山东省医学会食管癌多学科规范化诊疗指南（2023年版）

doi:10.3760/cma.j.cn371439-20230612-00077

摘要/Abstract

摘要：

食管癌是山东省的高发恶性肿瘤，目前的诊疗存在诸多不规范之处。包括肿瘤内科、肿瘤外科、放疗科、影像科、内镜科、病理科等多学科联合的规范化诊疗对于改善局部控制、提高总生存率和生命质量至关重要。基于临床需求，结合近年来多学科诊疗进展，特制定本指南。

关键词: 食管肿瘤, 多学科诊疗

Abstract:

Esophageal carcinoma is at a high incidence in Shandong province，and there are many non-standard aspects in the current diagnosis and treatment. The standardized diagnosis and treatment of multiple disciplines，including medical oncology，surgical oncology，radiotherapy，imaging，endoscopy，pathology，etc.，is crucial to improve local control，overall survival rate，and quality of life. This guideline is hereby formulated based on clinical needs and combined with the progress of multidisciplinary diagnosis and treatment in recent years.

Key words: Esophageal neoplasms, Multidisciplinary diagnosis and treatment

山东省医学会肺癌食管癌多学科联合委员会. 山东省医学会食管癌多学科规范化诊疗指南（2023年版）[J]. 国际肿瘤学杂志, 2023, 50(7): 385-397.

Shandong Medical Association Multidisciplinary Joint Committee on Lung Cancer. Shandong Provincial Medical Association multidisciplinary standardized diagnosis and treatment guidelines for esophageal carcinoma （2023 Edition）[J]. Journal of International Oncology, 2023, 50(7): 385-397.

