解读美国国家综合癌症网络食管癌临床诊疗指南

 美国国家综合癌症网络（National Comprehensive Cancer Network，NCCN）是由美国21个国际顶尖水平的癌症中心组成的协作组织，其主要任务是制定各类肿瘤的临床诊疗指南，目的是改善肿瘤治疗的质量、有效性和效率，以使患者更好地生存。目前，NCCN的肿瘤临床诊疗指南已经广泛应用于临床，并且根据最新的临床研究结果每年更新。关于NCCN食管癌临床诊疗指南目前国内还没有正式版本，也没有在临床推广执行。现对2007年NCCN食管癌临床诊疗指南进行解读，并与中国目前临床实践进行对照。     

中国食管癌规范诊疗质量控制指标(2022版)

食管癌是常见恶性肿瘤之一。全球范围内, 食管癌发病居恶性肿瘤第7位, 其中, 超过50%的食管癌新发病例发生在我国。食管鳞癌为我国特有的高发肿瘤之一。我国2020年肿瘤登记年报数据显示, 食管癌位于我国恶性肿瘤发病第6位, 死亡第4位。随着食管癌早期筛查、早期微创治疗技术的普及以及放化疗等综合诊疗水平的不断进步, 我国食管癌患者5年生存率已较前有所提高, 但不同地区间诊断及治疗水平仍存在较大差异。2012年, 国家卫生健康委员会领导成立国家肿瘤质控中心, 推行肿瘤诊疗质量控制, 规范肿瘤诊疗行为, 促进全国范围内肿瘤诊疗规范化、同质化、标准化, 最终提升恶性肿瘤患者的生存率和生活质量。为进一步推动食管癌规范化诊疗质控工作, 国家癌症中心、国家肿瘤质控中心委托国家癌症中心、国家肿瘤质控中心食管癌质控专家委员会, 依据《食管癌诊疗指南(2022年版)》等国家级食管癌诊疗指南规范, 结合循证医学、临床经验, 在符合科学性、普适性、规范性、可操作性指导原则下, 起草并制定了《中国食管癌规范诊疗质量控制指标(2022版)》, 具体如下。     

《肿瘤预防与治疗》文章荐读:2020年中国临床肿瘤学会《食管癌诊疗指南》解读

食管癌是常见的消化道肿瘤,其发病率在全球恶性肿瘤中排第7位,死亡率排第6位。中国是食管癌高发国家,每年新发病例约占全球的一半,其在男性的发病率和死亡率分别位于第5位和第4位。基于循证医学证据,结合我国食管癌特色,中国临床肿瘤学会(Chinese Society of Clinical Oncology,CSCO)2019年在人民卫生出版社首次发表了《食管癌诊疗指南》(ISBN 978-7-117-28359-5)。     

《中国成人患者肠外肠内营养临床应用指南(2023版)》解读

住院患者营养不良发生率高,合理的营养治疗能改善患者营养状况,降低应激损害,降低并发症发生率和病死率,从而加速患者康复。临床营养作为疾病治疗过程中不可缺少的重要组成部分,它的重要性越来越受到重视。建立规范化的临床营养诊疗路径以改善患者营养状况和临床结局是当今医学领域临床营养治疗的关键问题。2023年4月《中国成人患者肠外肠内营养临床应用指南(2023版)》正式发布,该指南基于已发表的临床营养指南及国内外最新临床证据,从营养筛查与评估、肠内营养及肠外营养临床实践等37个具体问题出发,提出60条推荐意见,全面概括了临床营养诊治原则和诊疗措施,提供了较为全面的营养治疗方案指导。本文将对该指南的部分重点内容进行解读,以期为临床患者的规范化营养诊疗及管理提供临床借鉴。     

编者的话

自上世纪40年代Pierre Denoix提出恶性肿瘤的TNM分期以来,这一方法逐步成为评估肿瘤进展程度、指导治疗方式选择、判断预后和比较疗效的主要依据.2009年国际抗癌联盟(UICC)和美国癌症联合会(AJCC)合作提出第七版食管癌TNM分期,在此基础上中国抗癌协会食管癌专业委员会根据我国食管癌病例特点和治疗现状及时推出新的诊疗指南,以规范食管癌的临床诊治、提高治疗效果.     

《中国肿瘤临床》2016年第12期“食管癌专栏”

我国是世界上食管癌高发地区之一,该病以中老年患者为主,长期缓解率、远期生存率并不乐观。目前食管癌治疗模式已从单一的外科手术转变为在规范化手术基础上合理应用围术期放、化疗等综合治疗模式。食管癌的术前准确分期、手术方式、淋巴结清扫范围和消化道重建方式尚有很多问题存在争议。我国食管癌诊疗需要结合国情,参考国际指南,开辟一条更经济实用且合理的道路。《中国肿瘤临床》2016年第12期由天津医科大学肿瘤医院食管肿瘤科主任于振涛教授牵头,推出“食管癌专栏”,特邀我国食管癌领域多位专家学者撰稿,发布食管癌发病相关数据、临床和基础研究进展及诊疗策略。希望通过本专栏为食管外科、放疗及病理等专业人员提供更完善、更便利的交流平台,推动我国食管癌研究成果的临床转化,造福广大患者。     

山东省医学会食管癌多学科规范化诊疗指南(2023年版)

食管癌是山东省的高发恶性肿瘤,目前的诊疗存在诸多不规范之处。包括肿瘤内科、肿瘤外科、放疗科、影像科、内镜科、病理科等多学科联合的规范化诊疗对于改善局部控制、提高总生存率和生命质量至关重要。基于临床需求,结合近年来多学科诊疗进展,特制定本指南。     

山东省医学会食管癌多学科规范化诊疗指南(2023年版)

食管癌是山东省的高发恶性肿瘤, 目前的诊疗存在诸多不规范之处。包括肿瘤内科、肿瘤外科、放疗科、影像科、内镜科、病理科等多学科联合的规范化诊疗对于改善局部控制、提高总生存率和生命质量至关重要。基于临床需求, 结合近年来多学科诊疗进展, 特制定本指南。     

《中国肿瘤临床》文章推荐:食管癌患者营养治疗指南

食管癌是营养不良发病率最高的恶性肿瘤。营养不良会降低食管癌细胞对放化疗的敏感性,增加治疗不良反应,延长住院时间,延缓身体康复,增加医疗费用,降低患者治疗疗效和生存质量。因此,开展规范化的营养治疗对食管癌患者具有重要的意义。迄今为止,国内外鲜见专门针对食管癌患者的营养治疗指南。为此,2020年第1期《中国肿瘤临床》特邀中国抗癌协会肿瘤营养专业委员会、中华医学会肠内肠外营养学分会和中国医师协会放射肿瘤医师分会营养与支持治疗学组的肿瘤营养专家,通过对食管癌营养治疗最新国内国外文献的全面检索与分析,撰写了《食管癌患者营养治疗指南》一文。该指南经过专家们反复讨论与修改,从食管癌患者的营养诊断、营养治疗适应证、治疗途径、治疗通路、营养素和疗效评价六个方面的内容分别进行了证据论述和意见推荐,以期对临床应用和研究能发挥一定的指导作用,改善患者生存质量。     

中国原发性肝癌2022年版诊疗指南与2019年版诊疗规范的比较分析

随着对原发性肝癌研究深入,国家卫生健康委员会相继在2019及2022年制定发布了《原发性肝癌诊疗规范(2019版)》和《原发性肝癌诊疗指南(2022年版)》。本研究比较2版指南在原发性肝癌诊疗过程中的差异,思考、总结新版指南提出的新方案、新观点及新设想,并参考国内外相关研究最新进展,加以补充,为临床原发性肝癌诊治提供借鉴和指导,希望肝病相关临床医师应用最新指南,规范诊疗行为,保障医疗质量。     

Considerations of treatment standardization from the procession of NCCN guideline of esophaqeal cancer

Esophageal carcinoma is one of the most common malignant tumors, especially in China which is the high incidence area. As a result of mild symptoms of early-stage esophageal cancer, the majority of patients cannot be diagnosed until they develop to advanced cancer, and the treatment outcome of surgery or chemoradiotherapy is still unsatisfactory at present. The guidelines of esophageal cancer issued by National Comprehensive Cancer Network (NCCN) are regarded as important reference tools by clinical oncologists, and provide uniform criteria for the diagnosis and treatment of esophageal carcinoma. However, the guidelines are not always suitable for Chinese patients because the data come from European and American population which have significant ethnical difference from Chinese. We retrospectively analyzed the changes of treatment strategy of esophageal cancer in NCCN guidelines and the advance of treatment for esophageal carcinoma in China, aiming to provide our oncologists with new research ideas. We also hope to set up clinical cancer cooperation organizations, and release our own cancer guidelines to serve Chinese patients and oncologists.     

