小细胞肺癌

小细胞肺癌的分期、影像学表现和治疗SmallCellLungCarcinoma:Staging,Imaging,andTreatmentConsiderations罗桂媛2015.6.15上海市东方医院南院影像科5/21/2020介绍Introduction•2004WHO将肺癌分为两个主要组织学类型:非小细胞肺癌和小细胞肺癌。SCLC占肺癌总数的13%-15%，是最常见的原发性肺神经内分泌肿瘤。•The2004WorldHealthOrganization(WHO)classificationschemedivideslungcancerintotwomajorhistologiccategories:non–smallcelllungcarcinoma(non-SCLC)andSCLC，SCLCsaccountfor13%–15%ofalllungcancersandarethemostcommonprimarypulmonaryneuroendocrineneoplasm。•在所有组织类型中，小细胞肺癌的发病与吸烟关系最为密切，大约95%的小细胞肺癌患者有吸烟史。•andofallthehistologicsubtypesoflungcancer,SCLChasthestrongestassociationwithcigarettesmoking.5/21/2020介绍Introduction•小细胞肺癌特点是肿瘤细胞倍增时间短，增殖指数高，比非小细胞肺癌更具侵略性，并有早期广泛转移的倾向。•SCLCismoreaggressivethannon-SCLCandischaracterizedbyarapiddoublingtime,highgrowthfraction(theratioofproliferatingcellstototalcells),andgreaterpropensityforearlydevelopmentofwidespreadmetastases5/21/2020介绍Introduction•美国老年委员会肺癌研究小组(VALSG)制定的分期系统将小细胞肺癌分为局限期和广泛期。不过现在已经被修订的TNM分期方法所代替。•SCLCisusuallycategorizedaccordingtoamodifiedversionoftheVeteransAdministrationLungCancerStudyGroup(VALSG)stagingsystemaseitherlimited-stageSCLC(LS-SCLC)orextensive-stageSCLC(ESSCLC).5/21/2020介绍Introduction•准确的分期对小细胞肺癌患者的治疗有指导性意义，放疗和化疗联合治疗对局限期小细胞肺癌是有效果的，其中一小部分患者能长期存活。•AccuratestagingofpatientswithSCLChelpsguideindividualtreatmentstrategies,sincepatientswithLS-SCLCarecandidatesforcurative-intentchemotherapy–radiationtherapy,asmallpercentageofwhomexperiencelong-termsurvival.5/21/2020介绍Introduction在本文献中，我们主要是复习小细胞肺癌的病理及它的发展，并讨论CT和PET-CT对患者疾病的分期和评价。Inthisarticle,wereviewthepathophysiologyandnaturalhistoryofSCLCanddiscusstheroleofcomputedtomography(CT)and2-[fluorine-18]fluoro-2-deoxy-d-glucose(FDG)positronemissiontomography(PET)/CTintheevaluationandstagingofpatientswiththedisease.5/21/2020肺神经内分泌肿瘤的分类ClassificationofPulmonaryNeuroendocrineNeoplasms•WHO将肺神经内分泌肿瘤分为3个病理等级以及4个分类：•低度恶性：典型类癌肿瘤；•中间级肿瘤：不典型类癌；•高度恶性肿瘤：包括大细胞神经内分泌肿瘤以及小细胞肺癌。•在这篇文章，我们专注于小细胞肺癌。•The2004WHOtumorclassificationschemeincludesfourmajortypesofpulmonaryneuroendocrinetumors,whicharegroupedintothreehistologicgrades.Low-grademalignantneoplasmsincludetypicalcarcinoidtumor,intermediate-gradeneoplasmsincludeatypicalcarcinoids,andhigh-gradeneoplasmsincludelargecellneuroendocrinetumorandSCLC.Inthisarticle,however,wefocusonSCLC5/21/2020流行病学和临床特点EpidemiologicandClinicalFeatures95%以上的高级别的神经内分泌肿瘤起源于肺，而肺外疾病：鼻咽部、胃肠道和泌尿生殖道等器官的肿瘤极为少见。