食管癌NCCN指南2009中文版

参见最佳支持治疗原则

(ESOPH-E)

.< /p>

w

进一步治疗须根据连续２个疗程后病 人的身体状态和临床有效率。

Note:

All recommendations are category 2A unless otherw

ise indicated.

Clinical T

rials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials

is especially encouraged.

Version 1.2009, 08/07/08

? 2008 National Comprehensive Cancer Network, Inc. All rights reserved.

T

hese guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

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Practice Guidelines

in Oncology

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v.1.

2009

Esophageal Cancer

Guidelines Index

Esophageal T

able of Contents

Staging, Discussion, References

多学科协作治疗胃、食管癌原则

１级证据支持联合治疗模式有益于 局限性胃、食管癌病人。ＮＣＣＮ专家小组坚信，任何关注这部分病人的各个学科作出的单一治疗的决定都遭

受挫败。

具备 下列因素，局限性胃食管癌联合治疗模式可得到理想的推广：

相关机构和来自各个学科的个体， 在规律的基础上，致力于对病人详细数据的联合考查。常规会议（１次／周或１次／２周）是鼓励的。

每次会议，应鼓励相关学科参加，包括肿瘤外科学，肿瘤内科学，胃肠外科学，肿瘤放射学，放射学，病 理学。除此之外，

营养服务、社会工作者、护士和其他支持这 一原则的人员的参加也是必要的。

充分分期完成后，所有长期治疗策略均可得到开展，但是，理 论上优先于可给予的任何治疗方法。

对于作出完整的治疗方案，联合考 查病人的实际医疗数据比阅读文献报道更有用。

由多学科小组为个别病人作出一致建议的简要资料是有用的。

由多学 科小组制定的建议可供特定病人的主要治疗小组的医师咨询。

入选病人治疗效果的回顾，对于整 个治疗小组是另一个有益的教育方法。

多学科会议过程中，周期性组织相 关文献的回顾，对整个治疗小组是非常鼓励的。

Note:

All recommendations are category 2A unless otherw

ise indicated.

Clinical T

rials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials

is especially encouraged.

Version 1.2009, 08/07/08

? 2008 National Comprehensive Cancer Network, Inc. All rights reserved.

T

hese guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

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外科原则

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1

在手术之前，对所有病人都应该评估其生理状况能否接受食管切除。

在手术 之前应该根据内镜超声、胸腹部ＣＴ和ＣＴ

-

ＰＥＴ进行临床分 期，以评估可切除性（推荐）。

接受食管切除手术的病人应该是生理状况较适宜，癌肿较局限 可切除，位于胸段食管（距会厌超过５ｃｍ）与腹内段的食管。

颈段食 管癌或胸段食管癌距会厌不超过５ｃｍ者，应接受根治性放化疗。

可切除的胸段食管癌（距会厌超过５ｃｍ）或贲门癌：

Tis

或

T1a,

定义为肿瘤侵犯粘膜但不侵犯粘膜下层

,

可考虑

EMR,

其他烧灼技术

,

或在有经验的中心行食管切除术

.

位于粘膜

下层

或更

深的

肿瘤需

手术治

疗

.

2,3,4,5,6,7

Ｔ１

-

Ｔ３，肿瘤可切除，即使有区域淋巴结转移（Ｎ１）

Ｔ４，肿瘤仅累及心包、胸膜或膈肌者是可切除的。

可切除的ⅣＡ期：病变位于低位食管，腹腔淋巴结可切除且腹腔动脉、主动脉或其它器官 未被累及。

不可切除的食管癌

:

Ｔ４，肿瘤累及心脏、大血管、气管或临近器官，包括肝脏、胰腺、肺和脾脏，是不可切除的。

不可切除的ⅣＡ期：癌肿位于低位食管，腹腔淋巴结不可切除且腹腔动 脉、主动脉或其它器官包括肝脏、胰腺、肺和脾脏被累及。

不可切除的ⅣＢ期：远处转移或非区域淋巴结转移。

手术方式取决于外科医生的经验和习惯以及病人的意愿。

Note:

All recommendations are category 2A unless otherw

ise indicated.

Clinical T

rials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

下页继续

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hese guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

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Staging, Discussion, References

手术原则

(2 of 3)

胸段食管癌或贲门癌（距会厌超过 ５ｃｍ）可选择的手术方式：

:

右侧或左侧开胸，胸部或颈部吻合

经膈肌裂孔，颈部吻合

微创，颈部或胸部吻合

8

可选择的食管替代器官

:

胃（推荐）

结肠

小段空肠

长段空肠微血管吻合，费用过高（激烈争议）

9

可接受的淋巴结清扫

:

标准

扩大

(En-Bloc)

应该切除至少 １５个淋巴结以得到充分的淋巴结分期。术前放化疗后的最适度淋巴结数目是未知的。

在根治 性放化疗后出现食管局部可切除的复发病灶的病人，如果没有远处转移，可以考虑姑息性手术治疗

1

0

食管切除术、内镜下粘膜切除术、其他烧灼技术应该在高水平 的医疗中心由有经验的医师进行。

1

1,12

< br>

Note:

All recommendations are category 2A unless otherw

ise indicated.