食管癌患者营养治疗指南

食管癌是营养不良发生率最高的恶性肿瘤。营养不良会降低食管癌细胞对放化疗的敏感性,增加治疗不良反应,延长住院时间,延缓身体康复,增加医疗费用,降低患者治疗疗效和生活质量。因此,开展规范化的营养治疗对食管癌患者具有重要的意义。然而,迄今为止,国内外均没有专门针对食管癌患者的营养治疗指南。因此,中国抗癌协会肿瘤营养专业委员会、中华医学会肠外肠内营养学分会和中国医师协会放射肿瘤治疗医师分会营养与支持治疗学组的肿瘤营养专家,通过对食管癌营养治疗最新国内国外文献的全面检索与分析,并经过反复讨论与修改,制定了本指南。指南从食管癌患者的营养诊断、营养治疗适应证、治疗途径、治疗通路、营养素和疗效评价六个方面的内容分别进行了证据论述和意见推荐。     

Endoscopic Diagnosis and Treatment of Superficial Esophageal Squamous Cell Cancer: Present Status and Future Perspectives

This review provides information regarding the preoperative examinations, indications for endoscopic resection (ER), and curability assessment in subjects with superficial esophageal squamous cell carcinoma (SCC). Narrow-band imaging (NBI) is a more sensitive modality for detecting esophageal cancer than conventional observation, and esophageal observation using NBI is thus recommended for the detection of superficial esophageal cancer. It is also important to adjust the volume of air in the esophagus during observation. Workup by non-magnifying followed by magnifying endoscopy is a common process for diagnosing the invasion depth of superficial esophageal SCCs in Japan. Endoscopic ultrasonography carries a risk of overdiagnosis, and its routine use is therefore not recommended. The Japanese endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer considered the indications for ER based on the results of studies focusing on clinical MM/SM1 cancers, and concluded that clinical MM/SM1 carcinomas, except circumferential carcinoma, were an indication for ER. The curative effect of ER should be assessed based on histologic examination of the resected specimens. ER should be conducted based on a thorough understanding of the preoperative diagnosis, indication, curability, and additional treatment of esophageal SCC.     

Neoadjuvant chemoradiation therapy for the treatment of esophageal carcinoma

An esophagectomy with three-field lymph node dissection is the standard therapy for esophageal cancer in many countries, including Japan. However, the results of esophagectomy are still unsatisfactory in comparison to the results of surgical treatment for gastric cancer or colon cancer. On the other hand, definitive chemoradiation therapy has recently shown progress as a treatment modality for resectable esophageal cancer, with data indicating the potential efficacy of combination therapy with chemoradiation and an esophagectomy. In fact, preoperative chemoradiotherapy for resectable esophageal cancer is becoming a standard therapy in Europe and North America. The latest metaanalysis concerning neoadjuvant chemoradiotherapy for resectable esophageal cancer concluded that a significant survival benefit was evident with preoperative chemoradiotherapy. However, there are still no supportive data for neoadjuvant chemoradiation and surgery from a well-designed large-scale randomized control trial (RCT). A well-designed large-scale RCT is needed to determine the utility of neoadjuvant chemoradiation. Future trials based on precise diagnosis and surgical procedures are required for the adequate interpretation of the results of treatment for resectable esophageal cancer. Of course, quality control of the operation is a very important factor, because operative mortality influences these results.     

Reflections on the New Classification of Tumors by the WHO and Changes in Esophageal Cancer in a High-risk Area

In year 2000, a book entitled the Pathology and Genetics of Tumors of the Digestive System was published by the WHO, presenting some new diagnostic criteria and treatment principles. I have analyzed the epidemiologic change of tumors in over 30 years in the high-risk area with esophageal cancer. The following phenomenon was found: accompanied by the sharp decrease in the incidence and mortality of esophageal cancer, there was an increase in the incidence and death rate of stomach cancer involving cardiac cancer. This fact should be considered when analyzing the sharp decrease in esophageal cancer incidence and mortality rate. More attention was given to diagnosis of cardiac cancer; at the same time it is more practical to improve the early screening of cancers. To observe the development of high and low -grade intraepithelial neoplasms will be an urgent task for esophageal cancer research in the high risk area, according to WHO'S new classification.     

