Shen K Robert, Meyers Bryan F, Larner James M, Jones David R
Division of Thoracic Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA.
Chest. 2007 Sep;132(3 Suppl):290S-305S. doi: 10.1378/chest.07-1382.
This chapter of the guidelines addresses patients who have particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLCs), solitary brain and adrenal metastases, and chest wall involvement.
The nature of these special clinical cases is such that in most cases, metaanalyses or large prospective studies of patients are not available. For ensuring that these guidelines were supported by the most current data available, publications that were appropriate to the topics covered in this chapter were obtained by performance of a literature search of the MEDLINE computerized database. When possible, we also referenced other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method (see "Methodology for Lung Cancer Evidence Review and Guideline Development" chapter), and reviewed by all members of the lung cancer panel before approval by the Thoracic Oncology NetWork, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physicians.
In patients with a Pancoast tumor, a multimodality approach seems to be optimal, involving chemoradiotherapy and surgical resection, provided appropriate staging has been conducted. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. Such patients, however, seem to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone when carefully staged and selected. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment than what would be dictated by the primary tumor alone. However, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLCs do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and a second primary lung cancer, although criteria to distinguish them have not been defined. Selected patients with a solitary focus of metastatic disease in the brain or adrenal gland seem to benefit substantially from resection. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, as long as tumors can be completely resected and there is absence of N2 nodal involvement, primary surgical treatment should be considered.
Carefully selected patients may benefit from an aggressive surgical approach.
本指南的这一章节涉及患有特定形式非小细胞肺癌且需要特殊考虑的患者。这包括患有潘科斯特瘤、T4N0,1M0肿瘤、同一肺叶内的卫星结节、同时性和异时性多原发性肺癌（MPLC）、孤立性脑转移和肾上腺转移以及胸壁受累的患者。
这些特殊临床病例的性质决定了在大多数情况下，无法获得针对患者的荟萃分析或大型前瞻性研究。为确保这些指南有最新数据支持，通过对MEDLINE计算机化数据库进行文献检索，获取了与本章涵盖主题相关的出版物。可能的情况下，我们还参考了其他共识意见声明。建议由写作委员会制定，采用标准化方法分级（见“肺癌证据审查与指南制定方法”章节），并在经胸肿瘤学网络、健康与科学政策委员会以及美国胸科医师学会董事会批准之前，由肺癌专家小组的所有成员进行审查。
对于患有潘科斯特瘤的患者，多模式方法似乎是最佳选择，包括放化疗和手术切除，前提是已进行适当分期。没有纵隔淋巴结受累的中央型T4肿瘤患者并不常见。然而，这类患者在经过仔细分期和选择后，作为治疗一部分进行切除似乎比单纯放化疗更有益。与原发性肿瘤在同一肺叶有卫星病灶的患者预后良好，与仅由原发性肿瘤决定的评估和治疗方法相比，无需调整。然而，很难知道如何最好地治疗在不同肺叶有同一类型癌症病灶的患者。虽然确实会发生MPLC，但对于肿瘤之间间隔<4年的同时性或异时性表现，切除后的生存结果各不相同且通常较差，这表明这些患者中的许多人可能已有肺转移而非第二原发性肺癌。尽管尚未确定区分两者的标准，但有必要对这些患者进行全面仔细的评估，以试图区分有转移的患者和第二原发性肺癌患者。选定的脑或肾上腺有孤立性转移病灶的患者似乎从切除中获益显著。在无病间期长的患者中尤其如此。最后，对于胸壁受累的患者，只要肿瘤能够完全切除且没有N2淋巴结受累，就应考虑进行原发性手术治疗。
经过仔细选择的患者可能从积极的手术方法中获益。
