107 年 Cancer of Clinical Guideline¨º療指引.pdf · 5. 非小細胞肺癌,第IV,...

107 年 Cancer of Clinical Guideline

發行日期：2018年7月

發行版次：第 1 版

編輯人員：侯明鋒、莊捷翰、吳政毅、王遜模、陳煌麒、蔡東霖、鐘堉緁、梁博程、林宜竑、陳映哲、蘇家弘、王秋

麟、張慧名、沈榮宗、楊凱富、唐世豪、方本詞、李欣樺、黃憶如、艾紀瑩、王亞婷、黃惠娟、洪麗君、

黃麗如、賴妙君、張玲瑄。

高雄市立小港醫院(委託財團法人高雄醫學大學經營)

107年癌症診療指引

目錄

診療指引修訂實證文獻參考來源 Page 1

Cancer of the Lung 肺癌 Non-Small-Cell Lung Cancer 非小細胞肺癌Small-Cell Lung Cancer 小細胞肺癌

CCRT 的原則

Esophageal Cancer 食道癌

A

A-1

A-24

A-30

A-32

Hepato-biliary Pancreatic Cancer 肝膽胰癌 Hepatoma 肝癌

B

B-1

Cancer of the Gastrointestinal Tract 胃腸癌 Colon Cancer 結腸癌

Rectum Cancer 直腸癌

Gastric Cancer 胃癌

C

C-1

C-14

C-34

Cancer of the Breast 乳癌 Breast Cancer 乳癌

D

D-1

Gynecologic Cancer 婦癌Cervical Cancer 子宮頸癌

Endometrial Cancer 子宮內膜

癌Ovarian cancer 卵巢癌

E

E-1

E-10

E-19

Cancer of the Head and Neck 頭頸癌Cancer of the Oral Cavity 口腔癌

Nasopharyngeal carcinoma 鼻咽癌

F

F-1

F-3

Urinary tract cancer 泌尿道癌 Bladder cancer 膀胱癌Prostate cancer 攝護腺癌

G

G-1

G-14

Lymphoma 淋巴癌 Diffuse large B-cell Lymphoma 瀰漫性大型 B 細胞淋巴癌Follicular Lymphoma 濾泡型淋巴癌

H

H-1

H-4

Cancer of the Lung

Treatment Guideline

KMHK

制定日期 : 97 年 1 月 1 日

修訂日期 : 107 年 6 月 5 日

肺癌修訂記錄修訂日期修訂內容摘要修訂頁次版本

97年 98年 99年 100年

101年

102年

第一版依照NCCN guideline 制定本院治療準則多專科會議討論檢視未修改。多專科會議討論檢視未修改。多專科會議討論檢視未修改。

＊non-small cell lung cancer 1.修訂non-small cell practice guideline 圖表中initial evaluation項目將原有的CXR、Abdominal sonography刪除。

2.stage I or II的 treatment plan改為consult chest surgery to evaluate the indication for surgery ± chemotherapy or chemoradiation。

3.修訂non-small cell clinical presentation，將原本N0-2改為 N0-1，並將treatment plan中refer to KMUH刪除，原先的N3 or Metastatic disease改為N2的treatment plan。

4.修訂small cell practice guideline 圖表中initial evaluation項目將原有的CXR、Abdominal sonography刪除。

＊non-small cell lung cancer 1.新增surgical exploration and resection + mediastinal LN

dissection or systematic LN sampling後 stage IA到IIIA的margin positive與negative的治療。

2.修訂stage IIIA中N2-metastatic的treatment 3.新增stage IIIB治療流程之圖表。 4.修訂NSCLC中新增 stage IV，M1a與M1b的pretreatment

evaluation圖表。 5.新增EGFR mutation 之治療流程。6.performance status 0-4建議治療方式圖表。 7.新增AJCC TNM 分期表＊small cell lung cancer 1.新增SCLC中limited stage與extensive stage圖表說明。 2.新增biopsy之pathology結果後續的治療流程。 3.新增CCRT原則。

A-1

A-2

A-3

A-2

A-3

A-4

A-5

1.0

2.0

3.0

肺癌修訂記錄

修訂日期修訂內容摘要修訂頁次版本 103年

104年

105年

106年

＊non-small cell lung cancer 1.新增stage IIB、stage IIIA為unresectable disease治療流程。 2.新增stage IIIA (N2、N3 nodes negative or N2 nodes positive)治療流程

3.新增suspected multiple lung cancers治療流程。 4.新增metastatic disease在adrenal的治療流程。 5.修訂EGFR mutation positive治療流程。 6.新增ALK positive治療流程。 7.新增EGFR mutation and ALK negative or unknown治療流程。 8.新增squamous cell carcinoma first-line therapy治療流程。 9.新增third-line therapy治療流程。

1.修改Sensitizing EGFR mutation positive，positive可選這三個藥物Erlotinib、Afatinib、Gefitinib。

多專科會議討論檢視後未修改。

1.非小細胞肺癌初步評估加入肺功能、心臟超音波、腹部超音波、腫瘤指數(可考慮)

2. 針對高風險IB-II期給予輔助型化療

(1)分化不佳

(2)血管侵犯

(3)腫瘤>4公分

(4)臟層肋膜侵犯 (5)Wedge resection (6)未明淋巴結

3.全部Reresection修改為resection。 4.非小細胞肺癌,為分散肺腫瘤,同側肺葉(T3, N0)或同側非原發肺葉(T4,N0)手術後為N0-1,可行化療 5. 非小細胞肺癌,第IV, M1b期:獨立腫瘤,轉移至其他部位可參考A-14,刪除轉移針對腎上腺部分 6.原EGFR ± ALK testing should be conduced as part of multiplex/next-generation sequencing刪除，修改為PDL-1 testing

7.在一線化療前或期間發現ALK受體重組,先行含鉑的化療,若有

A-6

A-7

A-8~A-9 A-10~A-11

A-13

A-14

A-4~ A-5

A-7

A-8~9

A-12、A-14

A-15 A-

16 A-17

A-18

A-19

A-15

4.0

5.0

6.0

肺癌修訂記錄

修訂日期修訂內容摘要修訂頁次版本

107年

惡化,可使用crizotinib,若有副作用或持續惡化多新增ceritinib(zykadia立克癌)之藥物選擇

.原考慮雙白金類±Bevacizumab(Avastin癌思停)，改Avastin± 雙白金類

1.修改成AJCC 8th版

A-1

A-2

A-20

7.0

Non-Small Cell Lung Cancer

Pathologic

Diagnosis of

NSCLC

Initial

Evaluation

Clinical Stage

Stage IA peripheral (T1ab,N0) Medistinal CT negative (lymph nodes


Clinical Assessment Pretreatment Evaluation

Operable See initial treatment and adjuvant

treatment(A-3)

Stage IA

(peripheral T1ab,N0)

*PFTs (If not previously done)

*Bronchoscopy

(intraoperative preferred) *Pathologic mediastinal lymph node

evaluation *Bone scan (refer to KMUH)

*PET/CT scan (refer to KMUH)

Negative mediastinal nodes

Positive mediastinal

nodes

Medically inoperable

Definitive RT or stereotactic

ablative radiotherapy (SABR)

(refer to KMUH)

See stage IIIA (A-7) or stage IIIAB(A-10)

Stage IB(pheripheral

T2a,N0)

Stage I(central

T1ab-T2a,N0)

Stage

II(T1ab-T2ab,N1;T2b,N0

)

Stage IIB(T3,N0)


*Bronchoscopy

(intraoperative preferred)

*Bone scan(refer to KMUH)

*Mediastinoscopy and/or

EBUS/EUS(refer to KMUH)

*PET/CT scan(refer to KMUH)

*Brain MRI (stage II, stage IB)

Negative mediastinal nodes

Positive mediastinal

nodes

Operable Medically inoperable

See initial treatment and adjuvant

treatment(A-3)

Adjuvant C/T for high Definitive RT

N0 risk stages IBII including SABR

N1 Definitive chemoradiation See stage IIIA (A-7) or stage

IIIAB(A-10)

A-2


Initial treatment Findings at surgery Adjuvant treatment

Stage IA

(T1ab,N0)

Stage IB

Margins negative

(R0)

Margins positive

(R1, R2) Margins negative

(R0)

Observe Reresection (preferred)

or RT Observe or Chemotherapy for high risk

patients

Surgical exploration and

resection + mediastinal

lymph node diseeection

or systematic lymph

(T2a,N0)

StageIIA

(T2b,N0) Stage IIA

Margins positive

(R1, R2) Margins negative

(R0)

node sampling (T1ab-T2a,N1)

Stage IIB

(T3,N0;T2b,N1)

Margins positive

R1

Resection + chemotherapy

or chemoradiation

R2 Resection + chemotherapy or Concurrent chemoradiation

Margins negative (R0)

Chemotherapy + RT or Sequential chemotherapy+RT (N2 only)

Stage IIIA (T1-3,N2;T3,N1)

Margins positive

R1 R2

Chemoradiation (sequential or concurrent)

Concurrent chemoradiation

Resection (preferred) ±chemotherapy or RT ±chemotherapy (chemotherapy for

stage IIA)

Chemotherapy

A-3


Clinical Assessment Pretreatment Evaluation Clinical Evaluation

Stage IIB (T3 invasion, N0)

Stage IIIA (T4 extension, N0-1;

T3, N1)

*PFTs (If not previously done) *Bronchoscopy * Pathologic mediastinal lymph node

evaluation *Brain MRI *Bone scan(refer to KMUH) *MRI of spine + thoracic inlet for superior

sulcus lesions abuttling the spine or

subclavian vessels (option)


Superior sulcus tumor Chest wall Proximal airway or

mediastinum

Unresectable disease Metastatic disease

See A-5 See A-5 See A-5 See A-5 See A-12 or A-13

A-4


Clinical Presentation

Superior suicus tumor

(T3 invasion, N0-1)

Superior suicus tumor

(T4 extension, N0-1)

Possibly

resectable

Initial treatment

Preoperative

concurrent

chemoradiation

Preoperative

concurrent

chemoradiation

Surgical

reevaluation

Resectable

Unresectable

Adjuvant Treatment Surgery+ chemotherapy

Surgery+ chemotherapy

Complete definitive RT

+ chemotherapy

Unresectable

Definitive

concurrent

chemoradiation

See A-13

Chest wall, proximal

airway or mediastinum

(T3 invasion, N0-1;

Resectable T4

extension, N0-1)

Concurrent

chemoradiation

or

Chemorherapy

Surgery

Margins negative

(R0)

Margins

positive(R1,R2)

Chemotherapy

Resection + chemotherapy or chemoradiation

R1 (sequential or

concurrent)

Resection + chemotherapy

R2 or


Stage III (T4, N0-1)

Unresectable

Definitive concurrent

chemoradiation

A-5


Clinical Assessment Pretreatment Evaluation Mediastinal Biopsy Findings and Resectability

N2, N3 nodes negative See A-7


*Bronchoscopy

* Pathologic mediastinal lymph node

N2 nodes positive

See A-7

Stage IIIA (T1-3, N2) evaluation



*Brain MRI

N3 nodes positive

Metastatic disease

See A-10

See A-12 or A-13

Separate pulmonary

nodule(s)

(Stage IIB, IIIA,IV)


*Bronchoscopy

* Mediastinoscopy(option)


*Brain MRI


Separate pulmonary nodule(s), same lobe (T3, N0) or

ipsilateral non-primary lobe (T4,N0)

Stage IV (N0, M1a): Contralateral lung (solitary

nodule)

Extrathoracic metastatic disease

See A-8

See A-8 See A-12or A-13

A-6


Mediastinal Biopsy

Findings

Initial Treatment Surgical resection +

N0-1

Adjuvant Treatment

See A-3

Resectable

mediastinal lymph

node dissection or

systematic lymph node sampling

Margins negative

Sequential chemotherapy +

RT See A-13

T1-3, N0-1 (including

T3 with multiple

nodules in same lobe

Surgery

N2 Margins positive

R1

Chemoradiation (sequential or concurrent)

See A-13

Medically

inoperable

See A-2

R2

Concurrent chemoradiation See A-13

Negative for

M1 disease

Definitive concurrent chemoradiation or induction chemotherapy

No apparent

progression

Surgery±chemotherapy±RT

T1-2, T3(≧7cm),

N2 nodes positive

*Brain MRI

*PET/CT(refer

to KMUH)

Progression

Local

Systemic

RT±chemotherapy

See A-12 or A-13

Positive See A-12 or A-13

T3(invasion), N2

nodes positive

*Brain MRI

*PET/CT(refer

to KMUH)

Negative for

M1 disease

Positive


chemoradiation See A-12 or A-13

A-7


Clinical Presentation Initial Treatment Adjuvant Treatment

N0-1 Chemotherapy See A-13

Separate pulmonary

nodule(s), same lobe (T3,

N0) or ipsilateral non-

Surgery

primary lobe (T4, N0) Margin negative (R0) Chemotherapy See A-13

N2 Margins positive

(R1,R2)


(if tolerated)

See A-13

Stage IV ( N0, M1a)

Contralateral lung (solitary

nodule)

Suspected multiple lung

cancers (based on the

presence of biopsy-proven

synchronous lesions or

history of lung cancer

Treat as two primary lung

tumors if both curable

*chest CT with contrast

*PET/CT(refer to KMUH)

*Brain MRI

See A-1

Disease outside of chest No disease outside of

chest

See A-14 Pathological

mediastinal lymph

node evaluation

N2-3

N0-1

See A-14

See A-9

A-8


Clinical Presentation Initial Treatment

Low risk of becoming

symptomatic

Observation

See A-13

Multiple lesions

Asymptomatic

High risk of becoming

symptomatic

Definitive

local therapy

Parenchymal sparing

resection (preferred) or

Multiple lung

cancers

Solitary lesion

(metachronous

disease

possible Definitive

local therapy

not possible

radiation or ablation Consider palliative

chemotherapy±local

palliative therapy

Symptomatic

See A-14

A-9


Clinical Assessment Pretreatment Evaluation Initial Treatment

Stage IIIB (T1-3, N3)



*Brain MRI

*Bone scan(refer to KMUH) * Pathologic confirmation of N3 disease by

either:

-Mediastinoscopy

-Superaclavicular lymph node biopsy

-Thoracoscopy

- Needle biopsy

- Mediastinotomy

- Endoscopic ultrasound (EUS)

biopsy(refer to KMUH)

- Endobronchial ultrasound (EBUS)

biopsy(refer to KMUH)

N3 negative

N3 positive

Metastatic disease

See A-7


chemoradiation

See A-12 or A-13

A-10


Clinical Assessment Pretreatment Evaluation Initial Treatment

Ipsilateral mediastinal

node negative (T4, See A-7

Contralateral N0-1)

*PET/CT scan(refer to KMUH)

*Brain MRI

*Bone scan (refer to KMUH)

* Pathologic confirmation of N2-3 disease

mediastinal node negative

Ipsilateral mediastinal

node positive (T4, N2)

Definitive

concurrent

chemoradiation

Stage IIIB

(T4 extension, N2-3)

by either: -

Mediastinoscopy

-Superaclavicular lymph node biopsy -Thoracoscopy

-Needle biopsy

-Mediastinotomy -EUS biopsy (refer to KMUH) -

EBUS biopsy (refer to KMUH)

Contralateral

mediastinal

node positive

(T4, N3)

Metastatic

disease

Definitive

concurrent

chemoradiation

See A-12 or A-13

Negative See A-7

Stage IV, M1a:

Pleural or pericardial

Thoracenfesis or pericardiocentesis ±

thoracoscopy if thoracentesis indeterminate

Local therapy if necessary (e.g.

effusion Positive

pleurodesis, ambulatory small

catheter drainage, pericardial

window) + See A-12 or A-13

A-11


Clinical

Assessment

Pretreatment

Evaluation

Initial Treatment

Surgical resection of lung lesion

or

Stereotactic ablative

Chemotherapy

Surgical resection followed by

T1-2, N0-1; T3, N0;

radiotherapy (SABR) of lung lesion

whole brain RT (WBRT) or

stereotactic radiosurgery (SRS)

or Chemotherapy

Surgical

resection of

Brain or SRS + WBRT (category 1 for one

lung lesion or SABR of lung

*Pathologic metastasis) lesion

Stage IV,

M1b:

Solitary site

mediastinal lymph

node evaluation

*Bronchoscopy

*Brain MRI

*Bone scan(refer to

KMUH) *PET/CT scan (refer

to KMUH)

or SRS alone

T1-2, N2;

T3, N1-2;

Any T, N3;

T4, Any N

See A-14

Other site See A-14

A-12


Surveillance

Endobronchial

obstruction

Therapy for recurrence and metastasis

*Laser/stent/other surgery

* External-beam RT or brachytherapy

*Photodynamic therapy

Resectable

recurrence

*Reresection (preferred) * External-beam RT or SABR

No evidence of

disseminated

disease

Observation or

systemic

chemorherapy

No evidence of

clinical/radiographic disease

Locoregional

recurrence

Mediadtinal lymph

node recurrence

No prior RT Prior RT

Concurrent

chemoradiation Systemic chemotherapy

Evidence of

disseminated

disease

See A-14

(NED), stage I-IV.

*History and physical and chest CT

± contrast every 6-12 mo for 2 y

(category 2B), then H&P and a

non-contrast- enchanced chest CT

annually (category 2B)

*Smoking cessation advice,

counseling and pharmacotherapy

*PET or brain MRI is not indicated

for routine follow-up.

Superior vena cava

(SVC) obstruction

Severe hemoptysis Localized symptom

* Concurrent chemoradiation

(if not previously given) *External-beam RT

* SVC stent *External-beam RT or brachytherapy * Laser or photodynamic therapy or

Embolization *Surgery

Palliative external-beam RT

Diffuse brain metastases

Palliative external-beam RT

* Palliative external-beam RT + orthopedic

See A-14

Distant

metastases

Bone metastasis

stabilization, if risk of fracture

*Consider bisphosphonate therapy or denosumab

Solitary metastasis

Disseminated metastases

See A-12

See A-14

A-13


Systemic Therapy for

Metastatic Disease

Evaluation

Histologic Subtype

*Adenocarcinoma

*Large cell

*NSCLC not otherwise

*EGFR mutation testing

*ALK testing * PDL-1 testing

Sensitizing EGFR

mutation positive

ALK positive

See A-15 See A-16

*Establish histologic subtype specified (NOS)

Metastatic

disease

with adequate tissue for

molecular testing (consider

rebiopsy if appropriate)

*Smoking cessation advice,

counseling *Intergrate palliative care

Sensitizing EGFR

mutation and ALK

negative or unknown *Consider EGFR mutation and ALK testing

especially in nerver smokers or small biopsy,

See A-17

Squamous cell

carcinoma

specimens, or mixed histology

* PDL-1 testing See A-18

A-14


Adenocarcinoma, large cell, NSCLC NOS: sensitizing EFGR mutation positive

First-line therapy Second-line therapy

Isolated

lesion

Consider local therapy

and continue erlotinib

or afatinib or Gefitinib

brain

EGFR

Multiple lesions

Consider WBRT and

continue erlotinib or

afatinib or Gefitinib

mutation

discovered

prior to first-

line

chemotherapy

EGFR mutation

discovered

during first-line

chemotherapy

Progre-

ssion

Symptomatic

Asymptomatic

Consider local

therapy and continue erlotinib or afatinib

or Gefitinib systemic

Consider platinum

double ± bevacizumab ±

erlotinib

Continue erlotinib or afatinib or

Gefitinib

Progre-

ssion

See A-19

Sensitizing

EGFR

mutation

positive

Erlotinib or Afatinib or Gefitinib

Interrupt or

complete planned

chemotherapy,

start erlotinib or

afatinib or

Gefitinib or

May add erlotinib

or afatinib to

current

chemotherapy

Multiple lesions

Isolated lesion

A-15


Adenocarcinoma, large cell, NSCLC NOS: ALK positive

First-line therapy Second-line therapy

Isolated

lesion

Consider local therapy

and continue crizotinib

brain

Multiple lesions

Consider WBRT and continue crizotinib

ALK

rearrangement

Symptomatic

Sensitizing

EGFR

mutation

positive

discovered

prior to first-

line

chemotherapy

ALK

rearrangement

discovered

during first-line

chemotherapy

Progre-

ssion

Asymptomatic

Isolated

lesion systemic

Multiple lesions

Continue crizotinib

Consider local

therapy and continue

crizotinib Avastin±雙白金類

Progre-

ssion

See A-19

Crizotinib

Interrupt or

complete planned

chemotherapy,

start crizotinib

A-16


Adenocarcinoma, large cell, NSCLC NOS: EGFR mutation and ALK negative or unknown

First-line Therapy

Doublet

chemotherapy

or

PS 0-2

Second-line Therapy

If not already given:

Docetaxel or Pemetrexed or

Erlotinib or Gemcitabine

See A-19

Bevacizumab+ Progression

PS 0-1 chemotherapy

or PS 3-4 Best supportive care

Erlotinib

or

Cetuximab/vinorelbin

Tumor

response

evaluation

Progression

See second-line

therapy, above

PS 2

PS 3-4

Chemotherapy Best supportive care

Reaponse

or stable

disease

4-6

cycles

(total)

Tumor

response

evaluation

Reaponse

or stable

disease

Continuation maintenance *bevacizumab

*cetuximab

*pemetrexed *bevacizumab+ pemetrexed

*gemcitavine or *Switch maintenance * pemetrexed or erlotinib

or Close observation

Progression,

see second-

line therapy,

above

A-17


Squamous cell carccinoma

First-line Therapy

Second-line Therapy


PS 0-2 Docetaxel or Erlotinib or See A-19

Doublet Gemcitabine

chemotherapy Progression

PS 0-1 or Cetuximab/

PS 3-4

Best supportive care

vinorelbine/

cisplatin

Tumor

response

evaluation

Progression

See second-line

therapy, above

PS 2

PS 3-4

Chemotherapy


Response

or stable

disease

4-6

cycles

(total)

Tumor

response

evaluation

Response

or stable

disease

Continuation maintenance *cetuximab

*gemcitavine

or Switch maintenance

or Close observation

Progression,

see second-

line therapy,

above

A-18


Adenocarcinoma, large cell, NSCLC NOS, or Squamous cell carccinoma

Third-line Therapy

PS 0-2


Docetaxel

or Pemetrexed( non-squamous) or

Erlotinib

or

Gemcitabine

Progression

PS 0-2 PS 3-4

Best supportive care or Clinical trial


Progression

PS 3-4

Erlotinib or Best supportive care

A-19

AJCC8th TNM (Tumor-Node-Metastasis) Stage：

Definition of Primary Tumor(T)

T Category T Criteria

TX Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or

bronchial washings but not visualized by imaging or bronchoscopy

T0 No evidence of primary tumor

Tis Carcinoma in situ

Squamous cell carcinoma in situ (SCIS) Adenocarcinoma in situ (AIS): adenocarcinoma with pure lepidic pattern, ≤ 3 cm in greatest dimension

T1 Tumor ≤ 3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic

evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)

T1mi Minimally invasive adenocarcinoma: adenocarcinoma (≤ 3 cm in greatest dimension) with a

predominantly lepidic pattern and ≤ 5 mm invasion in greatest dimension

T1a Tumor ≤1 cm in greatest dimension. A superficial, spreading tumor of any size whose invasive

component is limited to the bronchial wall and may extend proximal to the main bronchus also is

classified as T1a, but these tumors are uncommon.

T1b Tumor> 1 cm but ≤ 2 cm in greatest dimension

T1c Tumor> 2 cm but ≤ 3 cm in greatest dimension

T2 Tumor > 3 cm but ≤ 5 cm or having any of the following features: ●Involves the main bronchus regardless of distance to the carin, but without involvement of the carina ●Invades visceral pleura (PL1 or PL2) ●Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or

all of the lung T2 tumors with these features are classified as T2a if ≤ 4 cm or if the size cannot be determined and T2b

if > 4 cm but ≤ 5 cm.

A-20

T2a Tumor> 3 cm but ≤4 cm in greatest dimension

T2b Tumor> 4 cm but ≤5 cm in greatest dimension

T3 Tumor > 5 cm but ≤ 7 cm in greatest dimension or directly invading any of the following: parietal pleural

(PL3), chest wall (including superior sulcus tumors), phrenic nerve, parietal pericardium; or separate

tumor nodule(s) in the same lobe as the primary

T4 Tumor > 7 cm or tumor of any size invading one or more of the following: diaphragm, mediastinum,

heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; separate

tumor nodule(s) in an ipsilateral lobe different from that of the primary

Definition of Regional Lymph Node(N)

N Category N Criteria

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension

N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)

N3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or

supraclavicular lymph node(s)

Definition of Distant Metastasis(M)

M Category M Criteria

M0 No distant metastasis

M1 Distant metastasis

A-21

M1a Separate tumor nodule(s) in a contralatearl lobe; tumor with pleural or pericardial nodules or malignant pleural

or pericardial effusion. Most pleural (pericardial) effusion with lung cancer

are a result of the tumor. In a few patients, however, multiple microscopic examinations of pleural (pericardial) fluid are negative for tunor, and the fluid is nonbloody and not an exudates. If these

elements and clinical judgment dictate that the effusion is not related to the tumor, the effusion should be

excluded as a staging descriptor.

M1b Single extrathoracic metastasis in a single organ (including involvement of a single nonregional node)

M1c Multiple extrathoracic metastases in a single organ or in multiple organs

AJCC PROGNOSTIC STAGE GROUPS T N M GROUP

TX

Tis

T1mi

T1a

T1a

T1a

T1a

T1b

T1b

T1b

T1b

T1c

T1c

T1c

N0

N0

N0

N0

N1

N2

N3

N0

N1

N2

N3

N0

N1

N2

M0

M0

M0

M0

M0

M0

M0

M0

M0

M0

M0

M0

M0

M0

Occult carcinoma

0

IA1

IA1

IIB

IIIA

IIIB

IA2

IIB

IIIA

IIIB

IA3

IIB

IIIA

A-22

T1c N3 M0 IIIB

T2a N0 M0 IB

T2a N1 M0 IIB

T2a N2 M0 IIIA

T2a N3 M0 IIIB

T2b N0 M0 IIA

T2b N1 M0 IIB

T2b N2 M0 IIIA

T2b N3 M0 IIIB

T3 N0 M0 IIB

T3 N1 M0 IIIA

T3 N2 M0 IIIB

T3 N3 M0 IIIC

T4 N0 M0 IIIA

T4 N1 M0 IIIA

T4 N2 M0 IIIB

T4 N3 M0 IIIC

Any T Any N M1a IVA

Any T Any N M1b IVA

Any T Any N M1c IVB

A-23

Small Cell Lung Cancer

Diagnosis Initial Evaluation

*H & P

*Pathology review

Stage Limited stage (T any, N any, M0; except T3-4 due to multiple lung

* WBC, DC, Hgb, platelets

*Electrolytes, liver function

nodules that do not fit in a tolerance radiation on field)

See A-25

Small cell or combined small

cell/non-small cell lung

cancer on biopsy or cytology

of primary or metastatic site

*BUN, creatinine *Chest/liver/adrenal CT with IV contrast

whenever possible *Head MRI (preferred) or CT

*Bone scan (refer to KMUH)

*PET/CT scan (if limited stage is

suspected) (option)

*Smoking cessation counseling and

intervention

Extensive stage (T any, N any,

M1a/b; T3-4 due to multiple lung

nodules)

See A-27

A-24


Stage Additional Workup

*If pleural effusion is present,

thoracentesis is recommended; if

Clinical stage

(T1-2, N0)

PET/CT (if not

previous

obtained)

Pathologic

mediastinal

staging is

considered

See A-26

Limited stage (T any, N any, M0;

except T3-4 due to multiple lung

nodules that do not fit in a

tolerable radiation field)

thoracentesis inconclusive, consider

thoracoscopy

*Pulmonary function tests (PFTs) (if

clinically indicated) *Bone imaging(radiographs or MRI) as

appropriate if PET-CT equivocal *Unilateral marrow aspiration/biopsy in

select patients

Limited stage in

excess of T1-2,

N0

Bone marrow

biopsy,

thoracentesis, or

bone studies

consistent with

malignancy

See A-26

See A-27

A-25


Testing Results Initial Treatment Adjuvant Treatment

Pathologic mediastinal

staging negative

Lobectomy (preferred) and

mediastinal lymph node

dissection or sampling

N0

N+

Chemotherapy Concurrent

chemotherapy +

mediastinal RT

Clinical stage

T1-2, N0

Good performance status (PS 0-2)

Chemotherapy + concurrent thoracic RT

See A-28

Pathologic mediastinal

staging positive or

medically inoperable

Poor PS (3-4) due to

SCLC

Poor PS (3-4) not

due to SCLC

Chemotherapy ± RT Individualized treatment

including supportive care

Limited stage

excess T1-2, N0

Good performance

status (PS 0-2)

Poor PS (3-4) due to

SCLC

See A-28

Poor PS (3-4) not

due to SCLC

Individualized treatment

including supportive care

Chemotherapy ±RT

Chemotherapy +concurrent thoracic RT

A-26


Stage Initial Treatment

Extensive stage (T any,

N any, M1a/b; T3-4 due

to multiple lung nodules)

Extensive stage without

localized symptomatic

sites or brain metastases

Extensive stage +

localized symptomatic

sites

Extensive stage with

brain metastases

*Good PS (0-2)

*Poor PS (3-4) due to

SCLC

*Poor PS (3-4) not due

to SCLC *SVC syndrome

*Lobar obstruction

*Bone metastases

Spinal cord

compression

Asymptomatic

Symptomatic

Combination chemotherapy including supportive care

See NCCN Palliative Care Guidelines

Individualized therapy including supportive care See

NCCN Palliative Care Guidelines

Chemotherapy± RT to symptomatic sites If high risk of fracture due to osseous structural

impairment, consider palliative external-beam RT and

orthopedic stabilization

RT to symptomatic sites before chemotherapy unless

immediate systemic therapy is required.

