106年癌症診療指引中英文版 - kmhk.org.t¹´診療指引.pdf · 106 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

106年癌症診療指引中英文版

2017 Cancer of Clinical Guideline

高雄市立小港醫院(委託財團法人高雄醫學大學經營) 106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-22

A-28

A-29

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-18

C-33

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-7

E-11

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前列腺癌

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-3

發行日期：2017年 6月

發行版次：第 1版

編輯人員：侯明鋒、吳政毅、莊捷翰、許經偉、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、張美玉、艾紀瑩、王亞婷、黃惠娟、黃鈞民、李欣樺、蔡郁棻、伍秀瑩、陳雅玲

Cancer of the Lung

Treatment Guideline

KMHK 修訂日期 106 年 5 月 19 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



＊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


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

A-1

A-2

A-3

A-2

1.0

2.0

3.0

肺癌修訂記錄


103 年

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


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

A-3

A-4

A-5

A-6

A-7

A-8~A-9

A-10~A-11

A-13

A-14

A-4~ A-5

A-7

4.0

肺癌修訂記錄


104 年

105 年

106 年

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. 全部 Reresection 修改為 resection

2. 原 EGFR ± ALK testing should be conduced as part of

multiplex/next-generation sequencing 刪除，修改為

PDL-1 testing

A-8~9

A-12、A-14

A-15

A-16

A-17

A-18

A-19

A-15

A-3、A-5

A-14

5.0

6.0

Non-Small Cell Lung Cancer

Non-Small Cell Lung

Cancer(NSCLC)

*Pathology review

*H & P(include performance status+

weight loss)

*BW, BL, BSA

*CT chest and upper abdomen,

including adrenals

*WBC, DC, Hgb, platelets

*Chemistry profile

*HbsAg, Anti-HCV

*Smoking cessation advice,

counseling, and pharmacotherapy

*Integrate palliative care

Stage IA peripheral (T1ab,N0)

Medistinal CT negative (lymph nodes

Stage IA

(peripheral T1ab,N0)

Negative

mediastinal nodes

*PFTs (If not previously done)

*Bronchoscopy

(intraoperative preferred)

*Pathologic mediastinal lymph

node evaluation

*Bone scan (refer to KMUH)

*PET/CT scan (refer to KMUH)

*Brain MRI

Clinical Assessment Pretreatment Evaluation


Positive

mediastinal nodes

Operable

Medically

inoperable

See initial treatment and

adjuvant treatment(A-3)

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)

Negative

mediastinal nodes


*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)

Positive

mediastinal nodes

Operable

Medically

inoperable

See initial treatment and

adjuvant treatment(A-3)

Definitive RT

including SABR

See stage IIIA (A-7) or stage

IIIAB(A-10)

N0

N1

Adjuvant C/T for

high risk stages IB-II

Definitive chemoradiation

A-2

Surgical exploration

and resection +

mediastinal lymph

node diseeection or

systematic lymph

node sampling

Findings at surgery Initial treatment


Adjuvant treatment

Stage IA

(T1ab,N0)

Stage IB

(T2a,N0)

Stage IIA

(T2b,N0)

Stage IIA

(T1ab-T2a,N1)

Stage IIB

(T3,N0;T2b,N1)

Stage IIIA

(T1-3,N2;T3,N1)

Margins negative

(R0)

Margins positive

(R1, R2)

Observe

Reresection (preferred)

or RT

Observe or Chemotherapy for high risk

patients

Resection (preferred) ±chemotherapy

or RT ±chemotherapy (chemotherapy for

stage IIA)

Chemotherapy

Chemotherapy + RT or

Sequential chemotherapy+RT (N2 only)

Chemoradiation (sequential or concurrent)

Resection + chemotherapy

or chemoradiation

Margins negative

(R0)

Margins positive

(R1, R2)

Margins negative

(R0)

Margins positive

Margins negative

(R0)

Margins positive

R1

R2 Resection + chemotherapy

or Concurrent chemoradiation

R1

R2 Concurrent chemoradiation

A-3


Clinical Assessment Pretreatment Evaluation Clinical Evaluation

Stage IIB (T3 invasion, N0)

Stage IIIA (T4 extension,

N0-1; T3, N1)


*Bronchoscopy

* Pathologic mediastinal lymph node

evaluation

*Brain MRI


*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

Metastatic disease

See A-5

See A-5

See A-5

See A-12 or A-13

Unresectable disease See A-5

A-4

Superior suicus tumor

(T3 invasion, N0-1)


Clinical Presentation Initial treatment Adjuvant Treatment

Superior suicus tumor

(T4 extension, N0-1)

Chest wall, proximal

airway or

mediastinum (T3

invasion, N0-1;

Resectable T4

extension, N0-1)

Possibly

resectable

Unresectable

Preoperative

concurrent

chemoradiation

Preoperative

concurrent

chemoradiation

Definitive

concurrent

chemoradiation

Concurrent

chemoradiation

or

Chemorherapy

Surgical

reevaluation

Surgery

Resectable

Unresectable

Margins

negative (R0)

Margins

positive(R1,R2)

Surgery+

chemotherapy

Surgery+

chemotherapy

Complete definitive

RT + chemotherapy

Chemotherapy

Resection +

chemotherapy

or

Concurrent

chemoradiation

See A-13

R1

R2

Resection +

chemotherapy or

chemoradiation

(sequential or

concurrent)

Stage III (T4, N0-1)

Unresectable

Definitive concurrent

chemoradiation A-5


Clinical Assessment Pretreatment Evaluation Mediastinal Biopsy Findings and Resectability

Stage IIIA (T1-3, N2)


