台北榮總胸腺癌診療共識 V.1.0 2013 台北榮總肺癌團隊 Revised on 2013/9/2 Staging Staging THYM- Initial evaluation Mediastinal mass • CT chest with contrast • Serum beta-HCG, AFP, if appropriate • CBC, platelets •TSH, T3, T4 levels, as clinically indicated •Pulmonary function tests, as clinically indicated • MRI chest, as clinical indicated • PET-CT scan optional Small thymic tumor without evidence of invasion Locally advanced, or unresectable Surgical resection (VATS or Transsternal approach) Manage by a thoracic surgeon with experience in the management of thymoma and thymic carcinoma See Postoperative Management (THYM-3) Tissue diagnosis with core needle biopsy (avoid transpleural biopsy) Discuss in a multidisciplinary team with experience in the management of thymoma and thymic carcinoma See treatment (THYM-4) THYM-3 THYM-4 胸腺腫瘤與胸腺癌的手術切除原則 1 • 1. 胸腺腫瘤的手術切除應該經由訓練合格的胸腔外科醫師仔細 評估後執行。具局部侵犯性(或不可切除)或第二期以上的胸腺腫 瘤,治療方式則應經由多團隊會議討論及評估後執行。 • 2. 當臨床和影像學上的評估認為胸腺腫瘤是可以完全手術切除 時,手術前的組織切片診斷應該避免,以免造成腫瘤的擴散。 • 3. 組織切片診斷應該避免經過肋膜腔,造成腫瘤擴散。 • 4. 手術前,應仔細的評估病患有無合併肌無力症狀或徵象。若 合併有肌無力症應在手術前內科藥物控制穩定後再行手術。 • 5. 手術切除的目標是完全的將病灶(腫瘤)切除,加上胸腺組織 切除和其他鄰近的或非鄰近的可疑病灶切除。 胸腺腫瘤與胸腺癌的手術切除原則 2 • 6. 完全的腫瘤切除手術可能須合併切除腫瘤周微的組織結構包 括:心包膜、膈神經、肋膜、肺臟,甚至其他週圍重要的大血管。 為了避免術後的呼吸併發症,應避免同時將兩側的隔神經切除。 • 7. 實施胸腺瘤切除手術時,同時建議檢查兩側肋膜表面以排除 肋膜擴散。在某些病例,切除肋膜擴散病灶對病患可能可以達到 完全切除腫瘤的目的。 • 8. 由於目前仍缺乏長期的追蹤報告,所以並不建議常規採用微 創手術方式切除胸腺瘤。但是在不影響腫瘤治療原則的前提下, 在有經驗的醫學中心仍可以考慮用微創手術治療。 Rationale of Radiotherapy for Invasive thymoma and thymic carcinoma • Thymoma is the most common tumor of the anterior mediastinum, accounting for approximate 20% of all mediastinal tumors in adults. • Complete surgical resection is the treatment of choice for all thymomas regardless of invasiveness. • Radiotherapy is excellent adjuvant therapy for invasive thymomas, which are generally radio-responsive. • RT should be given for unresectable or incomplete resection patients with invasive thymoma or thymic carcinoma. Rationale of Radiotherapy for Invasive thymoma and thymic carcinoma For unresectable disease: 60-70 Gy (with daily fraction between 1.8 to 2 Gy) For post-operative status: 45-50 Gy for radical surgery 54 Gy for close margin and 60 Gy for gross residual lesions. Radiation dose less than 40 Gy possess higher relapse incidence. For large, invasive thymoma, neoadjuvant RT has been advocated. GTV: gross visible tumor volume CTV: encompassing the entire thymus, surgical clips and potential site with residual disease. PTV: including target motion and setup error. Post-operative radiotherapy will be arranged within 4-6 weeks after surgical intervention. Radiotherapy technique: including IMRT, VMAT and Tomotherapy Modern RT techniques can help to reduce the dose of normal tissues, including heart and lung. High Precision Radiotherapy Technique for Thymic carcinoma 化學治療用藥準則 台北榮總胸腺癌診療共識 主要依據- 1.NCCN v1 2014 台北榮總胸腺癌診療共識 本治療指引將每年檢討修訂一次 預定下次修訂日期:2014年09月