台北荣总肺癌诊疗共识V

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1、Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊V.1.0 2009台北榮總肺癌團隊台北榮總肺癌團隊Revised on 2009/04/13Released on 2009/05/04Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊Multidisciplinary TeamTaipei VGH Lung Cancer Panel MembersTNM sta

2、ging Taipei VGH supplement to TNM staging Table of stage groupingEvaluation and treatment Stage o(Tis)Stage I(T1-2,N0)and Stage II(T1-2,N1)Stage IIB(T3,N0)and stage IIIA(T3,N1)Stage IIIA(T1-3,N3)and stage IIIB(T4,N0-1)Stage IIIB(T1-3,N3)Stage IIIB(T4,N2-3)(T4:pleural effusion or pericardial effusion

3、)Stage IV(M1:solitary site or disseminated)SurveillanceTherapy for Recurrence and MetastasesOccult(Tx,N0,M0),Evaluation and TreatmentSecond Lung Primary,Evaluation,and TreatmentPrinciples of Surgical ResectionPrinciples of PathologyPrinciples of Radiation Therapy -Recommended Radiation Doses -Dose V

4、olume Data for Radiation PneumonitisPrinciples of CCRTPrinciples of Chemotherapy -Non-Small Cell Lung Cancer -Small Cell Lung CancerAdjuvant ChemotherapyNeoadjuvant ChemotherapyClinical Trials for Advanced/Metastatic NSCLCTracheal cancer References關於此臨床指引：關於此臨床指引：肺癌的診療仍在發展階肺癌的診療仍在發展階段，本指引主要在呈現目前肺癌診療

5、的進段，本指引主要在呈現目前肺癌診療的進展與共識，展與共識，醫師應鼓勵病患參與臨床試驗醫師應鼓勵病患參與臨床試驗 ，使其有機會得到最好的治療。在本指引，使其有機會得到最好的治療。在本指引中的化療用藥建議是基於現有的臨床證據，中的化療用藥建議是基於現有的臨床證據，和目前的衛生署或健保局規定無關。和目前的衛生署或健保局規定無關。Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊癌委會癌委會胸內胸內核心成員核心成員召集人：蔡俊明、許文虎召集人：蔡俊明、許文虎副召集人：賴信良、吳玉琮副召

6、集人：賴信良、吳玉琮肺癌委員會暨肺癌多專科團隊肺癌委員會暨肺癌多專科團隊非核心成員非核心成員胸外胸外放射放射病理病理骨科骨科核醫核醫社工社工營養營養放療放療藥劑部藥劑部個案管理師個案管理師：宋易珍宋易珍Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊胸腔胸腔內科內科陳育民陳育民賴信良賴信良李毓芹李毓芹蔡俊明蔡俊明胸外胸外吳玉琮吳玉琮許文虎許文虎放射放射吳美翰吳美翰許明輝許明輝病理病理林可瀚林可瀚周德盈周德盈放療放療陳一瑋陳一瑋顏上惠顏上惠邱昭華邱昭華陳俊谷陳俊谷核醫核醫王世楨王

7、世楨 Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCLC TNM StagingLababede,O.et al.Chest 1999;115:233-235Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊Clifton F.Mountain,CHEST1997-Extended mediastinoscopy-Mediastinotomy-VATS-E

8、US-FNA-VATS-EBUS-TBNA-VATS(limited to 10 and 11)-Mediastinoscopy-EUS-FNA-EBUS-TBNA-VATS-Mediastinoscopy;EUS-FNA,EBUS-TBNAN1=Ipisilateral hilar nodesN2=Subcarinal,ipisilateral mediastinal nodesN3=Contralateral hilar/mediastinal,or supraclavicular or scalene nodes How to Approach EUS:Endoscopic Ultras

9、ound;EBUS:Endobronchoscopic ultrasound;FNA:Fine Needle Aspiration;TBNA:Transbronchoscopic Needle Aspiration;VATS:Video Assisted Thoracoscopic SurgeryTaipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊PFT:Necessary for all operable stagesPET(PET/CT):recommend for all c

