NCCN非小細(xì)胞肺癌診斷治療指南(中文)

PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.Copyright?NationalComprehensiveCancerNetwork2011.Allrightsreserved.“NCCN”,theNCCNlogo,and“NationalComprehensiveCancerNetwork”areregisteredtrademarksoftheNationalComprehensiveCancerNetwork.TheChineseeditionofNCCNClinicalPracticeGuidelinesinOncology-Non-SmallCellLungCancerGuideline2011istheChineseadaptedversionofNCCNClinicalPracticeGuidelinesinOncology-Non-SmallCellLungCancerGuideline,V.3.2011aspermittedandendorsedbyNCCN.ItisthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TheoriginalguidelineandChineseeditionarebothavailableat:.Toviewthemostrecentandcompleteversionoftheguideline,goonlineto.TheseGuidelinesandillustrationshereinmaynotbereproducedinanyformforanypurposewithouttheexpresswrittenpermissionoftheNCCN.TheseGuidelinesareaworkinprogressthatwillberefinedasoftenasnewsignificantdatabecomesavailable.TheNCCNGuidelinesareastatementofconsensusofitsauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatment.AnyclinicianseekingtoapplyorconsultanyNCCNguidelineisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicalcircumstancetodetermineanypatient'scareortreatment.TheNationalComprehensiveCancerNetworkmakesnowarrantiesofanykindwhatsoeverregardingtheircontent,useorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanyway.Thispublicationshouldnotbeusedforcommercialpurpose.ItisprovidedforfreetoChinesemedicalprofessionswiththesupportoftheunrestrictiveeducationalgrantofShanghaiRochePharmaceuticalsLtd.whichexertsnoinfluencetotheformationoftheChineseeditionofNCCNClinicalPracticeGuidelinesinOncology-Non-SmallCellLungCancerGuideline2011.PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.*DavidS.Ettinger,MD/Chair?

TheSidneyKimmelComprehensiveCancerCenterat JohnsHopkins WallaceAkerley,MD?

HuntsmanCancerInstituteattheUniversityofUtah HosseinBorghaei,DO,MS?? FoxChaseCancerCenter AndrewChang,MD? UniversityofMichiganComprehensiveCancerCenter RichardT.Cheney,MD≠ RoswellParkCancerInstitute LucianR.Chirieac,MD≠ Dana-Farber/BrighamandWomen'sCancerCenter ThomasA.D’Amico,MD? DukeComprehensiveCancerCenter ToddL.Demmy,MD? RoswellParkCancerInstitute RamaswamyGovindan,MD?

SitemanCancerCenteratBarnes-JewishHospitaland WashingtonUniversitySchoolofMedicine FredericW.Grannis,Jr.,MD? CityofHopeComprehensiveCancerCenter LeoraHorn,MD,MSc? Vanderbilt-IngramCancerCenter ThierryJahan,MD?

UCSFHelenDillerFamilyComprehensiveCancerCenter AnneKessinger,MD?

UNMCEppleyCancerCenteratTheNebraskaMedical Center

RitsukoKomaki,MD§

TheUniversityofTexasM.D.AndersonCancer Center Feng-Ming(Spring)Kong,MD,PhD,MPH§

UniversityofMichiganComprehensiveCancer Center MarkG.Kris,MD?

MemorialSloan-KetteringCancerCenter LeeM.Krug,MD?

MemorialSloan-KetteringCancerCenter IngaT.Lennes,MD?

MassachusettsGeneralHospitalCancerCenter BillyW.Loo,Jr.,MD,PhD§

StanfordComprehensiveCancerCenter*RenatoMartins,MD?

FredHutchinsonCancerResearchCenter/Seattle CancerCareAlliance JanisO’Malley,MDф UniversityofAlabamaatBirmingham ComprehensiveCancerCenter RaymondU.Osarogiagbon,MD?