May administer chemotherapy first, with whole-brain

RT after chemotherapy

Whole-brain RT before chemotherapy, unless

immediate systemic therapy is required

See A-28

A-27


Response Assessment Following Initial Therapy Adjuvant Treatment Surveillance

*Chest x-ray (optional)

*Chest/liver/adrenal CT with IV

contrast whenever possible

*Brain MRI (preferred) or CT with IV

contrast whenever possible, if

prophylactic cranical irradiation

(PCI) to be given

*Other image studies, to assess prior

sites of involvement, as clinically

indicated

*CBC, platelets

*Electrolytic, LFTs, Ca, BUN,

creatinine

Complete response or

partial response

Stable disease Primary progressive

disease

Limited or extensive

stage: PCI

After recovery from primary therapy:

*Oncology follow-up visits every 3-4 mo

during y 1-2, at least every 6 mo during

y 3-5, then annually

-At every visit: H&P, chest imaging,

bloodwork as clinically indicated

*New pulmonary nodule should initiate

workup for potential new primary

*Smoking cessation intervention

*PET/CT is not recommended for routine

follow-up See A-24

See A-29

A-28


Progressive Disease Subsequent Therapy/Palliative Therapy

Subsequent chemotherapy

(category 1 for topotecan)

or

Continue until two cycles beyond

best response or progression of

disease or development of

unacceptable toxicity

Palliative symptom management,

including localized RT to

symptomatic sites

PS 0-2 palliative symptom management,

including localized RT to

symptomatic sites

Relapse or primary

progressive disease

PS 3-4 Palliative symptom management, including localized RT to

symptomatic sites

A-29

CCRT 的原則

NSCLC Dose: up to 60-66Gy/1.8-2Gy/day Limited SCLC

1.年齡小於等於70歲，PS：0~1，接受CCRT DOSE：50~60 Gy/1.8Gy/day。

排程：放療自開始持續做至50~60 Gy，而化學治療自開始先做三個療程後休息，須重新評估病患治療反應，之後再依實際情形

安排接續的治療。

如有CR，加做预防性全腦放射治療 (prophylactic cranial irradiation, PCI) 。

DOSE： 30Gy/ 2Gy/ day x15 fractions(一天一次共十五次）。

如有PR，持續化學治療，但不做PCI。

2.年齡大於70歲，PS：0~1，採用接續性化放療(sequential chemoradiotherapy)，DOSE：50~60 Gy/1.8Gy/day。

排程：連續的三個療程的化學治療後休息，在二週內重新評估。

如有CR，加做PCI, DOSE： 30Gy/ 2Gy/ day x15 fractions(一天一次共十五次）。

如有PR，加做胸腔的放療及三個療程的化學治療，但不做PCI。

3.如有PD，接受第二線化療。

Principles of chemotherapy regimen

1.Chemotherapy at systemic doses results in superior outcome but at the cost of an increased toxicity.

2.Platinum-based regimen is preferred

3.Reference regimens with combination of platinum

–Etoposide

–Vinorelbine or Vinblastine

A-30

4.Alternative regimens with combination of platinum

–Paclitaxel -Docetaxel -Pemetrexed

5.High-risk drugs for CCRT

–Gemcitabine -EGFR-TKI (gefitinib, erlotinib) - Bevacizumab

-Doxorubicin

A-31

參考文獻

1. Small Cell Lung Cancer NCCN V1.2017 from http://www.nccn.org

2. Non-Small Cell Lung Cancer NCCN V4.2017from http://www.nccn.org

3. Paumier, A. and C. Le Pechoux, Radiotherapy in small-cell lung cancer:where should it go Lung Cancer, 2010. 69: 133-40.

4. Sorensen, M., M. Pijls-Johannesma, and E. Felip, Small-cell lung cancer:ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.

Ann Oncol, 2010. 21 Suppl 5: v120-5.

5. Khan, A.J., P.S. Mehta, T.W. Zusag, et al., Long term disease-free survival resulting from combined modality management of patients presenting with

oligometastatic, non-small cell lung carcinoma (NSCLC). Radiother Oncol, 2006. 81: 163-7.

Cancer of the Esophagus

Treatment Guideline

KMHK

制定日期 : 104 年 1 月 1 日

修訂日期 : 107 年 6 月 5 日

食道癌修訂記錄


104年

105年

106年

第一版依照 NCCN guideline 制定本院治療準則

多科會議討論檢視後未修改

1.Endoscopic mucosal resection (EMR)修改為 Endoscopic resection (ER)並加入建議

分期為 T1a or T1b 之附註(A-29)

2.分期 Stage I-III (locoregional disease)Adenocarcinoma See ESOPH-10 改為 See A-29

3.分期 Stage IV (metastatic disease) Squamous cell carcinoma See ESOPH-9 改為 See A-29 4. Multidisciplinary evaluation-Consider nasogastric or J-tube for preoperative nutritional support 增加 PEG 亦可 support preoperative nutrition (A-30) 5.刪除 Squamous cell carcinoma Stage I-III (locoregional disease) Medically unfit

for surgery or surgery not ...(A-30)

6.新增 Non-surgical candidate(Refer to KMUH) (A-30)

7.修改 Squamous cell carcinoma (A-31) Tis 建議行Endoscopic therapies or Esophagectomy

T1a 建議行 Endoscopic therapies (preferred) or esophagectomy

T1b, N0 建議行 Eesophagectomy

T1b, N+, T2-T4a, N0- N+建議行 Chemoradiation (Refer to KMUH) or esophagectomy T4b(Refer to KMUH)

8.刪除 A-32、A-33、A-34 頁數全部內容

9.Palliative/Salvage therapy 更改為 Palliative therapy(A32) 10.Esophageal Cancer (squamous cell carcinoma) recurrent Palliative therapy See ESOPH-9 改為 See A32

11. Esophageal Cancer (squamous cell carcinoma) Unresectable locally advanced,

A-29

A-30

A-31

A-32

1.0

2.0

食道癌修訂記錄


107年

locally recurrent or metastatic disease Karnofsky performance score ≥ 60%

or ECOG

performance score≤ 2 修改建議 cheotherapy/Radiotherapy 更改為 Systemic

therapy

and/or best supportive care(A33)

12. Esophageal Cancer (squamous cell carcinoma) Unresectable locally

advanced, locally recurrent or metastatic disease ,ECOG performance score≥

2,改為≥ 3 建議 Best

supportive care(A33)

13. Esophageal Cancer Adenocarcinoma Stage I-III (locoregional

disease) See ESOPH-11 改為 See A35、新增 Non-surgical

candidate(Refer to KMUH)、移除

Medically unfit for surgery... (A-34) 14. Esophageal Cancer (Adenocarcinoma) Tis、T1a 建議行 Endoscopic

therapies(preferred)or Esophagectomy(A-35) T1b, N0 建議行

Eesophagectomy

T1b, N+, T2-T4a, N0- N+建議行 Chemoradiation (Refer to KMUH) or

esophagectomy

T4b(Refer to KMUH)

1.刪除 T4b 之(Refer to KMUH)改為 Chemoradiation or Chemotherapy or

Radiation or Best support care And/or hospice care or clinical trial (refer

to KMUH)、加入 R/T 說明。

A-33

A-34

A-35

A-31、A-35

3.0

Esophageal Cancer

Workup Clinical stage Histologic classification

Squamous cell carcinoma See A33

*H & P

*Upper GI endoscopy and biopsy

* Chest/abdomen CT with oral and IV contrast

Stage I-III

(locoregional

disease)

*PET-CT evaluation if no evidence of M1 disease(refer to KMUH)

*CBC and chemistry profile

*Endoscopic resection (ER) is essential for the accurate staging of

early stage cancers(T1a or T1b)

*Nutritional assessment and counseling

*Biopsy of metastatic disease as clinically indicated

*HER2-neu testing if metastatic adenocarcinoma is

documented/suspected

*Bronchoscopy, if tumor is at or above the carina with no evidence of

Adenocarcinoma Squamous cell carcinoma

See A37 See A36

M1 disease

*Assign Siewert category

*Smoking cessation advice, counseling, and pharmacotherapy

Stage IV

(metastatic

disease

Adenocarcinoma Palliative therapy

A-32

Esophageal Cancer

Histology Clinical stage Additional Evaluation

(as clinically indicated)

Medically fit for surgery See A34

Squamous

cell

carcinoma

Stage I-III

(locoregional

disease)

*Multidisciplinary evaluation -

Consider nasogastric or J-tube or PEG for preoperative nutritional

support

Non-surgical candidate(Refer to KMUH)

A-33

Esophageal Cancer

Histology Tumor

classifications

Primary treatment options for medically fit patients

Tis

T1a

Endoscopic therapies or Esophagectomy Endoscopic therapies (preferred) or esophagectomy

Squamous cell

carcinoma

T1b, N0 Eesophagectomy

T1b, N+, Chemoradiation or esophagectomy

T2-T4a, N0- N+

Chemoradiation or Chemotherapy or Radiation or Best support

T4b care

And/or hospice care or clinical trial (refer to KMUH) 說明：因本院無放射治療設備，故治療需放射線治療及同步化學治療病患協助轉診至高醫或他院治療