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参考文献 56

[1]	Ajani JA, D'Amico TA, Bentrem DJ, et al. Esophageal and Esophagogastric Junction Cancers, Version 2.2023, NCCN Clinical Practice Guidelines in Oncology[J]. J Natl Compr Canc Netw, 2023, 21(4): 393-422. DOI: 10.6004/jnccn.2023.0019. doi: 10.6004/jnccn.2023.0019
[2]	Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2021, 71(3): 209-249. DOI: 10.3322/caac.21660. doi: 10.3322/caac.21660
[3]	Morgan E, Soerjomataram I, Rumgay H, et al. The global landscape of esophageal squamous cell carcinoma and esophageal adenocarcinoma incidence and mortality in 2020 and projections to 2040: new estimates from GLOBOCAN 2020[J]. Gastroenterology, 2022, 163(3): 649-658.e2. DOI: 10.1053/j.gastro.2022.05.054. doi: 10.1053/j.gastro.2022.05.054 pmid: 35671803
[4]	Cao W, Chen HD, Yu YW, et al. Changing profiles of cancer burden worldwide and in China: a secondary analysis of the global cancer statistics 2020[J]. Chin Med J (Engl), 2021, 134(7): 783-791. DOI: 10.1097/CM9.0000000000001474. doi: 10.1097/CM9.0000000000001474
[5]	国家消化内镜专业质控中心, 国家消化系疾病临床医学研究中心上海, 国家消化道早癌防治中心联盟, 等. 中国早期食管癌及癌前病变筛查专家共识意见(2019年, 新乡)[J]. 中华消化内镜杂志, 2019, 36(11): 793-801. DOI: 10.3760/cma.j.issn.1007-5232.2019.11.001. doi: 10.3760/cma.j.issn.1007-5232.2019.11.001
[6]	孙秀彬. 小地域内食管癌空间流行病学特征及其地理危险因素研究[D]. 济南: 山东大学, 2017.
[7]	Li S, Chen H, Man J, et al. Changing trends in the disease burden of esophageal cancer in China from 1990 to 2017 and its predicted level in 25 years[J]. Cancer Med, 2021, 10(5): 1889-1899. DOI: 10.1002/cam4.3775. doi: 10.1002/cam4.3775
[8]	Zeng H, Chen W, Zheng R, et al. Changing cancer survival in China during 2003-15: a pooled analysis of 17 population-based cancer registries[J]. Lancet Glob Health, 2018, 6(5): e555-e567. DOI: 10.1016/S2214-109X(18)30127-X. doi: 10.1016/S2214-109X(18)30127-X pmid: 29653628
[9]	Allemani C, Matsuda T, Di Carlo V, et al. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries[J]. Lancet, 2018, 391(10125): 1023-1075. DOI: 10.1016/S0140-6736(17)33326-3. doi: S0140-6736(17)33326-3 pmid: 29395269
[10]	Zhang N, Li Y, Chang X, et al. Long-term effectiveness of one-time endoscopic screening for esophageal cancer: a community-based study in rural China[J]. Cancer, 2020, 126(20): 4511-4520. DOI: 10.1002/cncr.33119. doi: 10.1002/cncr.33119 pmid: 33460056
[11]	Min YW, Lee H, Song BG, et al. Comparison of endoscopic submucosal dissection and surgery for superficial esophageal squamous cell carcinoma: a propensity score-matched analysis[J]. Gastrointest Endosc, 2018, 88(4): 624-633. DOI: 10.1016/j.gie.2018.04.2360. doi: S0016-5107(18)32671-3 pmid: 29750981
[12]	Minashi K, Nihei K, Mizusawa J, et al. Efficacy of endoscopic resection and selective chemoradiotherapy for stage Ⅰ esophageal squamous cell carcinoma[J]. Gastroenterology, 2019, 157(2): 382-390.e3. DOI: 10.1053/j.gastro.2019.04.017. doi: S0016-5085(19)36710-1 pmid: 31014996
[13]	Tang H, Wang H, Fang Y, et al. Neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy followed by minimally invasive esophagectomy for locally advanced esophageal squamous cell carcinoma: a prospective multicenter randomized clinical trial[J]. Ann Oncol, 2023, 34(2): 163-172. DOI: 10.1016/j.annonc.2022.10.508. doi: 10.1016/j.annonc.2022.10.508
[14]	Shapiro J, Hulshof MCCM, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial[J]. Lancet Oncol, 2015, 16(9): 1090-1098. DOI: 10.1016/S1470-2045(15)00040-6. doi: S1470-2045(15)00040-6 pmid: 26254683
[15]	Yang H, Liu H, Chen Y, et al. Neoadjuvant chemoradiotherapy followed by surgery versus surgery alone for locally advanced squamous cell carcinoma of the esophagus (NEOCRTEC5010): a phase Ⅲ multicenter, randomized, open-label clinical trial[J]. J Clin Oncol, 2018, 36(27): 2796-2803. DOI: 10.1200/JCO.2018.79.1483. doi: 10.1200/JCO.2018.79.1483
[16]	Cooper JS, Guo MD, Herskovic A, et al. Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85-01). Radiation Therapy Oncology Group[J]. JAMA, 1999, 281(17): 1623-1627. DOI: 10.1001/jama.281.17.1623. doi: 10.1001/jama.281.17.1623
[17]	Goto H, Tokunaga M, Miki Y, et al. The optimal extent of lymph node dissection for adenocarcinoma of the esophagogastric junction differs between Siewert type Ⅱ and Siewert type Ⅲ patients[J]. Gastric Cancer, 2014, 18(2): 375-381. DOI: 10.1007/s10120-014-0364-0. doi: 10.1007/s10120-014-0364-0
[18]	Kurokawa Y, Takeuchi H, Doki Y, et al. Mapping of lymph node metastasis from esophagogastric junction tumors: a prospective nationwide multicenter study[J]. Ann Surg, 2021, 274(1): 120-127. DOI: 10.1097/SLA.0000000000003499. doi: 10.1097/SLA.0000000000003499
[19]	Zhang J, Li M, Zhang K, et al. Concurrent chemoradiation of different doses (50.4 Gy vs. 59.4 Gy) and different target field (ENI vs. IFI) for locally advanced esophageal squamous cell carcinoma: results from a randomized, multicenter phase Ⅲ clinical trial[J]. Int J Radiat Oncol Biol Phys, 2022, 114(3 Suppl): S15. DOI: 10.1016/j.ijrobp.2022.07.357. doi: 10.1016/j.ijrobp.2022.07.357
[20]	王玉祥, 杨琼, 何明, 等. Ⅲ期胸段食管鳞癌根治术后的复发规律[J]. 中华肿瘤杂志, 2017, 39(1): 48-55. DOI: 10.3760/cma.j.issn.0253-3766.2017.01.010. doi: 10.3760/cma.j.issn.0253-3766.2017.01.010
