非小细胞肺癌临床表现与风险评估NCCN指南2017第2版

Clinical Presentation and Risk Assessment 临床表现与风险评估

CLINICAL   PRESENTATION山东省肿瘤医院呼吸肿瘤内科张品良

RISK   ASSESSMENT b

Nodule   suspicious for lung cancer

*   Multidisciplinary evaluation a

*   Smoking cessation counseling

Patient   factors

* Age

*   Smoking history

*   Previous cancer history

*   Family history

*   Occupational exposures

* Other   lung disease (chronic obstructive pulmonary disease [COPD], pulmonary   fibrosis)

*   Exposure to infectious agents (eg, endemic areas of fungal infections,   tuberculosis) or risk factors or history suggestive of infection (eg, immune   suppression, aspiration, infectious respiratory symptoms)

Radiologic   factors c,d

* Size,   shape, and density of the pulmonary nodule

*   Associated parenchymal abnormalities (eg, scarring or suspicion of   inflammatory changes)

*   Fluorodeoxyglucose (FDG) avidity on PET imaging

Solid   nodules

See   Follow-up

(DIAG-2)

Subsolid   nodules

See   Follow-up

(DIAG-3)

临床表现

风险评估b

结节可疑肺癌

＊多学科评估a

＊戒烟咨询

患者因素

*年龄

*吸烟史

＊既往癌症病史

*家族史

*职业暴露

其他肺疾病（慢性阻塞性肺疾病[COPD]，肺纤维化）

＊暴露于传染性病原体（如真菌感染、肺结核流行区）或感染的危险因素或病史提示（如免疫抑制、吸入、呼吸系统感染症状）

放射性因素c、d

*肺结节的大小、形状与密度

*相关的实性异常（如疤痕或怀疑炎性改变）

*PET成像时对氟去氧葡萄糖（FDG）的亲和性

实性结节

见随访

(DIAG-2)

半实性结节

见随访

(DIAG-3)

a Multidisciplinary evaluation including thoracic surgeons, thoracic radiologists, and pulmonologists to determine the likelihood of a cancer diagnosis and the optimal diagnostic or follow-up strategy.
a 包括胸外科医生、胸放射科专家和肺脏专家的多学科评估以确定癌症诊断的可能性和最佳诊断或随访策略。

b Risk calculators can be used to quantify individual patient and radiologic factors but do not replace evaluation by a multidisciplinary diagnostic team with substantial experience in the diagnosis of lung cancer.
b 风险计算器可以用来量化具体患者和放射因素但不能代替在肺癌诊断方面有丰富经验的多学科诊断小组的评估。

c See Principles of Diagnostic Evaluation (DIAG-A 1 of 2).
c 见诊断评估原则（DIAG-A 1/2）。

d The most important radiologic factor is change or stability compared with a previous imaging study.
d 最重要的影像因素是与既往影像学检查相比是变化还是稳定。DIAG-1

* Lung nodules in asymptomatic, high-risk patients detected during lung cancer screening with LDCT, see the NCCN Guidelines for Lung Cancer Screening. 

* 在肺癌筛查过程中LDCT发现的无症状、高危患者的肺结节，见肺癌筛查NCCN指南。

* For incidentally detected lung nodules, see below.
*对于偶然发现的肺结节，见下文。

FINDINGS

FOLLOW-UP   c,d,g,h

Solid   nodule(s) on chest CT

Low   risk e

<4   mm

No   follow-up needed

4–≤6 mm

CT at   12 mo

Stable

No   further follow-up

6–≤8 mm

CT at   6-12 mo

Stable

Repeat   CT at 18–24 mo

≥8 mm

* CT at   3, 9, and 24 mo

*   Consider PET/CT i,j or Biopsy

High   risk f

<4   mm

CT at   12 mo

Stable

No   further follow-up

4–≤6 mm

CT at   6–12 mo

Stable

Repeat   CT at 18–24 mo

6–≤8 mm

CT at   3–6 mo

Stable

Repeat   CT at 9–12 mo and 24 mo

≥8 mm

* CT at   3, 9, and 24 mo

*   Consider PET/CT i,j or Biopsy

发现

随访c,d,g,h

胸部CT上的实性结节

低危e

＜4mm

无需随访

4–≤6mm

在12个月时CT扫描

稳定

无需进一步随访

6–≤8mm

在6-12个月时CT扫描

稳定

在18-24个月时重复CT扫描

≥8mm

* 在3、9和24个月时CT扫描

＊考虑PET/CT i,j或活组织检查

高危f

＜4mm

在12个月时CT扫描

稳定

无需进一步随访

4–≤6mm

在6-12个月时CT扫描

稳定

在18-24个月时重复CT扫描

6–≤8mm

在3-6个月时CT扫描

稳定

在9-12个月和24个月时重复CT扫描

≥8mm

* 在3、9和24个月时CT扫描

＊考虑PET/CT i,j或活组织检查

c See Principles of Diagnostic Evaluation (DIAG-A 1 of 2).
c 见诊断评估原则（DIAG-A 1/2）。

d The most important radiologic factor is change or stability compared with a previous imaging study.
d 最重要的影像因素是与既往影像学检查相比是变化还是稳定。

e Low risk = minimal or absent history of smoking or other known risk factors.
e 低危=几乎没有或没有吸烟史或其他已知的危险因素。

f High risk = history of smoking or other known risk factors. Known risk factors include history of lung cancer in a first-degree relative; exposure to asbestos, radon, or uranium.
f 高危=吸烟史或其他已知的危险因素。已知的危险因素包括一级亲属的肺癌史；接触石棉、氡或铀。

