国际肿瘤学杂志››2024,Vol. 51››Issue (1): 1-20.doi:10.3760/cma.j.cn371439-20231221-00001
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
收稿日期:2023-12-21修回日期:2023-12-29出版日期:2024-01-08发布日期:2024-01-23
Received:2023-12-21Revised:2023-12-29Online:2024-01-08Published:2024-01-23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（2023年版）[J]. 国际肿瘤学杂志, 2024, 51(1): 1-20.
图1
pTis-T1aN0期食管癌治疗策略[13⇓-15]注：ESD为内镜下黏膜下剥离术；EMR为内镜下黏膜切除术；MBM为多环黏膜切除术；SM1为黏膜下层内1/3"
图2
cT1b-2N0期食管癌治疗策略[16-17]"
图3
cT1b-2N+或cT3-4aN0/N+期食管癌治疗策略[18⇓⇓⇓⇓-23]注：a若达临床完全缓解，也可密切随访+挽救性手术（Ⅲ级推荐，2B类证据）；b限于cT3-4N0-1或不适于新辅助放化疗者"
图4
cT4bN0/N+期食管癌治疗策略[24-25]"
图5
远处转移食管癌治疗策略[26⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓-38]"
图6
未行新辅助治疗食管癌R0术后治疗策略[39⇓⇓⇓⇓⇓⇓⇓-47]注：a高危pT2N0指存在低分化、脉管癌栓、神经侵犯、<50岁中的任一项"
图7
食管癌R1/R2切除者治疗策略[48⇓-50]"
图8
食管癌放疗后局部复发转移者治疗策略[51⇓⇓-54]注;ESD为内镜下黏膜下剥离术;EMR为内镜下黏膜切除术;MBM为多环黏膜切除术;SM1为黏膜下层内1/3"
图9
食管癌患者放疗适应证[18⇓⇓⇓⇓⇓⇓-25,37⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓-49,53⇓⇓-56]"
图10
食管癌患者放疗禁忌证或相对禁忌证[18⇓⇓⇓⇓⇓⇓-25,37⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓⇓-49,53⇓⇓-56]"
图11
颈段食管癌适形计划射野分布及BEV所示肿瘤与脊髓的相对位置A为颈段食管癌4野共面适形照射示意图；B~E为4个照射野在BEV可见肿瘤和脊髓的相对位置，以及多叶光栅、准直器设置注：BEV为射野方向观"
图12
胸段食管癌适形计划射野分布及BEV所示肿瘤与脊髓的相对位置A为中下段食管癌5野共面适形照射示意图；B~F为5个照射野在BEV可见肿瘤和脊髓的相对位置，以及多叶光栅、准直器设置注：BEV为射野方向观"
表1
食管癌放疗危及器官受量推荐[77]"
| 剂量约束条件 | 对应并发症风险 |
|---|---|
| 颈段≤45 Gy，胸段脊髓≤50 Gy | 放射性脊髓病变 |
| V5<63%，V20≤30% | 有症状的放射性肺炎风险<20% |
| Dmean=7、13、20、24、27 Gy | 有症状的放射性肺炎风险分别为5%、10%、20%、30%、40% |
| Dmean<26 Gy | 心包炎风险<15% |
| V30<46% | 心包炎风险<15% |
| V25<10% | 远期心源性死亡风险<1% |
| Dmean<30~32 Gy | 典型放射性肝病风险<5%（适用于不存在既往肝病或肝细胞癌的患者） |
| Dmean<28 Gy | 典型放射性肝病风险<5%（适用于既往有肝脏疾病或肝细胞癌的肝功能Child-Pugh A级患者，且排除乙型肝炎病毒再激活患者） |
| 文献罕见关于常规分割下气管耐受剂量的报道，建议气管可耐受的最大剂量<75 Gy，并避免热点剂量（≥110%处方剂量）落入靶区内气管壁 | |
| 受照体积为1/3、2/3、全胃的TD5/5分别为60、55和50 Gy，TD50/5分别为70、67和65 Gy | |
| D100%<45 Gy | 胃溃疡风险<7% |
| 建议接受40 Gy的胃体积应小于全部胸腔胃的40%~50% | |
表2
食管癌特殊放疗技术的剂量推荐"
| 放疗技术 | 推荐剂量 | 危及器官受量 |
|---|---|---|
| 质子放疗 | 肺平均剂量<20 Gy（RBE），全肺V20<30%，心脏V40<40%，肝脏V30<30%，脊髓最大剂量<45 Gy（RBE） | |