10、linical stages,except Wet IIIB or stage IV with disseminate M1Mediastinoscopy:recommend for all clinical stages,except Peripheral T1N0 Wet IIIB or stage IV with disseminate M1p.s.N2 or N3 disease can be confirmed by other methods including mediastinotomy,thoracoscopy,EBUS-FNA,EUS-FNA,CT-guided-FNA,s

11、upraclavicle LN biopsy Brain MRI:recommend for all clinical stages,except Stage I Wet IIIB or stage IV with disseminate M1Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊 正子掃描（PET/CT SCAN）：肺癌clinical stage 的pre-treament workup，至於安排時間點是在胸腔電腦斷層（chest-CT）後。除非Chest CT或

12、PET SCAN都無縱膈腔異常發現且主要病灶在週邊(peripheral IA lesion)可以不做縱膈腔鏡外，否則縱膈腔鏡仍是評估縱膈腔淋巴結的gold standard Brain MRI取代brain CT建議在clinical stage II及stage III以上的病人安排。術中病理檢查若有R1(microscopic residual tumor)或R2(macroscopic residual tumor)，應視實際情形考慮reresection/（+chemotherapy）或是chemoradiation/（+chemotherapy）。Taipei VGH Practi

13、ce Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-1From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-2From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊

14、NSCL-3From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-4From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-5From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:O

15、ncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-6From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-7From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-8From NCCN

16、 guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-9From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-10From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidel

17、ines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-11From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-12From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-13Gefitinib or Erlotin

18、ib(if criteria met)z(2B)Gefitinib or Erlotinib(if criteria met)z(2B)(2B)(2B)Z Criteria for treatment with gefitinib(IPASS trial):Adenocarcinoma,non-smoker or light ex-smoker(quit 15yrs and 10 pack-years or fewer)No pre-existing idiopathic pulmonary fibrosisby evidence on chest CT From NCCN guideline

19、,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-14From NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊NSCL-15OrGefitinibOrGefitinibGefitinib and Erlotinib in 2nd-line therapy:adenocarcinomaGef

20、itnib in 3rd-line therapy:adenocarcinoma;Erlotinib in 3rd-line therapy:NSCLCFrom NCCN guideline,V.2.2009Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊PRINCIPLES OF SURGICAL RESECTION非緊急狀況下，術前所需影像學檢查應完備。是否可切除(resectablility)之決定建議應由有經驗之胸腔外科醫師來決定。如生理狀況許可(physiologic

21、ally feasible)，應採取lobectomy或pneumonectomy。如生理狀況受限制(physiologically compromised)，應採局部切除(Limited resection-segmentectomy or wedge resection)。在不違背標準腫瘤手術原則下，可採用VATS(Video-assisted thoracic surgery)。Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊PRINCIPLES OF SURGICAL

22、RESECTIONN1&N2 node resection and mapping(minimum of three N2 stations sampled or complete lymph node dissection)如內科狀況無法開刀(medically inoperable)，clinical stage I&II病人應接受potential curative radiotherapy。假如解剖位置適當與邊緣可切除乾淨(anatomically appropriate and margin-negative resection)，採取肺葉保存術式比全肺切除好(lung sparin

23、g anatomic resection-sleeve lobectomy preferred over pneumonectomy)。Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊PRINCIPLES OF PATHOLOGICAL REVIEW病理評估的目的包括:classify the lung cancer;determine the extent of invasion;establish the status of cancer involvement of su

24、rgical margins;determine the molecular abnormalities to predict for response to EGFR-TKI。手術病理報告應該有WHO肺癌組織分類。Pure bronchioloalveolar carcinoma(BAC)應無stroma、pleura與lymphatic spaces之侵犯。免疫染色:Non-mucinous BAC=TTF-1(+)/CK7(+)/CK20(-);Mucinous BAC=TTF-1(-)/CK7(+)/CK20(+)。免疫染色可幫助鑑別原發或轉移肺腺癌，區別腺癌及惡性間皮細胞癌，決定腫瘤

