非小细胞肺癌诊断评估NCCN指南2017第3版

NCCN Guidelines Version 3.2017 NCCN指南2017第3版

Non-Small Cell Lung Cancer
非小细胞肺癌

Discussion
讨论

Diagnostic Evaluation
诊断评估

Incidental Lung Nodules
偶发肺结节

Larger Tumors
较大肿瘤

Diagnostic Evaluation
诊断评估

Incidental Lung Nodules
偶发肺结节

Lung cancer screening is recommended for early diagnosis in asymptomatic patients at high risk. Risk assessment is used to determine which individuals are at high risk for lung cancer and thus are candidates for screening with low-dose CT. Clinicians are referred to the NCCN Guidelines for Lung Cancer Screening for risk assessment criteria to determine which patients are eligible for screening and for how to evaluate and follow up on low-dose CT screening findings. The NCCN Guidelines for Lung Cancer Screening were recently revised to harmonize with the LungRADs system developed by the American College of Radiology with the goal of decreasing the false-positive low-dose CT screening results reported in the NLST.
建议在高危无症状患者中进行肺癌筛查以早期诊断。风险评估用于确定哪些人是肺癌高危并因此适合低剂量CT筛查。临床医生参考肺癌筛查NCCN指南的风险评估标准以确定哪些患者适合筛查、如何评估及随访低剂量CT筛查的结果。诊断、分期与计划的切除（如叶切除术）是早期疾病患者理想的手术步骤（见非小细胞肺癌NCCN指南中的诊断评价原则）。

The diagnostic algorithm for pulmonary nodules in the NCCN Guidelines for NSCLC incorporates information from the NCCN Guidelines for Lung Cancer Screening. For the 2017 update (Version 1), the NCCN Panel revised the diagnostic algorithm to focus on incidental solid and subsolid lung nodules detected on chest CT (see the NCCN Guidelines for NSCLC). Note that the Fleischner Society Guidelines do not specify whether a CT with contrast is necessary for follow-up or whether a low-dose CT is sufficient. Low-dose CT is preferred unless contrast enhancement is needed for better diagnostic resolution.
非小细胞肺癌NCCN指南中肺结节的诊断工作步骤采用肺癌筛查NCCN指南的信息。2017第1版更新，NCCN小组修订了诊断工作步骤，关注胸部CT检出的偶发实性和半实性肺结节（见非小细胞肺癌NCCN指南）。注意费莱舍尔学会指南未详细说明随访是否必须强化CT还是低剂量CT就已足够。首选低剂量CT，除非为了获得更佳的诊断分辨率需要对比剂增强。

Solid and subsolid nodules are the 2 main types of pulmonary nodules that may be seen on chest CT scans. The Fleischner Society has recommendations for patients with solid and subsolid nodules. Subsolid nodules include 1) nonsolid nodules also known as ground-glass opacities (GGOs) or ground-glass nodules (GGNs); and 2) part-solid nodules, which contain both ground-glass and solid components. Nonsolid nodules are mainly adenocarcinoma in situ (AIS) or minimally invasive adenocarcinoma (MIA), formerly known as bronchioloalveolar carcinoma (BAC) (see Adenocarcinoma in this Discussion); patients have 5-year disease-free survival of 100% if these nonsolid nodules are completely resected. Data suggest that many nonsolid nodules discovered incidentally on CT imaging will resolve and many of those that persist may not progress to clinically significant cancer. Solid and part-solid nodules are more likely to be invasive, faster-growing cancers, factors that are reflected in the increased suspicion and follow-up of these nodules (see the NCCN Guidelines for Lung Cancer Screening, available at NCCN.org).
实性与半实性结节是在胸部CT扫描时可能看到的两种主要的肺结节类型。对于实性与半实性结节的患者费莱舍尔学会已推荐增强。半实性结节包括1）非实结节即磨玻璃样混浊影（GGOs）或磨玻璃样结节（GGNs）；和2）部分实性结节，包含磨玻璃样和实性两种成分。非实性结节主要是原位腺癌（AIS）或微浸润腺癌（MIA），曾称之为细支气管肺泡癌（BAC）（见本讨论中的腺癌）；如果这些非实性结节完全切除，患者的5年无病生存率可达100%。数据表明，这将解决CT影像偶然发现的许多非实性结节，但是，其中许多结节始终未发展为临床值得注意的癌症。实性和部分实性结节可能是更具侵袭性、生长更快的恶性肿瘤，在这些结节的随访过程中体现的因素逐渐增加怀疑（见肺癌筛查NCCN指南，可在NNCN.ogr获得）。