| 新辅助治疗 | 40~50.4 Gy（RBE），常规分割 | |
| 鳞癌根治性同步放化疗 | 50.4~60 Gy（RBE），常规分割（化疗方案为氟尿嘧啶+顺铂） | |
| 腺癌根治性同步放化疗 | 中位剂量50.4 Gy（RBE）[36~63 Gy（RBE）]，常规分割（化疗方案为氟尿嘧啶+顺铂） | |
| 单纯质子治疗 | 中位剂量50~65 Gy（RBE） | |
| 辅助放疗 | 45~50.4 Gy（RBE），常规分割 | |
| 与X线联合照射 | X线中位剂量36 Gy（16.2~60 Gy，常规分割），质子中位剂量36 Gy（RBE）[17.5~54.5 Gy，2.5~3.7 Gy（RBE）/次]，常规分割 | |
| 放化疗后复发者 | 中位剂量54.0 Gy（RBE）[50.4~61.2 Gy（RBE）]，常规分割 | |
| 碳离子放疗 | 食管Dmax<60 Gy（RBE） Dmax<40 Gy（RBE）[5 Gy（RBE）/次] |
|
| Ⅱ、Ⅲ期新辅助放疗 | 33.6 Gy（RBE）/8次 | |
| Ⅰ期根治性放疗 | 48~50.4 Gy（RBE）/12次 | |
| 根治术后孤立复发淋巴结 | 48 Gy（RBE）/12次 | |
| 后装腔内放疗 | 暂缺 | |
| 放疗未控不宜手术者 | 后装补量10~15 Gy，5~6 Gy/次，每周1次，共2~3次，黏膜下0.5 cm | |
| 原发灶放化疗后复发 | 外照射40~50 Gy，后装3~5 Gy/次，2~3次；或单纯后装20~40 Gy | |
| 放射性粒子植入 | 暂缺 | |
| 放疗后6个月内复发 | 100~120 Gy | |
| 放疗后6个月以上复发 | 120~160 Gy | |
| 注：RBE为相对生物学效应 | ||
表3
食管癌新辅助放化疗方案"
| 方案 | 剂量及用法 | 推荐等级 |
|---|---|---|
| 首选方案 | ||
| 紫杉醇+卡铂 | 紫杉醇50 mg/m2d1，卡铂AUC=2 d1，qw，共5周 | Ⅰ级推荐，1A类证据 |
| 顺铂+氟尿嘧啶/卡培他滨/替吉奥 | 顺铂75~100 mg/m2d1、29，氟尿嘧啶750~1 000 mg/m2qd CIV d1~4、d29~32，q5w；或顺铂15 mg/m2d1~5，氟尿嘧啶800 mg/m2qd CIV 120 h，q3w，共2周期 | Ⅰ级推荐，1A类证据 |
| 顺铂30 mg/m2d1，卡培他滨800 mg/m2bid d1~5，qw，共5周 | ||
| 顺铂70 mg/m2d1，替吉奥40 mg/m2bid（最大日剂量100 mg） d1~14，q3w，共2周期 | ||
| 长春瑞滨+顺铂 | 长春瑞滨25 mg/m2d1、8，顺铂75 mg/m2d1或25 mg/m2d1~4，q3w，共2周期 | Ⅰ级推荐，1A类证据 |
| 奥沙利铂+氟尿嘧啶/卡培他滨/ 替吉奥（腺癌） |
奥沙利铂85 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶400 mg/m2IV d1，2 400 mg/m2CIV 46 h，q2w，共3周期 | Ⅰ级推荐，1A类证据 |
| 奥沙利铂85 mg/m2d1、15、29，卡培他滨625 mg/m2bid d1~5，qw，共5周 | ||
| 奥沙利铂100 mg/m2d1，替吉奥40~60 mg bid d1~14，q3w，共2周期 | ||
| 其他方案 | ||
| 多西他赛+顺铂/卡铂 | 多西他赛75 mg/m2d1，顺铂75 mg/m2d1，q3w，共2周期 | Ⅱ级推荐，2A类证据 |
| 多西他赛75 mg/m2d1，卡铂AUC=5~6 d1，q3w，共2周期 | ||
| 紫杉醇+氟尿嘧啶/卡培他滨 | 紫杉醇45~50 mg/m2d1，氟尿嘧啶300 mg/m2CIV d1~5，qw，连用5周 | Ⅱ级推荐，2B类证据 |
| 紫杉醇45~50 mg/m2d1，卡培他滨625~825 mg/m2bid d1~5，qw，连用5周 |
表4
食管癌新辅助化疗方案"
| 方案 | 剂量及用法 | 推荐等级 |
|---|---|---|
| 顺铂+氟尿嘧啶 | 顺铂80 mg/m2d1，氟尿嘧啶1 000 mg/m2d1~4，q3w，共2周期 | Ⅱ级推荐，2A类证据 |
| 紫杉醇+顺铂（鳞癌） | 紫杉醇150 mg/m2d1，顺铂50 mg/m2d1，q2w，共3周期 | Ⅱ级推荐，2A类证据 |
| 紫杉醇175 mg/m2d1，顺铂75 mg/m2d1，q3w，共2周期 | ||