A-34

Esophageal Cancer

Follow-up for squamous

cell carcinoma

Recurrence Palliative therapy

*H & P

-if asymptomatic: H & P every

3-6 mo for 1-2y, every 6-12 mo

Locoregional only

recurrence: prior

esophagectomy, no

prior chemoradiation


(fluoropyrimidine- or

taxane-based) preferred or

surgery or chemotherapy or

best supportive care

Recurrence

See A36

for 3-5y, then annually

* Chemistry profile and CBC, as

Resectable and

medically

esophagectomy

Recurrence

See A36

clinically indicated

*Imaging study


*Dilatation for anastomotic

stenosis

*Nutritional assessment and

counseling

Locoregional only

recurrence: prior

chemoradiation, no

prior esophagectomy

Metastatic disease

operable Unresectable or

medically

inoperable

See A36

A-35

Esophageal Cancer

For squamous cell

carcinoma

Performance status

Palliative therapy

Karnofsky performance score ≥

60%

or

ECOG performance score≤ 2

Systemic therapy and/or best supportive care

Unresectable locally advanced,

locally recurrent or metastatic

disease

Karnofsky performance

score

Esophageal Cancer

Histology Clinical status Additional evaluation

(as clinically indicated)

*Multidisciplinary evaluation -

Consider nasogastric or J-tube or

PEG for preoperative nutritional

Medically fit for surgery See A38

Adenocarcinoma

Stage I-III

(locoregional

disease)

support -Laparoscopy (optional)

if no evidence of M1 disease and

tumor is at esophagogastric

junction(EGJ)


care

And/or hospice care or clinical trial (refer to KMUH)

A-37

Esophageal Cancer

Tumor classification Primary treatment options for medically fit patients

Endoscopic therapies(preferred)or Esophagectomy

T1b,N0 Esophagectomy

Adenocarcinoma Chemoradiation

T1b,N+

T2-T4a, N0-N+

T4b

Esophagectomy


care

And/or hospice care or clinical trial (refer to KMUH)

說明：因本院無放射治療設備，故治療需放射線治療及同步化學治療病患協助轉診至高醫或他院治療

T1a

Tis

A-38

Esophageal Cancer

Follow-up for

adenocarcinomas

Recurrence

Palliative/salvage therapy

*H & P

-if asymptomatic: H & P every 3-6 mo for

1-2y, every 6-12 mo for 3-5y, then

Locoregional only

recurrence: Prior

esophagectomy, no prior

chemoradiation

Surgery or

Chemotherapy or


Recurrence

Palliative therapy

annually

* Chemistry profiles and CBC, as clinically

indicated

*Imaging studies


*Dilatation for anastomotic stenosis

*Nutritional assessment and counseling

Locoregional only

recurrence: Prior

chemoradiation, no prior

esophagectomy

Metastatic disease

Resectable and

medically

operable

Unresectable or

medically

inoperable

Esophagectomy

Palliative

therapy

A-39

參考文獻

1. Esophagus Cancer V2.2017 from http://www.nccn.org

2. van Hagen P, Hulshof MC, van Lanschot JJ, et al.Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med

2012;366:2074-2084.

3. Tepper J, Krasna MJ, Niedzwiecki D, et al. Phase III trial of trimodality therapy with cisplatin, fluorouracil, radiotherapy,and surgery compared with

surgery alone for esophageal cancer: CALGB 9781. J Clin Oncol 2008;26:1086-1092.

4. Bedenne L, Michel P, Bouche O, et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the

esophagus: FFCD 9102. J Clin Oncol 2007;25:1160-1168.

http://www.nccn.org/

Cancer of the Liver

Treatment Guideline

KMHK

制定日期 : 97 年 1 月 1 日

修訂日期 : 107 年 6 月 1 5 日

肝癌修訂記錄


97年

98年

99年

100年

101年

102年

肝癌診療指引新制訂

多科會議討論檢視後未修改多




※診療指引 1.原甲種胎兒蛋白≧400ng/ml，無其他癌症，且無急性肝炎發作

或懷孕→修改為甲種胎兒蛋≧400ng/ml ，腫瘤>1cm，無其他癌症，且無急性肝炎發作或懷孕。

2.原甲種胎兒蛋白：>400ng/ml，但同時有其他癌症或急性發作‧

肝癌修訂記錄


103年

104年

105年

※肝癌各種治療法適應症指引

1.手術切除符合條件新增主治醫師認為手術對病患病情控

制較有利時，仍可與病人討論後採用手術治療。

2.局部消除治療:經皮藥物注射治療(PEI)：大型肝癌一般不建

議，但可施行血管內肝癌注射者或特殊情況時亦可嘗試，

請會診肝癌團隊會議→修改為大型肝癌一般不建議，但可施

行血管內肝癌注射者或特殊情況時亦可嘗試，可與其他治療併

用為輔助治療。

3.新增微波凝固治療(micro-wave)治療。

※修訂肝癌治療流程圖如附件

※新增分期：

1.HCC Staging :BCLC 新增 TNM 路徑

2.AJCC 7th TNM (Tumor-Node-Metastasis)

Stage 3.The Child-Pugh stage of Liver

cirrhosis

※修訂抗癌藥物處方

※診療指引

1.新增 TNM 治療路徑

※診療指引

1.新增術前建議評估：Chest x-ray、Cardio echo。

2.修訂 Strategy for staging and treatment assignment in

patients diagnose with HCC according to the BCLC

proposal 流程圖。

3. 新增 BCLC classification

※診療指引

1.刪除 : 做多次稀釋檢查 (multipledilution） .術前建議評估-Lung function test、Chest x-ray、

B-2

B-3

B-4

B-6~7

B-8~9

B-5

B-2

B-7

B-8

B-2

B4 B7

3.0

4.0

5.0

106年

107年

Cardio echo修改為開刀術前建議評估-Lung function

test、Chest x-ray、Cardio echo

3.刪除: (目前為每個月第二周禮拜二上午及第四周禮拜五

下午) 1.刪除 Child-pugh C 的治療中的標靶治療。

2.非常早期(0)新增治療方式為切除

※局部消除治療

1. 新增九、姑息性治療

(一)經導管動脈栓塞術

(二)放射性治療

(三)化學或標靶治療

2. (三)化學或標靶治療

動脈內灌注化學治療、全身靜脈化學治療---建議轉高醫

接受此治療

※肝癌治療準則

2.1.AJCC7th修改為AJCC8th

6.0 7.0

一、肝癌診斷導引

疑似病例

a.影像學檢查：Abdomen echo或CT或MRI

b.甲種胎兒蛋白檢查或 c.組織學檢查:細針穿刺細胞學或切片病理學檢查

細胞學或病理診斷有

且為確定診斷進入肝

癌治療

細胞學或病理學檢查未能

確診，或因特殊原因未做細

胞學或病理學檢查

未發現腫瘤、非惡性腫瘤或無法確定

甲種胎兒蛋白

≧400ng/ml，腫

瘤≧1cm，無其

他癌症，且無急

性肝炎發作或

懷孕。

甲種胎兒蛋

白：‧≧400ng/ml ，

腫瘤≧1cm，但同

時有其他癌症或

急性肝炎發

作‧

二、肝癌治療前評估項目建議檢查清單

(一)病因： HBsAg、Anti-HCV、飲酒及酗酒史、肝硬化家族史 Option： HBeAg、HBeAb、HBV-DNA、HCV-RNA

(二)診斷依據：

1.腫瘤標記：甲種胎兒蛋白(alpha-fetoprotein)，其他CEA、Ca19-9。

2.影像檢查:CT 或做 MR with enhancement dynamic is phase。三、建議診斷(依據共識會議診斷)

(一)細針抽吸細胞學診斷。

(二)管針切片病理學檢查。四、功能評估：

(一)Liver function Evaluation：膽色素、白蛋白、凝血酶原時間、GOT、GPT、腹水、肝昏迷。 (二)Performance ：WHO Performance Scale (ECOG) (三)Routine exam： EKG、BUN、Creatinine、CBC、urine、stool、開刀術前建議評估-Lung function test、Chest x-ray、Cardio echo

五、肝癌分級：Staging and TNM classification

影像學檢查含： 1.基本之胸、腹部X光片。 2.腹部超音波，有顯影之腹部電腦斷層掃瞄或磁振掃瞄（在開始治療之前），血管攝影（可與治療同時安排）等評估腫瘤大小、腫瘤侵犯、及腹部淋巴節轉移之檢查。

3.核醫科骨骼掃瞄(Bone scan)及正子電腦斷層掃描 PET(高度懷疑儘可能檢查)。---建議轉高醫接受此檢查。六、肝癌各種治療法適應症指引，有任何不確定或疑慮者，請會診肝癌團隊會議，肝癌各種

治療可單獨使用或合併治療。七、手術切除：需符合下列條件

(一)單一肝癌或多發位於同一肝葉且少於三個之肝癌。 (二)肝功能Child pugh classification A，或可施行小範圍切除之Child pugh classification B。

(三)無其他不適合手術之病況。 4.主治醫師認為手術對病患病情控制較有利時，仍可與病人討論後採用手術治療

八、局部消除治療：最大直徑小於三公分，少於三個之肝癌；或單一 5 公分以下肝癌，無嚴重出血傾向且可在超音波或電腦斷層導引下施行者。肝能 child-pugh classification A或B，及部分C者。

(一)經皮藥物注射治療(PEI)：大型肝癌一般不建議，但可施行血管內肝癌注射者或特殊情況時亦可嘗試，可與其他治療併用為輔助治療。

(二)高週波治療(RFA)及微波凝固治療(micro-wave)：肝功能及血液凝固能力要求較經皮藥物注射治療為嚴格。大型肝癌雖亦可使用，但最好在全身麻醉下施行，需可承受麻醉者方可使用。

B-2

九、姑息性治療:

(一)經導管動脈栓塞術：為姑息性治療，腫瘤數目範圍大小較無限制。肝功能Child pugh A及B之早期，無主肝門靜脈侵犯者；無肝腦病變或嚴重腹水，總膽色素需在3mg/dl以下，但總膽管阻塞者例外。需先評估出血傾向及血液凝固時間。

(二)放射線治療：任何可定位之病灶均可施行，通常為合併栓塞之輔助治療或在上述治療不適合時，做為主要治療適應症如下：無法手術切除或經導管動脈栓塞術的原發部位，肝癌轉移性病灶，肝門靜脈侵犯，總膽管侵犯。---建議轉高醫接受此治療

