1、1原发性支气管肺癌原发性支气管肺癌 Primary bronchogenic carcinoma呼吸内科呼吸内科Respiratory Department张惠兰张惠兰Huilan Zhang2定义定义Definition 原发性支气管肺癌简称肺癌，是起源于原发性支气管肺癌简称肺癌，是起源于支气管粘膜或腺体的肿瘤。支气管粘膜或腺体的肿瘤。 Primary bronchogenic carcinoma is abbreviated to lung cancer, it derives from bronchi mucosa or gland.3Epidemiology Lung Cancer W
2、orldwide: most common cancer 2,000,000 cases per year China : first leading cause of cancer death in urban area 5 yrs cessation At 15 years, 80-90% risk reduction Never gets to “never smoker” risk620 Year Lag7 If what happened on your inside happened on your outside, would you still smoke?8 2 职业致癌因子
3、职业致癌因子 2 Occupation carcinogenic factor: Asbestos, Radon 3 空气污染空气污染 3 Air pollution （1）室外大环境污染）室外大环境污染 （1）Outdoor environment pollution9 （2）室内小环境污染）室内小环境污染 （2）Indoor environment pollution Chinese women, many of whom are nonsmokers, have very high lung cancer rates. This phenomenon has been associate
4、d with exposure to cooking oil vapors and other forms of air pollution (such as passive smoking) in the indoor environments of China. 4 电离辐射电离辐射 4 Ionizing radiation10 5 饮食与营养饮食与营养 5 Diet and nutritionVITAMIN A?11 6 其他因素其他因素 6 Other factors 7 遗传因素遗传因素 7 Hereditary factor Tumor suppressor genes*p53 D
5、ominant oncogenes*Kras*Her-2/neu12病理和分类病理和分类Pathology and classification13解剖学分类解剖学分类Anatomy classification According to the position of tumor arising from, it can be divided into two types: 1 中央型肺癌中央型肺癌 1 Central lung cancer: tumor arises from main bronchus, lobar and segmental bronchus . 14 2 周围型肺癌
6、周围型肺癌 2 Peripheral lung cancertumor arises beyond segmental bronchus.15组织学分类组织学分类Histology classification 小细胞肺癌小细胞肺癌 Small cell lung cancer, SCLC 非小细胞肺癌非小细胞肺癌 Non-small cell lung cancer, NSCLC The histologic distinction between SCLC and NSCLC is extremely important. There are substantial differences
7、 between the two groups in both treatment and prognosis. 16 1 小细胞肺癌小细胞肺癌 1 Small cell lung cancer, SCLC （1）燕麦细胞型）燕麦细胞型 （1）oat cell type （2）中间细胞型）中间细胞型 （2）intermediate cell type （3）混合型）混合型 （3）mixed type17 SCLC Rare in non-smokers Large hilar mass 70% present with overt metastasis Very chemo-responsiv
8、e Worst prognosis1819SCLC20 2 非小细胞肺癌非小细胞肺癌 2 Non-small cell lung cancer, NSCLC （1）鳞状细胞癌（鳞癌）鳞状细胞癌（鳞癌） （1）Squamous cell carcinoma, SCC （2）腺癌和支气管肺泡癌）腺癌和支气管肺泡癌 （2）Adenocarcinoma，AC，and bronchoalveolar carcinoma （3）大细胞癌）大细胞癌 （3）Large cell carcinoma （4）鳞腺癌）鳞腺癌 （4）Adeno-squamous carcinoma21 Squamous cell c
9、arcinoma Now 2nd most common ( 1st in China) Strongly linked with smoking 60-80% in the proximal airways (central type) Cavitation Tendency to spread locally/regionally Prognosis slightly better than Adenocarcinoma22个别细胞角化23Squamous Cell Carcinoma24Squamous Cell Carcinoma25鳞癌鳞癌26 Adenocarcinoma Most
10、 common pathology(2nd in China) “Non-smokers lung cancer” Women Peripheral (75%) Aggressive metastases2728Adenocarcicoma Left Lower Lobe29Adenocarcinoma腺癌的脏层胸膜内陷3031Adenocarcinoma32Bronchoalveolar Cell Carcinoma BAC Aerogenous and lymphatic spread Least associated with cigarette smoking Usually peri
11、pheral Localized, multi-nodular or diffuse Slow metabolism Prognosis Localized vs. other33支气管肺泡癌支气管肺泡癌34 Large cell carcinoma Large peripheral mass with necrosis Poorly-differentiated3536Large cell carcinoma37Large cell carcinoma3810100d2530187d恶性度最高最常见发病率(%)倍增时间不明显有关密切吸烟女性较轻老年男性好发年龄性别202533d3035100
