小細(xì)胞肺癌的分期、影像學(xué)表現(xiàn)和治療

SmallCellLungCarcinoma:

Staging,Imaging,andTreatment

Considerations

羅2015.6.15介紹Introduction2004WHO將肺癌分為兩個主要組織學(xué)類型:非小細(xì)胞肺癌和小細(xì)胞肺癌。SCLC占肺癌總數(shù)的13%-15%，是最常見的原發(fā)性肺神經(jīng)內(nèi)分泌腫瘤。The2004WorldHealthOrganization(WHO)classificationscheme

divides

lungcancerintotwomajorhistologiccategories:non–small

celllungcarcinoma(non-SCLC)andSCLC，SCLCsaccountfor13%–15%ofalllung

cancersandarethemostcommonprimary

pulmonaryneuroendocrineneoplasm。在所有組織類型中，小細(xì)胞肺癌的發(fā)病與吸煙關(guān)系最為密切，大約95%的小細(xì)胞肺癌患者有吸煙史。andofallthehistologicsubtypesoflungcancer,SCLChasthestrongestassociationwithcigarettesmoking.介紹Introduction小細(xì)胞肺癌特點(diǎn)是腫瘤細(xì)胞倍增時間短，增殖指數(shù)高，比非小細(xì)胞肺癌更具侵略性，并有早期廣泛轉(zhuǎn)移的傾向。SCLCismoreaggressivethannon-SCLCandischaracterizedbyarapiddoublingtime,highgrowthfraction(theratioofproliferatingcellstototalcells),andgreaterpropensityforearlydevelopmentofwidespreadmetastases介紹Introduction美國老年委員會肺癌研究小組(VALSG)制定的分期系統(tǒng)將小細(xì)胞肺癌分為局限期和廣泛期。不過現(xiàn)在已經(jīng)被修訂的TNM分期方法所代替。SCLCis

usuallycategorizedaccordingtoamodifiedversionoftheVeteransAdministrationLungCancerStudyGroup(VALSG)stagingsystemas

eitherlimited-stageSCLC(LS-SCLC)or

extensive-stageSCLC(ESSCLC).介紹Introduction準(zhǔn)確的分期對小細(xì)胞肺癌患者的治療有指導(dǎo)性意義，放療和化療聯(lián)合治療對局限期小細(xì)胞肺癌是有效果的，其中一小部分患者能長期存活。AccuratestagingofpatientswithSCLChelpsguideindividual

treatmentstrategies,sincepatientswithLS-SCLC

arecandidatesforcurative-intentchemotherapy–

radiationtherapy,a

smallpercentageofwhom

experiencelong-termsurvival.介紹Introduction

在本文獻(xiàn)中，我們主要是復(fù)習(xí)小細(xì)胞肺癌的病理及它的發(fā)展，并討論CT和PET-CT對患者疾病的分期和評價。

Inthisarticle,wereviewthepathophysiologyandnaturalhistoryofSCLCanddiscussthe

roleofcomputedtomography(CT)and2-[fluorine-18]fluoro-2-deoxy-d-glucose(FDG)positron

emissiontomography(PET)/CTintheevaluation

andstagingofpatientswiththedisease.肺神經(jīng)內(nèi)分泌腫瘤的分類

Classification

ofPulmonary

NeuroendocrineNeoplasmsWHO將肺神經(jīng)內(nèi)分泌腫瘤分為3個病理等級以及4個分類：低度惡性：典型類癌腫瘤；中間級腫瘤：不典型類癌；高度惡性腫瘤：包括大細(xì)胞神經(jīng)內(nèi)分泌腫瘤以及小細(xì)胞肺癌。在這篇文章，我們專注于小細(xì)胞肺癌。The2004WHOtumorclassificationschemeincludesfourmajortypesofpulmonaryneuroendocrinetumors,whicharegroupedintothreehistologicgrades.Low-grademalignantneoplasmsincludetypicalcarcinoidtumor,intermediate-gradeneoplasmsincludeatypicalcarcinoids,andhigh-gradeneoplasmsincludelargecellneuroendocrinetumorandSCLC.Inthisarticle,however,wefocusonSCLC流行病學(xué)和臨床特點(diǎn)EpidemiologicandClinicalFeatures95%以上的高級別的神經(jīng)內(nèi)分泌腫瘤起源于肺，而肺外疾?。罕茄什?、胃腸道和泌尿生殖道等器官的腫瘤極為少見。Morethan95%ofhigh-gradeneuroendocrine