(三)化學或標靶治療：無法施行根除性治療且無法或不適合栓塞之肝癌，或併發多發轉移性病灶者。---建議轉高醫接受1、2治療 1.動脈內灌注化學治療。 2.全身靜脈化學治療。 3.口服藥物化學治療。 4.標靶治療或實驗用藥。

十、肝臟移植：需接受根除性治療，但肝功能不足無法手術者，而全身狀況可接受麻醉手術者，需無遠處轉移且影像學上沒有血管侵犯。

---建議轉高醫接受此治療(一)全肝(屍肝移植)： 1.單一肝癌，最大直徑小於5 公分。 2.多發性腫瘤，小於或等於 3 顆，最大直徑小於 3 公分。

(二)活體肝臟移植：

1.單一肝癌，最大直徑小於 6.5 公分。

2.多發性腫瘤，小於或等於 3 顆，其中最大肝癌不大於 4.5 公分或三顆直徑總和不大小於 8公分。

B-3

十一-1、肝癌治療流程圖：

確診病例

肝功能及影像學評估分

治療後經醫

師評估後可

行curative治

療

非主門靜脈侵犯

Child-pugh A-B

‧經導管動脈腫瘤栓塞術

‧標靶治療 ‧放射線治療

主門靜脈侵犯 Child- Child-pugh A-B pugh C ‧標靶治療 ‧放射線治療 ‧臨床試驗 ‧動脈或全身化學治療

醫師評估後無法行curative治

支持性療法

＊手術切除療

肝臟移植＊局部消除治療＊酒精注射

支持性療法

＊高週波微波治療

•單一肝癌>5cm 或

•兩葉多發性肝癌，或

•主要門靜脈或其他主要血管侵犯,或有遠處

轉移病灶或

•肝功能或全身狀況不適合施行根除性治療

•單一肝癌≦5cm 或

•多發但少於 3 顆於同一

肝葉或

•無轉移或位於同一小葉

或 •無主要血管及門靜脈侵犯

1.Child-pugh C 或

Child-pughA-B,但

肝癌位置、數目無

法接受根治性治療。

2.全肝移植(屍肝)：

單一肝癌,最大直徑

Hepatocellular carcinoma

十一-2、肝癌治療流程圖：

TNM Directed

T1 T2 T3 or T4 N1 or M1

1.治癒性治療： Resection Local ablation

2.無法進行治癒性治療： TACE 其他替代治療

腫瘤數3個以內儘可能

治癒性治療： TACE Combined

Therapy

TACE Combined

therapy Irradiation Chemotherapy Targeting

therapy Resection when

possible

Irradiation Targeting

therapy Local or

systemic Chemotherapy

Single may try

curative therapy

B-5


十二、HCC Post- treatment Follow Up Flowchart

(一)追蹤影像：

OP、RFA、PEI、TACE(TAE) (首次療程)

2 個月內

F/U Abd echo、CT、

1年內

F/U Abd echo、CT、MRI 需3次或以上

(二)追蹤AFP elevated：

第一次治療前AFP>20ng/ml 的肝癌病人有行(首次療程)

OP、RFA、PEI、TACE(TAE)

2 個月內

F/U AFP elevated

1年內

F/U AFP elevated需3次或以上

B-6


十三、分期：1 .Strategy for staging and treatment assignment in patients diagnose with HCC according to the BCLC proposal


Stage：0

PST：0

child-turcotte-pugh：A

stage：A-C

PST：0-2

child-turcotte-pugh：A or B

stage：D

PST：>2

child-turcotte-pugh：C

Very early

stage(0)

single< 2cm

Early stage:A single nodule< 5cm or 3 nodules≦3cm

PST：0

Intermediate stage: B

Multinodular，

PST：0

Advanced stage:C portal invasion

N1,M1, PST：1-2

Terminal stage:D

carcinoma in situ single

Increased portal pressure

and elevated bilirubin level

yes

3 nodules≦3cm

Association disease

TAE or TACE Supportive care

no Sorafenib

resection

no

Liver transplantion(CLT orLDLT)

yes

PEI orRFA

or target

therapy

B-7

2. AJCC8th TNM (Tumor-Node-Metastasis) Stage：

TX

T0

T1

T1a

T1b

T2 T3

T4

Primary Tumor (T) Primary tumor cannot be assessed No evidence of primary tumor Solitary tumor ≦2cm，or >2cm without vascular invasion Solitary tumor ≦2cm Solitary tumor ＞2cm without vascular invasion Solitary tumor ＞2cm with vascular invasion，or multiple tumors，none>5cm Multiple tumors，at least one of which is ＞5cm Single tumor or multiple tumors of any size involving a major branch of the

portal vein or hepatic vein，or tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritonem.

NX

N0

N1

Regional Lymph Nodes (N) Regional lymph nodes cannot be assessed

No regional lymph node metastasis

Regional lymph node metastasis

M0 M1

Distant Metastasis (M) No distant metastasis

Distant metastasis

A NATOMIC S TAGE / P ROGNOSTIC G ROUPS CLINICAL PATHOLOGIC

GROUP T N M

IA T1a N0 M0 IB T1b N0 M0 II T2 N0 M0

IIIA T3 N0 M0 IIIB T4 N0 M0 IVA Any T N1 M0

IVB Any T Any N M1

GROUP T N M

IA T1a N0 M0 IB Tb N0 M0 II T2 N0 M0

IIIA T3 N0 M0 IIIB T4 N0 M0 IVA Any T N1 M0

IVB Any T Any N M1

B-8

3. Barcelona-Clinic Liver Cancer (BCLC) classification

Stage Tumor Features Child-Pugh Score Performane Status

Test

Stage 0 Single≤2cm Carcinoma in situ

Child-Pugh A 0

Stage A Single≤ 5cm or 3

nodulars ≤ 3cm

Child-Pugh A-B 0

Stage B Single＞5cm or

Multinodulars

Child-Pugh A-B 0

Stage C Portal invasion N1,M1†

Child-Pugh A-B 1-2

Stage D Any Child-Pugh C 3-4

*BCLC期別摘錄規則依據行政院衛生署國民健康局書函(發文字號:國健癌字第1000302045號)

4. The Child-Pugh stage of Liver cirrhosis

Score 1 2 3

Total bilirubin (mg/dl) 3.0 Albumin (g/dl)

>3.5

2.8-3.5

normal

time,sec )

6 sec

Total score:

Child A: 5-6

Child B: 7-9

Child C: 10-15

B-9

(十)抗癌藥物治療處方：---建議轉高醫接受此治療

1.When WBC

---Subselective intra-aortic ---

Regimen I (A)

Continuous infusion of 5FU (50~250mg) a day using a portable pump

Regimen I (B)

Intermittent one shot of Epirubicin (10~20mg) + Mitomycin C(2~8mg)

Regimen I (C) Continuous infusion of 5FU (50~250mg) a day using a portable pump

Intermittent one shot of Epirubicin (10~20mg) + Mitomycin C(2~8mg)

regimenⅡ Intermittent one shot of Oncovin(2mg)

RegimenⅢ Intermittent one shot of Cisplatin(10-30mg)

RegimenⅣ

Day1 VP-16(50mg~mg)×30min + Cisplatin(150mg~mg) ×30min + Epirubicin (60mg~mg) ×30min

Day2 5FU(500mg- mg)×24hr×一天，每15天為1 cycle(每15天打一次)

---Intra-hepatic artery Chemotherapy A ---

Regimen I(A)

1st week 5FU(50-500mg)

2nd week 5FU(50-500mg)+Epirubcin(10-40mg)

3rd week 5FU(50-500mg)

4th week5FU(50-500mg)+Epirubcin(10-40mg)+Mitomycin-C (2-10mg)

Regimen I(B)

Cisplatin(2-40mg) in N/S or D5W 150cc keep 150CC/hr × 5 days×4weeks 5FU(50-500mg) + Leucovorin (25-100 mg)in N/S or D5W 250cc keep 50CC/hrfor total 5hr ×5 days×4weeks

B-11

Regimen I(C)

Cisplatin(2-40mg) in N/S or D5W 150cc keep 150CC/hr × 5 days×4weeks

Mitomycin-C(2-10mg) in N/S or D5W 150cc keep 150CC/hr × 5 days×4weeks

5FU(50-500mg) + Leucovorin (25-100 mg)in N/S or D5W 250cc keep 50CC/hrfor total 5hr ×5 days×4weeks

--- Intra-hepatic artery Chemotherapy B---

Regimen I(A)

Cisplatin(2-40mg) in N/S or D5W，50CC KEEP 100CC/HR × 5 days

5FU(50-500mg) in N/S or D5W 250cc KEEP 10CC/HR × 5 days 與Leucovorin (25-100 mg)+N/S100CC KEEP 5CC/HR × 5 days同步使用

Regimen I(B)

Cisplatin(2-40mg) in N/S or D5W 50CC KEEP 100CC/HR × 5 days

Mitomycin-C (2-10mg) in N/S or D5W 50CC KEEP 100CC/HR × 5 days

5FU(50-500mg) in N/S or D5W 250cc KEEP 10CC/HR × 5 days 與Leucovorin (25-100 mg)+N/S100CC KEEP 5CC/HR × 5 days同步使用

Systemic Chemotherapy therapy

(concesus Date:2011.2.17)

(1) Doxorubicin(or Epirubcin) is current acceptable mono-chemotherapy

(2) Encourage patents who are suitable for chemotherapy enter clinical trial

(3) All other therapy stated as experiment therapy.

B-12

--- Systemic oral chemotherapy ---

(1) 5FU 200mg-400mg qd in divided dose

Systemic Chemotherapy therapy

(1) Nexavar(sorafenib) 2# -4#/day in divided dose

參考文獻

1. Hepatobiliary Cancer NCCN V1.2017 from http://www.nccn.org

2. Song MJ. Hepatic artery infusion chemotherapy for advanced hepatocellular carcinoma.(2015) World J Gastroenterol ; 21(13): 3843-3849.