[21]	Liu Q, Cai XW, Wu B, et al. Patterns of failure after radical surgery among patients with thoracic esophageal squamous cell carcinoma: implications for the clinical target volume design of postoperative radiotherapy[J]. PLoS One, 2014, 9(5): e97225. DOI: 10.1371/journal.pone.0097225. doi: 10.1371/journal.pone.0097225
[22]	Wong AT, Shao M, Rineer J, et al. The impact of adjuvant post-operative radiation therapy and chemotherapy on survival after esophagectomy for esophageal carcinoma[J]. Ann Surg, 2017, 265(6): 1146-1151. DOI: 10.1097/SLA.0000000000001825. doi: 10.1097/SLA.0000000000001825
[23]	Xiao ZF, Yang ZY, Liang J, et al. Value of radiotherapy after radical surgery for esophageal carcinoma: a report of 495 patients[J]. Ann Thorac Surg, 2003, 75(2): 331-336. DOI: 10.1016/s0003-4975(02)04401-6. doi: 10.1016/s0003-4975(02)04401-6 pmid: 12607634
[24]	Chen J, Zhu J, Pan J, et al. Postoperative radiotherapy improved survival of poor prognostic squamous cell carcinoma esophagus[J]. Ann Thorac Surg, 2010, 90(2): 435-442. DOI: 10.1016/j.athoracsur.2010.04.002. doi: 10.1016/j.athoracsur.2010.04.002 pmid: 20667325
[25]	Chen SB, Weng HR, Wang G, et al. The impact of adjuvant radiotherapy on radically resected T₃ esophageal squamous cell carcinoma[J]. J Cancer Res Clin Oncol, 2016, 142(1): 277-286. DOI: 10.1007/s00432-015-2041-z. doi: 10.1007/s00432-015-2041-z
[26]	刘晓, 章文成, 于舒飞, 等. T_2-3N₀M₀期食管癌R0术后失败模式分析——术后放疗潜在价值与意义[J]. 中华放射肿瘤学杂志, 2015, 24(1): 19-24. DOI: 10.3760/cma.j.issn.1004-4221.2015.01.006. doi: 10.3760/cma.j.issn.1004-4221.2015.01.006
[27]	Yang J, Zhang W, Xiao Z, et al. The impact of postoperative conformal radiotherapy after radical surgery on survival and recurrence in pathologic T₃N₀M₀ esophageal carcinoma: a propensity score-matched analysis[J]. J Thorac Oncol, 2017, 12(7): 1143-1151. DOI: 10.1016/j.jtho.2017.03.024. doi: 10.1016/j.jtho.2017.03.024
[28]	Hermann RM, Christiansen H. A new standard is emerging: PD-1 maintenance therapy after neoadjuvant radiochemotherapy and curative resection of oesophageal and AEG carcinomas (CheckMate 577)[J]. Strahlenther Onkol, 2021, 197(11): 1040-1042. DOI: 10.1007/s00066-021-01849-3. doi: 10.1007/s00066-021-01849-3
[29]	Ji Y, Du X, Zhu W, et al. Efficacy of concurrent chemoradiotherapy with S-1 vs radiotherapy alone for older patients with esophageal cancer: a multicenter randomized phase 3 clinical trial[J]. JAMA Oncol, 2021, 7(10): 1459-1466. DOI: 10.1001/jamaoncol.2021.2705. doi: 10.1001/jamaoncol.2021.2705 pmid: 34351356
[30]	Liu Y, Zheng Z, Li M, et al. Comparison of concurrent chemoradiotherapy with radiotherapy alone for locally advanced esophageal squamous cell cancer in elderly patients: a randomized, multicenter, phase Ⅱ clinical trial[J]. Int J Cancer, 2022, 151(4): 607-615. DOI: 10.1002/ijc.34030. doi: 10.1002/ijc.34030
[31]	Huang W, Huang Y, Sun J, et al. Atlas of the thoracic lymph nodal delineation and recommendations for lymph nodal CTV of esophageal squamous cell cancer in radiation therapy from China[J]. Radiother Oncol, 2015, 116(1): 100-106. DOI: 10.1016/j.radonc.2015.06.024. doi: 10.1016/j.radonc.2015.06.024 pmid: 26142269
[32]	Huang W, Li B, Gong H, et al. Pattern of lymph node metastases and its implication in radiotherapeutic clinical target volume in patients with thoracic esophageal squamous cell carcinoma: a report of 1 077 cases[J]. Radiother Oncol, 2010, 95(2): 229-233. DOI: 10.1016/j.radonc.2010.01.006. doi: 10.1016/j.radonc.2010.01.006 pmid: 20189259
[33]	Cheng J, Kong L, Huang W, et al. Explore the radiotherapeutic clinical target volume delineation for thoracic esophageal squamous cell carcinoma from the pattern of lymphatic metastases[J]. J Thorac Oncol, 2013, 8(3): 359-365. DOI: 10.1097/JTO.0b013e31827e1f6d. doi: 10.1097/JTO.0b013e31827e1f6d pmid: 23263689
[34]	Ding X, Zhang J, Li B, et al. A meta-analysis of lymph node metastasis rate for patients with thoracic oesophageal cancer and its implication in delineation of clinical target volume for radiation therapy[J]. Br J Radiol, 2012, 85(1019): e1110-e1119. DOI: 10.1259/bjr/12500248. doi: 10.1259/bjr/12500248
[35]	Dong Y, Guan H, Huang W, et al. Precise delineation of clinical target volume for crossing-segments thoracic esophageal squamous cell carcinoma based on the pattern of lymph node metastases[J]. J Thorac Dis, 2015, 7(12): 2313-2320. DOI: 10.3978/j.issn.2072-1439.2015.12.10. doi: 10.3978/j.issn.2072-1439.2015.12.10 pmid: 26793353
[36]	Marks LB, Yorke ED, Jackson A, et al. Use of normal tissue complication probability models in the clinic[J]. Int J Radiat Oncol Biol Phys, 2010, 76(3 Suppl): S10-S19. DOI: 10.1016/j.ijrobp.2009.07.1754. doi: 10.1016/j.ijrobp.2009.07.1754
[37]	You J, Zhu S, Li J, et al. High-dose versus standard-dose intensity-modulated radiotherapy with concurrent paclitaxel plus carboplatin for patients with thoracic esophageal squamous cell carcinoma: a randomized, multicenter, open-label, phase 3 superiority trial[J]. Int J Radiat Oncol Biol Phys, 2023, 115(5): 1129-1137. DOI: 10.1016/j.ijrobp.2022.11.006. doi: 10.1016/j.ijrobp.2022.11.006