*Bronchoscopy

* Pathologic mediastinal lymph node

evaluation



*Brain MRI

N2, N3 nodes negative

N2 nodes positive

Metastatic disease

See A-7

See A-7

See A-10

See A-12 or A-13

N3 nodes positive

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)

See A-8

See A-8

See A-12or A-13 Extrathoracic metastatic disease

A-6

T1-3, N0-1 (including

T3 with multiple

nodules in same lobe


Surgery

Resectable

Medically

inoperable

Surgical resection +

mediastinal lymph

node dissection or

systematic lymph

node sampling

See A-2

N0-1

N2

Margins

negative

Margins

positive

R1

R2

Chemoradiation

(sequential or concurrent)

Concurrent

chemoradiation

Sequential chemotherapy

+ RT See A-13

See A-13

See A-3

See A-13

Mediastinal Biopsy

Findings Initial Treatment Adjuvant Treatment

T1-2, T3(≧7cm),

N2 nodes positive

*Brain MRI

*PET/CT(refer

to KMUH)

Negative

for M1

disease

Positive


chemoradiation

or

induction

chemotherapy

No apparent

progression

Progression

Local

Systemic

RT±chemotherapy

See A-12 or A-13

Surgery±chemotherapy±RT

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


Separate pulmonary

nodule(s), same lobe (T3,

N0) or ipsilateral non-

primary lobe (T4, N0)

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

Surgery

Treat as two primary lung

tumors if both curable

Margin negative (R0)

Margins positive

(R1,R2)

Chemotherapy

Concurrent chemoradiation

(if tolerated)

See A-13

See A-13

See A-1

Clinical Presentation Initial Treatment Adjuvant Treatment

*chest CT with contrast

*PET/CT(refer to KMUH)

*Brain MRI

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


Multiple lung

cancers

Asymptomatic

Symptomatic

Multiple

lesions

Solitary lesion

(metachronous

disease

Low risk of becoming

symptomatic

High risk of becoming

symptomatic

Definitive

local therapy

possible

Definitive

local therapy

not possible

Parenchymal sparing

resection (preferred) or

radiation or ablation

Consider palliative

chemotherapy±local

palliative therapy

See A-14

See A-13

Clinical Presentation Initial Treatment

Observation

A-9


Clinical Assessment Pretreatment Evaluation Initial Treatment

Stage IIIB (T1-3, N3)



*Brain MRI


* 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

Stage IIIB

(T4 extension, N2-3)

*PET/CT scan(refer to KMUH)

*Brain MRI


* Pathologic confirmation of N2-3

disease by either:

-Mediastinoscopy

-Superaclavicular lymph node biopsy

-Thoracoscopy

-Needle biopsy

-Mediastinotomy

-EUS biopsy (refer to KMUH)

-EBUS biopsy (refer to KMUH)

Contralateral

mediastinal

node negative

Metastatic

disease

See A-7

Definitive

concurrent

chemoradiation

See A-12 or A-13

Ipsilateral

mediastinal node

negative (T4, N0-1)

Ipsilateral

mediastinal node

positive (T4, N2)

Contralateral

mediastinal

node positive

(T4, N3)

Definitive

concurrent

chemoradiation

Stage IV, M1a:

Pleural or pericardial

effusion

Thoracenfesis or pericardiocentesis ±

thoracoscopy if thoracentesis

indeterminate

Negative

Positive

See A-7

Local therapy if necessary

(e.g. pleurodesis, ambulatory

small catheter drainage,

pericardial window) + See

A-12 or A-13 A-11


Clinical

Assessment

Pretreatment

Evaluation

Initial Treatment

Stage IV,

M1b:

Solitary site

*Pathologic

mediastinal

lymph node

evaluation

*Bronchoscopy

*Brain MRI

*Bone scan(refer

to KMUH)

*PET/CT scan

(refer to KMUH)

Surgical resection followed by

whole brain RT (WBRT) or

stereotactic radiosurgery (SRS)

or

SRS + WBRT (category 1 for

one metastasis)

or

SRS alone

T1-2, N2;

T3, N1-2;

Any T, N3;

T4, Any N

T1-2, N0-1;

T3, N0;

Surgical resection of lung

lesion

or

Stereotactic ablative

radiotherapy (SABR) of lung

lesion

or

Chemotherapy

Chemotherapy

Surgical

resection of

lung lesion or

SABR of lung

lesion

See A-14

Brain

Adrenal

Pathologic

diagnosis

by needle

or resection

Local therapy for adrenal

lesion (if lung lesion curable,

based on T and N stage)

or

see A-14

A-12


No evidence of

clinical/radiographic disease

(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)


counseling and

pharmacotherapy

*PET or brain MRI is not

indicated for routine follow-up.

Locoregiona

l recurrence

Distant

metastases

Endobronchial

obstruction

Resectable

recurrence

Mediadtinal lymph

node recurrence

Superior vena

cava (SVC)

obstruction

Severe

hemoptysis

Localized symptom

Diffuse brain metastases

Bone metastasis

Solitary metastasis

Disseminated metastases

*Laser/stent/other surgery

* External-beam RT or

brachytherapy

*Photodynamic therapy

*Reresection (preferred)

* External-beam RT or SABR

Concurrent

chemoradiation No prior RT

Prior RT Systemic

chemotherapy

* Concurrent chemoradiation

(if not previously given)