Clinical T

rials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials

is especially encouraged.

参考文献见下页

Version 1.2009, 08/07/08

? 2008 National Comprehensive Cancer Network, Inc. All rights reserved.

T

hese guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

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N

?

Practice Guidelines

in Oncology

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v.1.

2009

Esophageal Cancer

Guidelines Index

Esophageal T

able of Contents

Staging, Discussion, References

外科原则

(3 of 3)

参考文献

1

Steyerberg EW, Neville BA, Kopper LB, Lemmens VE, et al. Surgical mortality in patients with esophageal cancer: development and validation of

a simple risk

score. J Clin Oncol 2006;24 (26):4277-4284.

2

Fujita H, Sueyoshi S, Yamana H, Shinozaki K et al., Optimum treatment strategy for superficial esophageal cancer: Endoscopic mucosal resection versus

radical esophagectomy. World Journal of Surgery; 2001; 25: 424-431.

3

Ell C, May A, Gossner L, Pech O, et al., Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus. Gastroenterology 2000;

118: 670-677.

4

Conio M, Repici A, Cestari R, Blanchi S, et al., Endoscopic mucosal resection for high- grade dysplasia and intramucosal carcinoma in Barrett's esophagus: An

Italian experience. World Journal of Gastroenterology 2005; 11(42): 6650-6655.

5

Larghi A, Lightdale CJ, Ross AS, Fedi P

, et al., Long-term follow-up of complete Barrett's eradication endoscopic mucosal resection (CBE-EMR) for the

treatment of high-grade dysplasia and intramucosal carcinoma. Endoscopy 2007;39: 1086-1091.

6

Lopes CV, Hela M, Pesenti C, Bories E, et al., Circumferential endoscopic resection of Barrett's esophagus with high-grade dysplasia or early adenocarcinoma.

Surgical Endoscopy 2007; 21: 820-824.

7

Overholt BF, Wang KK, Burdick S, Lightdale CJ, et al., Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett's high

-grade dysplasia.

Gastrointestinal Endoscopy 2007; 66(3): 460-468.

8

de Hoyos A, Litle VR, and Luketich JD. Minimally invasive esophagectomy. Surg Clin North Am 2005;85 (3): 631-647.

9

Hofstetter WL. Lymph Node Dissection in Esophageal Cancer. Current Therapies in Thoracic and Cardiovascular Surgery, edited by SC Yang and DE Cameron.

Mosby, Inc., Philadelphia, Pennsylvania, pp. 360-363, 2004.

10

Swisher SG, Wynn P

, Putnam JB, Mosheim MB, et al. Salvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy.

J Thorac

Cardiovasc Surg 2002;123:175-183.

11

Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel T

A, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346(15):

1128-1137.

12

Hulscher JBF, van Sandick JW, de Boer AG, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the

esophagus. N Engl J Med, 2002;347(21):1662-1669.

Note:

All recommendations are category 2A unless otherw

ise indicated.

Clinical T

rials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

Version 1.2009, 08/07/08

? 2008 National Comprehensive Cancer Network, Inc. All rights reserved.

T

hese guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

ESOPH-B

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N

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Practice Guidelines

in Oncology

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v.1.

2009

Esophageal Cancer

食管癌或贲门癌的系统治疗原则

(1 of 2)

Guidelines Index

Esophageal T

able of Contents

Staging, Discussion, References

对于局限性食管癌，所列出的治疗方案包括Ⅱ期试验中参与机 构的优选方案，这些方案并不优于１级证据的方案。

.

对于远处转移的食管癌，多年来Ⅲ期试验并未开展，以下列出的一些方案来自包括下段食管和／ 或贲门癌病人的胃腺癌Ⅲ期试验。

.

请参考关于疗程、剂量和剂量调整的原始报告。

请参考放疗原则中有关放疗管理的细节

.