25、之神經內分泌分化。EGFR:Epidermal Growth Factor ReceptorTKI:Tyrosine Kinase InhibitorTTF-1:Thyroid transcription factor-1Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊PRINCIPLES OF PATHOLOGICAL REVIEWTTF-1對區分原發或轉移肺腺癌很重要。大部分原發肺腺癌TTF-1為陽性，轉移腺癌(甲狀腺癌除外)為陰性反應。Primary lung adeno

26、carcinoma:TTF-1(+)/CK7(+)/CK20(-)/CDX-2(-)Metastatic colorectal carcinoma:TTF-1(-)/CK7(-)/CK20(+)/CDX-2(+)EGFR mutation之有無與TKI治療之反應相關；如TKI 對exon19 deletion之腫瘤治療效果良好。K-ras與吸煙相關；K-ras與EGFR mutation為mutually exclusive；有K-ras mutation對TKI治療效果不佳。小細胞癌多數(95%)原發自肺，少數則來自肺外器官，二者有類似之臨床和生物特性，極易廣泛轉移。小細胞癌細胞通常Kera

27、tin 及至少一種之neuroendocrine differentiation markers(CD56,synaptophysin或 chromogranin A)呈陽性免疫染色。Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊3D conformal techniqueTaipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊 按2009年NCCN guidelin

28、e的精神，其所建議的放射治療已非傳統二次元定位的方式，而是因應放射治療技術的進步，以電腦斷層評估腫瘤的位置、體積和淋巴結引流的三次元定位方式，來決定照射的角度、劑量和範圍。美國NCCN所建議的放射照射劑量並不完全適用於國人，本共識以依國內病人狀況要做適度的調整。Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊Treatment PlanTotal DoseFraction SizePreoperative45-50 Gy1.8-2 GyPostoperative1.Negati

29、ve margin2.Extracapsular nodal extension or microscopic positive margin3.Gross residual tumor50 Gy 54-60 Gy 60-66 Gy Up to 70 Gy1.8-2 Gy1.8-2 Gy1.8-2 Gy1.8-2 GyDefinitive1.Without concurrent chemotherapy2.With concurrent chemotherapy (Mainly paclitaxel+carboplatin)Up to 70 Gy for volume 25%Up to 60-

30、66 Gy for volume between 25-36%Up to 60-66 Gy1.8-2 Gy1.8-2 Gy1.8-2 GyTaipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊RT +/-Induction ChemotherapyConcurrent ChemotherapyParameterRange Pneumonitis(%)Range Pneumonitis(%)MLD 300-109-1624-2724-44 42338 LP(20)20(%)20-31

31、320-2(%)7-1513-48319185185 LP(30)8(%)86(%)24MLD-Mean Lung Dose,LP:percentage of lung that received radiation(Gy)Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊同步化學併放射治療同步化學併放射治療(CCRT)原則原則 NSCLC Dose:up to 60-66Gy/1.8-2Gy/day Limited SCLC1.年齡小於等於年齡小於等於70歲，歲，PS：01，接

32、受，接受CCRT DOSE：5060 Gy/1.8Gy/day 排程：放療自開始持續做至排程：放療自開始持續做至5060 Gy，而化學治療自開始先做三個療程後休，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。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。如有如有CR 加做预防性全腦放射治療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）一天一次共十五次）如有如有PR 持續化學治療，但不做持續化學治療，但

33、不做PCI2.年齡大於年齡大於70歲，歲，PS：01，採用接續性化放療，採用接續性化放療(sequential chemoradiotherapy)DOSE：5060 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 如有如有CR 加做加做PCI,DOSE：30Gy/2Gy/day x15 fractions(一天一次共十五次）一天一次共十五次）如有如有PR 加做胸腔的放療及三個療程的化學治療，但不做加做胸腔的放療及三個療程的化學治療，但不做PCI3.如有如有PD 接受第二線化療。接受第二線化療。Taipei