[38]	徐裕金, 朱卫国, Liao Z, 等. 同步放化疗60 Gy对比50 Gy剂量治疗不可手术食管鳞状细胞癌的多中心随机对照研究[J]. 中华医学杂志, 2020, 100(23): 1783-1788. DOI: 10.3760/cma.j.cn112137-20200303-00574. doi: 10.3760/cma.j.cn112137-20200303-00574
[39]	Peng Z, Liu T, Wei J, et al. Efficacy and safety of a novel anti-HER2 therapeutic antibody RC48 in patients with HER2-overexpressing, locally advanced or metastatic gastric or gastroesophageal junction cancer: a single-arm phase Ⅱ study[J]. Cancer Commun (Lond), 2021, 41(11): 1173-1182. DOI: 10.1002/cac2.12214. doi: 10.1002/cac2.12214
[40]	Doi T, Piha-Paul SA, Jalal SI, et al. Safety and antitumor activity of the anti-programmed death-1 antibody pembrolizumab in patients with advanced esophageal carcinoma[J]. J Clin Oncol, 2018, 36(1): 61-67. DOI: 10.1200/JCO.2017.74.9846. doi: 10.1200/JCO.2017.74.9846 pmid: 29116900
[41]	Kudo T, Hamamoto Y, Kato K, et al. Nivolumab treatment for oesophageal squamous-cell carcinoma: an open-label, multicentre, phase 2 trial[J]. Lancet Oncol, 2017, 18(5): 631-639. DOI: 10.1016/S1470-2045(17)30181-X. doi: S1470-2045(17)30181-X pmid: 28314688
[42]	Huang J, Xu B, Mo H, et al. Safety, activity, and biomarkers of SHR-1210, an anti-PD-1 antibody, for patients with advanced esophageal carcinoma[J]. Clin Cancer Res, 2018, 24(6): 1296-1304. DOI: 10.1158/1078-0432.CCR-17-2439. doi: 10.1158/1078-0432.CCR-17-2439 pmid: 29358502
[43]	Sun H, Yang W, Luo J, et al. Safety and tolerability of neoadjuvant radiotherapy combined with anti-PD-1 antibody toripalimab for locally advanced, resectable esophageal squamous cell cancer: a prospective phase ⅠB trial[J]. Int J Radiat Oncol Biol Phys, 2021, 111(3 Suppl): S102-S103. DOI: 10.1016/j.ijrobp.2021.07.238. doi: 10.1016/j.ijrobp.2021.07.238
[44]	Janjigian YY, Shitara K, Moehler M, et al. First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma (CheckMate 649): a randomised, open-label, phase 3 trial[J]. Lancet, 2021, 398(10294): 27-40. DOI: 10.1016/S0140-6736(21)00797-2. doi: 10.1016/S0140-6736(21)00797-2 pmid: 34102137
[45]	Chau I, Dok Y, Ajani JA, et al. Nivolumab (NIVO) plus ipili-mumab (IPI) or NIVO plus chemotherapy (chemo) versus chemo as first-line (1L) treatment for advanced esophageal squamous cell carcinoma (ESCC): first results of the CheckMate 648 study[J]. J Clin Oncol, 2021, 39(Suppl 15): LBA4001. DOI: 10.1200/JCO.2021.39.15_suppl.LBA4001. doi: 10.1200/JCO.2021.39.15_suppl.LBA4001
[46]	Sun JM, Shen L, Shah MA, et al. Pembrolizumab plus chemotherapy versus chemotherapy alone for first-line treatment of advanced oesophageal cancer (KEYNOTE-590): a randomised, placebo-controlled, phase 3 study[J]. Lancet, 2021, 398(10302): 759-771. DOI: 10.1016/S0140-6736(21)01234-4. doi: 10.1016/S0140-6736(21)01234-4
[47]	Kojima T, Shah MA, Muro K, et al. Randomized phase Ⅲ KEYNOTE-181 study of pembrolizumab versus chemotherapy in advanced esophageal cancer[J]. J Clin Oncol, 2020, 38(35): 4138-4148. DOI: 10.1200/JCO.20.01888. doi: 10.1200/JCO.20.01888
[48]	Luo H, Lu J, Bai Y, et al. Effect of camrelizumab vs placebo added to chemotherapy on survival and progression-free survival in patients with advanced or metastatic esophageal squamous cell carcinoma: the ESCORT-1st randomized clinical trial[J]. JAMA, 2021, 326(10): 916-925. DOI: 10.1001/jama.2021.12836. doi: 10.1001/jama.2021.12836 pmid: 34519801
[49]	Lu Z, Wang J, Shu Y, et al. Sintilimab versus placebo in combination with chemotherapy as first line treatment for locally advanced or metastatic oesophageal squamous cell carcinoma (ORIENT-15): multicentre, randomised, double blind, phase 3 trial[J]. BMJ, 2022, 377: e068714. DOI: 10.1136/bmj-2021-068714. doi: 10.1136/bmj-2021-068714
[50]	Wang ZX, Cui C, Yao J, et al. Toripalimab plus chemotherapy in treatment-naive, advanced esophageal squamous cell carcinoma (JUPITER-06): a multi-center phase 3 trial[J]. Cancer Cell, 2022, 40(3): 277-288.e3. DOI: 10.1016/j.ccell.2022.02.007. doi: 10.1016/j.ccell.2022.02.007
[51]	Shen L, Kato K, Kim SB, et al. Tislelizumab versus chemotherapy as second-line treatment for advanced or metastatic esophageal squamous cell carcinoma (RATIONALE-302): a randomized phase Ⅲ study[J]. J Clin Oncol, 2022, 40(26): 3065-3076. DOI: 10.1200/JCO.21.01926. doi: 10.1200/JCO.21.01926
[52]	Lyu J, Li T, Xie C, et al. Enteral nutrition in esophageal cancer patients treated with radiotherapy: a Chinese expert consensus 2018[J]. Future Oncol, 2019, 15(5): 517-531. DOI: 10.2217/fon-2018-0697. doi: 10.2217/fon-2018-0697 pmid: 30457348
[53]	吕家华, 李涛, 朱广迎, 等. 肠内营养对食管癌同步放化疗患者营养状况、不良反应和近期疗效影响——前瞻性、多中心、随机对照临床研究(NCT02399306)[J]. 中华放射肿瘤学杂志, 2018, 27(1): 44-48. DOI: 10.3760/cma.j.issn.1004-4221.2018.01.009. doi: 10.3760/cma.j.issn.1004-4221.2018.01.009
[54]	中国医师协会放射肿瘤治疗医师分会, 中华医学会放射肿瘤治疗学分会, 中国抗癌协会肿瘤放射治疗专业委员会. 同步放化疗期间应用聚乙二醇化重组人粒细胞刺激因子中国专家共识(2023版)[J]. 国际肿瘤学杂志, 2023, 50(4): 193-201. DOI: 10.3760/cma.j.cn371439-20230227-00039. doi: 10.3760/cma.j.cn371439-20230227-00039
[55]	中国临床肿瘤协会指南工作委员会. 中国临床肿瘤协会(CSCO)肿瘤治疗所致血小板减少症诊疗指南2023[M]. 北京: 人民卫生出版社, 2023.
[56]	中国医师协会放射肿瘤治疗医师分会, 中华医学会放射肿瘤治疗学分会, 中国抗癌协会肿瘤放射治疗专业委员会. 中国食管癌放射治疗指南(2022年版)[J]. 国际肿瘤学杂志, 2022, 49(11): 641-657. DOI: 10.3760/cma.j.cn371439-20221011-00129. doi: 10.3760/cma.j.cn371439-20221011-00129