St.JudeChildren’sResearchHospital/Universityof TennesseeCancerInstitute GregoryA.Otterson,MD?

TheOhioStateUniversityComprehensiveCancer Center-JamesCancerHospitalandSolove ResearchInstitute JyotiD.Patel,MD? RobertH.LurieComprehensiveCancerCenterof NorthwesternUniversityMaryPinder-Schenck,MD?H.LeeMoffittCancerCenter&ResearchInstituteKatherineMPisters,MD?TheUniversityofTexasM.D.AndersonCancerCenterKarenReckamp,MD,MS??CityofHopeComprehensiveCancerCenterGregoryJ.Riely,MD,PhD?MemorialSloan-KetteringCancerCenterEricRohren,MD,PhDфTheUniversityofTexasM.D.AndersonCancerCenterScottJ.Swanson,MD?Dana-Farber/BrighamandWomen'sCancerCenterDouglasE.Wood,MD?FredHutchinsonCancerResearchCenter/SeattleCancerCareAllianceStephenC.Yang,MD?TheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsNCCNKristinaGregory,RN,MSNMirandaHughes,PhD

?腫瘤內(nèi)科

?外科/腫瘤外科

§腫瘤放射科/放療科

≠病理科

?血液科/血液腫瘤科

ф診斷/介入放射科

*編委會成員PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌

NCCN非小細(xì)胞肺癌專家組成員執(zhí)筆人：張力中山大學(xué)附屬腫瘤醫(yī)院NCCN指南中國版專家組召集人：孫燕中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院腫瘤醫(yī)院NCCN代表：DavidS.Ettinger,MDTheSidneyKimmelComprehensiveCancerCenteratJohnsHopkins成員（按拼音排序）：程剛北京醫(yī)院儲大同中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院腫瘤醫(yī)院韓寶惠上海交通大學(xué)附屬胸科醫(yī)院蔣國復(fù)旦大學(xué)附屬腫瘤醫(yī)院焦順昌中國人民解放軍總醫(yī)院（三○一醫(yī)院）李凱天津醫(yī)科大學(xué)附屬腫瘤醫(yī)院李龍蕓中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院北京協(xié)和醫(yī)院陸舜上海交通大學(xué)附屬胸科醫(yī)院

樸炳奎 中國中醫(yī)研究院廣安門醫(yī)院?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.NCCN非小細(xì)胞肺癌臨床實踐指南（中國版）專家組組長：廖美琳上海交通大學(xué)附屬胸科醫(yī)院

秘書：王子平中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院腫瘤醫(yī)院石遠(yuǎn)凱中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院腫瘤醫(yī)院王潔北京大學(xué)臨床腫瘤學(xué)院、北京腫瘤醫(yī)院王綠化中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院腫瘤醫(yī)院王長利天津醫(yī)科大學(xué)附屬腫瘤醫(yī)院吳一龍廣東省人民醫(yī)院支修益首都醫(yī)科大學(xué)肺癌診療中心北京宣武醫(yī)院周彩存同濟大學(xué)附屬上海市肺科醫(yī)院周清華天津醫(yī)科大學(xué)總醫(yī)院PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌

NCCN特別鳴謝（（（（（（（●隨診（NSCL-12）●復(fù)發(fā)和轉(zhuǎn)移的治療（NSCL-12）●病理評估原則（NSCL-A）●●●●●●外科治療原則（NSCL-B）放射治療原則（NSCL-C）輔助化療方案（NSCL-D）化放療方案（NSCL-E）晚期或轉(zhuǎn)移性NSCLC的全身治療（NSCL-F）癌癥幸存者照護(hù)（NSCL-G）分期（ST-1）討論參考文獻(xiàn)作為共識，NCCN腫瘤學(xué)臨床實踐指南反映了作者們對目前認(rèn)可的治療方法的觀點，欲參考或應(yīng)用這些指南的臨床醫(yī)師應(yīng)根據(jù)個人具體的臨床情況做出獨立的醫(yī)療判斷，以決定患者所需的護(hù)理和治療。任何尋求使用這些指南的病人或非醫(yī)生人員應(yīng)咨詢醫(yī)生關(guān)于它們的合理應(yīng)用。NCCN腫瘤學(xué)臨床實踐指南編譯力求精確表達(dá)反映原版英文指南。NCCN不保證指南編譯的有效性，也不承認(rèn)任何無限制性的擔(dān)保、表達(dá)及暗示。NCCN不擔(dān)保指南編譯或指南本身的精確性和完整性。NCCN不保證或擔(dān)?；蜿愂鲋改系膽?yīng)用及應(yīng)用結(jié)果。NCCN及其成員不對涉及指南無限制性應(yīng)用的任何偶然的、間接的、特殊的、懲罰性或作為結(jié)果的補償費承擔(dān)任何責(zé)任。

?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN. TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensive CancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.臨床試驗：NCCN認(rèn)為任何腫瘤患者都可以在臨床試驗中得到最佳處理，因此特別鼓勵腫瘤患者參加臨床試驗研究。NCCN對證據(jù)和共識的分類：除非特別指出，NCCN對所有建議均達(dá)成2A類共識。見NCCN證據(jù)和共識的分類聲明：本指南中標(biāo)注“※”處為中國專家根據(jù)國內(nèi)實際情況進(jìn)行明顯改動或補充之處，內(nèi)容有別于英文版，參考時請注意。?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.“NSCL-13

●復(fù)發(fā)或轉(zhuǎn)移患者全身治療的評估流程修訂為首先明確組織學(xué)亞型，然后根據(jù)組織學(xué)亞型推薦

EGFR檢測。

●EGFR檢測對于以下肺癌組織學(xué)類型為1類推薦：腺癌、大細(xì)胞癌和NSCLCNOS。

●對鱗癌推薦EGFR檢測?！?/p>

●本頁現(xiàn)為對EGFR突變陽性的腺癌、大細(xì)胞癌、NSCLCNOS和鱗癌的一線全身治療。

●新增腳注：“§中國的薈萃分析中鱗癌EGFR基因突變率為10%，日本研究中顯示有突變的鱗癌

EGFR-TKI治療緩解率達(dá)到30%，疾病控制率70%，中位PFS為3個月，這些數(shù)據(jù)支持鱗癌EGFR突 變檢測。Yi-LongWuetal,Epidermalgrowthfactorreceptormutationsandtheircorrelationwith gefitinibtherapyinpatientswithnon-small-celllungcancer:ameta-analysisbasedonupdated individualpatientdatafromsixmedicalcentersinmainlandChina.JThoracOncol.2007;2: 430-439.TakehitoShukuya,etal.Efficacyofgefitinibfornon-adenocarcinomanon-small-cell lungcancerpatientsharboringepidermalgrowthfactorreceptormutations:Apooledanalysisof publishedreports.CancerSci,doi:10.1111/j.1349-7006.2011.01887.x,2011.”※

●新增腳注“y”：注明厄洛替尼適用于體力狀態(tài)評分0~4的患者。NSCL-14

●本頁現(xiàn)為對EGFR突變陰性或未知的腺癌、大細(xì)胞癌和NSCLCNOS的一線全身治療。

●刪除了化療1周期后的腫瘤反應(yīng)評估。

●培美曲塞換藥維持由2B類改為2A類。NSCL-15

●本頁現(xiàn)為對EGFR突變陰性或未知的鱗狀細(xì)胞癌的一線全身治療?！?/p>

●刪除了化療1周期后的腫瘤反應(yīng)評估。NSCL-16

●體力狀態(tài)評分0~2——新增貝伐珠單抗作為含鉑兩藥方案的可選聯(lián)合用藥，適用于一線治療中用 過厄洛替尼的腺癌患者。NSCL-A3-2

分子學(xué)診斷研究：

●“EGFR和K-ras”評估項中新增第5~7條。

●新增EML4-ALK評估項。NSCL-B4-1

●第二條：增加了“高?；颊呖紤]行立體定向放療時，建議由包含腫瘤放射醫(yī)生的多學(xué)科團(tuán)體進(jìn)行綜 合評估”。NSCL-B4-2至NSCL-B4-4

