Willers Henning, Stinchcombe Thomas E, Barriger R Bryan, Chetty Indrin J, Ginsburg Mark E, Kestin Larry L, Kumar Sanath, Loo Billy W, Movsas Benjamin, Rimner Andreas, Rosenzweig Kenneth E, Videtic Gregory M M, Chang Joe Yujiao
*Massachusetts General Hospital, Boston, MA †University of North Carolina Health Care System, American Society of Clinical Oncology, Chapel Hill, NC ‡Indiana University School of Medicine, Indianapolis, IN §Henry Ford Health System #Henry Ford Hospital, Detroit, MI ¶21st Century Oncology/Michigan Healthcare Professionals, Farmington Hills, MI ∥Society of Thoracic Surgeons, Columbia University, New York, NY ††Memorial Sloan Kettering Cancer Center, New York, NY ‡‡Mount Sinai School of Medicine, New York, NY **Stanford University and Stanford Cancer Institute, Stanford, CA §§Cleveland Clinic Foundation, Cleveland, OH ∥∥University of Texas MD Anderson Cancer Center, Houston, TX.
Am J Clin Oncol. 2015 Apr;38(2):197-205. doi: 10.1097/COC.0000000000000154.
The integration of chemotherapy, radiation therapy (RT), and surgery in the management of patients with stage IIIA (N2) non-small-cell lung carcinoma is challenging. The American College of Radiology (ACR) Appropriateness Criteria Lung Cancer Panel was charged to update management recommendations for this clinical scenario. The Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. There is limited level I evidence to guide patient selection for induction, postoperative RT (PORT), or definitive RT. Literature interpretation is complicated by inconsistent diagnostic procedures for N2 disease, disease heterogeneity, and pooled analysis with other stages. PORT is an appropriate therapy following adjuvant chemotherapy in patients with incidental pN2 disease. In patients with clinical N2 disease who are potential candidates for a lobectomy, both definitive and induction concurrent chemotherapy/RT are appropriate treatments. In N2 patients who require a pneumonectomy, definitive concurrent chemotherapy/RT is most appropriate although induction concurrent chemotherapy/RT may be considered in expert hands. Induction chemotherapy followed by surgery +/- PORT may also be an option in N2 patients. For preoperative RT and PORT, 3-dimensional conformal techniques and intensity-modulated RT are most appropriate.
在IIIA期（N2）非小细胞肺癌患者的治疗中，化疗、放射治疗（RT）和手术的整合具有挑战性。美国放射学会（ACR）肺癌适宜性标准小组负责更新针对这种临床情况的管理建议。适宜性标准是针对特定临床情况的循证指南，由多学科专家小组每3年进行审查。指南的制定和审查包括对同行评审期刊上的当前医学文献进行广泛分析，并应用成熟的共识方法（改良德尔菲法）由小组对成像和治疗程序的适宜性进行评分。在证据不足或不确定的情况下，可使用专家意见来推荐成像或治疗。指导诱导治疗、术后放疗（PORT）或根治性放疗患者选择的I级证据有限。由于N2疾病的诊断程序不一致、疾病异质性以及与其他分期的汇总分析，文献解读变得复杂。对于偶然发现pN2疾病的患者，PORT是辅助化疗后的合适治疗方法。对于可能适合肺叶切除术的临床N2疾病患者，根治性和诱导同步放化疗都是合适的治疗方法。对于需要全肺切除术的N2患者，根治性同步放化疗是最合适的，尽管在专家手中也可考虑诱导同步放化疗。诱导化疗后手术±PORT也可能是N2患者的一种选择。对于术前放疗和PORT，三维适形技术和调强放疗最合适。