All findings and factors for a patient need to be carefully evaluated in a multidisciplinary diagnostic team before establishing a diagnosis of lung cancer and before starting treatment. The NCCN Guidelines recommend biopsy or surgical excision for highly suspicious nodules seen on low-dose CT scans or further surveillance for nodules with a low suspicion of cancer depending on the type of nodule and a multidisciplinary evaluation of other patient factors (see the NCCN Guidelines for Lung Cancer Screening, available at NCCN.org). For patients having repeat scans, the most important radiologic factor is change or stability of a nodule when compared with a previous imaging study. False-positive results (eg, benign intrapulmonary lymph nodes, noncalcified granulomas) frequently occurred with low-dose CT when using the original cutoffs for nodule size deemed suspicious for malignancy from the NLST. However, the revised cutoff values for suspicious nodules recommended by the American College of Radiology and incorporated into the LungRADs system have been reported to decrease the false-positive rate from low-dose CT.
在建立肺癌诊断并开始治疗前，患者所有的检查结果及因素均需要多学科诊断小组仔细评估。对于低剂量CT扫描见到的高度可疑的结节NCCN指南推荐活检或手术切除，或对于低度怀疑癌症的结节进一步监测，取决于结节的类型和其他患者因素的多学科评估（见肺癌筛查NCCN指南，可在NCCN.org获得）。对于重复扫描的患者，最重要的影像学因素是与以前的影像检查相比结节变化或稳定。当使用国家肺癌筛查试验（NLST）独创的认为可疑恶性肿瘤的结节大小阈值时，低剂量CT经常出现假阳性结果（如肺内良性淋巴结、非钙化肉芽肿）。不过，美国放射学会推荐的修改后的可疑结节阈值已纳入LungRADs系统，已报道可降低低剂量CT的假阳性率。

Larger Tumors
较大肿瘤

The NCCN Guidelines recommend that the diagnostic strategy should be individualized for each patient depending on the size and location of the tumor, the presence of mediastinal or distant disease, patient characteristics (eg, comorbidities), and local expertise. The diagnostic strategy needs to be decided in a multidisciplinary setting. Decisions regarding whether a biopsy (including what type of biopsy) or surgical excision is appropriate depend on several factors as outlined in the NSCLC algorithm (see Principles of Diagnostic Evaluation in the NCCN Guidelines for NSCLC). For example, a preoperative biopsy may be appropriate if an intraoperative diagnosis seems to be difficult or very risky. The preferred biopsy technique depends on the site of disease and is described in the NSCLC algorithm (see Principles of Diagnostic Evaluation). For example, radial endobronchial ultrasound (EBUS; also known as endosonography), navigational bronchoscopy, or transthoracic needle aspiration (TTNA) are recommended for patients with suspected peripheral nodules. PET/CT imaging is useful before selecting a biopsy site, because it is better to biopsy the site that will confer the highest stage. Patients with suspected nodal disease should be assessed by endoscopic ultrasound–guided fine-needle aspiration (EUS-FNA), EBUS–guided transbronchial needle aspiration (EBUS-TBNA), navigational bronchoscopy, or mediastinoscopy (see Mediastinoscopy in this Discussion and Principles of Diagnostic Evaluation in the NCCN Guidelines for NSCLC). EBUS provides access to nodal stations 2R/2L, 4R/4L, 7, 10R/10L, and other hilar nodal stations. EUS provides access to nodal stations 5, 7, 8, and 9.
NCCN指南建议应该根据肿瘤的大小和位置、存在纵隔或远隔病变、患者特征（如合并症）以及本地医生的专业技巧为每个病人制定个体化的诊断策略。诊断策略需要在多学科背景下决定。决定是否活检（包括活检型式）或是否适合手术切除取决于几个因素，在非小细胞肺癌工作步骤中概述（见非小细胞肺癌NCCN指南中的诊断评估原则）。例如，如果术中诊断似乎困难或非常危险，术前活检可能是合理的。首选的活检技术取决于疾病部位，在非小细胞肺癌工作步骤中描述（见诊断评估原则）。例如，径向支气管内超声（EBUS；也称为内镜超声技术）、导航支气管镜或经胸针吸检查（TTNA）推荐用于疑似外周结节患者。在选择活检部位前，PET/CT影像是有用的，因为确认活检部位它是更好的，所以给予最高级别的推荐。可疑淋巴结疾病患者应通过超声内镜引导下细针穿刺活检（EUS-FNA）、EBUS引导下经支气管针吸活检（EBUS-TBNA）、导航支气管镜或纵隔镜检查评估（见本讨论中的纵隔镜检查和非小细胞肺癌NCCN指南中的诊断评估原则）。支气管内超声（EBUS）可进入2R/2L、4R/4L、7、10R/10L和肺门淋巴结区。超声内镜（EUS）可进入5、7、8和9淋巴结区。

If pathology results from biopsy or surgical excision indicate a diagnosis of NSCLC, then further evaluation and staging need to be done so that the patient’s health care team can determine the most appropriate and effective treatment plan (see Pathologic Evaluation of Lung Cancer and Staging in this Discussion and the NCCN Guidelines for NSCLC). Diagnosis, staging, and planned resection (eg, lobectomy) are ideally one operative procedure for patients with early-stage disease (see the Principles of Diagnostic Evaluation in the NCCN Guidelines for NSCLC). A preoperative or intraoperative tissue diagnosis of lung cancer should be established before doing a lobectomy.
如果活检或手术切除病理结果诊断为非小细胞肺癌，则需要进行进一步评估并分期，以便患者的卫生保健小组能够确定最合理有效的治疗计划（见本讨论和非小细胞肺癌NCCN指南中的肺癌病理学检查与分期）。诊断、分期与计划的切除（如叶切除术）是早期疾病患者理想的手术步骤（见非小细胞肺癌NCCN指南中的诊断评价原则）。在进行叶切除术之前，应在术前或术中确定肺癌的组织学诊断。