carcinomasoriginatein

thelung,whereasextrapulmonarytumorsinvolvingorganssuchasthe

nasopharynx,gastrointestinaltract,andgenitourinarytractare

exceptionallyrare,withaprevalenceof0.1%–0.4%intheUnitedStates流行病學(xué)和臨床特點(diǎn)EpidemiologicandClinicalFeatures據(jù)美國的流行病學(xué)資料顯示小細(xì)胞肺癌的患病率在20世紀(jì)80年代達(dá)到頂峰，之后一直在下降，此后，在過去的30年從17%-20%降至13%-15%。原因有很多，例如降低吸煙率，增加過濾的香煙的使用，以及對小細(xì)胞肺癌的病理標(biāo)準(zhǔn)所做的更改。小細(xì)胞肺癌好發(fā)年齡在60和70歲之間。男女比例2.6:1。TheprevalenceofSCLCintheUnitedStates

peakedinthe1980sandhasbeendecliningsince

thattime,decreasingfrom17%–20%to

13%–15%overthepast30years(4,12).Several

factorsmay,atleastinpart,beresponsiblefor

thisdecline,suchasadecreaseinsmokingrates,

increaseduseoffilteredcigarettes,andchanges

thathavebeenmadetothepathologiccriteriafor

SCLC。SCLCtypicallyaffectspatientsbetweentheagesof60and70years,SCLChashistorically

beenseenmorefrequentlyinmen

thaninwomenbyaratioof2.6:1。流行病學(xué)和臨床特點(diǎn)EpidemiologicandClinicalFeatures最常見的臨床癥狀包括咳嗽、胸痛、咯血、呼吸困難，通常會伴有一些全身性疾病，比如體重下降，疲勞和厭食等癥狀。Themostcommonsignsandsymptoms

reportedatthetimeofpresentationinclude

cough,chestpain,hemoptysis,anddyspnea.Becausepatientstypicallyhavesystemicdiseaseat

thetimeofdiagnosis,symptomssuchasweight

loss,fatigue,andanorexiaareoftenpresent.

流行病學(xué)和臨床特點(diǎn)EpidemiologicandClinicalFeatures侵襲性的腫瘤或晚期的患者會有特定的臨床癥狀。例如，大約10%的患者伴有上腔靜脈綜合征相關(guān)的癥狀。侵犯食管及縱隔結(jié)構(gòu)(如，喉返神經(jīng)和氣管)會導(dǎo)致吞咽困難和聲音嘶啞，另外肺外轉(zhuǎn)移性疾病可表現(xiàn)為骨痛、皮膚瘙癢、黃疸、癲癇發(fā)作、精神失常，和/或共濟(jì)失調(diào)。Patientswithinvasiveoradvanceddiseasemay

presentwithspecificsymptoms.Forinstance,

10%ofpatientsreportsymptomsrelatedtosuperiorvenacavasyndrome(9,13).Invasionof

theesophagusandmediastinalstructures(eg,

therecurrentlaryngealnerveandtrachea)can

resultindysphagiaandhoarseness,respectivelyExtrapulmonarymetastaticdiseasecanmanifestasbonepain,pruritus,jaundice,seizures,changesinmentalstatus,and/orataxia(9,13).組織學(xué)和病理特點(diǎn)Histologicand