(ESOPH-D)

建议化疗前各器官功能和情况必须达到适当的要求。

疗程、毒性和疗效须与病人及其家 属彻底交流，还包括并发症的先兆及降低其毒性和持续时间的处理措施。

化疗期间密切观察和处理病人的并发症，准备适当的血制品。

化疗后，须评估病人的反应，监测任何远期并发症。

术后化疗（仅用于曾行术前化疗的患者）

术前化疗

ＥＣＦ（级别１）

(

仅用于下段食管或贲门腺癌

):

ＥＣＦ修正（级别１）

ＥＣＦ（表柔比星，顺铂和５

-

ＦＵ）

1

2

ＥＣＦ修正（级别１）

术后放化疗（仅用于低位食管或贲门腺癌）

9

氟尿嘧啶类（５

-

< br>ＦＵ或卡培他滨）（级别１）

术前放化疗

:

顺铂加 氟尿嘧啶类（５

-

ＦＵ或卡培他滨）

3

4,5

转移或局部进展的肿瘤（不推荐放化疗）：

伊立替康加顺铂

(

级别

2B)

6

ＤＣＦ（多西紫杉醇、顺铂和５

-

ＦＵ）（ 级别１）

10

紫杉醇加顺铂或卡铂

(

级别

2B)

11

ＥＣＦ（级别１）

多西紫杉醇加顺铂

(

级别

2B)

ＥＣＦ修正（级别１）

多西紫杉醇或 紫杉醇加氟尿嘧啶类（

5-

Ｆ

7

伊立替康加顺铂（级别２Ｂ）

4

Ｕ或卡培他滨）

(

级别

2B)

奥沙利铂加氟尿嘧啶类（５

-

ＦＵ或卡培他滨）（级别２Ｂ）

奥沙利铂加氟尿嘧啶类（５

-

ＦＵ或卡培他滨）

(

级别

2B)

8

12,13

根治性放化疗

:

顺铂加５

-

ＦＵ（级别１）

3

伊立替康加顺铂（级别２Ｂ）

紫杉醇加顺铂（级别２Ｂ）

多西紫杉醇加顺铂

(

级别

2B)

多西紫杉醇或紫杉醇 加氟尿嘧啶类（５

-

ＦＵ或卡培他滨）（级别２Ｂ）

奥沙利铂加氟尿嘧啶类（５

-

ＦＵ或卡培他滨）（级别２Ｂ）

ＤＣＦ修正（级别２Ｂ）

14

伊立替康加氟尿嘧啶类（５

-

ＦＵ或卡培他

滨）（级别２Ｂ）

15

紫杉醇为主的用药

(

证据级别

2B)

?

Leucovorin or levoleucovorin is indicated with certain infusional 5-FU-based regimens

Note:

All recommendations are category 2A unless otherw

ise indicated.

Clinical T

rials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials

is especially encouraged.

参考文献见下页

Version 1.2009, 08/07/08

? 2008 National Comprehensive Cancer Network, Inc. All rights reserved.

T

hese guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

ESOPH-C

(1 of 2)

NCC

N

?

Practice Guidelines

in Oncology

–

v.1.

2009

Esophageal Cancer

食管癌或贲门癌的系统治疗原则

(2 of 2)

Guidelines Index

Esophageal T

able of Contents

Staging, Discussion, References

参考文献

1

Cunningham D, Allum WH, Stenning SP

, Thompson JN, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cance

r. N Engl J

Med 2006;355(1):11-20.

2

Cunningham D, Starling, N., Rao, S., Iveson, T

., et al. Capecitabine and oxaliplatin for advanced esophagogastric cancer. N Engl J Med 2008;358:36-46.

3

Cooper JS, Guo MD, Herskovic A, Macdonald JS, Martenson JA, Jr., Al-Sarraf M, et al. Chemoradiotherapy of locally advanced esophageal cancer: long-term

follow-up of a prospective randomized trial (RTOG 85-01). Radiation Therapy Oncology Group. Jama 1999;281(17):1623-1627.

4

Ilson DH. Cancer of the gastroesophageal junction: Current therapy options. Curr Treat Options Oncol 2006;7(5):410-423.

5

Ilson DH. Phase II trial of weekly irinotecan/cisplatin in advanced esophageal cance

r. Oncology (Williston Park) 2004;18(14 Suppl 14):22-25.

6

Meluch AA, Greco FA, Gray JR, Thomas M, et al. Preoperative therapy with concurrent paclitaxel/carboplatin/infusional 5-FU and radiation therapy in locoregional

esophageal cancer: final results of a Minnie Pearl Cancer Research Network phase II trial. Cancer J 2003;9(4):251

-260.

7

Schnirer, II, Komaki R, Yao JC, Swisher S, et al. Pilot study of concurrent 5-fluorouracil/paclitaxel plus radiotherapy in patients with carcinoma of the esophagus

and gastroesophageal junction. Am J Clin Oncol 2001;24(1):91-95.

8

Khushalani NI, Leichman CG, Proulx G, Nava H, et al. Oxaliplatin in combination with protracted-infusion fluorouracil and radiation: report of a clinical trial for

patients with esophageal cancer. J Clin Oncol 2002;20(12):2844-2850.