12、d大细胞癌腺癌小细胞癌鳞癌39鳞癌小细胞癌腺癌大细胞癌解剖分类中央型中央型周围周围生长方式管腔内管腔外管腔外转移晚早较早手术机会多少较大放化疗敏感40临床表现临床表现Clinical manifestation41Symptoms There are no symptoms of early lung cancer in some patients. Symptoms caused by lung cancer are non-specific. People often decide to visit the doctor only after they have been bothered
13、 by certain complaints over a period of time. Individuals who have lung cancer frequently experience symptoms such as: 42原发肿瘤引起的症状和体征原发肿瘤引起的症状和体征Symptoms and physical signs due to primary tumor 1 咳嗽咳嗽 1 Cough 2 咯血咯血 2 Hemoptysis 3 喘鸣喘鸣 3 Wheeze 4 气急气急 4 Breath lessness 5 发热发热 5 Fever 6 其他其他 6 Others
14、43肿瘤局部扩展引起的症状和体征肿瘤局部扩展引起的症状和体征Symptoms and physical signs due to tumor local expanding 1 胸痛胸痛 1 Chest pain 2 呼吸困难呼吸困难 2 Dyspnea 3 吞咽困难吞咽困难 3 Dysphagia: esophageal compression 4 声音嘶哑声音嘶哑 4 Hoarseness: laryngeal nerve paralysis 5 上腔静脉阻塞综合征上腔静脉阻塞综合征 5 Superior vena cava obstruction syndrome: due to obs
15、truction of the superior vena cava, the patient may have noticed that his collar is tight, the neck is enlarged and the jugular vein and the veins of anterior chest wall are distension and edema of the face.44 6 Horner综合征，肺上沟瘤综合征，肺上沟瘤 6 Horners syndrome, Pancoasts tumor: it is caused by invading the
16、 cervical sympathetic ganglia on the involved side, the pupils small ptosis of the up eyelids, retraction of the eyeball and no sweat of the face. 7 臂丛神经压迫征臂丛神经压迫征 7 Brachial plexus compression syndrome45肿瘤远处转移引起的症状和体征肿瘤远处转移引起的症状和体征Symptoms and physical signs due to tumor distant metastasis 1 脑、中枢神经
17、系统转移脑、中枢神经系统转移 1 Metastasize to brain, central nervous system46 2 肝转移肝转移 2 Metastasize to liver 3 骨转移骨转移 3 Metastasize to bone 4 皮下转移性结节皮下转移性结节 4 Subcutaneouly metastatic nodus 5 颈部或锁骨上淋巴结转移颈部或锁骨上淋巴结转移 5 Cervical or supraclavicular lymph node metastasis47肺癌作用于其他系统引起的肺外表现肺癌作用于其他系统引起的肺外表现Manifestation
18、 out of lung due to other systems affected by lung cancer 1 异位内分泌综合征异位内分泌综合征 1 Ectopic endocrine syndrome, EES （1） 抗利尿激素分泌异常综合征抗利尿激素分泌异常综合征 （1） Syndrome of inapprpriate antidiuretic hormone(SIADH) secretion （2） 异位异位ACTH综合征综合征 （2） Ectopic ACTH syndrome （3） 神经肌肉综合征神经肌肉综合征 （3） Neuromyopathic syndrome （
19、4） 高钙血症高钙血症 （4） Hypercalcinemia （5） 其他：类癌综合征其他：类癌综合征 （5） Others: Carcinoid syndrome48 2 其他肺外表现其他肺外表现 2 Other manifestation out of lung （1）多发性周围神经炎）多发性周围神经炎 （1）Multiple peripheral neuritis （2）肌无力样综合征）肌无力样综合征 （2）Eaton-Lambert syndrome49 （3）肥大性肺性骨关节病）肥大性肺性骨关节病 （3）Hypertrophic pulmonary osteoarthropathy
20、, HPO病人病人正常人正常人50实验室和辅助检查实验室和辅助检查Laboratory and auxiliary examination51影像学检查影像学检查Imageology examination Taught by the teacher from the department of radiology52胸部胸部X线检查线检查 Chest radiograph 1 中央型肺癌中央型肺癌 1 Central lung cancer5354 2 周围型肺癌周围型肺癌 2 Peripheral lung cancer55565758电子计算机体层扫描电子计算机体层扫描CT59Poste
21、rior basal segment of left lower lobe, AC 60左上叶肺癌并左上叶不张Left upper lobe cancer combining atelectasis61Left lower lobe cancer combining obstructive pneumonia6263磁共振磁共振MRI6465痰脱落细胞学检查痰脱落细胞学检查Sputum exfoliative cytology test Dependent on adequacy and number of samples and location of tumor Sensitivity h
22、igh variation when studied Central: 71% Peripheral: 49% Specificity: 99% Underutilized for central tumors Collect 3 specimens is a reasonable 1st step66痰脱落细胞学检查痰脱落细胞学检查Sputum exfoliative cytology testSCC（鳞癌）AC（腺癌）SCLC（小细胞）67纤维支气管镜检查纤维支气管镜检查BronchofiberscopyA visual examination of lung branches using
23、 a flexible scope performed by a pulmonologist.68 Diagnosis of primary tumor Bronchoscopy- endobronchial disease Sensitivity Endobronchial biopsy: 74% Brushing (cyto): 59% Washing: 48% All: 88%69 Bronchoscopy- peripheral disease Sensitivity Transbronchial biopsy: 46% Brushing (cyto): 52% Washing: 43