g Non-solid, partially solid, or ground-glass nodules may require longer follow-up to exclude indolent adenocarcinoma.
g 非实性、半实性或磨玻璃结节可能需要更长时间的随访以排除进展缓慢的腺癌。

h Adapted from Fleischner Society Guidelines: MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology 2005;237:395-400. (C) Radiological Society of North America. Fleischner Society Guidelines do not direct whether or not contrast is necessary or if an LDCT is appropriate. LDCT is preferred unless there is a reason for contrast enhancement for better diagnostic resolution.
h 根据美国弗莱施纳学会指南改编：MacMahon H, Austin JH, Gamsu G，等。CT扫描发现的小的肺结节管理指南：美国弗莱施纳学会综述。放射学2005;237:395-400。©北美国放射学会。美国弗莱施纳学会指南并未规定是否有必要强化或LDCT是合适的。LDCT是首选的，除非有为了更好的诊断分辨率而进行对比剂增强的理由。

i PET/CT performed skull base to knees or whole body. A positive PET result is defined as a standardized uptake value (SUV) in the lung nodule greater than the baseline mediastinal blood pool. A positive PET scan finding can be caused by infection or inflammation, including absence of lung cancer with localized infection, presence of lung cancer with associated (eg, postobstructive) infection, and presence of lung cancer with related inflammation (eg, nodal, parenchymal, pleural). A false-negative PET scan can be caused by a small nodule, low cellular density (nonsolid nodule or ground-glass opacity [GGO]), or low tumor avidity for FDG (eg, adenocarcinoma in situ [previously known as bronchoalveolar carcinoma], carcinoid tumor).
i 颅底至膝关节或全身PET/CT检查。阳性PET结果定义为肺结节标准摄取值（SUV）大于基线纵隔血池。PET扫描阳性发现可以是由感染或炎症引起的，包括无肺癌合并局部感染、存在肺癌合并相关的（如阻塞性）感染以及存在肺癌合并相关的炎症（如淋巴结、实性、胸膜）。假阴性PET扫描可以是由小结节、细胞密度低（非实性结节或磨玻璃影[GGO]）或肿瘤FDG亲和力低（如原位腺癌[以前称为细支气管肺泡癌]、类癌）所引起的。

j Patients with a suspicion of lung cancer after PET/CT require histologic confirmation before any nonsurgical therapy. When a biopsy is not possible, a multidisciplinary evaluation should be done including radiation oncology, surgery, and interventional pulmonology.
j PET/CT怀疑肺癌的患者，在任何非手术治疗前均需要组织学证实。当不可能活检时，应开展包括放射肿瘤学、外科和介入肺脏病学的多学科评估。

DIAG-2

* Lung nodules in asymptomatic, high-risk patients detected during lung cancer screening with LDCT, see the NCCN Guidelines for Lung Cancer Screening. 

* 在肺癌筛查过程中LDCT发现的无症状、高危患者的肺结节，见肺癌筛查NCCN指南。

* For incidentally detected lung nodules, see below.
*对于偶然发现的肺结节，见下文。

FINDINGS

FOLLOW-UP   c,d,g

Subsolid   nodule(s) on chest CT

Solitary   pure ground-glass nodules k

＜5   mm

No   further follow-up

≥5 mm

* CT at   3 mo

*   Annual CT for at least 3 y

Solitary   part-solid nodules k

Persistent   and solid component<5 mm

* CT at   3 mo

*   Annual CT for at least 3 y

Persistent   and solid component ≥5 mm

Biopsy

or

Surgical   resection

Multiple   subsolid nodules

Pure   ground glass ≤5 mm

CT at 2   and 4 y

Pure   ground glass >5 mm, without a dominant lesion

* CT at   3 mo

*   Annual CT for at least 3 y

Dominant   nodules(s) with part-solid or solid component

* CT at   3 mo

* If   persistent, biopsy or surgical resection (especially if has ≥5 mm solid component)

发现

随访c,d,g

胸部CT上的亚实性结节

孤立的纯磨玻璃结节k

＜5mm

无需进一步随访

≥5mm

* 在3个月时CT扫描

*每年1次CT至少3年

孤立的部分实性结节k

实性成分持续< 5mm

* 在3个月时CT扫描

*每年1次CT至少3年

实性成分持续≥5mm

活检

或

手术切除

多发半实性结节

纯磨玻璃≤5mm

在2年和4年时CT扫描

纯磨砂玻璃>5mm，无占优势的病变

* 在3个月时CT扫描

*每年1次CT至少3年

部分实性或实性成分占优势的结节

* 在3个月时CT扫描

*如果持续存在，活检或手术切除（特别是如果实性成分≥5mm）

c See Principles of Diagnostic Evaluation (DIAG-A 1 of 2).
c 见诊断评估原则（DIAG-A 1/2）。

d The most important radiologic factor is change or stability compared with a previous imaging study.
d 最重要的影像因素是与既往影像学检查相比是变化还是稳定。

g Non-solid, partially solid, or ground-glass nodules may require longer follow-up to exclude indolent adenocarcinoma.
g 非实性、半实性或磨玻璃结节可能需要更长时间的随访以排除进展缓慢的腺癌。

k Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected on CT: A statement from the Fleischner Society. Radiology 2013;266:304-317. Guidelines do not direct whether or not contrast is necessary or if an LDCT is appropriate. LDCT is preferred unless there is a reason for contrast enhancement for better diagnostic resolution.
k Naidich DP, Bankier AA, MacMahon H，等。CT检出亚实性肺结节的管理建议：美国弗莱施纳学会综述。放射学2013;266:304-317。指南并未规定是否有必要强化或LDCT是合适的。LDCT是首选的，除非有为了更好的诊断分辨率而进行对比剂增强的理由。

DIAG-3