●新增頁面，闡述IIIA期（N2）肺癌外科治療中存在的爭議。NSCL-C

●放射治療原則有多處修訂，詳見內(nèi)頁。NSCL-C7-5

●表2——標(biāo)題由“常規(guī)分割放療的推薦劑量”修訂為“常規(guī)分割放療的常用劑量”。NSCL-C7-6

●表4——標(biāo)題由“肺部腫瘤SBRT方案和適應(yīng)證”修訂為“常用SBRT方案”。NSCL-E

●刪除了多西他賽鞏固方案。

●修改腳注“*”：隨機研究資料支持……”修訂為“研究資料支持……”。MS-1

●討論部分根據(jù)流程圖更新?！埃?“UPDATESPrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌

指南更新概要

2011年非小細(xì)胞肺癌指南中國版同2010年中國版相比，主要更新內(nèi)容包括：?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.肺癌是一種以煙草為主要病因的獨特疾病。美國85%~90%以上的肺癌是由于主動吸煙或被動吸“二手”煙所致，而在中國為87%。降低肺癌的死亡率需要采取旨在預(yù)防煙草暴露的有效公共衛(wèi)生措施、對煙草制品生產(chǎn)和加工的監(jiān)督以及其他煙草控制等措施。※長期吸煙容易導(dǎo)致第二原發(fā)癌、治療并發(fā)癥、藥物相互作用、其它吸煙相關(guān)疾病、生活質(zhì)量降低和生存期縮短。根據(jù)美國醫(yī)事總署（SurgeonGeneral）的報告，主動吸煙（）和被動吸煙都可以導(dǎo)致肺癌。有證據(jù)表明，和吸煙者生活在一起從而吸二手煙的人群罹患肺癌的風(fēng)險上升20%~30%（library/secondhandsmoke/report/executivesummary.pdf）。每個公民都應(yīng)被告知吸煙和暴露于煙霧環(huán)境可對健康產(chǎn)生危害、導(dǎo)致成癮并可威脅生命，政府需要采取恰當(dāng)?shù)?、有效的措施如立法、行政、管理或其他手段以保護(hù)所有的公民免于煙草的危害（final_text/en/）。煙草中還含有高度成癮性物質(zhì)尼古丁，這使問題進(jìn)一步復(fù)雜化。為了降低肺癌死亡率，需要深入貫徹衛(wèi)生保健研究和質(zhì)量機構(gòu)（AHRQ）指南（/path/tobacco.htm#Clinic），以發(fā)現(xiàn)、勸告和治療尼古丁成癮患者。吸煙者或有吸煙史的人發(fā)生肺癌的風(fēng)險明顯增高。對于這些人，尚無可用的化學(xué)預(yù)防藥物。如有可能，應(yīng)該鼓勵這些人參加化學(xué)預(yù)防研究。NCCN專家組目前不推薦在臨床實踐中常規(guī)進(jìn)行CT篩查（3類）?，F(xiàn)有數(shù)據(jù)[1-5]不一致，因此有必要通過正在進(jìn)行中的全國性試驗獲得結(jié)論性數(shù)據(jù)，明確低劑量CT用于肺癌篩查的益處和風(fēng)險。專家組建議有肺癌高危因素的人參加旨在評估CT篩查的臨床試驗。對于不能參加臨床試驗或不適合參加試驗的高危人群，則建議前往優(yōu)秀的癌癥中心尋求專業(yè)醫(yī)生的意見（包括放射學(xué)、病理學(xué)、細(xì)胞學(xué)、胸外科的意見以及肺癌治療的一般性建議），探討CT篩查的潛在風(fēng)險和益處[2]。如果進(jìn)行篩查，應(yīng)該遵循I-ELCAP的篩查規(guī)程（）?！瘛瘛瘛瘛瘛?2345HenschkeCI,YakelevitzDF,LibbyDM,etal.SurvivalofpatientswithstageIlungcancerdetectedonCTscreening.NEnglJMed2006;355:1763-71.BachPB,JettJR,PastorinoU,etal.Computedtomographyscreeningandlungcanceroutcomes.JAMA2007;297:953-961.McMahonPM,KongCY,JohnsonBF,etal.Estimatinglong-termeffectivenessoflungcancerscreeningintheMayoCTScreeningStudy.Radiology2008;248:278-287.JettJR,MidthunDE.Commentary:CTscreeningforlungcancer--caveatemptor.Oncologist2008;13(4):439-444.MulshineJL.Commentary:lungcancerscreening--progressorperil.Oncologist2008;13(4):435-438.PREV-1PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌

肺癌的預(yù)防和篩查?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.非小細(xì)胞肺癌（NSCLC）病理評估a病史和體格檢查(包括體力狀態(tài)和體重下降情況）胸部和上腹部CT，包括腎上腺血常規(guī)生化常規(guī)戒煙勸告、輔導(dǎo)和用藥●●●●●●IV期（M1a）（胸腔積液或心包積液）eIV期（M1b）單個轉(zhuǎn)移灶，肺原發(fā)灶可切除IV期（M1b）多發(fā)轉(zhuǎn)移見治療前評估（NSCL-4）見治療前評估（NSCL-6）見治療前評估（NSCL-6）見治療前評估（NSCL-9）見治療前評估（NSCL-10）見治療前評估（NSCL-10）見治療前評估（NSCL-11）見全身治療（NSCL-13）基線評估臨床分期

IA期，周圍型b（T1ab,N0），縱隔CT陰性（淋巴結(jié)小于1cm）

I期，周圍型b（T2a,N0）；中央型b（T1ab~T2a,N0）；

II期（T1ab~T2ab,N1;T2b,N0）；IIB期（T3,N0）c

縱隔CT陰性（淋巴結(jié)小于1cm）abcdeNSCL-1NSCLC的病理診斷檢查，如有臨床指征見治療前評估（NSCL-2）見治療前評估（NSCL-2）PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.臨床分期IA期（周圍型T1ab,N0）IB期（周圍型T2a,N0）I期（中央型T1ab~T2a,N0）II期（T1ab~2ab,N1;T2b,N0）IIB期（T3,N0）c縱隔淋巴結(jié)陰性●●●●●治療前評估g

肺功能檢查（如尚未檢查）縱隔鏡（I期除外）如合適，行支氣管內(nèi)鏡超聲（EBUS）*（2B類）PET/CT掃描f（懷疑有淋巴結(jié)轉(zhuǎn)移或遠(yuǎn)處轉(zhuǎn)移者建議做此項檢查，如果不能做PET/CT則應(yīng)做骨掃描）腦MRI[限II期、IB期（2B類）]●●●●●●縱隔淋巴結(jié)陽性見IIIA期（NSCL-7）或IIIB期（NSCL-9）cfg＊T3,N0指腫瘤＞7cm或伴衛(wèi)星結(jié)節(jié)。PET/CT掃描或骨掃描陽性者需要組織學(xué)或其他影像學(xué)證實。如PET/CT掃描縱隔淋巴結(jié)陽性，需經(jīng)病理證實。※見外科治療原則（NSCL-B）。建議有條件的醫(yī)院行此項檢查?！鵑SCL-2國不要求常規(guī)PET/CT檢查）※肺功能檢查（如尚未檢查）纖維支氣管鏡※※根治性放療（見NSCL-C）見初始治療和輔助治療（NSCL-3）PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.IA期（T1ab,N0）IB期（T2a,N0）；IIA期（T2b,N0）IIA期（T1ab~T2a,N1）IIB期（T3,N0;T2b,N1）IIIA期T1~3,N2切緣陰性（R0）h切緣陽性（R1，R2）h切緣陰性（R0）h切緣陽性（R1，R2）h切緣陰性（R0）h切緣陽性（R1，R2）h切緣陰性（R0）h切緣陽性（R1，R2）h化療k（1類）+放療j化放療j,m+化療ghij胸膜受累，NX。見放射治療原則（NSCL-C）。初始治療輔助治療隨診（NSCL-12）NSCL-3klm見輔助化療方案（NSCL-D）。評估是否需輔助化療時腫瘤增大應(yīng)為重要評估變量。見化放療方案（NSCL-E）。PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.臨床分期治療前評估●●●●●●臨床評價

