非小细胞肺癌NCCN指南2017第5版：常用化疗方案

2018年07月27日【健康号】张品良阅读 7248

CHEMOTHERAPY REGIMENS FOR NEOADJUVANT AND ADJUVANT THERAPY新辅助与辅助治疗化疗方案

* Cisplatin 50 mg/m2 days 1 and 8; vinorelbine 25 mg/m2 days 1, 8, 15, 22, every 28 days for 4 cycles顺铂50mg/㎡ d1、8；长春瑞滨25mg/㎡ d1、8、15、22，每28天为1周期，共4周期山东省肿瘤医院呼吸肿瘤内科张品良

* Cisplatin 100 mg/m2 day 1; vinorelbine 30 mg/m2 days 1, 8, 15, 22, every 28 days for 4 cycles顺铂100mg/㎡ d1；长春瑞滨30mg/㎡ d1、8、15、22，每28天为1周期，共4周期

* Cisplatin 75–80 mg/m2 day 1; vinorelbine 25–30 mg/m2 days 1 + 8, every 21 days for 4 cycles顺铂75-80mg/㎡ d1；长春瑞滨25–30mg/㎡ d1、8，每21天为1周期，共4周期

* Cisplatin 100 mg/m2 day 1; etoposide 100 mg/m2 days 1–3, every 28 days for 4 cycles 顺铂100mg/㎡ d1；依托泊苷100mg/㎡ d1–3，每28天为1周期，共4周期

* Cisplatin 75 mg/m2 day 1; gemcitabine 1250 mg/m2 days 1, 8, every 21 days for 4 cycles顺铂75mg/㎡ d1；吉西他滨1250mg/㎡ d1、8，每21天为1周期，共4周期

* Cisplatin 75 mg/m2 day 1; docetaxel 75 mg/m2 day 1 every 21 days for 4 cycles 顺铂75mg/㎡ d1；多西他赛75mg/㎡ d1，每21天为1周期，共4周期

* Cisplatin 75 mg/m2 day 1, pemetrexed 500 mg/m2 day 1 for nonsquamous every 21 days for 4 cycles对于非鳞癌：顺铂75mg/㎡ d1，培美曲塞500mg/㎡ d1，每21天为1周期，共4周期

Chemotherapy Regimens for Patients with Comorbidities or Patients Not Able to Tolerate Cisplatin有合并症或不能耐受顺铂患者的化疗方案

Paclitaxel 200 mg/m2 day 1, carboplatin AUC 6 day 1, every 21 days紫杉醇200mg/㎡ d1，卡铂AUC 6 d1，每21天为1周期

CHEMOTHERAPY REGIMENS USED WITH RADIATION THERAPY联合放疗的化疗方案

Concurrent Chemotherapy/RT Regimens同步化/放疗方案

* Cisplatin 50 mg/m2 on days 1, 8, 29, and 36; etoposide 50 mg/m2 days 1–5, 29–33; concurrent thoracic RT *,**顺铂50mg/㎡ d1、8、29、36；依托泊苷50mg/㎡ d1–5、29–33；同期胸部放疗*,**

* Cisplatin 100 mg/m2 days 1 and 29; vinblastine 5 mg/m2 /weekly x 5; concurrent thoracic RT *,**顺铂100mg/㎡ d1、29；长春花碱5mg/㎡ /周×5；同期胸部放疗*,**

* Carboplatin AUC 5 on day 1, pemetrexed 500 mg/m2 on day 1 every 21 days for 4 cycles; concurrent thoracic RT (nonsquamous)*,** 卡铂AUC 5 d1，培美曲塞500mg/㎡ d1，每21天为1周期，共4周期；同期胸部放疗（非鳞癌）*,**

* Cisplatin 75 mg/m2 on day 1, pemetrexed 500 mg/m2 on day 1 every 21 days for 3 cycles; concurrent thoracic RT (nonsquamous)*,** ± additional 4 cycles of pemetrexed 500 mg/m2 ** 顺铂75mg/㎡ d1，培美曲塞500mg/㎡ d1，每21天重复共3周期；同期胸部放疗（非鳞）*,**±追加4周期的培美曲塞500 mg/㎡ d2 **

* Paclitaxel 45–50 mg/m2 weekly; carboplatin AUC 2, concurrent thoracic RT *,** ± additional 2 cycles of paclitaxel 200 mg/m2 and carboplatin AUC 6** 紫杉醇45-50mg/㎡每周1次；卡铂AUC 2，同期胸部放疗*,**±追加2周期紫杉醇200mg/㎡加卡铂AUC 6 **