24、% All: 69% 2 cm Sensitivity: 33% vs. 62%70717273SCCSCLCACLCC74核素闪烁显像核素闪烁显像Nuclide scintigraphy 1 骨骨闪烁显像闪烁显像 1 Bone scintigraphy 2 正电子发射断层显像正电子发射断层显像 2 Positron emission tomography (PET)7576 病理学检查病理学检查 Pathology 癌标志物的检测癌标志物的检测 Cancer mark test 基因诊断基因诊断 Gene diagnosis 手术探查手术探查 Operations research77诊断和
25、鉴别诊断诊断和鉴别诊断Diagnosis and differential diagnosis78Early diagnosis in high risk group Persistent irritable cough for 2 w without any inducing factor The character of original cough be changed Persistent or recurrent hemoptysis Repeated localized pneumonia, lung abscess, regional emphysema or atelectas
26、is79 Solitary nodule or single hilar shadow enlarge Appearance or quality of past TB nodule be changed Pleural effusion no effective by using anti-TB drug Hypertrophic pulmonary osteoarthropathy （肥大性肺性骨关节病）（肥大性肺性骨关节病） without definitive reason 80诊断诊断Diagnosis 症状症状 Symptom 体征体征 Physical sign 检查检查 Exa
27、mination81鉴别诊断鉴别诊断Differential diagnosis 1 肺结核肺结核 1 Pulmonary tuberculosis82TuberculosisLung cancer83 2 肺炎肺炎 2 Pneumonia 抗菌药物治疗有效，病灶吸收快而完全抗菌药物治疗有效，病灶吸收快而完全 Usually, antibacterial drug therapy is effective, and focus is absorbed quickly and completely.84 肺真菌病肺真菌病 Pulmonary mycosis85 3 肺脓肿肺脓肿 3 Lung a
28、bscess86 4 结核性渗出性胸膜炎结核性渗出性胸膜炎 4 Tuberculous exudative pleurisy87临床分期临床分期Clinical stage Primary Tumor Lymph Nodes Metastases 88 Non-small cell lung cancer-T Tumor -N Node-M Metastases Small cell lung cancer -Limited Stage-Extensive Stage89 Small cell lung cancer -Limited Stage：肿瘤局限于一侧胸腔肿瘤局限于一侧胸腔（包括其引
29、流的区域淋巴结，如同侧肺（包括其引流的区域淋巴结，如同侧肺门、纵隔或锁骨上淋巴结）且能被纳入门、纵隔或锁骨上淋巴结）且能被纳入一个放射治疗野即为局限期一个放射治疗野即为局限期-Extensive Stage90 TNM classification (NSCLC) Tumor T1: 3cm or invading visceral pleura or in MS (2cm) or associated with atelectasis to the hilum T3: invades chest wall, diaphragm, mediastinal pleura, or parietal
30、 pericardium; or in MS (not on carina but 2cm); or total atelectasis of lung T4: invades mediastinum, heart, great vessels, trachea, esophagus, spine or main carina; pleural or pericardial effusion; satellite tumor nodules in same lobe91 Nodes N0: None N1: intrapulmonary, ipsilateral hilar N2: ipsil
31、ateral mediastinal or subcarinal N3: contralateral mediastinal or hilar nodes; ipsilateral or contralateral scalene or supraclavicular Metastases Distant Tumor nodules outside of primary lobe92 IA: T1N0 IB: T2 N0 IIA: T1 N1 IIB: T2 N1, T3 N0 IIIA: T3 N1, and T1-3 N2 IIIB: any T4, any N3 IV: any meta
32、stases93治治 疗疗Treatment94手术治疗手术治疗Operation treatment 1 NSCLC 2 SCLC95化学药物治疗化学药物治疗Chemotherapy 1 SCLC 2 NSCLC96放射治疗放射治疗Radiotherapy 根治性根治性 Radical cure 姑息性姑息性 Palliative cure97介入性治疗介入性治疗Interventional therapy 1 支气管动脉灌注支气管动脉灌注 1 Bronchial artery infusion, BAI 2 经纤支镜经纤支镜 2 Through bronchofiberscopy98 生物
33、反应调节剂和生物靶向治疗生物反应调节剂和生物靶向治疗 Biological response modifiers (BRM) and biological targeted therapy 中医药中医药 Chinese medicine99预后和预防预后和预防Prognosis and prevention100预后预后Prognosis The overall prognosis in bronchial carcinoma is very poor; With around 80% of patients dying within a year of diagnosis and less
34、than 6% of patients surviving 5 years after diagnosis; The best prognosis is well-differentiated squamous cell tumors which have not metastasized and are amenable to surgical treatment.101预防预防Prevention 1 戒烟戒烟 1 Stop smoking 2 加强劳动保护加强劳动保护 2 Enhance labor protection 3 早期发现早期发现 3 Early discovery 4 化学预防化学预防 4 Chemical prophylaxis102Thanks!