肺上溝瘤胸壁接近氣管或縱隔腫瘤轉(zhuǎn)移見治療（NSCL-5）見治療（NSCL-5）見治療（NSCL-5）見轉(zhuǎn)移的治療單發(fā)（NSCL-11）或多發(fā)（NSCL-13）fPET/CT掃描或骨掃描陽性者需要組織學(xué)或其他影像學(xué)證實。如PET/CT掃描縱隔淋巴結(jié)陽性，需經(jīng)病理證實?！鵑SCL-4肺功能檢查（如尚未檢查）纖維支氣管鏡縱隔鏡或EBUS腦MRI脊柱+胸廓入口MRI（鄰近脊柱或鎖骨下血管的肺上溝瘤）PET/CT掃描f（如果不能做PET/CT則應(yīng)做骨掃描）※PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌接近可切除?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.g不可切除g

j,m,n根治性同步化放療j,m,o,p可切除不可切除g切緣陰性（R0）h切緣陽性（R1，R2）h化療k（如初始（如初始治療ghjkmnopqrNSCL-5隨診（NSCL-12）+化療k根治性放療j+化療k化療m,rPrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.IIIA期（T1~3,N2）●●●●●N2陽性N3陽性遠(yuǎn)處轉(zhuǎn)移分散的一個或多個肺結(jié)節(jié)（IIB、IIIA、IV期）肺功能檢查（如尚未檢查）纖維支氣管鏡縱隔鏡腦MRIPET/CT掃描f（如果不能做PET/CT則應(yīng)做骨掃描）※●●●●●分散的一個或多個肺結(jié)節(jié)，原發(fā)腫瘤的同一肺葉（T3,N0）或同側(cè)肺（T4,N0）IV期（N0,M1a）：對側(cè)肺（孤立性肺結(jié)節(jié)）不可切除遠(yuǎn)處轉(zhuǎn)移見T1~3,N0~1的治療（NSCL-7）見治療（NSCL-7）見IIIB期（NSCL-9）見轉(zhuǎn)移的治療單發(fā)（NSCL-11）或多發(fā)（NSCL-13）見轉(zhuǎn)移的治療單發(fā)（NSCL-11）或多發(fā)（NSCL-13）見治療（NSCL-8）見治療（NSCL-8）見治療（NSCL-8）fs臨床分期治療前評估