Sequential Chemotherapy/RT Regimens (Adjuvant)序贯化/放疗方案（辅助）

* Cisplatin 100 mg/m2 on days 1 and 29; vinblastine 5 mg/m2 /weekly on days 1, 8, 15, 22, and 29; followed by RT顺铂100mg/㎡，d1、29；长春花碱5mg/㎡/周，d1、8、15、22、29；序贯放疗

* Paclitaxel 200 mg/m2 over 3 hours on day 1; carboplatin AUC 6 over 60 minutes on day 1 every 3 weeks for 2 cycles followed by thoracic RT 紫杉醇200mg/㎡，3小时以上，d1；卡铂AUC 6，60分钟以上，d1，每3周为1周期共2周期，然后胸部放疗

*Regimens can be used as neoadjuvant/preoperative/induction chemoradiotherapy. 方案可作为新辅助/术前/诱导化放疗使用。

**Regimens can be used as adjuvant or definitive concurrent chemotherapy/RT.方案可作为辅助或根治性同步化/放疗使用。

SYSTEMIC THERAPY FOR ADVANCED OR METASTATIC DISEASE 晚期或转移性疾病的全身治疗

ADVANCED DISEASE:晚期疾病：

* The drug regimen with the highest likelihood of benefit with toxicity deemed acceptable to both the physician and the patient should be given as initial therapy for advanced lung cancer.应该给予最可能受益的、毒性对医患双方都可接受的药物方案作为晚期肺癌的初始治疗。

* Stage, weight loss, performance status, and gender predict survival.分期、体重减轻、一般情况以及性别预测生存。

* Platinum-based chemotherapy prolongs survival, improves symptom control, and yields superior quality of life compared to best supportive care.与最佳支持治疗相比，以铂类为基础的化疗延长生存期、提高症状控制率并可获得更好的生活质量。

* Histology of NSCLC is important in the selection of systemic therapy.在全身治疗的选择方面非小细胞肺癌的组织学是重要的。

* New agent/platinum combinations have generated a plateau in overall response rate (≈ 25%–35%), time to progression (4–6 mo), median survival (8–10 mo), 1-year survival rate (30%–40%), and 2-year survival rate (10%–15%) in it patients.患者接受新药/铂二联的疗效有个平台：总有效率（≈25%–35%）、至进展时间（4–6个月）、中位生存期（8–10个月）、1年生存率（30%–40%）、2年生存率（10%–15%）。

* Unit patients of any age (performance status 3–4) do not benefit from cytotoxic treatment, except erlotinib, afatinib, or gefitinib for EGFR mutation-positive and crizotinib for ALK-positive tumors of nonsquamous NSCLC or NSCLC NOS. PS 3–4、任何年龄段的患者均不能从细胞毒性治疗中获益，除了厄洛替尼、阿法替尼或吉非替尼用于治疗EGFR突变阳性和克唑替尼用于治疗ALK阳性的非鳞非小细胞肺癌或非小细胞肺癌非特指患者。

First-line Therapy一线治疗

* There is superior efficacy and reduced toxicity for cisplatin/pemetrexed in patients with nonsquamous histology, in comparison to cisplatin/gemcitabine. 在组织学非鳞癌患者中，与顺铂/吉西他滨相比，顺铂/培美曲塞有优越的疗效和较低的毒性。

* There is superior efficacy for cisplatin/gemcitabine in patients with squamous histology, in comparison to cisplatin/pemetrexed.在组织学鳞癌患者中，与顺铂/培美曲塞相比，顺铂/吉西他滨有优越的疗效。

* Two drug regimens are preferred; a third cytotoxic drug increases response rate but not survival. Single-agent therapy may be appropriate in select patients. 首选两药方案；第3个细胞毒药物增加有效率，但不改善生存。在选择性的患者中单药治疗可能是合理的。

* Response assessment after 2 cycles, then every 2–4 cycles with CT of known sites of disease with or without contrast or when clinically indicated. 两周期后评估疗效，然后每2-4周期或有临床指征时对已知部位强化或平扫CT检查。

