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中华临床医师杂志(电子版) ›› 2022, Vol. 16 ›› Issue (01) : 1 -16. doi: 10.3877/cma.j.issn.1674-0785.2022.01.001

所属专题: 指南共识

专家共识

陕西省恶性浆膜腔积液诊治专家共识(2021版)
陕西省抗癌协会肿瘤转移专业委员会, 陕西省抗癌协会罕见肿瘤专业委员会:恶性浆膜腔积液诊治专家联盟   
  • 收稿日期:2021-09-08 出版日期:2022-01-15
  • 基金资助:
    陕西省自然科学基础研究计划(2019SF217)

Expert consensus on diagnosis and treatment of malignant serous effusion in Shaanxi Province (2021 version)

Professional Committee on Tumor Metastasis of Shaanxi Province Anticancer Association, Professional Committee on Rare Tumors of Shaanxi Province Anticancer Association: Expert Alliance for Diagnosis and Treatment of Malignant Serous Effusion   

  • Received:2021-09-08 Published:2022-01-15
引用本文:

陕西省抗癌协会肿瘤转移专业委员会, 陕西省抗癌协会罕见肿瘤专业委员会:恶性浆膜腔积液诊治专家联盟. 陕西省恶性浆膜腔积液诊治专家共识(2021版)[J]. 中华临床医师杂志(电子版), 2022, 16(01): 1-16.

Professional Committee on Tumor Metastasis of Shaanxi Province Anticancer Association, Professional Committee on Rare Tumors of Shaanxi Province Anticancer Association: Expert Alliance for Diagnosis and Treatment of Malignant Serous Effusion. Expert consensus on diagnosis and treatment of malignant serous effusion in Shaanxi Province (2021 version)[J]. Chinese Journal of Clinicians(Electronic Edition), 2022, 16(01): 1-16.

本共识所言浆膜腔是指心包腔、胸膜腔及腹膜腔,恶性浆膜腔积液是指浆膜腔积液中经脱落细胞学检查发现恶性细胞或浆膜组织活检病理诊断为恶性肿瘤,它是肿瘤转移的一种特殊表现形式,为晚期恶性肿瘤患者常见合并症之一,大量积液时可严重影响患者生活质量,甚至危及生命。我国与欧美国家之诊疗理念存在明显差异,目前全球尚缺乏明确的恶性浆膜腔积液诊疗指南或规范。我国现有2014年发表的《恶性胸腔积液诊断与治疗专家共识》,不包括恶性心包腔与腹膜腔积液,且部分治疗方法(如滑石粉胸膜固定术)在临床上并未广泛应用。本共识主要分为三大部分,一是介绍了目前全球恶性浆膜腔积液治疗现状,欧美国家治疗核心思想,我国治疗进展;二是详细介绍了该病诊断流程,包括病史询问、临床表现、影像学检查、肿瘤标志物检测,重点说明了脱落细胞学或浆膜组织活检病理检查方法,包括近年来兴起的细胞块石蜡包埋切片技术在分子基因检测方面的应用;三是该病治疗流程,包括局部治疗与系统治疗原则,对普通式抽液/引流联合药物灌注治疗方法的适应证、主要药物推荐、药物剂量、灌注时间、不良反应的预防与处理,以及特殊类型的恶性浆膜积液处理方法等进行了详细介绍,对系统治疗原则、全身给药选择亦给予了明确指导;最后简要说明了恶性胸、腹腔积液体外热循环灌注化疗技术的适应证与操作流程。目前,恶性浆膜腔积液诊治的中文期刊报道文献虽众多,但高质量文献极少,更谈不上证据级别,但本共识充分考虑到不同级别的医疗机构条件,具有广泛的普适性、较强的实用性及可操作性。