肺功能檢查（如尚未檢查）縱隔活檢結(jié)果和可切除性

N2、N3陰性NSCL-6纖維支氣管鏡縱隔淋巴結(jié)病理檢查sPET/CT掃描f（如果不能做PET/CT則應(yīng)做骨掃描）※腦MRIPrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.T1~3，N0~1（原發(fā)腫瘤的同一肺葉）可切除不可切除縱隔淋巴結(jié)清掃或系統(tǒng)性淋巴結(jié)采樣據(jù)臨床分期行相應(yīng)治療（NSCL-1）N0~1N2切緣陰性（R0）h切緣陽性（R1，R2）hT1~2,T3（≥7cm）N2陽性腦MRI●●●●無遠(yuǎn)處轉(zhuǎn)移根治性同步化放療j,m（1類）無進(jìn)展進(jìn)展化療k（1類）+放療j化放療j,m+化療fghjkmPET/CT掃描或骨掃描陽性者需要組織學(xué)或其他影像學(xué)證實。如PET/CT掃描縱隔淋巴結(jié)陽性，需病理證實?！娡饪浦委熢瓌t（NSCL-B）。R0=無腫瘤殘留，R1=鏡下腫瘤殘留，R2=肉眼腫瘤殘留。見放射治療原則（NSCL-C）。見輔助化療方案（NSCL-D）。見化放療方案（NSCL-E）。隨診（NSCL-12）縱隔活檢結(jié)果初始治療

g輔助治療見NSCL-3或NSCL-4NSCL-7有遠(yuǎn)處轉(zhuǎn)移無遠(yuǎn)處轉(zhuǎn)移有遠(yuǎn)處轉(zhuǎn)移PET/CT掃描f（如尚未檢查；如果不能做PET/CT則應(yīng)做骨掃描）※腦MRIPET/CT掃描f（如尚未檢查；如果不能做PET/CT則應(yīng)做骨掃描）※局部全身或誘導(dǎo)化療k±放療j見轉(zhuǎn)移的治療單發(fā)（NSCL-11）或多發(fā)（NSCL-13）根治性同步化放療j,m見轉(zhuǎn)移的治療單發(fā)（NSCL-11）或多發(fā)（NSCL-13）放療j（如尚未進(jìn)行過） ±化療k

見轉(zhuǎn)移的治療 單發(fā)（NSCL-11）或多發(fā)（NSCL-13）PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.臨床表現(xiàn)初始治療輔助治療ghjkmr見外科治療原則（NSCL-B）。R0=無腫瘤殘留，R1=鏡下腫瘤殘留，R2=肉眼腫瘤殘留。見放射治療原則（NSCL-C）。見輔助化療方案（NSCL-D）。見化放療方案（NSCL-E）。若初始同步化放療中未使用足量化療。隨診（NSCL-12）隨診（NSCL-12）隨診（NSCL-12）NSCL-8分散的一個或多個肺結(jié)節(jié)，原發(fā)腫瘤的同一肺葉（T3,N0）或同側(cè)肺（T4,N0）IV期（N0,M1a）：對側(cè)肺（孤立性肺結(jié)節(jié)）IIIA期（T4,N0~1）不可切除化療k同步化放療j,m（如果能耐受）見評估（NSCL-1）化療m,rPrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.IIIB期(T1~3,N3)N3陰性N3陽性遠(yuǎn)處轉(zhuǎn)移同步化放療j,m（1類）見I~IIIA期初始治療（NSCL-1）化療m,rfjmrPET/CT掃描或骨掃描陽性者需要組織學(xué)或其他影像學(xué)證實。如PET/CT掃描縱隔淋巴結(jié)陽性，需病理證實。※見放射治療原則（NSCL-C）。見化放療方案（NSCL-E）。若初始同步化放療中未使用足量化療。臨床分期治療前評估