Considerations of treatment standardization from the procession of NCCN guideline of esophagealcancer

Esophageal carcinoma is one of the most common malignant tumors, especially in China which is the high incidence area. As a result of mild symptoms of early-stage esophageal cancer, the majority of patients cannot be diagnosed until they develop to advanced cancer, and the treatment outcome of surgery or chemoradiotherapy is still unsatisfactory at present. The guidelines of esophageal cancer issued by National Comprehensive Cancer Network (NCCN) are regarded as important reference tools by clinical oncolog...     

Managed Clinical Network for esophageal cancer enables reduction of variation between hospitals trends in treatment strategies,lead time,and 2-year survival

IntroductionDespite evidence-based guidelines, variation in esophageal cancer care exists in daily practice. Many oncology networks deployed regional agreements to standardize the patient care pathway and reduce unwarranted clinical variation. The aim of this study was to explore the trends in variation of esophageal cancer care between participating hospitals of the Managed Clinical Network (MCN) in the Netherlands.Materials and methodsPatients with esophageal cancer diagnosed from 2012 to 2016 were selected from the Netherlands Cancer Registry. Variation on treatment strategies, lead time to start of treatment, and 2-year survival, were calculated and compared between five clusters of hospitals within the network.ResultsA total of 1763 patients, diagnosed in 17 hospitals, were included. 71% of all patients received treatment with a curative intent, which ranged from 69% to 77% between the clusters of hospitals in 2015–2016. Although variation in treatment modalities between the clusters was observed in 2012–2014, no significant variation existed in 2015–2016, except for patients receiving no treatment at all. The 2-year overall survival of patients receiving treatment with a curative intent did not vary significantly between the clusters of hospitals (range: 56%–63%). Nevertheless, the median lead time before patients started treatment with a curative intent varied between clusters of hospitals in 2015–2016 (range: 34–47 days; p < 0.001).ConclusionLimited variation in esophageal cancer treatment between clusters of hospitals in the MCN existed. This study shows that oncology networks can promote standardization of cancer care and reduce variation between hospitals through insight into variation.     

四川省食管癌早诊早治效果评价

[目的]评价食管癌高发区早诊早治项目筛查人群食管癌及癌前病变的患病情况。[方法]在四川省食管癌高发地区,采取整群随机抽样的方法选择至少一个乡或村作为筛查对象,对40~69岁人群采取内镜下碘染色及指示性活检技术进行筛查,并行病理学诊断。[结果]全省合计筛查11021人,筛查率100.19%;重度异形增生/原位癌及以上病人检出168例,检出率为1.53%;其中食管癌61例,检出率为0.55%。全省早诊率67.86%;治疗率67.26%。[结论]在食管癌高发区人群中存在着一定数量的无明显临床症状的癌前病变及早期食管癌患者,对该部分高危人群进行食管癌普查并进行癌症综合知识宣传,提高其防癌意识,是提高早期食管癌检出率,做好食管癌二级预防工作的关键。     

食管癌伴肺部肿块16例分析

目的探讨食管癌同时伴有肺部肿块的处理方法.方法分析16例食管癌同时伴有肺部肿块,经术中或术后病理检查证实为非肿瘤转移患者的临床资料.结果肺隔离症2例,肺结核瘤3例,双肺炎性假瘤2例,双原癌9例.行肺叶切除10例,肺楔形切除2例,病灶切除或活检4例.结论食管癌同时伴有肺部肿块并非都是转移,可能存在多种可能性,应在获得病理诊断的情况下,采取相应的治疗方法.     

食管癌围术期治疗的争议与共识

食管癌是全球排名第七的恶性肿瘤,在癌症相关的死亡原因中排名第六。手术治疗是可切除食管癌的主要治疗方式,但对于局部晚期食管癌患者,单纯手术治疗后,局部复发和远处转移缩短了患者的生存期,因此除极早期肿瘤外,所有患者推荐术前行新辅助放化疗或新辅助化疗。但是仍然有一部分患者未能在术前行新辅助治疗,这就需要术后辅助治疗来改善患者预后。本文系统回顾了食管癌围术期治疗的研究进展,包括新辅助治疗和辅助治疗,并结合指南对食管癌围术期的治疗方案进行了总结。