推荐级别	说明
Ⅰ级	可及性好、获益性高的1A类证据、部分2A类证据
Ⅱ级	可及性差、效价比低的1B类证据、部分2A类证据
Ⅲ级	探索性的、但有一致共识的2B类证据、3类证据

方案	推荐级别	证据级别	备注
卡瑞利珠单抗+紫杉醇+顺铂	Ⅰ级	1A类	鳞状细胞癌
帕博利珠单抗+氟尿嘧啶/卡培他滨+顺铂	Ⅰ级	1A类	CPS≥10
纳武利尤单抗+氟尿嘧啶+顺铂	Ⅰ级	1A类	鳞状细胞癌
纳武利尤单抗+氟尿嘧啶/卡培他滨+奥沙利铂	Ⅰ级	1A类	HER-2阴性腺癌，CPS≥5
信迪利单抗+顺铂+氟尿嘧啶/紫杉醇	Ⅰ级	1A类	鳞状细胞癌
信迪利单抗+奥沙利铂+卡培他滨	Ⅰ级	1A类	HER-2阴性腺癌，CPS≥1
特瑞普利单抗+紫杉醇+顺铂	Ⅰ级	1A类	鳞状细胞癌
替雷利珠单抗+顺铂+紫杉醇/氟尿嘧啶/卡培他滨	Ⅰ级	1A类	鳞状细胞癌
替雷利珠单抗+顺铂+氟尿嘧啶	Ⅰ级	1A类	PD-L1阳性、HER-2阴性腺癌
替雷利珠单抗+奥沙利铂+卡培他滨	Ⅰ级	1A类	HER-2阴性腺癌
斯鲁利单抗+顺铂+氟尿嘧啶	Ⅰ级	1A类	鳞状细胞癌，CPS≥1
纳武利尤单抗+奥沙利铂+氟尿嘧啶/卡培他滨	Ⅱ级	1A类	CPS<5，或未检测PD-L1
纳武利尤单抗+伊匹木单抗	Ⅱ级	1A类	不宜或拒绝化疗的鳞状细胞癌，CPS≥1
卡瑞利珠单抗+紫杉醇脂质体+奈达铂+阿帕替尼	Ⅲ级	3类	鳞状细胞癌