GrossPathologicFeatures小細(xì)胞肺癌的確診通過核心活檢或細(xì)針穿刺活檢。在光學(xué)顯微鏡，小細(xì)胞肺癌細(xì)胞呈藍(lán)色圓形、橢圓形，或紡錘狀，細(xì)胞胞漿稀少，邊界模糊不清，細(xì)顆粒細(xì)胞核的染色質(zhì)，核缺失或，核仁不明顯(圖1a)，對于肺的神經(jīng)內(nèi)分泌腫瘤，小細(xì)胞肺癌具有最高的有絲分裂率，并且廣泛壞死。ThediagnosisofSCLCmaybeestablished

byexaminingtissueobtainedatfine-needle

aspirationbiopsyorcorebiopsy.Atlightmicroscopy,SCLCischaracterizedbysmallblue

round,oval,orspindle-shapedcellswithscant

cytoplasm,ill-definedborders,finelygranular

nuclearchromatin,andabsentorinconspicuous

nucleoli(Fig1a)(2,6).Ofthepulmonary

neuroendocrinetumors,SCLChasthehighestmitoticrate(>10mitosesper10high-power

fields;

median,80mitosesper10high-powerfields),

andextensivenecrosisistypicallypresent.組織學(xué)和病理特點(diǎn)Histologicand

GrossPathologicFeaturesWHO將它分為兩種亞型的小細(xì)胞肺癌:單純性小細(xì)胞肺癌和復(fù)合性SCLC。大多數(shù)腫瘤是單純性小細(xì)胞肺癌;因?yàn)橥ǔＶ挥袛?shù)量有限的組織可供分析，復(fù)合性類型很少見。復(fù)合性SCLC具有非小細(xì)胞肺癌成分，比如腺癌、鱗狀細(xì)胞癌、大細(xì)胞癌、梭形細(xì)胞癌或巨細(xì)胞癌的存在。TheWHOrecognizestwosubtypesofSCLC:

pureSCLCandcombinedSCLC.The

majorityoftumorsarepureSCLCs;because

onlyalimitedamountoftissueistypicallyavailableforanalysis,thecombinedsubtypeisrarely

seen.CombinedSCLCischaracterizedbyth

presenceofanon-SCLCcomponentsuchas

adenocarcinoma,squamouscellcarcinoma,large

cellcarcinoma,spindlecellcarcinoma,orgiant

cellcarcinoma.組織學(xué)和病理特點(diǎn)Histologicand

GrossPathologicFeatures90%SCLC以上都集中在中央位置，環(huán)繞和壓迫支氣管生長。腫瘤可能直接侵襲周邊淋巴結(jié)和伴有遠(yuǎn)處淋巴結(jié)轉(zhuǎn)移，以及肺內(nèi)淋巴管播散。然而，小細(xì)胞肺癌也可能作為一種相對較小的支氣管腫瘤出現(xiàn)。Over90%ofSCLCsarecentrallylocatedand

