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参会专家
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和小编一起来回顾一下本场精彩讨论点吧！
病例1安徽医院
视频在0：04：00
首先，由安徽医院顾康生教授团队的韦炜主治医师分享的以“体检胸部CT提示右肺中叶结节灶”为主诉入院就诊的56岁男性患者。具体诊疗过程如下：
病史简介
既往史：平素健康状况良好，无基础疾病及肺癌家族史。
否认肝炎、结核、疟疾病史。
否认高血压、心脏病史，否认糖尿病、脑血管疾病、精神疾病史。
.9.11在全麻下行右肺中叶切除术，否认药物过敏史。
现病史：
辅助检查
基因检测提示：ERBB2（+）（第20外显子非移码插入突变），TP53（+），EGFR（-），ALK（-），ROS1（-），RET(-)，MET（-）
临床诊断
右肺腺癌术后伴双肺多发转移，IV期，ERBB2（+）,ECOG1分
治疗方案
?.07.02至.11.03安罗替尼12mgd1-14/q3w+吉西他滨1.6gd1,d8方案化疗6程；疗效评估:SD。
?.12.05疗效评估:PD，口服阿法替尼40mgQD治疗。
?.1.10疗效评估:PD。
?.1.12、.2.3使用信迪利单抗mgd1+替吉奥胶囊40mgbidd1-14治疗2程。
?.3.5患者出现呼吸困难，医院行胸部CT提示:PD。
?.3.8开始口服吡咯替尼mgQD治疗，使用10天后，患者呼吸困难症状明显改善。
?.4.6再次就诊于我院，行胸部CT检查提示疗效评估达PR，继续口服吡咯替尼，出现不良反应：腹泻2级，给予蒙脱石散对症治疗可缓解；皮疹1级。
?.10.10患者出现头痛伴进食后呕吐，偶有神志模糊。
?.10.18头颅、胸腹盆CT平扫+增强：提示双肺病灶进展。
本病例讨论点：
脑膜转移治疗手段
专家观点概要
1.脑膜转移的放疗，其实不如颅脑这般成块的转移灶敏感，所以会加入替莫唑胺增敏。
2.出现颅脑转移时建议做颅脑磁共振增强来直观的观察脑膜有没有转移灶。
安徽医院
病例2医院
视频在0：38：57
第二个病例是由医院王彩霞教授团队的付国斌副主任医师分享的以“左颈部肿块2周”为主诉入院就诊的42岁男性患者。具体诊疗过程如下：
病史简介
现病史：患者左颈部无诱因出现包块，约2*2cm，质韧，活动度差，偶有鼻衄，无鼻塞流涕，无头痛头晕，无耳鸣耳痛，无视物模糊，无进食阻挡，无咳嗽咳痰，无发热。至我院门诊行B超引导下颈部包块穿刺活检考虑转移性腺癌，为行进一步治疗收入院。患者院外睡眠饮食可，体重变化不明显，大小便未见异常。
既往史：否认高血压、冠心病、糖尿病病史，否认肝炎等传染病病史及接触史。无重大外伤史，无输血史，否认药物过敏史，无食物过敏史，否认有中毒史，预防接种史随当地。
个人史、家族史：吸烟史20年，平均每日1包；偶有饮酒，否认有毒物及放射线长期密切接触史。23岁结婚，育有2女1子，配偶及子女均体健。否认家族重大传染病及遗传病史。
查体：左颈部可及淋巴结肿大，约2*2cm，质韧，活动度差，余浅表淋巴结未及肿大。心肺未及异常。
既往辅助检查
-03-30颈、胸、全腹(含盆腔)CT平扫+增强(医院53):右肺上叶结节，考虑恶性肿瘤，建议病理学检查；纵隔及左侧锁骨上多发增大淋巴结，考虑转移，建议治疗随访；右肺下叶小结节，建议随访；右肾结石。