3. Tsai W-L, Lai K-H, Liang H-L, Hsu P-I, Chan H-H, et al. (2014) Hepatic Arterial Infusion Chemotherapy for Patients with Huge

Unresectable Hepatocellular Carcinoma. PLoS ONE 9(5),1-5.

4. Wang .S-N, Chuang. S-C, Lee. K-T,(2014) Efficacy of sorafenib as adjuvant therapy to prevent early recurrence of hepatocellular carcinoma

after curative.

5. Xiao C, Hai-Peng, Mei L, Liang Q.Advances in non-surgical management of primary liver cancer. World J Gastroenterol 2014 November 28;

20(44): 16630-16638

B-13

Cancer of the Colon

Treatment Guideline

KMHK 制定日期 : 97 年 1 月 1 日

修訂日期 : 107 年 7 月 1 0 日

大腸癌修訂紀錄


97 年

98 年

99 年

100 年

101 年

102 年

大腸癌診療指引新制訂

多科會議討論檢視後未修改



(1)大腸直腸癌 MONITORING/SURVEILANCE Colonscopy 2-5 years:

Q3-6m，Q12m 改 Q5Y。 (2)結腸癌追蹤準則：對於有高度復發危險者，腹部及骨盆腔電腦斷層檢查

(3)High Risk Stage II or Stage III 門診第一線用藥準則（1

m2 Weekly for 6 of 8 weeks 改 Weekly for 6 of 8 weeks2-

(4)High Risk Stage II or Stage III IV 門診第一線用藥準則

劑量改 900-1000 mg/m2 bid(Stage II 需自費)。

(5)直腸癌治療準則 Lesion 5cm 改 8cm。

(6)直腸癌 Stage B1 改 T2N0M0，治療 Transanal or posterior

and chemotheraopy 刪除 chemotheraopy、新增 LAR or APR

(7)直腸癌 Stage B2 改 T3N0M0， Stage C 改 T1-3N1-2M0，Pre-

改 LV and 5-FU、新增 LAR or APR。

(8)直腸癌 Stage B3, C3 T4 N0-2 M0 治療準則 Pre-op chemotherapy

anterior resection ± intraoperative brachytherapy 改

then OP or low anterior resection ±then RT。

(1)修訂 Pedunculated or Sessile polyp(adenoma [tubular,

Invasive cancer 治療準則。

(2)修訂 Colon cancer Appropriate for Resection(non-

Obstruction lesion for new lesion,

，連續執行三年改二年。

）：5FU 500 mg/m2 ＋ Leucorvin 100mg/

3 cycle。

（3）： Capecitabine 1250 mg/m2

local excision + post-op radiotherapy

。

operative chemotherapy (MMC and 5-FU)

+ radiotherapy, then AP or low

Pre-op chemotherapy + radiotherapy,

C-3

C-4

C-6

C-7

C-11

C-12

C-12

C-14

C-6

C-7

1.0

2.0

3.0

Tubulovillous,or Villous]) with

metastatic) 治療準則。

103 年

104 年

105 年

106 年 7 月 21 日

(3)修訂 Patient appropriate for intensive therapy (metastasis)治療準則。

(1)修訂 Pedunculated or Sessile polyp(adenoma [tubular, Tubulovillous,or Villous]) with

Invasive cancer 治療準則。

(2)修訂 Suspected or proven metastatic adenocarcinoma form large bowel (Duke`s D or stage

IV) 治療準則。

(3)修訂 Colon cancer Appropriate for Resection(non- metastatic) 治療準則。

(4)修訂大腸癌 MONITORING/SURVEILANCE Abdominal CT or sonography≦2 years: Q6m 改 Q3-6m。

(5)修訂直腸癌 MONITORING/SURVEILANCE Pelvis CT/MRI or sonography≦2 years: Q6m 改 Q3-6m。

(6)修訂結腸癌第四期合併肝轉移追蹤準則。

(7)修訂結腸癌（Adjuvant therapy）治療準則。

(8)修訂 Patient appropriate for intensive therapy (metastasis)治療準則。

(9)修訂 Rectal Cancer T3 N0 M0(high risk),T1-3 N1-2 M0 治療準則。

(10)修訂 Rectal Cancer stage B3,C3 T4N0-2M0、stage D Any T and N M1 治療準則。

(1)增訂大腸直腸癌目的、參考文件、範圍、定義、內容。

(2)增訂大腸癌簡易治療指引、直腸癌簡易治療指引。

(3)增訂大腸直腸 AJCC 分期、化療藥物、文獻查證。

(1)修訂大腸直腸癌治療準則

(1) 增訂 colon cancer colectomy with en bloc removal of regional lymph node or Observe

(2) 刪除 colon cancer workup PET-CT scan 、核子醫學須轉至高醫

增加 colon cancer surgery colostomy

(3) 增加 colon cancer treatment FOLFIRI ±Panitumumab or cetuximab

C-10~12

C-2 C-

3

C-4

C-5

C-6

C-8

C-9~10

C-12~13

C-14

C-1

C-2~3

C-18~21

C-3

C-4

C-5

C-7

C-11

C-8

4.0 5.0

6.0 7.0

107 年 7 月 10 日

(4)增加 colon cancer therapy after second progression 可用 Stivarga

(5)增加 rectum cancer findings fragmented specimen or margin cannot be assessed or unfavorable histological

features 可 operation 或 observe

(6)刪除 rectal cancer patients with medical contraindication to combined modality therapy

(7)刪除 primary treatment 5-FU/RT 或轉介高醫

(8)刪除 rectal cancer resectable 後續 workup

(9)增加 rectal cancer therapy after second progression 可用 Stivarga

(10)增加大腸直腸癌化療藥物 Vectibix、Stivarga、Ziv-aflibercept

(1)增加 4.14 RAS基因突變測試(RAS test)：RAS基因突變也可以評估轉移性結大腸直腸癌 (mCRC)患者

對EGFR標靶治療的主要預測因子之一。

(2)增加 T3, N0, M0 (no high risk features)治療藥物 UFUR

(3)刪除 Neoadjuvant therapy (for 2-3 months)

(4)增加 FOLFIRI ± (bevacizumab or ziv-aflibercept or ramucirumab )

(5)刪除 Irinotecan ± (bevacizumab or ziv-aflibercept )

(6)刪除 Irinotecan + (cetuximab or panitumumab) [RAS WT only]

(7)更新AJCC分期為8TH

(8)更新參考文獻National Comprehensive Cancer Network. Clinical Practice Guideline in Oncology: Colon

Cancers V2.2018

(9)更新參考文獻National Comprehensive Cancer Network. Clinical Practice Guideline in Oncology: Rectal

Cancers V2.2018

C-9

C-14

C-17

C-20

C-22

C-24

C-25

C-31

C-2

C-5

C-7,C-23

C-11,C-24,C-25

C-11,C-24,C-25

C-12,C-25

C-28

C-31

C-31

8.0

1. 目的：高雄市立小港醫院大腸直腸癌擬參考相關國內外治療指引與相關文獻，依據現有的設施、健保給付制度，大腸直腸癌團對相關研究成果與

臨床經驗修訂完成「高雄市立小港醫院大腸直腸癌之診療共識」。

2. 範圍：大腸直腸癌治療。

3. 定義：泛指臨床科醫療人員皆可參考適用。

4. 內容：

4.1. 大腸直腸癌診斷及評估。

4.2. 糞便潛血反應：為大腸直腸癌篩檢廣泛使用之初步檢查方式，以檢驗大便中是否有潛血反應。

4.3. 肛門指診：病人不需要任何準備，由醫師戴手套以Xylocaine Jelly 潤滑右手食指慢慢插入至直腸7~8公分，直腸癌患者一半以上可以摸到硬塊，

是最簡單的檢查方法。

4.4. 肛門鏡檢(Anoscopy)：長約8公分，屬於硬的管狀器械，由肛門插入以肉眼直接檢查。

4.5. 直腸乙狀結腸鏡檢(Sigmoidoscopy)：此乃利用約 60 公分長的腸鏡，從肛門進入直腸乙狀結腸作診斷，約有 60％的結腸癌可由此法發現，檢

查時應使肌肉放鬆，採左側臥或膝胸臥式。

4.6. 結腸鋇劑灌腸攝影術：須做清潔灌腸後，從肛門灌入鋇劑，簡單省時，對於結腸內之病灶，雙對比鋇劑照影可偵測出較小的病變。

4.7. 大腸鏡檢查（Colonoscopy)：須做清潔灌腸後，由肛門進入結腸，直接觀看整條大腸黏膜內部情形，若發現瘜肉可同時切除，如無法切除必須

切片檢查，且再確認其他結腸處有無同時發生之腫瘤病變。

4.8. 組織切片檢查（Bioposy)：使用內視鏡檢查時對可疑的部分取出體外，再作組織切片，以判定是否為惡性腫瘤。亦可先行瘜肉切除再作切片，

以確定是否有惡性變化及侵蝕至黏膜下肉層。

4.9. 腫瘤記號蛋白（CEA)：又稱腫瘤胚胎抗原，係從大腸直腸癌細胞分離出來的蛋白，它在血中濃度會隨著大腸直腸癌的發生而升高，臨床上腫瘤

記號蛋白用於手術後，大腸直腸癌有否局部再發或遠端轉移之偵測參考。

4.10. 腹部及骨盆腔之電腦斷層掃描（Abdominal and Pelvic CT)：藉由腹部及骨盆腔之電腦斷層掃描檢查，可以整體評估腫瘤所在位置，和腹

腔與骨盆腔內腫瘤細胞侵犯鄰近組織與器官的情形，以及是否已有肝臟等部位之轉移。

4.11. 核磁共振掃描（MRI)：與電腦斷層掃描同為影像學之檢查，當上述影像學檢查無法確定診斷時，或病人因腎功能不全或對於電腦斷層顯影

劑過敏時使用，屬於第二線的檢查，用來評估直腸癌局部侵犯深度及CCRT之反應。

4.12. 胸部 X 光檢查（Chest X-ray )：胸部 X 光片可以初步篩檢肺部有無病後灶，評估腫瘤細胞是否已有肺部轉移的情形。

4.13. 全身正子攝影（PET-CT)：利用腫瘤組織對放射性藥物（氧化去氧葡萄糖）的吸收與代謝，轉換成體內分布影像，並結合電腦斷層，達到準確定位的功能，屬全身性的檢查。此檢查雖然比單獨電腦斷層掃描或單獨一正子放射更靈敏，但仍有約 10 ％的偽陰性或偽陽性發生，並非常

規術前檢查。

C-1

4.14. RAS基因突變測試(RAS test)：RAS基因突變也可以評估轉移性結大腸直腸癌 (mCRC)患者對EGFR標靶治療的主要預測因子之一。

＊intraoperative radiation therapy(IORT),if available , should be considered for patients with T4 or recurrent cancers as an additional boost.