The serous cavity mentioned in this consensus refers to the pericardial cavity, pleural cavity, and peritoneal cavity. Malignant serous effusion refers to the detection of malignant cells in the serous effusion through exfoliate cytology or the diagnosis of malignant tumor by serosal tissue biopsy. Malignant serous effusion is a special manifestation of tumor metastasis, and it is one of the common complications of patients with advanced malignant tumors. Large amounts of malignant serous effusion can affect the quality of life seriously and be even life-threatening. The treatment concepts for malignant serous effusion are obviously different between China and European and American. Currently, diagnosis and treatment guidelines or norms are insufficient worldwide. The existing expert consensus on the diagnosis and treatment of malignant serous effusion in China was published in 2014. It does not include pericardial effusion and ascites effusion, and some treatment strategies (such as talcum pleurodesis) are not widely used in clinical practice. This consensus mainly includes three parts. The first is to introduce the global treatment status and the main treatment concepts in European and American countries, as well as the progress of treatment in China. The second part gives a detailed introduction to the diagnosis process, including medical history, clinical manifestations, imaging examinations, and tumor marker detection. The focus is on the exfoliative cytology and serosal biopsy methods, including the application of paraffin-embedded section technology of cell blocks in molecular genetic testing that has emerged in recent years. The third part discusses the treatment process, including the principles of local and systemic treatment. In terms of local treatment, the indications, main drug recommendations, drug dosage, infusion time, prevention and treatment of adverse reactions, and treatment methods for special types of malignant effusion are introduced in detail for common fluid drainage or drainage combined with drug infusion therapy. In terms of systemic therapy, clear guidance is also given to the principles of systemic therapy and the choice of systemic drug delivery. In the last part, the indications and operating procedures of external thermo-circulation perfusion chemotherapy are explained briefly. At present, although there is a large amount of Chinese literature on the diagnosis and treatment of malignant serous effusions, the quality of the literature is not high, let alone the level of evidence. However, this consensus has fully considered the actual conditions of different levels of medical institutions, and has universal applicability, strong practicability, and maneuverability.

表1 恶性浆膜腔积液腔内灌注药物名称与剂量
表2 恶性浆膜腔积液常见原发肿瘤全身/系统给药
原发肿瘤 全身药物
鼻咽癌 (白蛋白结合型)紫杉醇、多西他赛、吉西他滨、长春瑞滨、氟尿嘧啶、卡培他滨
甲状腺癌

(1)髓样癌:凡他尼布或卡博替尼或达卡巴嗪(氮烯咪胺)

(2)间变性癌:(白蛋白结合型)紫杉醇、多西他赛、多柔比星或表柔比星

乳腺癌

(1)细胞毒药物:(白蛋白结合型)紫杉醇、多西他赛、吉西他滨、长春瑞滨、氟尿嘧啶、卡培他滨、(脂质体)多柔比星或表柔比星、环磷酰胺、甲氨蝶呤、艾立布林、伊沙匹隆

(2)人表皮生长因子受体-2(HER2)过表达:曲妥珠单抗、帕妥珠单抗、拉帕替尼、吡咯替尼、曲妥珠单抗-美坦新偶联物(TDM1)、DS-8201(T-DXd)

(3)内分泌治疗药物:他莫昔芬、来曲唑、阿那曲唑、依西美坦、氟维司群

(4)靶向药物:细胞周期蛋白依赖性激酶4/6(CDK4/6)抑制剂(哌柏西利)、哺乳动物雷帕霉素靶点(mTOR)抑制剂(依维莫司)、组蛋白去乙酰化酶(HDAC)抑制剂(西达本胺)、奥拉帕利

小细胞肺癌 依托泊苷(注射剂、胶囊剂)、伊立替康、托泊替康、(白蛋白结合型)紫杉醇、多西他赛、吉西他滨、长春瑞滨(注射剂、胶囊剂)、异环磷酰胺、环磷酰胺、替莫唑胺、长春新碱、多柔比星或表柔比星
非小细胞肺癌

(1)细胞毒药物:(白蛋白结合型)紫杉醇、多西他赛、吉西他滨、长春瑞滨(注射剂、胶囊剂)、培美曲塞(非鳞癌)、伊立替康、依托泊苷(注射剂、胶囊剂)

(2)有明确驱动基因异常的分子靶向药物

1)敏感性表皮生长因子受体(EGFR)突变阳性:奥希替尼(Osimertinib)、阿法替尼(Afatinib)、厄洛替尼(Erlotinib)、达可替尼(Dacomitinib)、吉非替尼(Geftinib)、埃克替尼、阿美替尼

2)间变性淋巴瘤激酶(ALK)基因重排阳性:阿来替尼(Alectinib)、布加替尼(Brigatinib)、色瑞替尼(Ceritinib)、克唑替尼(Crizotinib)、劳拉替尼(Lorlatinib)

3)c-ros原癌基因(ROS1)重排阳性:色瑞替尼(Ceritinib)、克唑替尼

4)V-raf鼠科肉瘤病毒癌基因同源物B1(BRAF)V600E突变阳性:达拉菲尼(Dabrafenib)/曲美替尼(Trametinib)

5)神经营养因子受体酪氨酸激酶(NTRK)基因融合阳性:拉罗替尼(Larotrectinib)

(3)抗血管生成药物:重组人血管内皮抑制素、安罗替尼(非中央型鳞癌)、贝伐珠单抗(非鳞癌)

(4)免疫检查点抑制剂:程序性死亡配体-1(PD-L1)肿瘤细胞阳性比率评分≥1%时帕博利珠单抗(Pembrolizumab)、纳武利尤单抗(Nivolumab)、卡瑞利珠单抗(与PD-L1表达高低无关)