Maintenance Therapy维持治疗

* Continuation maintenance refers to the use of at least one of the agents given in first line, beyond 4–6 cycles, in the absence of disease progression. Switch maintenance refers to the initiation of a different agent, not included as part of the first-line regimen, in the absence of disease progression, after 4–6 cycles of initial therapy. 继续维持治疗是指在4至6周期后疾病无进展者，使用至少一种一线给予的药物。转换维持治疗是指在4-6周期初始治疗后疾病无进展者，启动一线方案中不包含的另一个不同的药物。

Subsequent Therapy后续治疗

* Response assessment with CT of known sites of disease with or without contrast every 6–12 weeks.每6-12周对已知病变部位强化或平扫CT检查评估疗效。

First-line Systemic Therapy Options一线全身治疗方案

Adenocarcinoma, Large Cell, NSCLC NOS (PS 0-1)腺癌、大细胞肺癌、非小细胞肺癌非特指（PS 0-1）

* Bevacizumab/carboplatin/paclitaxel (category 1) 贝伐单抗/卡铂/紫杉醇（1类） *,**,***

* Bevacizumab/carboplatin/pemetrexed贝伐单抗/卡铂/培美曲塞*,**,***

* Bevacizumab/cisplatin/pemetrexed贝伐单抗/顺铂/培美曲塞*,**,***

* Carboplatin/albumin-bound paclitaxel (category 1)卡铂/白蛋白结合型紫杉醇（1类）

* Carboplatin/docetaxel (category 1)卡铂/多西他赛（1类）

* Carboplatin/etoposide (category 1)卡铂/依托泊苷（1类）

* Carboplatin/gemcitabine (category 1)卡铂/吉西他滨（1类）

* Carboplatin/paclitaxel (category 1)卡铂/紫杉醇（1类）

* Carboplatin/pemetrexed (category 1)卡铂/培美曲塞（1类）

* Cisplatin/docetaxel (category 1)顺铂/多西他赛（1类）

* Cisplatin/etoposide (category 1)顺铂/依托泊苷（1类）

* Cisplatin/gemcitabine (category 1)顺铂/吉西他滨（1类）

* Cisplatin/paclitaxel (category 1)顺铂/紫杉醇（1类）

* Cisplatin/pemetrexed (category 1)顺铂/培美曲塞（1类）

* Gemcitabine/docetaxel (category 1)吉西他滨/多西他赛（1类）

* Gemcitabine/vinorelbine (category 1)吉西他滨/长春瑞滨（1类）

Adenocarcinoma, Large Cell, NSCLC NOS (PS 2)腺癌，大细胞肺癌，非小细胞肺癌非特指（PS 2）

* Albumin-bound paclitaxel白蛋白结合型紫杉醇

* Carboplatin/albumin-bound paclitaxel卡铂/白蛋白结合型紫杉醇

* Carboplatin/docetaxel卡铂/多西他赛

* Carboplatin/etoposide卡铂/依托泊苷

* Carboplatin/gemcitabine卡铂/吉西他滨

* Carboplatin/paclitaxel卡铂/紫杉醇

* Carboplatin/pemetrexed卡铂/培美曲塞

* Docetaxel多西他赛

* Gemcitabine吉西他滨

* Gemcitabine/docetaxel吉西他滨/多西他赛

* Gemcitabine/vinorelbine吉西他滨/长春瑞滨

* Paclitaxel紫杉醇

* Pemetrexed培美曲塞

+ Albumin-bound paclitaxel may be substituted for either paclitaxel or docetaxel in patients who have experienced hypersensitivity reactions after receiving paclitaxel or docetaxel despite premedication, or for patients where the standard premedications (ie, dexamethasone, H2 blockers, H1 blockers) are contraindicated. 在接受紫杉醇或多西他赛的患者中，尽管预处理用药仍有过敏反应者，或标准预处理用药（即地塞米松、H2受体阻滞剂、H1受体阻滞剂）禁忌者，白蛋白结合型紫杉醇可以取代紫杉醇或多西他赛。

*Bevacizumab should be given until progression. 应该给予贝伐单抗直至疾病进展。

**Any regimen with a high risk of thrombocytopenia and the potential risk of bleeding should be used with caution in combination with bevacizumab.任何具有血小板减少高危和潜在出血风险的方案，联合贝伐单抗时均应谨慎。

***Criteria for treatment with bevacizumab: non-squamous NSCLC, and no recent history of hemoptysis. Bevacizumab should not be given as a single agent, unless as maintenance if initially used with chemotherapy.联合贝伐单抗是标准治疗：非鳞非小细胞肺癌并且近期无咯血史。贝伐单抗不应单药给予，除非最初联合化疗使用然后作为维持。