颅脑MR：散在缺血梗死灶。
全身骨ECT：未见明显放射性异常。
临床诊断
右肺腺癌并纵隔、左锁骨上淋巴结转移（cT1N3M0，ⅢB）
治疗方案
?第一次治疗：
.04予培美曲塞+卡铂方案化疗，尚未放疗
?第二次治疗：
调整后续治疗为阿法替尼（吉泰瑞）40mgqd，疾病控制后建议局部放疗。疗效示SD。
?后续治疗：
继续阿法替尼40mgqd治疗；如发生TM突变，可序贯奥希替尼治疗。
专家观点概要
1.当前不可手术ⅢB期肺癌标准治疗为同步放化疗+Durvalumab巩固，但真实世界中药物可及性差，对于驱动基因阳性患者是否可以一线首选TKI治疗需要更多的临床研究支持。
2.精准治疗的前提是精准诊断分期，当前肺癌的治疗已进入分子病理时代。
3.阿法替尼在一线的治疗效果比二线好，对于局部晚期的非小细胞肺癌而言放疗的介入在某种时机可以改变患者生存的。
4.19外显子突变截断的片段分为多种，可能有8个、6个、4个、3个氨基酸缺失的，比例有一些差异。目前的研究还未证实这些差异是否明确不同病人治疗的效果存在差异，后续值得继续探讨。
5.无论是阿法替尼、吉非替尼还是厄洛替尼，不良反应反应都有间质性肺炎，且发生率均在1%-1.5%左右。放疗可能会引起放射性肺炎，间质性肺炎与放射性肺炎的重叠会增加患者肺炎的发生率。所以放疗的介入时机一定要结合疾病的临床进展、基础肺的情况、患者治疗意愿和一般情况综合考虑，如果患者本身基础肺的功能不太好，那么放疗的介入和时机一定要慎重。
医院
病例3医院
视频在1：11：37
第三个病例是由医院吴平平教授团队的周青副主任医师分享的以“咳嗽，伴胸闷1月”为主诉入院就诊的59岁男性患者。具体诊疗过程如下：
病史简介
吸卷烟史支/年。
辅助检查
血清肿瘤标记：CA.14U/ml，CEA、NSE、CY21-1正常
-02-02胸部CT:左侧胸腔积液伴左肺不张。
-02-06胸水脱落细胞：腺癌细胞。
IHC:CK(3+),TTF-1(3+),CEA(3+),Ki67(+40%),CK20(-),CK5/6(-),P40(-),PSA(-),Villin(-),WT1(-),ALK(-),CDX-2(-)，符合腺癌，考虑肺来源可能大。
-02-13PET/CT：左肺不张，不张肺组织内见多发结节状/团块状FDG代谢增高，考虑左肺恶性病变伴肺内转移；左侧肺门、纵膈多发小淋巴结，FDG代谢增高；左侧胸腔大量积液，左侧胸膜弥漫不均匀增厚，FDG代谢增高，考虑胸膜转移。
临床诊断
左肺腺癌IV期
cT4N2M1,PS:1分
驱动基因状况未知
治疗方案
一线方案
局部治疗：胸腔积液引流，送检基因检测，灌注生物制剂
全身治疗：贝伐珠单抗mgq3w
培美曲塞1.0+卡铂mgq3w×6周期
培美曲塞1.0q3w×2周期
第1次PD-09-04胸部CT提示右肺新见多发实性小结节，拟转移灶。
二线方案
基因检测：EGFRExon19p.L_T缺失突变（胸水丰度58.9%,血浆丰度5.2%）。
埃克替尼mgtid
贝伐珠单抗mgq3w继续维持
第2次PD-11-26复查CT提示左肺新发转移灶。
三线方案
阿法替尼40mgqd+安罗替尼12mgqd
第3次PD-02-26复查CT提示左肺转移灶较前增大，左侧胸水较前稍增多。
四线方案
奥希替尼80mgqd+安罗替尼12mgqd