食管癌(鳞癌) (白蛋白结合型)紫杉醇、多西他赛、氟尿嘧啶
胃癌(腺癌)

(1)细胞毒药物:(白蛋白结合型)紫杉醇、多西他赛、氟尿嘧啶、表柔比星、伊立替康、替吉奥、卡培他滨、雷替曲塞、奥沙利铂

(2)HER-2过表达:曲妥珠单抗

(3)微卫星高度不稳定(MSI-H):免疫检查点抑制剂帕博利珠单抗

(4)抗肿瘤血管生成:雷莫卢单抗(Ramucirumab)

原发性肝癌

(1)细胞毒药物:氟尿嘧啶、替吉奥、卡培他滨、奥沙利铂、表柔比星

(2)抗血管生成药物:阿帕替尼、索拉菲尼、仑伐替尼、瑞戈菲尼

(3)免疫检查点抑制剂:卡瑞利珠单抗+阿帕替尼、帕博利珠单抗+仑伐替尼

胆囊癌、胆管癌 吉西他滨、(白蛋白结合型)紫杉醇、氟尿嘧啶、卡培他滨、替吉奥
胰腺癌 吉西他滨、(白蛋白结合型)紫杉醇、氟尿嘧啶、卡培他滨、替吉奥
结直肠癌

(1)细胞毒药物:氟尿嘧啶、卡培他滨、雷替曲塞、伊立替康

(2)左半结肠癌伴RAS基因野生型:西妥昔单抗、帕尼单抗

(3)BRAF V600E突变阳性:维莫非尼(Vemurafenib)、达拉非尼、曲美替尼、康奈非尼(Encorafenib)、比美替尼(Binimetinib)

(3)MSI-H:免疫检查点抑制剂纳武利尤单抗或帕博利珠单抗

(4)抗血管生成药物:贝伐珠单抗、阿柏西普(Ziv-aflibercept)、雷莫卢单抗、瑞戈菲尼

(5)HER-2过表达或扩增:曲妥珠单抗(Trastuzumab)、帕妥珠单抗(Pertuzumab)、拉帕替尼(Lapatinib)、吡咯替尼

膀胱癌

(1)细胞毒药物:吉西他滨、长春花碱、多柔比星、表柔比星、(白蛋白结合型)紫杉醇、氟尿嘧啶、异环磷酰胺、培美曲塞、甲氨蝶呤、丝裂霉素

(2)免疫检查点抑制剂:PD-L1抑制剂

卵巢癌

(1)细胞毒药物:(白蛋白结合型)紫杉醇、多西他赛、(脂质体)多柔比星、吉西他滨、长春瑞滨、卡培他滨、异环磷酰胺、拓扑替康、伊立替康、培美曲塞、依托泊苷

(2)抗肿瘤血管生成药物:贝伐珠单抗、安罗替尼、阿帕替尼

(3)多聚二磷酸腺苷核糖聚合酶(PARP)抑制剂:奥拉帕利、尼拉帕利(BRCA突变患者)

宫颈癌

(1)细胞毒药物:(白蛋白结合型)紫杉醇、多西他赛、托泊替康、伊立替康、培美曲塞、吉西他滨、长春瑞滨、异环磷酰胺、氟尿嘧啶、异环磷酰胺、丝裂霉素

(2)抗肿瘤血管生成药物:贝伐珠单抗、安罗替尼、阿帕替尼

间皮瘤 培美曲塞、(白蛋白结合型)紫杉醇
霍奇金淋巴瘤 ABVD方案
弥漫大B细胞淋巴瘤、外周T细胞淋巴瘤 R-CHOP、CHOEP、CVAD、GVD、ICE、DHAP、GDP(去掉顺铂)、Gemox(去掉奥沙利铂)、ESHAP、EPOCH
尤文肉瘤

单药:长春新碱、(脂质体)多柔比星、环磷酰胺、异环磷酰胺、依托泊苷

联合方案:VAC/IE、VAI、VIDE

骨肉瘤

(1)细胞毒药物:(脂质体)多柔比星、异环磷酰胺、甲氨蝶呤(大剂量)、表柔比星、多西他赛、吉西他滨、依托泊苷、托泊替康

(2)靶向药物:索拉菲尼、依维莫司

非特指性软组织肉瘤 (脂质体)多柔比星、(脂质体)表柔比星、异环磷酰胺、多西他赛、吉西他滨、长春瑞滨、达卡巴嗪、替莫唑胺
非多形性横纹肌肉瘤 长春新碱、放线菌素D、多柔比星、异环磷酰胺、托泊替康、伊立替康、依托泊苷、甲氨蝶呤(大剂量)、环磷酰胺
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