胃癌NCCN更新解讀課件

胃癌NCCN更新解讀胃癌NCCN更新解讀NcCN胃癌更新解讀AnhuiprovincialhospitalNcCN胃癌更新解讀2放療更新(1)增加了PET作為治療前后的腫瘤應(yīng)答的評估方法。2015年版《指南》在放療的治療原則中提到,對于胃癌病人進(jìn)行放療前應(yīng)盡可能明確腫瘤靶體積(targetvolume),所以,2015年版《指南》中增加了PET檢查方法langatVolume(GeneralGudelinesTargetVolume(GeneralGuidelines).shouldbeusedtoidentifythetumorandpertinentnodalgroups.2.3.Pre-treatmentdiagnosticstudies(EUS,UGl,EGDPET,ndCTpre-treatmentdiagnosticstudies(EUS.UGLEGD,andCTscans)icnodalfactorsincludingwidthanddepthofinvasionofthegastricwalldotherfactorsincludingwidthanddenosticstudies(EUS,UGL,EGD,andCTscans)Pre-treatmentdlagnosticstudles(EUS,UGL,EGDPET,ndCTandclipplacementshouldbeusedtoidentifythetumorgastribed,theanastomosisorstumps,andpertinentgstomachshoulddependonabalanceabalanelocalrelapseintheresidualstomach.Therelativeriskofnodalpendentonboththedependentonbothsiteoforiginoftheprimarytumorandotherfactorsincludingthesiteofonginofthepnmarytuorandotherfactorsincludingwidthanddepthofinvasionofthegastricwall.放療更新3放療更新(2)修改了放療時對正常組織放療劑量的限量。①治療計劃中必須減少不必要的放療耐受劑量對正常組織的損傷。肝臟:平均接受劑量≤25Gy,60%體積的肝臟接受放療劑量<30Gy:腎臟:一側(cè)腎臟的2/3體積<20Gy:;脊髓<45Gy:心臟的13體積<40Gy,盡量使左心室的劑量降到最低;肺放射體積與劑量應(yīng)降到最低。②普遍認(rèn)為,在實際的臨床治療中可適當(dāng)超過《指南》推薦的放療劑量。BlockingCustomblockingisnecesseunnecessarydosetoofliver<30Gy),kidneys(atleast2/3ofonekidney<20Gy),spinalcord(<45Gy),heart(1/ofeart<50Gy,effortshouldbemadetokeeptheleftventricledosestoaminimum)andlungs.NormalTissueToleranceDose-LimitsTreatmentplanningisessentialtoreduceunnecessarydosetoorgansatriskincludingliver(60%ofliver<0Gy,$25Gymeandosetoliver),kidneys(atleast2/3ofonekidney<20Gy),spinalheart(1/3ofheart<40Gy,effortshouldbemadetokeeptheleftventricledosesandlungsItisrecognizedthatthesedoseguidelinesmaybeappropriatelyexceededbasedonclinicalcircumstances放療更新4放療更新(3)在治療劑量中增加了“對切緣陽性的病人應(yīng)增加放療劑量使其能增加陽性切緣部位的放射劑量”?！吨改稀吩黾拥膬?nèi)容只是作為專家推薦,證據(jù)級別為2A,所以該結(jié)論還需要有高質(zhì)量的臨床證據(jù)來證實。Dose4550.4Gy(1.8Gy/day)Dose45-50.4Gy(1.8Gy/day)Higherdosesmaybeusedforpositivesurgicalmarginsinselectedcasesasaboosttothatarea放療更新5治療概述(1)將舊版《指南》的“身體狀況差,不能耐受手術(shù)的病人(medicallyunfit”更名為“不適合外科手術(shù)的病人(non-surgicalcandidate)”,包含了“不能耐受手術(shù)病人”和“能耐受手術(shù)但不愿手術(shù)病人”。此類病人的重新分類,使臨床治療更具人性化,充分尊重病人個人意愿,體現(xiàn)了個體化的治療模式enttiuorcpyrimiaIne-orChenotherapyAdditionalon.-surgicalcandidate(category1(DennrivelPalliativeManagement(seeGA5T-7)findingsofPalliateManagement(seeGAST-ase已meastsyalofaAPristinARAfRMiationTIPostTreatmentchemoradiation"ncategory1)(seeGASt-5)PostreatmentoncumentfuoropyrImdPalliativeManaqement(seeGASI-0治療概述6治療概述(2)對于不可切除的進(jìn)展期胃癌、局部復(fù)發(fā)或存在遠(yuǎn)處轉(zhuǎn)移的病人,把舊版《指南》中姑息性治療方案中的“化學(xué)治療”更改為“系統(tǒng)治療”,系統(tǒng)治療包含了術(shù)前新輔助放化療、手術(shù)治療及術(shù)后放化療等系列的治療,這一名稱的更改體現(xiàn)了綜合治療的模式。