胃癌NCCN更新解读课件

胃癌NCCN更新解读胃癌NCCN更新解读NcCN胃癌更新解读AnhuiprovincialhospitalNcCN胃癌更新解读2放疗更新(1)增加了PET作为治疗前后的肿瘤应答的评估方法。2015年版《指南》在放疗的治疗原则中提到,对于胃癌病人进行放疗前应尽可能明确肿瘤靶体积(targetvolume),所以,2015年版《指南》中增加了PET检查方法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.放疗更新3放疗更新(2)修改了放疗时对正常组织放疗剂量的限量。①治疗计划中必须减少不必要的放疗耐受剂量对正常组织的损伤。肝脏:平均接受剂量≤25Gy,60%体积的肝脏接受放疗剂量<30Gy:肾脏:一侧肾脏的2/3体积<20Gy:;脊髓<45Gy:心脏的13体积<40Gy,尽量使左心室的剂量降到最低;肺放射体积与剂量应降到最低。②普遍认为,在实际的临床治疗中可适当超过《指南》推荐的放疗剂量。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放疗更新4放疗更新(3)在治疗剂量中增加了“对切缘阳性的病人应增加放疗剂量使其能增加阳性切缘部位的放射剂量”。《指南》增加的内容只是作为专家推荐,证据级别为2A,所以该结论还需要有高质量的临床证据来证实。Dose4550.4Gy(1.8Gy/day)Dose45-50.4Gy(1.8Gy/day)Higherdosesmaybeusedforpositivesurgicalmarginsinselectedcasesasaboosttothatarea放疗更新5治疗概述(1)将旧版《指南》的“身体状况差,不能耐受手术的病人(medicallyunfit”更名为“不适合外科手术的病人(non-surgicalcandidate)”,包含了“不能耐受手术病人”和“能耐受手术但不愿手术病人”。此类病人的重新分类,使临床治疗更具人性化,充分尊重病人个人意愿,体现了个体化的治疗模式enttiuorcpyrimiaIne-orChenotherapyAdditionalon.-surgicalcandidate(category1(DennrivelPalliativeManagement(seeGA5T-7)findingsofPalliateManagement(seeGAST-ase已meastsyalofaAPristinARAfRMiationTIPostTreatmentchemoradiation"ncategory1)(seeGASt-5)PostreatmentoncumentfuoropyrImdPalliativeManaqement(seeGASI-0治疗概述6治疗概述(2)对于不可切除的进展期胃癌、局部复发或存在远处转移的病人,把旧版《指南》中姑息性治疗方案中的“化学治疗”更改为“系统治疗”,系统治疗包含了术前新辅助放化疗、手术治疗及术后放化疗等系列的治疗,这一名称的更改体现了综合治疗的模式。EcoGpertormancessupportiveECOGperformancescores2rentormetastasKamofskyperormancescore<60%治疗概述7治疗概述(3)对于T2N0术后患者,增加D2术后患者给予化疗;高危因素为肿瘤低分化或组织学高分级,脉管,神经(+),年龄小于50岁,增加患者未行D2手术。治疗概述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mComPrehensiveNCCNGuidelines9ComprebensiveNCCNGuidelinesversion3,2015NCCNCancerGasticcance1abotcontGastricCancerDiscussionALOUICOMESCLINICALPOSTOPERATIVEMANAGEMENTCLASSIFICATIONneNotReceivedsurveillanceChemoradiationSurveillance5-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系统性治疗原2015年版《指南》对于全身治疗的原则删除了以下内容:(1)对于局限性食管胃或胃贲门腺癌,应首选术前化放疗;(2)术前化疗作为系统治疗的一个可选方案,但不作为首选mprcheriweNCCNGuidelinesversion3.2015NCCNoflowertoxicity.Thret-drugcyootomkregimensbereferred(esinrfiratadk.withavidancesupportingamcr14dependingcnthecircstan.morbidities,andtoxicityprone.加单mnodadissection.ISeAPnnrplesotSITANYIGASI-CUthcrapy-reatsdcoisasuggestion,andsubjecttoappropriatemodificarioofcytotoxicsbasedontheaailabilityofthepants,pacticecoutrainalicajonsinemaybeusediercnangeadrywinoutcomprosingeFicacy(ExceptInfusionarcinoma.2Perioreratvechemerherapy4isanalter