*External-beam RT

* SVC stent

*External-beam RT or brachytherapy

* Laser or photodynamic therapy or

Embolization

*Surgery

No evidence of

disseminated

disease

Evidence of

disseminated

disease

Observation or

systemic

chemorherapy

See A-14

Palliative external-beam RT

Palliative external-beam RT

* Palliative external-beam RT + orthopedic

stabilization, if risk of fracture

*Consider bisphosphonate therapy or

denosumab

See A-12

See A-14

See A-14

Surveillance

Therapy for recurrence and metastasis

A-13


Metastatic

disease

*Establish histologic subtype

with adequate tissue for

molecular testing (consider

rebiopsy if appropriate)


counseling

*Intergrate palliative care

*Adenocarcinoma

*Large cell

*NSCLC not

otherwise specified

(NOS)

Squamous cell

carcinoma

*EGFR mutation testing

*ALK testing

* PDL-1 testing

Sensitizing EGFR

mutation positive

ALK positive

Sensitizing EGFR

mutation and ALK

negative or unknown

See A-15

See A-17

*Consider EGFR mutation and ALK testing

especially in nerver smokers or small biopsy,

specimens, or mixed histology

* PDL-1 testing See A-18

Systemic Therapy for

Metastatic Disease

Evaluation

Histologic Subtype

See A-16

A-14

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


Sensitizing

EGFR

mutation

positive

EGFR

mutation

discovered

prior to

first-line

chemotherap

y

EGFR

mutation

discovered

during

first-line

chemotherapy

Interrupt or

complete planned

chemotherapy,

start erlotinib or

afatinib or

Gefitinib or

May add erlotinib

or afatinib to

current

chemotherapy

Erlotinib

or Afatinib

or Gefitinib

Progre-

ssion

Symptomatic

Asymptomatic

brain

systemic

Isolated

lesion

Multiple

lesions

Isolated

lesion

Multiple

lesions

Continue erlotinib or afatinib or

Gefitinib

Consider local

therapy and continue

erlotinib or afatinib

or Gefitinib

Consider WBRT and

continue erlotinib or

afatinib or Gefitinib

Consider local

therapy and

continue erlotinib

or afatinib or

Gefitinib

Consider platinum

double ±

bevacizumab ±

erlotinib

First-line therapy Second-line therapy

Progre-

ssion

See A-19

A-15

Adenocarcinoma, large cell, NSCLC NOS: ALK positive


Sensitizing

EGFR

mutation

positive

ALK

rearrangement

discovered

prior to

first-line

chemotherapy

ALK

rearrangement

discovered

during

first-line

chemotherapy

Interrupt or

complete

planned

chemotherapy,

start crizotinib

Crizotinib

Progre-

ssion

Symptomatic

Asymptomatic

brain

systemic

Isolated

lesion

Multiple

lesions

Isolated

lesion

Multiple

lesions

Continue crizotinib

Consider local

therapy and continue

crizotinib

Consider WBRT and

continue crizotinib

Consider local

therapy and

continue crizotinib

Consider platinum

double ±

bevacizumab

First-line therapy Second-line therapy

Progre-

ssion

See A-19

A-16

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

PS 0-1

Best supportive care

Doublet

chemotherapy

or

Bevacizumab+

chemotherapy

or

Erlotinib

or

Cetuximab/vinorelbi

ne/ cisplatin

First-line Therapy


Second-line Therapy

PS 3-4

PS 0-2

PS 3-4

If not already given:

Docetaxel or Pemetrexed

or Erlotinib or Gemcitabine

Progression

PS 2 Chemotherapy

Tumor

response

evaluation

See A-19

Reaponse

or stable

disease

4-6

cycles

(total)

Tumor

response

evaluation

Progression See second-line

therapy, above

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

PS 0-1


Doublet

chemotherapy

or

Cetuximab/

vinorelbine/

cisplatin

First-line Therapy Second-line Therapy

PS 3-4

PS 0-2

PS 3-4


Docetaxel or Erlotinib or

Gemcitabine

Progression

PS 2 Chemotherapy

Tumor

response

evaluation

See A-19

Response

or stable

disease

4-6

cycles

(total)

Tumor

response

evaluation

Progression See second-line

therapy, above

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


Progression

PS 0-2

PS 3-4

Erlotinib

or



Docetaxel

or

Pemetrexed( non-squamous)

or

Erlotinib

or

Gemcitabine

Progression

PS 0-2

PS 3-4 Best supportive care


or

Clinical trial

Third-line Therapy

A-19

分期

Primary Tumor (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis The Carcinoma in situ

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) *

T1a Tumor is ≤ 2 cm in greatest dimension

T1b Tumor > 2 cm but ≤ 3 cm in greatest dimension

T2 Tumor >3 cm but ≤ 7cm or tumor with any of the following features ( T2 tumors with

these features are classified T2a if ≤ 5cm)

Involves main bronchus, ≥ 2 cm distal to the carina

Invades visceral pleura(PL1 or PL2)

Associated with atelectasis or obstructive pneumonitis that extends to the hilar

region but does not involve the entire lung

T2a Tumor > 3 cm but ≤ 5 cm in greatest dimension

T2b Tumor > 5 cm but ≤ 7 cm in greatest dimension

T3 Tumor >7cm or one that directly invades any of the following: parietal pleural(PL3)

chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal

pleura, parietal pericardium; or tumor in the main bronchus( < 2 cm distal to the

carina*, but without involvement of the carina; or associated atelectasis or obstructive

pneumonitis of the entire lung or separate tumor nodule(s) in the same lobe

T4 Tumor of any size that invades any of the following: mediastinum, heart, great vessels,

trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina; or separate tumor

nodule(s) in a different ipsilateral lobe

* The uncommon superficial tumor of any size with its invasive component limited

to the bronchial wall, which may extend proximal to main bronchus, is also

classified as T1a.

Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

A-20

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 nodes(s)

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

scalene, or supraclavicular lymph nodes(s)

Distant Metastasis (M)

M0 No distant metastasis (no pathologic M0; use clinical M to complete stage group)

M1 Distant metastasis

M1a Separate tumour nodule(s) in a contralateral lobe; Tumour with pleural nodules or

malignant pleural( or pericardial) effusion.

M1b Distant Metastasis**

** Most pleural (and pericardial) effusions with lung cancer are due to tumor. In a

few patients, however, multiple cytopathologic examinations of pleural

(pericardial) fluid are negative for tumor, and the fluid is nonbloody and is not an

exudate. Where these elements and clinical judgement dictate that the effusion is

not related to the tumor, the effusion should be excluded as a staging element and

the patient should be classified as M0.

T1a T1b T2a T2b T3 T4

N0 IA IB IIA IIB IIIA

N1 IIA IIA IIB IIIA IIIA

N2 IIIA IIIA IIIA IIIA

N3 IIIB IIIB IIIB IIIB

1.J Thorac Oncol. 2007, 2:706-714

2.Staging Manual in Thoracic Oncology, IASLC, 2009.

3.AJCC, 7th

edition.

A-21

A-13

Small Cell Lung Cancer

Small cell or combined

small cell/non-small cell

lung cancer on biopsy or

cytology of primary or

metastatic site

*H & P

*Pathology review

* WBC, DC, Hgb, platelets

*Electrolytes, liver function

*BUN, creatinine

*Chest/liver/adrenal CT with IV

contrast whenever possible

*Head MRI (preferred) or CT


*PET/CT scan (if limited stage is

suspected) (option)

*Smoking cessation counseling and

intervention

Diagnosis Initial Evaluation Stage

Limited stage (T any, N any,

M0; except T3-4 due to

multiple lung nodules that do

not fit in a tolerance radiation

on field)

Extensive stage (T any, N any,

M1a/b; T3-4 due to multiple

lung nodules)

See A-23

See A-25

A-22

Limited stage (T any, N any,

M0; except T3-4 due to

multiple lung nodules that do

not fit in a tolerable radiation

field)

Clinical stage

(T1-2, N0)

Limited stage in

excess of T1-2,

N0

Bone marrow

biopsy,

thoracentesis, or

bone studies

consistent with

malignancy

See A-24


Additional Workup Stage

*If pleural effusion is present,

thoracentesis is recommended; if

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

PET/CT (if

not previous

obtained)

Pathologic

mediastinal

staging is

considered

See A-24

See A-25

A-23

Clinical stage

T1-2, N0

Pathologic

mediastinal staging

negative

N0

N+


Pathologic

mediastinal staging

positive or medically

inoperable

Lobectomy (preferred) and

mediastinal lymph node

dissection or sampling

Chemotherapy

Concurrent

chemotherapy +

mediastinal RT

Good performance

status (PS 0-2)

Poor PS (3-4) due

to SCLC

Poor PS (3-4) not

due to SCLC

Chemotherapy + concurrent

thoracic RT

Chemotherapy ± RT

Individualized treatment

including supportive care

Initial Treatment Testing Results Adjuvant Treatment

See A-26

Limited stage

excess T1-2, N0

Poor PS (3-4) due

to SCLC

Poor PS (3-4) not

due to SCLC

Good performance

status (PS 0-2)

Chemotherapy + concurrent

thoracic RT

Chemotherapy ±RT

Individualized treatment

including supportive care

See A-26

A-24

Extensive stage (T

any, N any, M1a/b;

T3-4 due to multiple

lung nodules)


Initial Treatment Stage

Extensive stage

without localized

symptomatic sites or

brain metastases

Extensive stage +

localized

symptomatic sites

Extensive stage with

brain metastases

*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-26

*Good PS (0-2)

*Poor PS (3-4) due

to SCLC

A-25

*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

Limited or extensive

stage: PCI


Stable disease

Primary

progressive disease

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-27

See A-22

Adjuvant Treatment Response Assessment Following Initial Therapy Surveillance

A-26

Relapse or primary

progressive disease


Subsequent Therapy/Palliative Therapy Progressive Disease

Subsequent chemotherapy

(category 1 for topotecan)

or

palliative symptom management,

including localized RT to

symptomatic sites

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

Palliative symptom management, including localized RT to

symptomatic sites

PS 0-2

PS 3-4

A-27

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

4.Alternative regimens with combination of platinum

-Paclitaxel -Docetaxel -Pemetrexed

5.High-risk drugs for CCRT

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

A-28

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

修訂日期 106年 4月 18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

ESOPH-6(A-29)

(3)分期 Stage IV (metastatic disease) Squamous cell carcinoma See ESOPH-9 改為 See

ESOPH-5 (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 ESOPH-5 (A32)

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

A-29

A-30

A-31

A32

1.0

2.0

食道癌修訂記錄


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 ESOPH-7、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)

A33

A-34

A-35

2.0

Esophageal Cancer

*H & P

*Upper GI endoscopy and biopsy

* Chest/abdomen CT with oral and IV contrast

*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 M1 disease

*Assign Siewert category

*Smoking cessation advice, counseling, and pharmacotherapy

Workup Clinical stage Histologic classification

Stage I-III

(locoregional

disease)

Stage IV

(metastatic

disease

Squamous cell carcinoma

Adenocarcinoma

Squamous cell carcinoma

Adenocarcinoma

See ESOPH-2

See ESOPH-6

See ESOPH-5

Palliative therapy

A-29

Histology Additional Evaluation

(as clinically indicated)