肺功能檢查（如尚未檢查）初始治療NSCL-9●●●●PET/CT掃描f（如果不能做PET/CT

※則應(yīng)做骨掃描）腦MRI

通過以下途徑獲得N3的病理學(xué)證據(jù)：?縱隔鏡檢查?鎖骨上淋巴結(jié)活檢?胸腔鏡見轉(zhuǎn)移的治療單發(fā)（NSCL-11）或多發(fā)（NSCL-13）PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌陽性?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.PET/CT掃描f（如果不能做PET/CT●●●對側(cè)縱隔淋巴結(jié)陰性對側(cè)縱隔淋巴結(jié)陽性（T4,N3）遠(yuǎn)處轉(zhuǎn)移同側(cè)縱隔淋巴結(jié)陰性（T4,N0~1）同側(cè)縱隔淋巴結(jié)陽性（T4,N2）同步化放療j,m（1類）同步化放療j,m（1類）IV期，M1a：胸腔積液或心包積液行胸腔穿刺或心包穿刺，如胸腔穿刺未確定積液性質(zhì)，行胸腔鏡檢查陰性e e心包開窗）+針對IV期的治療（見NSCL-11）efjmr大多數(shù)肺癌患者的胸腔積液由腫瘤引起。只有極少數(shù)患者的胸腔液多次細(xì)胞病理學(xué)檢查呈陰性。積液為非血性液，亦非滲出液。綜合考慮這些因素并結(jié)合臨床確定積液與腫瘤無關(guān)時，積液將不作為分期依據(jù)。心包積液參照同樣的標(biāo)準(zhǔn)。PET/CT掃描或骨掃描陽性者需要組織學(xué)或其他影像學(xué)證實。如PET/CT掃描縱隔淋巴結(jié)陽性，需病理證實。※見放射治療原則（NSCL-C）。見化放療方案（NSCL-E）。若初始同步化放療中未使用足量化療。臨床分期治療前評估初始治療

見IIIA期的治療（NSCL-6）NSCL-10則應(yīng)做骨掃描）※腦MRI通過以下途徑獲得T4，N2~3的病理學(xué)證據(jù)：?縱隔鏡檢查?鎖骨上淋巴結(jié)活檢?胸腔鏡?細(xì)針穿刺活檢化療m,r化療m,r見轉(zhuǎn)移的治療單發(fā)（NSCL-11）或多發(fā)（NSCL-13）PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌化療（2B類）化療（2B類）?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.IV期M1b：單個轉(zhuǎn)移灶縱隔鏡檢查纖維支氣管鏡腦MRIPET/CT掃描f（如果不能做PET/CT則應(yīng)做骨掃描）※●●●●腦t腎上腺經(jīng)細(xì)針穿刺活檢診斷腎上腺轉(zhuǎn)移瘤局部治療（如果根據(jù)T和N分期，肺部病灶可（治愈）2B類）或見全身治療（NSCL-13）序貫全腦放療（WBRT）（1類）或立體定向放射外科（SRS）或SRS+WBRT或單純SRST1~2,N0~1；T3,N0T1~2,N2；T3,N1~2；任何T,N3；T4,任何N見全身治療（NSCL-13）fgtPET/CT掃描或骨掃描陽性者需要組織學(xué)或其他影像學(xué)證實。如PET/CT掃描縱隔淋巴結(jié)陽性，需病理證實?！娡饪浦委熢瓌t（NSCL-B）。見NCCNCNS指南。隨診（NSCL-12）臨床分期治療前評估初始治療

腦轉(zhuǎn)移瘤切除，NSCL-11PrintedbyDongZhaoon7/26/20113:30:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2011NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.

非小細(xì)胞肺癌姑息性外照射放療+骨科固定?NationalComprehensiveCancerNetwork,Inc.Allrightsreserved.TheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.TheChineseedition2011isthecollaborativeoutcomeoftheNationalComprehensiveCancerNetworkandChinesekeyopinionleadersofthefield.TranslatedandadaptedwithpermissionandendorsementfromtheNationalComprehensiveCancerNetwork.Toviewthemostrecentandcompleteversionofthisoranyotherguideline,visit.常規(guī)隨訪NED，I~IV期：u●病史和體格檢查+胸部 增強CT，每4~6個月1

次，持續(xù)2年（2B類）； 隨后每年1次病史和體 格檢查+胸部非增強CT

（2B類）●戒煙勸告、輔導(dǎo)和用藥●PET或腦MRI不用于局部復(fù)發(fā)遠(yuǎn)處