EcoGpertormancessupportiveECOGperformancescores2rentormetastasKamofskyperormancescore<60%治療概述7治療概述(3)對于T2N0術(shù)后患者,增加D2術(shù)后患者給予化療;高危因素為腫瘤低分化或組織學(xué)高分級,脈管,神經(jīng)(+),年齡小于50歲,增加患者未行D2手術(shù)。治療概述8ComPrehensiveNCCNGuidelinesversion1.2014NCCNGuidelnesIndexNCCNCanceetworkGastricCancerDISCusslonSURGICALOUTCOMESCLINICALTUMORPOSTOPERATIVEMANAGEMENTPreoperativeChemotherapyorChemoradiationR0resection°5-FU±eucowonhen5-FU+leucovorinorcapecitabineupforselectedpatients9▲T3,T4AnyNthen5-FUtleucovorinorcapecitabinem-P(category1Follow-uhemotherapyforpatientswhohaveundergoneprimaryd2Chemoradiation(floopyR2resectionPalliateanaoementseeGAstl,asclinicallyindicated(seeGASMicroseopieresiduelcncerorM122troseoEha9se|wnc;n.Nnal↓M。2001:345(10725-730.5'Lsuocvornadesen。n的hrolonger世m(xù)ComPrehensiveNCCNGuidelines9ComprebensiveNCCNGuidelinesversion3,2015NCCNCancerGasticcance1abotcontGastricCancerDiscussionALOUICOMESCLINICALPOSTOPERATIVEMANAGEMENTCLASSIFICATIONneNotReceivedsurveillanceChemoradiationSurveillance5-FUtleucovorinorcapecitabine,qthenfluoropyrimidine-basedchemoradiation,,othen5-FU+leucovorinorcapecitabinePforselectedpatientsChemotherapyforpatientswhohaveundergoneprimaryD2lymphnodedissectioned5-FU+leucovorinorcapecitahthenfluoropyrtion,o13,14,AnyNthen5-FU+leucovorinorcapecitabine(categoryorAnyT,N+forpatientswhohaveundergoneprimaryD2mphnodeRiresectionChemoradiation"(filuoropyrimidine-basedChemoradiation(tluoropyrimdine-basedl22resectionPalliativeMananement(seeGAST-n,asclinicallyindicated.rthestomachjunction.NEnglJMod2001:345(10)725-730.5-Fu/auoovorinacdesoribedinthisrsi=nolongersd.sosPrincipleofcancerlymphovascularinvasio9ComprebensiveNCCNGuidelines10系統(tǒng)性治療原2015年版《指南》對于全身治療的原則刪除了以下內(nèi)容:(1)對于局限性食管胃或胃賁門腺癌,應(yīng)首選術(shù)前化放療;(2)術(shù)前化療作為系統(tǒng)治療的一個可選方案,但不作為首選mprcheriweNCCNGuidelinesversion3.2015NCCNoflowertoxicity.Thret-drugcyootomkregimensbereferred(esinrfiratadk.withavidancesupportingamcr14dependingcnthecircstan.morbidities,andtoxicityprone.加單mnodadissection.ISeAPnnrplesotSITANYIGASI-CUthcrapy-reatsdcoisasuggestion,andsubjecttoappropriatemodificarioofcytotoxicsbasedontheaailabilityofthepants,pacticecoutrainalicajonsinemaybeusediercnangeadrywinoutcomprosingeFicacy(ExceptInfusionarcinoma.2Perioreratvechemerherapy4isanalter