Esophageal Cancer

Clinical stage

Squamous

cell

carcinoma

Stage I-III

(locoregional

disease)

*Multidisciplinary evaluation

-Consider nasogastric or

J-tube or PEG for

preoperative nutritional

support

Medically fit for surgery

Non-surgical candidate(Refer to KMUH)

See ESOPH-3-

A-30

Tumor

classifications Primary treatment options for medically fit patients

Esophageal Cancer

Histology

Squamous cell

carcinoma

Tis

T1a

T4b(Refer to KMUH)

Endoscopic therapies or Esophagectomy

T1b, N0

T1b, N+,

T2-T4a, N0- N+

Endoscopic therapies (preferred) or esophagectomy

Eesophagectomy

A-31

Chemoradiation (Refer to KMUH) or esophagectomy

Follow-up for squamous

cell carcinoma Recurrence

Palliative therapy

Esophageal Cancer

*H & P

-if asymptomatic: H & P

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

6-12 mo for 3-5y, then

annually

* Chemistry profile and CBC,

as clinically indicated

*Imaging study

*Upper GI endoscopy and

biopsy

*Dilatation for anastomotic

stenosis

*Nutritional assessment and

counseling

Locoregional only

recurrence: prior

esophagectomy, no

prior chemoradiation

Locoregional only

recurrence: prior

chemoradiation, no

prior esophagectomy

Resectable

and medically

operable

Unresectable

or medically

inoperable

Metastatic disease

Concurrent chemoradiation

(fluoropyrimidine- or

taxane-based) preferred or

surgery or chemotherapy or

best supportive care

Recurrence

esophagectomy Recurrence See

ESOPH-5

See

ESOPH-5

-

See

ESOPH-5

A-32

For squamous cell

carcinoma

Performance status Palliative therapy

Esophageal Cancer

Unresectable locally

advanced, locally recurrent

or metastatic disease

Karnofsky performance

score ≥ 60%

or

ECOG performance score≤ 2

Karnofsky performance

score

Esophageal Cancer

Histology

Clinical status Additional evaluation

(as clinically indicated)

Adenocarcinoma

*Multidisciplinary evaluation

-Consider nasogastric or J-tube

or PEG for preoperative

nutritional support

-Laparoscopy (optional) if no

evidence of M1 disease and

tumor is at esophagogastric

junction(EGJ)

Medically fit for surgery

Stage I-III

(locoregional

disease)

See ESOPH-7

A-34

Non-surgical candidate(Refer to KMUH)

Tumor classification Primary treatment options for medically fit patients

Esophageal Cancer

Adenocarcinoma

Tis

T1a

T1b,N0

T1b,N+

T2-T4a, N0-N+

T4b(Refer to KMUH)

Endoscopic therapies(preferred)or Esophagectomy

Esophagectomy

Chemoradiation(Refer to KMUH)

Esophagectomy

A-35

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 annually

* Chemistry profiles and CBC, as


*Imaging studies

*Upper GI endoscopy and biopsy

*Dilatation for anastomotic stenosis

*Nutritional assessment and counseling

Locoregional only

recurrence: Prior

esophagectomy, no

prior chemoradiation

Locoregional only

recurrence: Prior

chemoradiation, no

prior esophagectomy

Metastatic disease

Resectable

and medically

operable

Unresectable

or medically

inoperable

Esophagectomy

Recurrence Palliative

therapy

Surgery or

Chemotherapy or


Palliative

therapy

A-36

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

修訂日期 106 年 5 月 9 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





※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 (multiple dilution）

2.術前建議評估-Lung function test、Chest x-ray、Cardio echo

B-2

B-3

B-4

B-6~7

B-8~9

B-5

B-2

B-7

B-8

B-2

3.0

4.0

5.0

肝癌修訂記錄


106 年

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)

刪除 Child-pugh C的治療中的標靶治療。

非常早期(0)新增治療方式為切除

B4

B7

6.0

一、肝癌診斷導引

未發現腫瘤、非惡性腫瘤或無法確定

門診追蹤，每 3個月定期追蹤甲種胎兒蛋白及腹部超音波

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

腫瘤≧1cm有影像學或臨床資料足以診斷

臨床資料不足以診斷

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。

B-2

(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。

(三)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。

(四)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

(五)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。---建議轉高醫接受此治療

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。

(六)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

1.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。

2.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

九-1、肝癌治療流程圖：

Child- pugh C

醫師評估後無法

行 curative 治療

治療後經醫

師評估後可

行 curative

治療

支持性療法

‧標靶治療 ‧放射線治療 ‧臨床試驗 ‧動脈或全身化學治療

確診病例

1.Child-pugh C 或 Child-pugh A-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

九-2、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

Cancer of the Liver Treatment Guideline

肝癌治療準則

B-5

十、HCC Post- treatment Follow Up Flowchart

(一)追蹤影像：

(二)追蹤 AFP elevated：

OP、RFA、PEI、TACE(TAE) (首次療程)

F/U Abd echo、CT、MRI

F/U Abd echo、CT、MRI 需 3 次或以上

2 個月內

1年內

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)

