324.4 📋 章末速記 Summary

324.4.1 🔑 一句話總結

Lung cancer 全球 #1 cancer killer；risk factors：smoking (80-85%) + radon + asbestos (multiplicative with smoking) + air pollution + occupational + genetic；分 NSCLC ~ 85% (adenocarcinoma most common + squamous + large cell) 與 SCLC ~ 15% (almost all smokers, central, neuroendocrine, aggressive)；LDCT screening (USPSTF 2021)：age 50-80 + ≥ 20 pack-years + current smoker or quit < 15 yr → annual LDCT；NLST (20%) + NELSON (24-33%) mortality reduction；台灣 2022 LDCT 政府補助 (50-74 男 / 45-74 女 + 重度吸菸 or 家族史)；diagnosis：tissue biopsy + IHC + comprehensive molecular profiling (EGFR + ALK + ROS1 + KRAS G12C + MET + HER2 + BRAF V600E + NTRK + RET + PD-L1 + TMB)；staging TNM 8th 2017：CT + PET-CT + brain MRI + EBUS for mediastinal；Pancoast syndrome (apical + Horner + arm pain) + paraneoplastic syndromes (SCLC: SIADH/ACTH/LEMS; squamous: PTHrP hypercalcemia; adeno: HOA + clubbing)；EGFR in Asian women non-smokers 50% prevalence；ctDNA / liquid biopsy + MRD for monitoring and emerging adjuvant decisions。

324.4.2 💊 治療精要

• LDCT screening：USPSTF 2021 (age 50-80, ≥ 20 pack-years, current/quit < 15 yr) + Taiwan 2022 (重度吸菸 or 家族史)
• comprehensive molecular profiling：所有 advanced/metastatic NSCLC，especially adenocarcinoma；EGFR, ALK, ROS1, KRAS G12C, MET exon 14, HER2, BRAF V600E, NTRK fusion, RET fusion, PD-L1 TPS, TMB
• mediastinal staging：EBUS-TBNA preferred over mediastinoscopy
• TNM 8th edition (2017)：T (size + invasion), N (regional LN), M (distant mets); stages I-IV
• brain MRI for staging in stages III-IV NSCLC + routinely in SCLC
• PET-CT for whole body staging (SUVmax > 2.5 concerning)
• NLST + NELSON trials foundation of LDCT screening (20-33% mortality reduction)

324.4.3 🎯 盧醫師的考前提醒

1. lung cancer 流行病學：smoking 80-85% of US cases；radon 第二大原因；adenocarcinoma 在 Asian women non-smokers EGFR mutation 高比例 (~ 50%)
2. USPSTF 2021 LDCT screening criteria：age 50-80 + ≥ 20 pack-years + current smoker or quit < 15 yr → annual LDCT；Taiwan 2022 政府補助 (重度吸菸 or 家族史)
3. NLST 2011 (20% mortality reduction) + NELSON 2020 (24% 男, 33% 女) trials 確立 LDCT screening
4. NSCLC vs SCLC：NSCLC 85% (adeno > squamous > large cell)；SCLC 15% (almost all smokers + central + aggressive + neuroendocrine)
5. NSCLC comprehensive molecular profiling 必做：EGFR + ALK + ROS1 + KRAS G12C + MET exon 14 + HER2 + BRAF V600E + NTRK + RET + PD-L1 + TMB；adenocarcinoma 特別重要
6. Pancoast syndrome：apical (superior sulcus) tumor → shoulder + arm pain (C8/T1/T2) + Horner syndrome (sympathetic chain compression) + hand weakness/atrophy；neoadjuvant chemoradiation + surgery
7. paraneoplastic syndromes：SCLC SIADH (hyponatremia) + Cushing (ACTH ectopic) + LEMS (anti-VGCC, fatigue) + limbic encephalitis；squamous PTHrP (hypercalcemia)；adenocarcinoma HOA + clubbing；Trousseau (hypercoagulability)
8. 8th TNM 2017 AJCC/UICC：T (size/invasion), N (regional LN — N1 hilar/peribronchial, N2 mediastinal, N3 contralateral/supraclavicular), M (M1a contralateral lung/pleural; M1b single extrathoracic; M1c multiple)
9. EBUS-TBNA 是 mediastinal LN staging preferred method (vs mediastinoscopy more invasive)
10. ctDNA + MRD (molecular residual disease) 是 2024 新興 paradigm — for monitoring resistance + emerging adjuvant decision tool（LUNGSCAPE、MERMAID trials）