-04-15胸部CT:左肺病灶较前缩小。
第4次PD-11-12胸部CT:左肺病灶进展
专家观点概要
1.建议在患者每一次病情进展时再活检或者再进行NGS检测，对后续治疗起到很好的指导作用。一、二、三代靶向药物治疗以后再进展可以考虑化疗、抗血管、免疫治疗。如果该患者再次进展，建议做一个组织活检联合血液学的检测，完成全套的NGS检测来判断患者是否还存在EGFR突变。如果没有，考虑介入免疫治疗；如果有，考虑测定PD-L1表达。
2.该患者后续治疗方案考虑进一步靶向治疗或者化疗联合免疫治疗联合抗血管生成。
医院
病例4医院
视频在1：35：12
第四个病例是由医院谭洁教授团队的王晨洁副主任医师分享的主诉为“反复咳嗽咳痰，咳嗽剧烈时有胸闷不适”入院就诊的57岁女性患者。具体诊疗过程如下：
病史简介
年8月起反复咳嗽咳痰，白粘痰，无痰中带血，咳嗽剧烈时有胸闷不适，无畏寒发热，无潮热盗汗，无腹痛腹泻；
外院查胸部CT：右肺上叶中央肺癌伴双肺多发转移，右侧胸腔积液，左胸第6肋骨骨质破坏。
辅助检查
年10月22日收住我科，进一步头颅MR：脑内多发腔梗；右额叶白质结节异常信号灶，考虑转移可能。
胸腹盆增强CT：右肺癌伴双肺多发转移；右侧胸腔积液，右侧部分胸膜增厚；左侧第6肋局部膨胀性骨破坏，考虑转移；腹部、盆腔未见明显占位。
年10月23日予胸腔穿刺置管，胸水病理：（胸水）查见癌细胞，结合HE形态及免疫组化标记结果，支持诊断为肺腺癌胸水转移。
免疫组化结果：癌细胞示Calrentin（-），BerEP4（弱+），MOC31（+），TTF1（+），P40（-），CK5/6（-），NapsinA（+），PAX8（-），GCDFP15（-），CEA（+）。
基因检测提示：MAP2K1基因2号外显子突变，丰度0.5%；CDH1基因6号外显子突变，丰度1.8%；BAP1基因12号外显子突变，丰度1.0%；KIT基因18号外显子突变，丰度0.8%；未发现扩增和融合；BIM基因野生型。
PD-L1检测：22C3抗体、SP抗体、SP抗体、28-8抗体TPS均为0。
临床诊断
右肺腺癌伴两肺、骨、脑转移
T4NxM1Ⅳ期
恶性胸腔积液
驱动基因野生型PD-L1阴性
ECOG评分2分
治疗方案
方案选择：
治疗过程：
治疗小结
专家观点概要
1.患者在整个治疗过程中，通过胸腺法新的介入提高了机体免疫力，减轻了化疗的毒副反应，使患者对化疗及免疫治疗耐受性良好，生活质量明显提高。说明胸腺法新能提高机体免疫功能，守护患者治疗过程。
2.该病例关于肺癌的治疗在传统公认的基础上联合药物对于免疫治疗和减轻药物不良反应是很好的治疗方式。
3.在免疫治疗的时代，尤其是用PD-1、PD-L1的时代，能够提高细胞免疫的药物有其一定的地位。
4.弥漫性病变采用免疫治疗后出现免疫性肺炎的概率非常高。
医院
此次e连线肺癌MDT——肺腑之道举办得非常成功,在顾康生和陈嘉教授的带领下，来自合肥、南京、济南和苏州的医生们聚在一起，分享了4个精彩病例，并就一些诊疗方面的疑点难点交流了宝贵的经验，促进了肺癌诊疗领域的交流与合作,明确了诊治规范。不仅让线上的专家们受益匪浅，也解决了相关医生的临床实际问题，得到了线上线下参与直播的医生们的一致好评
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