C-2

Cancer of the Colon Treatment Guideline

結腸癌治療準則

Clinical presentation

workup findings surgery

Pedunculated or

sessile polyp

(adenoma) with

invasion cancer

• Pathology review • Colonoscopy • Marking of

cancerous polyp site

(at time of

colonoscopy or

within 2 wks)

Single specimen

completely removed

with favorable

histological features and

clear margins

Fragmented specimen or

margin cannot be

assessed or unfavorable

histological features

Pedunculated

polyp with

invasive cancer

Senssile polyp

with invasive

cancer

Observe Observe (告知觀

察,有較高機會復

發或轉移) or Radical colectomy

Radical colectomy

or Observe

See pathologic

stage adjuvant

therapy(C-5)

and surveillance(C-9)

C-3



Clinical

presentation

workup findings surgery

Locally unresectable or medically inoperable

Discuss with patient, may consider

systemic therapy (C-12,C-13)

Colon cancer

Appropriate for

resection

(non-metastatic)

Radical

colectomy Diversion colostomy

• Colonoscopy • CBC,chemistry

profile,CEA • Chest X-ray • Abdominal pelvic

CT

Radical colectomy or radical

colectomy with diversion

Radical colectomy

Resectable obstructing

Resectable

Non-obstructing See pathologic

stage adjuvant

therapy (C-5)

and

surveillance

(C11)

C-4



Pathologic stase

Tis; T1, N0, M0

T2, N0, M0

T3, N0, M0 (no high risk features)

T3, N0, M0 with high risk

for systemic recurrence or

T4, N0, M0

T any,N1-2,M0

Adjuvant treatment

Observation

Observation or

UFUR

or

5-FU/leucovorin

or

Capecitabine UFUR or

Capecitabine.

or 5-FU/leucovorin or

FOLFOX

or

XELOX

or Observation FOLFOX

or

XELOX

or Capecitabine

See Surveillance(C-9) See Surveillance(C-9) See Surveillance(C-9) See Surveillance(C-9)

or 5-

FU/leucovorin or UFUR

C-5



Clinical presentation Workup Findings

Suspected or proven

metastatic synchronous

adenocarcinoma from

large bowel (Any T, any N ,M1)

• colonoscopy • chest X-ray • abdominal/pelvic CT • CBC, chemistry profile • Determination of RAS gene

status • Multidisciplinary team

evaluation including a

surgeon experienced in the

resection of hepatobiliary

and lung metastases

Synchronous liver only

and/or lung only metastases Synchronous

abdominal/peritoneal

metastases Synchronous unresectable

metastases

Resectable or potential resectable

(C-7) See Treament (C-8) See Systemic Therapy (C-15,C-16)

C-6



Treatment Therapy after resection

Synchronous or staged colectomy with liver or lung

resection or Neoadjuvant therapy FOLFOX or XELOX or FOLFIRI ±bevacizumab or

FOLFIRI or FOLFOX ± panitumumab or cetuximab

[RAS WT only] followed by synchronous or staged

colectomy and resection of metastatic disease or Colectomy, followed by chemotherapy FOLFOX or XELOX or FOLFIRI ±bevacizumab or

FOLFIRI or FOLFOX ± panitumumab or cetuximab

[RAS WT only]and staged resection of metastatic disease

FOLFOX or XELOX or FOLFIRI ±

bevacizumab or FOLFIRI or FOLFOX ± panitumumab or

cetuximab [RAS WT only]

See Surveillance (C-9)

C-7



Finding Primary treatment

Nonobstructing See Systemic Therapy (C-15,C-16)

Synchronous

abdominal/

Peritoneal

merastases

Colon resection

or

Obstructing Diverting colostomy or Bypass surgery

See Systemic Therapy (C-15,C-16)

C-8


結腸癌治療準則 surveillance

StageⅠ, II, III

Stage IV

• History and physical every 3-6 mo for 2 y, then every 6 mo for a total of 5 y • CEA every 3-6 mo x 2 y, then every 6 mo x 3-5 y

• Chest/abdominal/pelvic CT scan every 3-6 mo x 2 y, then every 6-12 mo for a total of 5 y

• Colonoscopy in 1 y except if no preoperative colonoscopy due to obstructing lesion, colonoscopy in 3-6 mo

• History and physical every 3-6 mo for 2 y, then every 6 mo for a total of 5 y • CEA every 3-6 mo for 2 y, then every 6 mo for a total of 5 y

• Chest/abdominal/pelvic CT every 6-12 mo for a total of 5 y • Colonoscopy in 1 y except if no preoperative colonoscopy due to obstructing lesion, colonoscopy in 3-6 mo

Serial CEA

elevation or

documented

recurrence

C-9



Recurrence workup

Serial

CEA

elevation

• physical exam • colonoscopy • chest/abdominal/ • pelvic CT • Abdominal echo • bone scan if

necessary

Negative findings

Conside PET-CT Scan 轉介

高醫檢查

Negative findings

Positive findings

See treatment for

documented

metastases, below

Documented

metastases

by CT, MRI,

PET

Resectable Unresectable

See Systemic Therapy (C-15,C-16)

or Observation See Systemic Therapy (C-15,C-16)

C-10



Unresectable metastases

Primary treatment

Previous adjuvant

FOLFOX within 6-12

months

FOLFIRI±Bevacizumab or

ziv-aflibercept or ramucirumab

FOLFIRI±panitumumab or


Resection

Converted to resectable

See Systemic Therapy(C-15,C-16)

or Observation

Previous adjuvant

FOLFOX

Re-evaluate for

conversion to resectable

every 2-3 mo

Remains unresectable

See Systemic Therapy(C-15,C-16)

more then 6-12 months

Previous 5-FU/LV or

capecitabine NO previous

chemotherapy

See Systemic Therapy

(C-15,C-16)

C-11



Systemic treatment

Initial therapy Subsequent Therapy Therapy after second progression

FOLFOX±Bevacizumab

or

XELOX±Bevacizumab

or FOLFOX+panitumumab or


FOLFIRI ± (bevacizumab or ziv-

aflibercept or ramucirumab ) or FOLFIRI

+ (cetuximab or panitumumab) [RAS

WT only]

Regorafenib


or

Patient

Appropriate

For

Intensive

therapy

FOLFIRI±Bevacizumab or

FOLFIRI+ panitumumab

or cetuximab [RAS WT

only]

FOLFOX ± bevacizumab or

XELOX ± bevacizumab

Regorafenib


or

5-FU/leucovorin or

Capecitabine±

Bevacizumab

FOLFOX ± Bevacizumab or XELOX ± Bevacizumab

Regorafenib


or FOLFIRI ± (bevacizumab

or ziv-aflibercept or ramucirumab)

FOLFOX

or

XELOX

Regorafenib


FOLFOXIRI±

Bevacizumab

Regorafenib


C-12



Initial therapy

Systemic treatment

Therapy after first progression

Improvement in Consider initial therapy as function status above

Patients not

appropriate for

intensive

therapy

Infusional 5-FU + leucovorin

±bevacizumab or Capecitabine ± bevacizumab or

(Cetuximab or panitumumab) [RAS

WT only]

No improvement

in function status


C-13

Cancer of the Rectum

Treatment Guideline

KMHK

制定日期 : 97 年 1 月 1 日

修訂日期 : 107 年 7 月 1 0 日

C-14

Cancer of the Rectum Treatment Guideline

直腸癌治療準則

Clinical presentation Workup Findings

Pedunculated polyp

with invasive cancer

Observe

Pedunculated

polyp or sessile

polyp(adenoma)

with invasive

cancer

• Pathology review • Colonscopy • Marking of cancerous

polyp site(at time of

colonscopy or within 2

wks if deemed necessary

by the surgeon)

Single specimen,

completely removed with

favorable histological

feature and clear margins

Sessile polyp with

invasive cancer

Observe

(會告知僅觀察有

較高機會復發或

轉移) or Transanal excision

if appropriate or

Fragmented specimen or

margin cannot be assessed

or unfavorable histological

features

Transanal excision

if appropriate or Transabdominal resection

or Observe

(會告知僅觀察有較高機

會復發或轉移)

Transabdominal resection

C-15



Clinical presentation Workup Clinical stage

T1-2, N0 (C-17)

Rectal cancer

appropriate for

resection

• Biopsy • Pathology review • Chest X-ray • Colonscopy • Abdominal/pelvic CT or MRI • CEA • Colonoscopy marking if small tumor

T3, N0 (C-18) or T any, N1-2 (C-18)

Suspected or proven

metastatic

adenocarcinoma

T4 and/or locally

unresectable (C-18)

T any, N any, M1

Resectable metastases

(C-19) See management of suspected or proven metastatic synchronous adenocarcinoma

(C-20)

C-16



Clinical primary treatment stage Adjuvant treatment (6mo perioperative treatment preferred)

T1,Nx;

Margins

negative

Observe

pT1-2, N0, M0

Observ

107 年 Cancer of Clinical Guideline¨º療指引.pdf · 5. 非小細胞肺癌,第IV,...

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