9

Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, et al. Chemoradiotherapy after surgery

compared with surgery alone for adenocarcinoma of the stomach or

gastroesophageal junction. N Engl J Med 2001;345(10):725

-730.

10

Van Cutsem E, Moiseyenko VM, Tjulandin S, Majlis A, et al. Phase III study of docetaxel and cisplatin plus fluorouracil compared with cisplatin and fluorouracil as

first-line therapy for advanced gastric cancer: a report of the V325 Study Group. J Clin Oncol 2006;24(31):4991-4997.

11

Ross P

, Nicolson M, Cunningham D, Valle J, et al. Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI

5-FU) With epirubicin, cisplatin, and PVI 5-FU in advanced esophagogastric cancer. J Clin Oncol 2002;20(8):1996-2004.

12

Kang Y

, Kang WK, Shin DB, et al. Randomized phase III trial of capecitabine/cisplatin (XP) vs. continuous infusion of 5-FU/cisplatin (FP) as first-line therapy in

patients (pts) with advanced gastric cancer (AGC): Efficacy and safety results. J Clin Oncol (Meeting Abstracts). 2006;24(18_suppl):LBA4018.

13

Al-Batran SE, Hartmann JT

, Probst S, et al. Phase III trial in metastatic gastroesophageal adenocarcinoma with fluorouracil, leucovorin plus either ox

aliplatin or

cisplatin: a study of the Arbeitsgemeinschaft Internistische Onkologie.

J Clin Oncol. 2008 Mar 20;26(9):1435-42.

14

Van Cutsem E, Van de Velde C, Roth A, et al. European Organisation for Research and Treatment of Cancer (EORTC)-gastrointestinal cancer group. Expert

opinion on management of gastric and gastro-oesophageal junction adenocarcinoma on behalf of the Europea

n Organisation for Research and Treatment of

Cancer (EORTC)-gastrointestinal cancer group. Eur J Cancer. 2008;44(2):182-94.

15

Dank M, Zaluski J, Barone C, et al. Randomized phase III study comparing irinotecan combined with 5-fluorouracil and folinic acid to cisplatin combined with 5-

fluorouracil in chemotherapy naive patients with advanced adenocarcinoma of the stomach or esophagogastric junction.

Ann Oncol. 2008;19(8):1450-1457.

Note:

All recommendations are category 2A unless otherw

ise indicated.

Clinical T

rials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials

is especially encouraged.

Version 1.2009, 08/07/08

? 2008 National Comprehensive Cancer Network, Inc. All rights reserved.

T

hese guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

ESOPH-C

(2 of 2)

NCC

N

?

Practice Guidelines

in Oncology

–

v.1.

2009

Esophageal Cancer

Guidelines Index

Esophageal T

able of Contents

Staging, Discussion, References

放疗原则

(1 of 2)

一般放疗信息

治疗建议须由多学科专家讨论制定，包括肿瘤外科学、放疗学 、内科

学、放射学、胃肠病学和病理学的专家。

必要时，由多学科小组对ＣＴ扫描，吞钡，超声内镜，内镜检查和ＰＥＴ

／Ｐ ＥＴ

-

ＣＴ报告进行回顾。这可提示治疗剂量和范围边界。

模拟和治疗计划

鼓励ＣＴ下模拟定位和三维治疗。

条件适宜时，静脉和／或口服造影剂可增强靶区域的ＣＴ模拟。

由于日常调定的重复性，大力推荐固定化设备。

大体肿瘤区域（ＧＴＶ）应包括经 过扫描和上述一般信息中提及的其

他检查确认出来的原发肿瘤和受累的区域淋巴结。临床 靶区（ＣＴＶ）

应包括有转移风险的区域。一些特定区域淋巴结相对的转移风险，主要< /p>

根据肿瘤的发源位置。计划靶区（ＰＴＶ）应包括肿瘤加上距肿瘤两端

各５ｃｍ的边缘，半径１．５～２ｃｍ，呼吸运动引起的误差也须考虑

在内。

封闭

< /p>

常规封闭对减少正常组织不必要的照射剂量是很必要的，

包括肝（ ６０％肝＜３０Ｇｙ），肾（至少２／３肾＜２

０Ｇｙ），骨髓（＜４５Ｇｙ），心脏（ １／３心脏＜

5

０

a

< br>

Ｇｙ，需保证左心室剂量最小）和肺。

剂量

3

50-50.4 Gy (1.8-2 Gy/

天

)

支持治疗

避免因可处理的急性

并发症，终止化疗或

减少剂量，间歇期，

对

病人进行密切观察和支持治疗