Morethan95%ofhigh-gradeneuroendocrinecarcinomasoriginateinthelung,whereasextrapulmonarytumorsinvolvingorganssuchasthenasopharynx,gastrointestinaltract,andgenitourinarytractareexceptionallyrare,withaprevalenceof0.1%–0.4%intheUnitedStates5/21/2020流行病学和临床特点EpidemiologicandClinicalFeatures据美国的流行病学资料显示小细胞肺癌的患病率在20世纪80年代达到顶峰，之后一直在下降，此后，在过去的30年从17%-20%降至13%-15%。原因有很多，例如降低吸烟率，增加过滤的香烟的使用，以及对小细胞肺癌的病理标准所做的更改。小细胞肺癌好发年龄在60和70岁之间。男女比例2.6:1。•TheprevalenceofSCLCintheUnitedStatespeakedinthe1980sandhasbeendecliningsincethattime,decreasingfrom17%–20%to13%–15%overthepast30years(4,12).Severalfactorsmay,atleastinpart,beresponsibleforthisdecline,suchasadecreaseinsmokingrates,increaseduseoffilteredcigarettes,andchangesthathavebeenmadetothepathologiccriteriaforSCLC。SCLCtypicallyaffectspatientsbetweentheagesof60and70years,SCLChashistoricallybeenseenmorefrequentlyinmenthaninwomenbyaratioof2.6:1。5/21/2020流行病学和临床特点EpidemiologicandClinicalFeatures最常见的临床症状包括咳嗽、胸痛、咯血、呼吸困难，通常会伴有一些全身性疾病，比如体重下降，疲劳和厌食等症状。Themostcommonsignsandsymptomsreportedatthetimeofpresentationincludecough,chestpain,hemoptysis,anddyspnea.Becausepatientstypicallyhavesystemicdiseaseatthetimeofdiagnosis,symptomssuchasweightloss,fatigue,andanorexiaareoftenpresent.5/21/2020流行病学和临床特点EpidemiologicandClinicalFeatures•侵袭性的肿瘤或晚期的患者会有特定的临床症状。例如，大约10%的患者伴有上腔静脉综合征相关的症状。侵犯食管及纵隔结构(如，喉返神经和气管)会导致吞咽困难和声音嘶哑，另外肺外转移性疾病可表现为骨痛、皮肤瘙痒、黄疸、癫痫发作、精神失常，和/或共济失调。•Patientswithinvasiveoradvanceddiseasemaypresentwithspecificsymptoms.Forinstance,10%ofpatientsreportsymptomsrelatedtosuperiorvenacavasyndrome(9,13).Invasionoftheesophagusandmediastinalstructures(eg,therecurrentlaryngealnerveandtrachea)canresultindysphagiaandhoarseness,respectivelyExtrapulmonarymetastaticdiseasecanmanifestasbonepain,pruritus,jaundice,seizures,changesinmentalstatus,and/orataxia(9,13).5/21/2020组织学和病理特点HistologicandGrossPathologicFeatures小细胞肺癌的确诊通过核心活检或细针穿刺活检。在光学显微镜，小细胞肺癌细胞呈蓝色圆形、椭圆形，或纺锤状，细胞胞浆稀少，边界模糊不清，细颗粒细胞核的染色质，核缺失或，核仁不明显(图1a)，对于肺的神经内分泌肿瘤，小细胞肺癌具有最高的有丝分裂率，并且广泛坏死。•ThediagnosisofSCLCmaybeestablishedbyexaminingtissueobtainedatfine-needleaspirationbiopsyorcorebiopsy.Atlightmicroscopy,SCLCischaracterizedbysmallblueround,oval,orspindle-shapedcellswithscantcytoplasm,ill-definedborders,finelygranularnuclearchromatin,andabsentorinconspicuousnucleoli(Fig1a)(2,6).Ofthepulmonaryneuroendocrinetumors,SCLChasthehighestmitoticrate(10mitosesper10high-powerfields;median,80mitosesper10high-powerfields),andextensivenecrosisistypicallypresent.5/21/2020组织学和病理特点HistologicandGrossPathologicFeaturesWHO将它分为两种亚型的小细胞肺癌:单纯性小细胞肺癌和复合性SCLC。大多数肿瘤是单纯性小细胞肺癌;因为通常只有数量有限的组织可供分析，复合性类型很少见。复合性SCLC具有非小细胞肺癌成分，比如腺癌、鳞状细胞癌、大细胞癌、梭形细胞癌或巨细胞癌的存在。TheWHOrecognizestwosubtypesofSCLC:pure