F/U AFP elevated

F/U AFP elevated 需 3 次或以上

2 個月內

1年內

Cancer of the Liver Treatment Guideline 肝癌治療準則

B-6

十一、分期：

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

Hepatocellular carcinoma

Stage：0

PST：0

child-turcotte-pugh：A

Very early

stage(0)

single< 2cm

carcinoma in situ

resection

stage：A-C

PST：0-2

child-turcotte-pugh：A or B

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

single 3 nodules≦3cm

Increased portal pressure and

elevated bilirubin level

no

yes

Association disease

no yes

Liver transplantion

(CLT or LDLT) PEI orRFA

stage：D

PST：>2

child-turcotte-pugh：C

Terminal

stage:D

Supportive

care

Sorafenib

TAE or TACE

Cancer of the Liver Treatment Guideline

肝癌治療準則

B-7

2.AJCC7th TNM (Tumor-Node-Metastasis) Stage：

TX

T0

T1

T2

T3a

T3b

T4

Primary Tumor (T)

Primary tumor cannot be assessed

No evidence of primary tumor

Solitary tumor without vascular invasion

Solitary tumor with vascular invasion or multiple tumors none more than 5 cm

Multiple tumors more than 5 cm

Single tumor or multiple tumors of any size involving a major branch of the

portal vein or hepatic vein

Tumor(s) with direct invasion of adjacent organs other than the gallbladder or

with perforation of visceral peritoneum.

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 (no pathologic M0; use clinical M to complete stage

group)

Distant metastasis

A NATOMIC S TAGE / P ROGNOSTIC G ROUPS

CLINICAL PATHOLOGIC

GROUP T N M GROUP T N M

I T1 N0 M0 I T1 N0 M0

II T2 N0 M0 II T2 N0 M0

IIIA T3a N0 M0 IIIA T3a N0 M0

IIIB T3b N0 M0 IIIB T3b N0 M0

IIIC T4 N0 M0 IIIC T4 N0 M0

IVA Any T N1 M0 IVA Any T N1 M0

IVB Any T Any N M1 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

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

week 5FU(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

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--

B-11

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.

--------------- Systemic oral chemotherapy

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

Systemic Chemotherapy therapy

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

B-12

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.

Cancer of the Colon

Treatment Guideline

KMHK 修訂日期106年6月16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




(1)大腸直腸癌 MONITORING/SURVEILANCE Colonscopy 2-5 years: Obstruction lesion for new lesion,

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，連續執行三年改二年。

(3)High Risk Stage II or Stage III 門診第一線用藥準則（1）：5FU 500 mg/m2 ＋ Leucorvin 100mg/ m2

Weekly for 6 of 8 weeks 改 Weekly for 6 of 8 weeks2-3 cycle。

(4)High Risk Stage II or Stage III IV 門診第一線用藥準則（3）： Capecitabine 1250 mg/m2

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 local excision + post-op radiotherapy 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-operative chemotherapy (MMC and 5-FU)

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 + radiotherapy, then AP or low anterior

resection ± intraoperative brachytherapy 改 Pre-op chemotherapy + radiotherapy, then OP or low anterior

resection ±then RT。

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

準則。

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

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

C-3

C-4

C-6

C-7

C-11

C-12

C-12

C-14

C-6

C-7

C-10~12

1.0

2.0

3.0

103 年

104 年

105 年

106 年

(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、文憲查證。

(1)修訂大腸直腸癌治療準則


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

COL-1~COL-13

REC-1~REC-12

4.0

5.0

6.0

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 參考文件： 3.1 National Comprehensive Cancer Network. Clinical Practice Guideline in Oncology:Colon Cancers V2.2017

3.2 National Comprehensive Cancer Network. Clinical Practice Guideline in Oncology:Rectal Cancers V2.2017

4 定義：泛指臨床科醫療人員皆可參考適用。

5 內容： 5.1大腸直腸癌診斷及評估。

5.2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。

5.3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。

5.4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。

5.5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。

5.6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。

5.7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。

5.8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。

5.9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

C-1

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。

5.10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。

5.11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。

5.12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。

5.13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。

＊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

C-3

(須轉介高醫檢查)is not routinely

C-5

(須轉介高醫檢查)is not

C-6

Pretreatment ≦2 years 2-5 years >5 years

Physical exam, including DRE ˇ Q3m Q6m Q12m

Stool occult blood test ˇ ── ── Q12m

CBC + panel A ˇ Q3-6m Q6m Q12m

CEA ˇ Q3m Q6m Q12m

Chest X-ray ˇ Q6m Q6m Q12m

Abdominal CT or sonography

(for colon cancer) ˇ Q3-6m Q12m ──

Pelvis CT / MRI or sonography

(for rectal cancer) ˇ Q3-6m Q12m ──

Colonscopy ˇ Q12m Q5Y Q5Y

MONITORING / SURVEILANCE

Cancer of the Colon Treatment Guideline 結腸癌治療準則 (Follow up)

C-16

Cancer of Rectum

Treatment Guideline

KMHK

修訂日期106年6月16日

Cancer of the Rectum Treatment Guideline 直腸癌治療準則

C-17

大腸直腸癌AJCC分期

C-29

5.16 大腸直腸癌化療藥物

5-FU/LV (sLV5FU2) 1 mFOLFOX62.3 FOLFIRI4 XELOX5.6 Xeloda7

Leucovorin 400 mg/m2

5-FU 400 mg/m2

5-FU 2400 mg/m2

Oxaliplatin 85 mg/m2


5-FU 400 mg/m2

5-Fu 2400 mg/m2

Irinotecan 180 mg/m2


5-Fu 400 mg/m2

5-FU 2400 mg/m2

Oxaliplatin 130 mg/m2

Xeloda 850-1000 mg/m2

po

Xeloda 850-1250 mg/m2

po

UFUR8.9 FOLFOX415 Avastin10 Erbitux11

UFUR 200-300 mg po Oxaliplatin 85 mg/m2


for 2days

5-FU 400 mg/m2 for

2days

5-Fu 600 mg/m2 for

2days

Avastin 劑量 5mg/kg

Erbitux為水劑 500

mg/m2

CCRT:

1.RT+5-FU/Leuconvorin12：

5-FU400mg/m2 iv bolus + Leuconvorin20 mg/ m2 iv bolus for 4 day

during week 1 and 5 of RT

2.RT+Capecitabine13.14：

Capecitabine 825mg/m2 twice daily 5 days/week + RT×5weeks

C-31

參考文獻

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

2.National Comprehensive Cancer Network. Clinical Practice Guideline in Oncology: Colon & Rectal Cancers V2.2015

3. Hofheinz R, Wenz FK, Post S, et al. Chemoradiotherapy with capecitabine versus fluorouracil for locally advanced rectal cancer: A randomized, multicentre,

noninferiority,phase 3 trial. Lancet Oncol 2012;13:579-588.9

4. Roh MS, Yothers GA, O'Connell MJ, et al. The impact of capecitabine and oxaliplatin in the preoperative multimodality treatment in patients with carcinoma

of the rectum: NSABP R-04 [abstract]. J Clin Oncol 2011;29 (suppl):3503.Available at:

http://meeting.ascopubs.org/cgi/content/abstract/29/15_suppl/3503?sid=671faff0=9-2de9-4f22-9b93-e6520eafcd08

http://www.nccn.org/

Cancer of the Gastric

Treatment Guideline

KMHK 修訂日期 106年 6月 16日

胃癌修訂紀錄


97 年

98 年

99 年

100 年

101 年

102 年

103 年

104 年

105 年

胃癌診療指引新制訂





(1)T2,N0 治療 Observe or ECF if received preoperatively

or Chemoradiation ( Fluoropyrimidine-based) for selected

patients 改 UFUR or follow up。

(2)T3,T4 or Any T,N+治療 ECF if received

preoperatively or RT,45-50.4 Gy + concurrent 5-FU-based

radiosensitization + 5-FU ± leucovorin

改 Adjuvant Chemotherapy(ECF、EOX、FOLFOX4、Xeloda、

UFUR、TS1)。

(1)因本院沒有再做 Laparoscopic staging 故 Workup 診斷為

Locoregional ( M0 )之後 Multidisciplinary→

Evaluation。

(1)增訂目的、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。

(1)增訂胃癌簡易版治療準則 Stage 3、Stage 4

C-21

C-15

C-22

C-23

C-24

C-23

1.0

2.0

3.0

4.0

5.0

106 年

(2)修訂胃癌診療指引共識

多專科會議檢視後未修改

GAST-1

GAST-2

GAST-3

GAST-4

GAST-5

GAST-6

GAST-7

目的：根據國家衛生研究院 TCOG 所制定的胃癌治療準則，同時會同各相關次專科根據國人胃癌現況加以修訂，建立標準化流程，以藉此提升本院

以及南台灣癌症照護品質。

1. 範圍：適用本院臨床科醫師。

2. 參考文獻 :

2.1.TCOG 胃癌工作群編撰小組(2012)。胃癌臨床診療指引。苗栗縣。國家衛生研究院

2.2.National Comprehensive Cancer Network. Clinical Practice Guideline in Oncology:Gastric Cancer V3.2015

3. 定義：

4.1 權責：臨床科學相關科系醫療人員

4.2 修訂時機:定期修訂一次，但當 TCOG 胃癌臨床診療指引有重大修訂或文獻有重大結論時，可另行召開診治共識修訂會。

4.3 修訂依據:主要以最新版的 TCOG 胃癌臨床診療指引為依據，以最新文獻證據為輔，並參考團隊診療資料庫的數據分析及研究成果。

5.內容：

5.1 胃癌簡易版治療準則

AJCC/治療 OP C/T R/T Target Hospice

Stage 0 ESD or EMR

(轉高醫)Gastrectomy

Stage 1 ESD or EMR

(轉高醫)Gastrectomy

Stage 2 Gastrectomy Preoperative Chemotherapy:

1.Fluorouracil+ Cisplatin

2.Cisplatin+Capecitabine(口服)

3.Oxalipltin+Capecitabine(口服)

4.Oxalipltin+Fluorouracil+Leucovorin

Perioperative Chemotherapy:


2.Epirubicin+Cisplatin+Xeloda(口服)

CCRT

C-33

3.Epirubicin+Oxaliplatin+Xeloda(口服)

Stage 3 Gastrectomy Preoperative Chemotherapy:


2.Cisplatin+Capecitabine(口服)

3.Oxalipltin+Capecitabine(口服)


Perioperative Chemotherapy:




4.TS-1(自費)

CCRT

Stage 4 Gastrectomy 1.Fluorouracil+ Cisplatin



4.Epirubicin+Oxaliplatin+Fluorouracil

5.Docetaxel+Cisplatin+Fluorouracil


7. TS-1(自費)

8.Paclitaxel,Taxol

Trastuzumab Symptomati

care

C-34

5.2 胃癌分期

C-35

Cancer of the Gastric Treatment Guideline

胃癌治療準則

WORKUP

CLINICAL

STAGE

Surgically

unresectable

Medically fit,

potentially

resectable

Stage IV

(cM1)

Palliative

Management

(see GAST-7)

ADDITIONAL

EVALUATION

H&P

Upper GI endoscopy and biopsy

Chest /abdomen/pelvic CT with

oral

and IV contrast

PET-CT evaluation(if need)

CBC and comprehensive

chemistry profile

Endoscopic ultrasound (EUS) if no

evidence of M1 disease(optional

轉介高醫執行)

Biopsy of metastatic disease (if

clinically indicated)

