Treatment of Stage I and II Non-small Cell Lung Cancer Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Treatment of Stage I and II Non-small Cell Lung Cancer Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
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DOI：
10.1378/chest.12-2359
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发表时间：
2013-05-01
期刊：
影响因子：
9.6
通讯作者：
Murthy, Sudish C.
中科院分区：
文献类型：
--
作者：
Howington, John A.;Blum, Matthew G.;Murthy, Sudish C.
背景资料：手术风险良好或较低的I期和II期非小细胞肺癌（NSCLC）患者的治疗主要是手术切除。然而，这一领域正在发生许多变化。随着CT成像的普及，许多肺癌被发现是小的或主要构成磨玻璃影。目前正在探索诸如肺叶切除术和立体定向体部放疗（SBRT）等非手术方法的治疗方法。随着微创切除术的出现，标准来分类一个病人病得太重，接受解剖肺切除术正在redefined.Methods：写作小组选择的主题进行审查的基础上，临床相关性的治疗早期肺癌和数量和质量的数据可用于分析和相对争议的最佳方法在I期和II期非小细胞肺癌：普通外科护理与专科护理; I期肺癌的肺叶与肺叶手术入路;视频辅助胸外科手术与开放性切除术;手术切除时纵隔淋巴结采样与淋巴结切除术;放射治疗（重点是SBRT）的使用，用于高风险或医学上无法手术的患者的早期NSCLC的主要治疗，以及肺叶和肺叶切除术中的辅助放射治疗;早期NSCLC的辅助化疗;以及种族、地理和社会经济地位对肺癌生存率的影响。由写作委员会的建议是基于以证据为基础的文献回顾，并按照美国胸科医师学会的指导方针监督委员会所描述的方法。结果：手术切除仍然是治疗I期和II期NSCLC的主要和首选方法。肺叶切除术或更大的切除术仍然是T1 b和更大肿瘤的首选方法。目前正在大型临床试验中积极研究T1 a肿瘤的肺叶切除术和辅助放射治疗在该组中的应用。每一个病人在根治性手术切除时都应该有系统的纵隔淋巴结取样，纵隔淋巴结切除术可以在不增加发病率的情况下进行。当外科切除术是由一个委员会认证的胸外科医生进行时，围手术期的发病率和死亡率降低，长期生存率提高。建议对II期NSCLC使用辅助化疗，并已显示出获益。I期NSCLC使用辅助放疗或化疗的益处尚未得到证实。对于拒绝手术切除或由多学科团队确定为不可手术的患者，原发性放射治疗仍然是主要的治疗方法。越来越多的证据表明，对于高风险和医学上不可手术的NSCLC患者，SBRT比标准放疗提供更好的局部控制。消融治疗在I期NSCLC高危患者治疗中的作用正在演变。射频消融是研究最多的消融方式，已有效地用于医学上无法手术的小（
Background: The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined.Methods: The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians.Results: Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (