Transcript Taipei Veterans General Hospital Practices Guidelines Oncology

台北榮總胸腺癌診療共識
V.1.0 2013
台北榮總肺癌團隊
Revised on 2013/9/2
Staging
Staging
THYM- Initial evaluation
Mediastinal
mass
• CT chest with contrast
• Serum beta-HCG, AFP, if appropriate
• CBC, platelets
•TSH, T3, T4 levels, as clinically indicated
•Pulmonary function tests, as clinically indicated
• MRI chest, as clinical indicated
• PET-CT scan optional
Small thymic tumor
without evidence of
invasion
Locally advanced, or
unresectable
Surgical resection (VATS
or Transsternal approach)
Manage by a thoracic surgeon
with experience in the
management of thymoma and
thymic carcinoma
See Postoperative
Management (THYM-3)
Tissue diagnosis with core needle
biopsy (avoid transpleural biopsy)
Discuss in a multidisciplinary
team with experience in the
management of thymoma and
thymic carcinoma
See treatment (THYM-4)
THYM-3
THYM-4
胸腺腫瘤與胸腺癌的手術切除原則 1
• 1. 胸腺腫瘤的手術切除應該經由訓練合格的胸腔外科醫師仔細
評估後執行。具局部侵犯性(或不可切除)或第二期以上的胸腺腫
瘤，治療方式則應經由多團隊會議討論及評估後執行。
• 2. 當臨床和影像學上的評估認為胸腺腫瘤是可以完全手術切除
時，手術前的組織切片診斷應該避免，以免造成腫瘤的擴散。
• 3. 組織切片診斷應該避免經過肋膜腔，造成腫瘤擴散。
• 4. 手術前，應仔細的評估病患有無合併肌無力症狀或徵象。若
合併有肌無力症應在手術前內科藥物控制穩定後再行手術。
• 5. 手術切除的目標是完全的將病灶(腫瘤)切除，加上胸腺組織
切除和其他鄰近的或非鄰近的可疑病灶切除。
胸腺腫瘤與胸腺癌的手術切除原則 2
• 6. 完全的腫瘤切除手術可能須合併切除腫瘤周微的組織結構包
括:心包膜、膈神經、肋膜、肺臟，甚至其他週圍重要的大血管。
為了避免術後的呼吸併發症，應避免同時將兩側的隔神經切除。
• 7. 實施胸腺瘤切除手術時，同時建議檢查兩側肋膜表面以排除
肋膜擴散。在某些病例，切除肋膜擴散病灶對病患可能可以達到
完全切除腫瘤的目的。
• 8. 由於目前仍缺乏長期的追蹤報告，所以並不建議常規採用微
創手術方式切除胸腺瘤。但是在不影響腫瘤治療原則的前提下，
在有經驗的醫學中心仍可以考慮用微創手術治療。
Rationale of Radiotherapy for Invasive thymoma
and thymic carcinoma
• Thymoma is the most common tumor of the anterior
mediastinum, accounting for approximate 20% of all
mediastinal tumors in adults.
• Complete surgical resection is the treatment of choice for
all thymomas regardless of invasiveness.
• Radiotherapy is excellent adjuvant therapy for invasive
thymomas, which are generally radio-responsive.
• RT should be given for unresectable or incomplete
resection patients with invasive thymoma or thymic
carcinoma.
Rationale of Radiotherapy for Invasive thymoma
and thymic carcinoma
For unresectable disease: 60-70 Gy (with daily fraction between 1.8 to 2 Gy)
For post-operative status: 45-50 Gy for radical surgery
54 Gy for close margin and 60 Gy for gross residual lesions.
Radiation dose less than 40 Gy possess higher relapse incidence.
For large, invasive thymoma, neoadjuvant RT has been advocated.
GTV: gross visible tumor volume
CTV: encompassing the entire thymus, surgical clips
and potential site with residual disease.
PTV: including target motion and setup error.
Post-operative radiotherapy will be arranged within 4-6 weeks
after surgical intervention.
Radiotherapy technique: including IMRT, VMAT and Tomotherapy
Modern RT techniques can help to reduce the dose of normal tissues,
including heart and lung.
High Precision Radiotherapy Technique
for
Thymic carcinoma
化學治療用藥準則
台北榮總胸腺癌診療共識
主要依據- 1.NCCN v1 2014
台北榮總胸腺癌診療共識
本治療指引將每年檢討修訂一次
預定下次修訂日期:2014年09月