tendtosurroundandconstrictthemajorbronchi

(21).Tumorsmaydirectlyinvadeandmetastasizetoregionallymphnodesandmayspread

inalymphangiticpatterninthelung.However,

SCLCmayoccasionallyariseasarelativelysmall

bronchialtumor.組織學(xué)和病理特點(diǎn)Histologicand

GrossPathologicFeatures小細(xì)胞肺癌手術(shù)切除是很少執(zhí)行的。然而，在切除的情況下，腫瘤典型的表現(xiàn)為局限的周圍型肺癌結(jié)節(jié)，棕褐色，切割表面可見壞死。在CT上，這些周圍型小細(xì)胞肺癌周邊常有毛刺，通常表示血管、淋巴的侵犯，或者不規(guī)則肺泡內(nèi)的擴(kuò)散，邊緣磨玻璃密度多反應(yīng)的是腫瘤周圍的水腫和出血。SurgicalresectionofSCLCisrarelyperformed.However,incasesofresection,thetumortypicallymanifestsasacircumscribedperipherallungnodulemeasuring2–4cmwithatan,ne-croticcutsurface(9).AtCT,theseperipheraltumorsaretypicallyspiculated,afindingthatrepresentsvascular,lymphatic,orintraalveolarinvasion,withsurroundingground-glassopacityrepresentingfocaledemaandhemorrhage。小細(xì)胞肺癌的分期StagingofSCLCVALSG分期系統(tǒng)將SCLC分為局限期-小細(xì)胞肺癌LS-SCLC、廣泛期-小細(xì)胞肺癌ES-SCLC。局限期-小細(xì)胞肺癌是指：病變局限于同側(cè)半胸廓，沒有遠(yuǎn)處轉(zhuǎn)移，局限于單個輻射端口，同側(cè)縱膈和鎖骨上淋巴結(jié)轉(zhuǎn)移如果可以安全的被單一放射野所包繞，也被視為局限期-小細(xì)胞肺癌。廣泛期-小細(xì)胞肺癌是指：病變超出同側(cè)半胸廓，包括惡性胸腔積液和心包積液、對側(cè)肺門或鎖骨上淋巴結(jié)轉(zhuǎn)移，以及不能在一個單一的輻射端口治療的轉(zhuǎn)移性疾病。小細(xì)胞肺癌的分期StagingofSCLCTheVALSGstagingsystemtraditionallydivideSCLCintoLS-SCLCandES-SCLC(Table1).HistoricallyLS-SCLCwascharacterizedastumoralinvolvementlimitedtoonehemithorax(withorwithoutlocalextension)withnodistantextrathoracicmetastaticdisease.RegionalandipsilateralsupraclavicularlymphnodeswereconsideredLS-SCLCiftheycouldbeincludedinasinglesafeandadequateradiationport.AllothercaseswerethoughttorepresentES-SCLCandincludedfeaturessuchasmalignantpleuralandpericardialeffusions,contralateralhilarorsupraclavicularlymphnodes,andmetastaticdiseasethatcouldnotbetreatedinasingleradiationport。小細(xì)胞肺癌的影像學(xué)表現(xiàn)ImagingofSCLC一般特征GeneralFeatures：因?yàn)?0%-95%的SCLC來自肺葉或主支氣管，所以小細(xì)胞肺癌最常見的表現(xiàn)是肺中央較大團(tuán)塊影或縱隔、肺門的腫塊影。位于中央的SCLC可以導(dǎo)致肺葉和整個肺的肺不張。Because90%–95%ofSCLCsarisefromlobarormainbronchi,themostcommonmanifestationofSCLCisalargemasscentrallylocatedwithinthelungparenchyma(Fig2)oramediastinalmassinvolvingatleastonehilum(Fig3)CentrallylocatedSCLCscanresultinatelectasisofeitheralobeortheentirelung.CT檢查ComputedTomographySCLC以中心型居多，伴有縱膈和肺門淋巴結(jié)腫大，增強(qiáng)ct掃描可以有助于提示縱隔侵犯(圖5)的程度。包埋縱隔結(jié)構(gòu)，比如氣管、食管、心臟(圖6)和血管，包括上腔靜脈(圖7)，大多數(shù)患者存在縱膈侵犯。少數(shù)患者伴有瘤內(nèi)鈣化(圖8)。少部分患者，小細(xì)胞肺癌表現(xiàn)為孤立性外周結(jié)節(jié)不伴有淋巴結(jié)腫大。MostSCLCsarelocatedwithinthe

centralaspectofthechestandmanifestasamediastinal(92%ofcases)orhilar(84%)lymphadenopathy.Contrast-enhancedCTcanbeusefulinrevealingtheextentofmediastinalinvasion(Fig5).