方案	推荐级别	证据级别	备注
卡瑞利珠单抗	Ⅰ级	1A类	鳞状细胞癌
帕博利珠单抗	Ⅰ级	1A类	鳞状细胞癌，CPS≥10
纳武利尤单抗	Ⅰ级	1A类	鳞状细胞癌（二线或以上）；腺癌（三线或以上）
替雷利珠单抗	Ⅰ级	1A类	鳞状细胞癌
卡瑞利珠单抗+阿帕替尼	Ⅲ级	3类	鳞状细胞癌

FN发生率	治疗模式	推荐措施
>20%	高危方案（如DCF方案）±同步放疗	预防性使用长效或短效G-CSF
10%~20%	中危方案（如紫杉醇+顺铂、伊立替康+顺铂、表柔比星+顺铂+氟尿嘧啶、表柔比星+顺铂+卡培他滨；新辅助放化疗者接受长春瑞滨+顺铂方案；不能手术者接受顺铂+紫杉醇联合放疗剂量>60 Gy）	有高危因素者推荐预防性使用长效或短效G-CSF
<10%	低危方案	不常规推荐，但有高危因素者可考虑使用长效或短效G-CSF

分层	Ⅰ级推荐	Ⅱ级推荐	Ⅲ级推荐
CTIT有出血	输注血小板，或输注血小板+IL-11/rhTPO（1A类证据）	TPO-RA（2B类证据）
CTIT无出血
血小板≤10×10⁹/L	输注血小板，或输注血小板+IL-11/rhTPO（1A类证据）	TPO-RA（2B类证据）
10×10⁹/L<血小板<75×10⁹/L	IL-11或rhTPO（1A类证据）	TPO-RA（2B类证据）	咖啡酸片（3类证据）
75×10⁹/L≤血小板<100×10⁹/L	密切观察血小板变化及出血情况（1A类证据）