（见NSCLC NCCN指南中的临床表现）。重要的是确定多发性肺癌是转移还是独立的肺原发癌（同时或异时性），因为大部分多发性肺肿瘤是转移性的。因此，必需确定肺肿瘤的组织学（见NSCLC NCCN指南中的病理学检查原则）。还需要排除感染和其他良性疾病（如炎性肉芽肿）。尽管已经建立了诊断多发性肺癌的标准，但是治疗前未建立明确的方法。常用于诊断多发性肺癌的Martini-Melamed标准如下：1）组织学不同；或2）组织学相同但无淋巴结受累且无胸外转移。

Treatment of multiple lung cancers depends on status of the lymph nodes (eg, N0–1) and on whether the lung cancers are asymptomatic, symptomatic, or at high or low risk of becoming symptomatic (see Initial Treatment in the NCCN Guidelines for NSCLC). Patients should be evaluated in a multidisciplinary setting (eg, surgeons, radiation oncologists, medical oncologists). In patients eligible for definitive local therapy, parenchymal-sparing resection is preferred (see the Principles of Surgical Therapy in the NCCN Guidelines for NSCLC). VATS or SABR are reasonable options depending on the number and distribution of the tumors requiring local treatment. Multiple lung nodules (eg, solid, subsolid nodules) may also be detected on CT scans; some of these nodules can be followed with imaging, whereas others need to be biopsied or excised (see the Diagnostic Evaluation of Incidental Lung Nodules in this Discussion and the NCCN Guidelines for Lung Cancer Screening, available at NCCN.org). 多发性肺癌的治疗取决于淋巴结情况（如，N0–1）以及肺癌有无症状，或出现症状的风险高或低（见NSCLC NCCN指南中的初始治疗）。应该对患者进行多学科（即外科医生、放射肿瘤学家、内科肿瘤学家）评估。在适合根治性局部治疗的患者中，首选保留肺组织的切除术（见NSCLC NCCN指南中的外科治疗原则）。电视胸腔镜（VATS）或立体定向消融放疗（SABR）是合理的选择，取决于需要局部治疗的肿瘤数量和分布。CT扫描也可能检出双肺多发结节（如实性、半实性结节）；这些结节有些可用影像学随访，而另外一些需要活检或切除（见本讨论中偶发肺结节的诊断评估和肺癌筛查NCCN指南，可在NCCN.org获得）。