Encasementofmediastinalstructuressuchasthetrachea,esophagus,heart(Fig6),andvessels,includingthesuperiorvenacava(Fig7),ispresentinapproximately68%ofpatients.Intratumoralcalcificationhasbeenreportedinupto23%ofpatients(Fig8)Inaminority(<5%)ofpatients,SCLCmanifestsasaperipheralnodulewithoutassociatedlymphadenopathy。CT檢查ComputedTomography周圍型腫瘤通常表現(xiàn)為邊界清楚的、密度均勻的實(shí)性結(jié)節(jié)，腫塊邊緣有較多的毛刺。周圍的毛玻璃水腫或出血可能也會出現(xiàn)。Peripheraltumorstypicallymanifestaswell-defined,homogeneousnodulesormasseswithlobularmarginsandspiculations(Fig9)(37).Surroundinggroundglassopacityduetoedemaorhemorrhagemayalsobepresent.CT檢查ComputedTomography胸膜轉(zhuǎn)移性可表現(xiàn)為胸腔積液、胸膜增厚、或者胸膜下多發(fā)結(jié)節(jié)和腫塊，心包的改變可表現(xiàn)為心包積液和/或心包增厚。此外，CT經(jīng)常用于評估治療效果和評價病灶的殘余或復(fù)發(fā)。Pleuralmetastaticdiseasecanmanifestasapleuraleffusion,pleuralthickening,and/ornodulesandmasses(Fig12),andpericardialinvolvementcanmanifestasapericardialeffusionand/orpericardialthickening.Inaddition,CTisroutinelyusedtoassesstreatmentresponse(Fig13)andevaluateforresidualorrecurrentdiseaseinpatientswhoareundergoingtherapy.小細(xì)胞肺癌患者，表現(xiàn)為后縱隔占位，向前侵犯心臟，并導(dǎo)致右肺下葉不張。61歲老年男性，ES-SCLC，增強(qiáng)CT顯示在右縱隔巨大軟組織占位，導(dǎo)致局部右肺上葉不張。臨近上腔靜脈受侵、閉塞；右胸壁廣泛側(cè)枝血管形成。57歲男性，右肺上葉小細(xì)胞肺癌伴胸膜轉(zhuǎn)移，胸水。CT增強(qiáng)顯示右側(cè)胸腔積液和胸膜下多發(fā)結(jié)節(jié)(箭頭)。CT用于評估SCLC的治療效果。MRImaging胸部磁共振成像不經(jīng)常用來評價小細(xì)胞肺癌，但在特定情況下很有用。例如，當(dāng)患者存在一些過敏反應(yīng)和腎衰竭這些靜脈注射對比劑的禁忌癥時，磁共振成像可以用于顯示縱隔或血管的侵犯程度；它也可以用來檢測顱內(nèi)轉(zhuǎn)移(圖14)，這點(diǎn)是優(yōu)于CT及PET/CT，因?yàn)槟X實(shí)質(zhì)廣泛的FDG攝取通常會影響轉(zhuǎn)移灶的檢出率。ThoracicMRimagingisnotroutinelyusedtoevaluateSCLCbutmaybeusefulinspecificscenarios.Forinstance,MRimagingcanbeusedtodemonstratemediastinalorvascularinvasioninthesettingofcontraindicationsfortheadministrationofintravenouscontrastmaterialsuchasallergyandrenalfailure.Itcanalsobeusedtoidentifyintracranialmetastases(Fig14)andissuperiortoFDGPETandFDGPET/CTinthissettingbecauseextensiveFDGuptakewithinthebrainparenchymausuallyhampersthevisualizationofmetastasis.PET/CTFDGPET/CT是小細(xì)胞肺癌功能信息(FDGPET)與解剖信息(CT)結(jié)合評價的重要輔助檢查。