34、 VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊肺癌化學治療用藥準則肺癌化學治療用藥準則 非小細胞肺癌非小細胞肺癌 第一線第一線 -Gemcitabine(GC-G)G(1000-1250mg/m2)+Cisplatin(60-75mg/m2),Q3-4W.-Vinorelbine(NC-N)Vinorelbine(25-30 mg/m2 i.v.or 60-80 mg/m2 p.o.)+Cisplatin(60-75 mg/m2),Q3-4W.-Paclitaxel(TaC or TaC

35、-Ta-Ta)1.Paclitaxel(160-175 mg/m2)-D1+Cisplatin(60-75 mg/m2)-D1,Q3W.2.Paclitaxel(60-80 mg/m2)-D1,8,15+Cisplatin(60-75 mg/m2)-D1,Q4W.-Docetaxel(TC or TC-T)1.Docetaxel(60-75 mg/m2)-D1+Cisplatin(60-75 mg/m2)-D1,Q3W.2.Docetaxel(30-35 mg/m2)-D1,8+Cisplatin(60-75 mg/m2)-D1,Q3W.備註備註:1.Elderly or poor perfo

36、rmance status：cisplatin omited 2.Cisplatin 若改成 Carboplatin,劑量為(CCr+25)x AUC,AUC=4-6 3.Bevacizumab 7.5 mg/kg 可與 Gemcitabine/cisplatin或 paclitaxel/carboplatin可並用於第一線化學治療(2B)4.Gefitinib可用於第一線治療,if adenocarcinoma,non-smoker or light ex-smoker(quit 15yrs and 10 pack-years or fewer)and no pre-existing idi

37、opathic pulmonary fibrosisby evidence on chest CT(2B)5.Pemetrexate/cisplatin可用於第一線化學治療 in non-squamous(2B)第二線第二線 -Docetaxel 1.Docetaxel(60-75mg/m2)-D1,Q3W.2.Docetaxel(30-35mg/m2)-D1,8,Q3W.-Pemetrexed(500mg/m2)-D1,Q3W.-Gefitinib 250 mg,QD.(if Adeno)-Erlotinib 150 mg,QD.(if Adeno)第三線第三線 -Gefitinib 250

38、 mg,QD.(if Adeno)-Erlotinib 150 mg,QD(if NSCLC)*病患若參加本院病患若參加本院 IRB 同意之同意之臨床試驗臨床試驗，則依該臨床試驗之則依該臨床試驗之治療計畫進行治療計畫進行Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊肺癌化學治療用藥準則肺癌化學治療用藥準則 小細胞肺癌小細胞肺癌 （臨床試驗病例除外臨床試驗病例除外）Standard regimens(PVP):1.Cisplatin(60-75 mg/m2)+VP-16(60-

39、80 mg/m2)D1,2,3/Q3W 2.Carboplatin(AUC=5)D1+VP-16(60-80 mg/m2)D1,2,3/Q3W Relapsed regimens:1.Ifosfamide 1000 mg/m2 D1-3+oral VP16 50 mg D1-10/Q3W 2.Topotecan 1.5 mg/m2 D1-3+epirubicin 30 mg/m2 D1/Q3W Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊Chemotherapy Regim

40、ens for Adjuvant Therapy-Cisplatin basePublished Chemotherapy RegimensSchedulesNC-NVinorelbine(25-30 mg/m2 i.v.or 60-80 mg/m2 p.o.)-D1,8+Cisplatin(60-75 mg/m2)-D1Q3W for 4 cyclesOther Acceptable Chemotherapy RegimensSchedulesGC-GG(1000-1250mg/m2)-D1,8+Cisplatin(60-75mg/m2)-D1Q3W for 4 cyclesTCDoceta

41、xel(60-75 mg/m2)-D1+Cisplatin(60-75 mg/m2)-D1Q3W for 4 cyclesTaC*Paclitaxel(160-175 mg/m2)-D1+Cisplatin(60-75 mg/m2)-D1Q3W for 4 cyclesChemotherapy Regimens for Adjuvant Therapy-AlternativeCisplatin 若改成若改成 Carboplatin,劑量為劑量為(CCr+25)x AUC,AUC=4-6*Palitaxel+carboplatin regimen showed no survival benef