H.pylori test Non-surgical candidate

Locoregional

(cM0)

Consider

laparoscopy

with

cytology

(category 2B)

cTis

or

cT1a

Medically fit

Non-surgical candidate

Multidisciplinary

review preferred See GAST-2

GAST-1

C-36


胃癌治療準則

CONCLUSIONS OF

MULTIDISCIPLINARY

REVIEW

FINAL STAGEh

PRIMARY TREATMENT

cTis or cT1a

Metastatic disease (cM1)

Locoregional

disease (cM0)

Non-surgical

candidatej

Medically fit

Non-surgical candidate

Surgically,

unresectable

cT1b

Medically fit,

potentially

resectable cT2 or higher,

Any N

ER

Palliative Management (see GAST-7)

ER

or

Surgery

Surgery

or

Perioperative chemotherapy

(category 1)

or

Preoperative chemoradiation

(category 2B)

Concurrent fluoropyrimidine- or taxane-based

chemoradiationn,o

(category 1)

or

Chemotherapy

Concurrent fluoropyrimidine- or taxane-based

Chemoradiation (category 1) (Definitive)

or

Palliative Management (see GAST-7)

Surgery

Surgeryd,e,m

Endoscopic

surveillance

Surgical Outcomes

For Patients Who

Have Not Received

Preoperative Therapy

(see GAST-3)

Surgical Outcomes

For Patients Who Have

Received Preoperative

Therapy (see GAST-4)

Post-Treatment

Assessment/

Additional

Management (see GAST-5)

Post-Treatment

Assessment/

Additional

Management (see GAST-5)

GAST-2

C-37


胃癌治療準則

SURGICAL OUTCOMES/CLINICAL

PATHOLOGIC FINDINGS

(Patients Have Not Received

Preoperative Chemotherapy or

Chemoradiation)

TUMOR

CLASSIFICATION

pTis or

pT1, N0

R0 resectionp

R2 resection

pM1

R1 resection

pT2, N0

pT3, pT4, Any N

or Any pT, N+

POSTOPERATIVE MANAGEMENT

Surveillance

Chemoradiation (fluoropyrimidine-based)

Follow-up

(see GAST-6)

Surveillance

or

UFUR

Adjuvant Chemotherapy

(ECF、EOX、FOLFOX4、Xeloda

、UFUR、TS1)


or

Palliative Management (see GAST-7), as clinically indicated

Palliative

Management

(see GAST-7) ＊放射線治療需轉介

GAST-3

C-38


胃癌治療準則

SURGICAL OUTCOMES/CLINICAL

PATHOLOGIC FINDINGS

(Patients Have Received

Preoperative Chemotherapy or

Chemoradiation)

TUMOR

CLASSIFICATIONh

R0 resection

R2 resection

ypM1

R1 resection

Node negative

(yp Any T, N0

Node positive

(yp Any T, N+)

POSTOPERATIVE MANAGEMENT

Chemoradiation

(fluoropyrimidine-based),

only if not received preoperatively

Follow-up

(see GAST-6)


only if not received preoperatively

or

Palliative Management (see GAST-7), as clinically indicated

Palliative

Management

(see GAST-7)

Chemotherapy,

if received preoperatively (category 1)

Surveillance

or

Chemotherapy,

if received preoperatively (category 1)

＊放射線治療需轉介

GAST-4

C-39


胃癌治療準則

Restaging :

˙Chest/abdomen/pelvic CT with oral and IV contrast

˙CBC and comprehensive chemistry profile

˙PET/CT scan (optional 轉介高醫執行) Unresectable

or

Medically inoperable

and/or

Metastatic disease

Resectable and medically operable

Surgery

(preferred),

if appropriate

or

Follow-up

(see GAST-6)

Palliative

Management

(see GAST-7)

Unresectable disease or

Non-surgical candidatej

following primary

treatment

POST-TREATMENT

ASSESSMENT OUTCOME ADDITIONAL

MANAGEMENT

GAST-5

C-40


胃癌治療準則

FOLLOW-UP/SURVEILLANCE

˙H&P every 3-6 mo for 1-2y,

every 6-12 mo for 3-5y,

then annually

˙CBC and chemistry

Profile as indicated

˙Radiologic imaging or upper GI endoscopy, as


˙Monitor for nutritional deficiency (eg, B12 and

iron) in surgically

resected patients and

treat as indicated

Locoregional

recurrence

Metastatic

disease

Resectable and

medically operable

Unresectable

or medically

inoperable

RECURRENCE

Consider surgery

or

Palliative Management

(see GAST-7)

See Palliative Management

(GAST-7)

See Palliative Management

(GAST-7)

GAST-6

C-41


胃癌治療準則

Karnofsky performance score≧60%

or

ECOG performance score≦2

Systemic therapyn

or

Clinical trial

or

Palliative/Best supportive caret

Palliative/Best supportive caret

Unresectable locally

advanced , Locally

recurrent or metastatic

disease

PERFORMANCE STATUS PALLIATIVE

MANAGEMENT

Karnofsky performance score＜60% or

ECOG performance score≧3

GAST-7

C-42

參考文獻

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

2.Bang YJ, Van Cutsem E, Feyereislova A, et al. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of

HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): a phase 3, open-label, randomised controlled trial. Lancet

2010;376:687-697.

Cancer of the Breast

Treatment Guideline

KMHK 修訂日期 106年 6月 16日

乳癌修訂紀錄


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�

Documents

106年癌症診療指引 中英文版 - kmhk.org.t¹´診療指引.pdf · 106 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

106年癌症診療指引中英文版 - kmhk.org.t¹´診療指引.pdf · 106 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