FDGPET/CT對臨床分期、治療和預(yù)后有重要的指導(dǎo)意義。因?yàn)樾〖?xì)胞肺癌的葡萄糖代謝活性高，所以在PET檢查中容易顯像(圖15)。FDGPET/CTisanimportantadjunctexaminationintheevaluationofSCLC,combiningfunctionalinformation(FDGPET)withanatomicinformation(CT).FDGPET/CTisinvaluableinclinicalstagingandrestaging,guidingtherapy,andsuggestingprognosis.SCLCisreadilyidentifiedatFDGPETbecauseofitshighmetabolicactivity(Fig15).PET/CT雖然FDGPET對于腦轉(zhuǎn)移的檢測率不如MRI，但相對于其他影像學(xué)檢查來講，它仍然是對全身轉(zhuǎn)移性病灶檢測更為敏感、和精確。當(dāng)然，PET/CT比單獨(dú)的PET更精確。AlthoughFDGPETisinferiortoCTorMRimagingforthedetectionofbrainmetastases,itismoresensitiveandspecificthanconventionalimagingfordetectingmetastaticdisease.發(fā)展和預(yù)后NaturalHistoryandPrognosis由于小細(xì)胞肺癌的侵襲性，在診斷后沒有治療的情況下平均存活時間只有2-4個月。小細(xì)胞肺癌對化療敏感度高，一線化療的響應(yīng)率是60%-70%。盡管如此，大多數(shù)患者還是會復(fù)發(fā)，在2年內(nèi)死亡。BecauseoftheaggressivenessofSCLC,mediansurvivaltimeafterdiagnosisisonly2–4monthsintheabsenceoftreatment(52).SCLCistypicallyveryresponsivetochemotherapy,andtheratesofresponsetofirst-linecombinationchemotherapyare60%–70%(53).Inspiteofthisinitialresponse,however,themajorityofpatientssufferrelapseanddiewithin2years.發(fā)展和預(yù)后NaturalHistoryandPrognosis根據(jù)監(jiān)測、流行病學(xué)和最終結(jié)果(SEER)的數(shù)據(jù)，在美國，5年生存率，LS-小細(xì)胞肺癌患者大約有10%-15%，ES-小細(xì)胞肺癌生存率大約有1%-2%。LS-小細(xì)胞肺癌患者平均存活時間為15-20個月，而ES-小細(xì)胞肺癌患者平均存活時間為8-10個月和2年生存率為10%。OnthebasisofSurveillance,Epidemiology,andEndResults(SEER)dataintheUnitedStates,the5-yearsurvivalratesareapproximately10%–15%forpatientswithLS-SCLCand1%–2%forpatientswithES-SCLC.PatientswithLS-SCLChaveamediansurvivaltimeof15–20months,whereasthosewithES-SCLChaveamediansurvivaltimeof8–10monthsanda2-yearsurvivalrateof10%.