42、it in stage IB patientsTaipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊StagingProposed TNM classification and staging for primary tracheal carcinoma*Primary Tracheal Cancer*Ref:Paolo Macchiarini,Lancet Oncol 2006;7:8391Taipei VGH Practice Guidelines:Oncology Guidel

43、ines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊H&PCBC,plateletChemistry profileSmoking cessation counselingPFTChest CT scanBronchoscopy Brain MRIStage I-III,IVAStage IVBMetastatic cancer Multidisciplinary evaluation is encouragedPET/CT scanConsider 3D-CT reconstruction(multi-planar reconstruction,volume rende

44、ring technique,minimal intensity projector)Medical fit for surgery,resectableMedical unfit for surgery,or unresectable,or surgery not elected and patient medically able to tolerate chemotherapy Medical unfit for surgery and patient unable to tolerate chemotherapy See Primary Treatment(TRACH-1)See Pr

45、imary Treatment(TRACH-2)See Primary Treatment(TRACH-2)See Primary Treatment(TRACH-3)WORKUPCLINICAL STAGEADDITIONAL EVALUATION(as clinically indicated)Primary Tracheal Canceraa Medically able to tolerate major thoracic surgery b Unresctable tumor:greater than 50%of tracheal length involved by tumor,“

46、frozen”mediastinum,poor general condition of patient,distant metastases in squamous cell carcinoma;Oncologist 1997;2;245-253bTaipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊Primary Tracheal CancerMedically fit for surgery,resectablePRIMARY TREATMENTSurgeryADJUNCTIV

47、E/ADJUVANT TREATMENTRadiation Complete resection(R0):50Gy over tumor bed and adjacent mediastinum Incomplete resection with residual margin R1:R2:60Gy over tumor bed and 50Gy over adjacent mediastinumaa Medically able to tolerate major thoracic surgery c R0=No cancer at resection margins,R1=Microsco

48、pic residual cancer,R2=Macroscopic residual cancer TRACH-1ccTaipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊Primary Tracheal CancerMedical unfit for surgery,or unresectable,or surgery not elected and patient medically able to tolerate chemotherapy Medical unfit for

49、 surgery and patient unable to tolerate chemotherapy RT,60Gy+concurrent chemotherapy(Cisplatin-based)(preferred)or Best supportive care RT 60-66Gy or Best supportive care PRIMARY TREATMENTBest Supportive CareObstruction:stent,laser,photodynamic therapy,RT (external 30-50Gy or brachytherapy)Pain cont

50、rol:RT and/or medicationsNutrition b Unresctable tumor:greater than 50%of tracheal length involved by tumor,“frozen”mediastinum,poor general condition of patient,distant metastases in squamous cell carcinoma;Oncologist 1997;2;245-253TRACH-2bTaipei VGH Practice Guidelines:Oncology Guidelines IndexLun

51、g Cancer台北榮總肺癌團隊台北榮總肺癌團隊Primary Tracheal CancerStage IVBMetastatic cancer Karnofsky performance score 60 or ECOG performance score2Karnofsky performance score 60 or ECOG performance score3SALVAGE THERPAY RT,60Gy+concurrent chemotherapy(Cisplatin-based)(preferred)or Chemotherapy or Best supportive ca

52、reBest supportive careBest Supportive CareObstruction:stent,laser,photodynamic therapy,RT (external 30-50Gy or brachytherapy)Pain control:RT and/or medicationsNutrition TRACH-3Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊Taipei VGH Practice Guidelines:Oncology Guidelines IndexLung Cancer台北榮總肺癌團隊台北榮總肺癌團隊本治療指引將每六個月檢討修訂一次本治療指引將每六個月檢討修訂一次預定下次修訂日期預定下次修訂日期:2009年年10月月