TreatmentofSCLC一般注意事項(xiàng)GeneralConsiderations：

LS-SCLC通常是聯(lián)合化療和早期合并胸照射治療，而ES-小細(xì)胞肺癌主要是全身化療。LS-或ES-SCLC對于化療有響應(yīng)的患者，一般要進(jìn)行預(yù)防性頭顱照射。LS-SCLCistypicallytreatedwithacombinationofchemotherapyandearlyconcurrentthoracicirradiation,whereasES-SCLCistreatedwithsystemicchemotherapyProphylacticcranialirradiationmaybeperformedaftercompletionofchemotherapyinpatientswithLS-orES-SCLCwhohaverespondedtochemotherapyTreatmentofSCLC化療Chemotherapy當(dāng)前的臨床實(shí)踐中，最常見的化療方案是足葉乙甙、順鉑聯(lián)合化療。并且證明了當(dāng)化療與放射治療結(jié)合使用能夠提高存活率。ES-SCLC患者，對足葉乙甙、順鉑聯(lián)合化療的響應(yīng)率是60%到80%。平均存活時間是大約8-12個月，其5年生存率均小于5%。Severalchemotherapyregimensareusedincurrentclinicalpractice,themostcommonofwhichcombinesetoposideandcisplatin.Thisregimenisassociatedwithafavorabletoxicityprohasdemonstratedimprovedsurvivalrateswhenusedincombinationwithradiationtherapy.InpatientswithES-SCLC,responseratestoetoposide-cisplatinchemotherapyrangefrom60%to80%.Mediansurvivaltimesareapproximately8–12monthsand5-yearsurvivalratesarelessthan5%TreatmentofSCLC盡管一線化療有著較高的響應(yīng)率，但是幾乎所有的的LS-SCLC和ESSCLC患者治療后都會復(fù)發(fā)或漸進(jìn)式的惡化。Despitehighresponseratestofirst-linecombinationchemotherapy,approximately80%ofpatientswithLS-SCLCandvirtuallyallpatientswithES-SCLCdeveloprecurrentorprogressivediseaseTreatmentofSCLC對于SCLC治療后復(fù)發(fā)再次化療是否有效，主要取決于兩個因素：1、初次化療是否有效，尤其是達(dá)到完全緩解的患者再次化療的有效率較高；2、復(fù)發(fā)時間距初次化療結(jié)束的時間越短，再次化療效果越差。對于初次化療結(jié)束后3個月內(nèi)復(fù)發(fā)的患者，再次化療效果較差，效率低。Forpatientswhoexperiencerelapsewithin3monthsofinitialtherapy(refractoryorresistantdisease),theresponseratetoadditionalchemotherapyislessthan15%.However,whenthetimebetweeninitialtherapyandrelapseisgreaterthan3months(sensitivedisease),theresponseratetoadditionalchemotherapyis15%–60%胸部放射治療ThoracicRadiationTherapy胸部放射通常與全身化療結(jié)合治療LS-小細(xì)胞肺癌(圖17)。這種方法已被證明能夠提高患者的生存率，并降低胸腔腫瘤控制的失敗率。TRTistypicallyadministeredwithsystemicchemotherapyinpatientswithLS-SCLC(Fig17).Thisapproachhasbeenshowntoimprovepatientsurvivalandreduceintrathoracicfailureratesfrom75%–90%(combinationchemotherapyalone)to30%–60%LS-SCLC伴左胸壁侵犯。左肺門的淋巴結(jié)轉(zhuǎn)移和主支氣管閉塞。

給予聯(lián)合化療以及單個輻射端口胸部照射治療。治療后效果較顯著，腫塊和左肺門淋巴結(jié)明顯減小，左肺大量輻射后的纖維化。預(yù)防性頭顱放療ProphylacticCranialIrradiation腦是小細(xì)胞肺癌常見的轉(zhuǎn)移部位，腦轉(zhuǎn)移的發(fā)生率高達(dá)50%；多藥聯(lián)合化療和放射治療的應(yīng)用，長期生存率提高，腦轉(zhuǎn)移的發(fā)生也隨之增加。文中數(shù)據(jù)表明，預(yù)防性頭顱放療可以降低腦轉(zhuǎn)移發(fā)生率和增加小細(xì)胞肺癌患者的存活率，所以預(yù)防性頭顱放療被用于無論是局限性還是廣泛性的小細(xì)胞肺癌患者。AtrialconductedbytheEuropeanOrganisationforResearchandTreatmentofCancer(EORTC)RadiationOncologyandLungCancergroupdemonstratedthatprophylacticcranialirradiationdecreasedtheincidenceofsymptomaticbrainmetastasesandprolongedsurvivalinpatientswithES-SCLC(26).Onthebasisoftheseresults,prophylacticcranialirradiationisnowrecommendedforpatientswitheitherLS-orESSCLCwhodemonstrateagoodresponsetochemotherapyorchemotherapy–radiationtherapy.手術(shù)治療Surgery小細(xì)胞肺癌患者很少手術(shù)切除（小細(xì)胞癌惡性程度高、轉(zhuǎn)移早，一般認(rèn)為不宜手術(shù)治療）。有研究表明手術(shù)治療被添加到聯(lián)合放化療中，對生存或復(fù)發(fā)率沒有較大影響。surgicalresection