| 奥沙利铂+氟尿嘧啶类（腺癌） | 奥沙利铂85 mg/m2d1，氟尿嘧啶400 mg/m2IV d1，2 400 mg/m2CIV 46 h，q2w，共3周期 | Ⅰ级推荐，2A类证据 |
| 奥沙利铂130 mg/m2d1，卡培他滨1 000 mg/m2bid d1~14，q3w | Ⅰ级推荐，2A类证据 | |
| 多西他赛+奥沙利铂+亚叶酸钙+ 氟尿嘧啶（FLOT，腺癌） |
多西他赛50 mg/m2d1，奥沙利铂85 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶2 600 mg/m2CIV d1，q2w，术前4个周期+术后4个周期，共8周期 | Ⅰ级推荐，2A类证据 |
表5
食管癌根治性放化疗方案"
| 方案 | 剂量及用法 | 推荐等级 |
|---|---|---|
| 首选方案 | ||
| 顺铂+氟尿嘧啶 | 顺铂75~100 mg/m² d1，氟尿嘧啶750~1 000 mg/m² CIV 96 h，q4w，同步放疗2周期，放疗后2周期 | Ⅰ级推荐，1A类证据 |
| 顺铂+卡培他滨 | 卡培他滨800 mg/m2bid d1~5，顺铂30 mg/m2d1，qw，共5周 | Ⅰ级推荐，1A类证据 |
| 紫杉醇+卡铂 | 紫杉醇50 mg/m² d1，卡铂AUC=2 d1，qw，共5周 | Ⅰ级推荐，1A类证据 |
| 奥沙利铂+氟尿嘧（腺癌） | 奥沙利铂85 mg/m² d1，亚叶酸钙400 mg/m² d1，氟尿嘧啶400 mg/m2IV d1， 2 400 mg/m2CIV 46 h，q2w，同步放疗3周期，放疗后3周期 |
Ⅰ级推荐，2A类证据 |
| 奥沙利铂+卡培他滨（腺癌） | 奥沙利铂85 mg/m2d1、15、29，卡培他滨625 mg/m2bid d1~5，qw，共3次，共5周 | Ⅰ级推荐，2A类证据 |
| 紫杉醇+氟尿嘧啶 | 紫杉醇50 mg/m2d1，氟尿嘧啶300 mg/m2CIV 96 h，qw，共5周。放疗结束后巩固2周期：紫杉醇175 mg/m2d1，氟尿嘧啶1 800 mg/m2CIV 72 h，q4w | Ⅰ级推荐，2A类证据 |
| 其他方案 | ||
| 多西他赛或紫杉醇+顺铂 | 多西他赛20~30 mg/m2d1，顺铂20~30 mg/m2d1，qw，连用5周；或多西他赛 60 mg/m2d1，顺铂60~80 mg/m2d1，q3w，共2周期 |
Ⅰ级推荐，2A类证据 |
| 紫杉醇45~50 mg/m2d1，顺铂20 mg/m2d1，qw，共6周期 | ||
| 顺铂+伊立替康 | 顺铂20 mg/m2d1，伊立替康60 mg/m2d1，qw，共6周期 | Ⅱ级推荐，2B类证据 |
| 紫杉醇+卡培他滨 | 紫杉醇45~50 mg/m2d1，卡培他滨625~825 mg/m2bid，d1~5，qw，连用5周 | Ⅱ级推荐，2B类证据 |
| 替吉奥单药（≥70岁者） | 替吉奥40 mg/m2bid d1~14，q3w，同步放疗2周期，放疗后2周期 | Ⅰ级推荐，1A类证据 |
表6
食管癌术后化疗/放化疗方案"
| 方案 | 剂量及用法 | 推荐级别 |
|---|---|---|
| 顺铂+氟尿嘧啶类 | 顺铂50 mg/m2d1，q2w，氟尿嘧啶1 000 mg/m2CIV d1~2，术前4~6周期+术后4~6周期，共12周期 | Ⅰ级推荐，1A类证据 |
| 顺铂80 mg/m2d1，卡培他滨1 000 mg/m2bid d1~14，q3w，共6周期 | ||
| 顺铂80 mg/m2d1，替吉奥40~60 mg bid d1~14，q3w，共6周期 | ||
| 紫杉醇+卡铂 | 紫杉醇135~175 mg/m2d1，卡铂AUC=5~6 d1，q3w，共6周期 | Ⅰ级推荐，1A类证据 |
| 紫杉醇+顺铂（鳞癌） | 紫杉醇150 mg/m2d1，顺铂50 mg/m2d1，q2w，共6周期 | Ⅰ级推荐，2A类证据 |
| 奥沙利铂+氟尿嘧啶类（腺癌） | 奥沙利铂85 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶400 mg/m2IV d1，2 400 mg/m2CIV 46 h，q2w；或奥沙利铂85 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶2 600 mg/m2CIV 46 h，q2w，共12周期 | Ⅰ级推荐，1A类证据 |
| 奥沙利铂130 mg/m2d1，q3w，卡培他滨1 000 mg/m2bid d1~14，共8周期 | ||
| 奥沙利铂130 mg/m2d1，替吉奥40~60 mg bid d1~14，q3w，共8周期 |
表7
食管癌姑息性化疗方案"
| 方案 | 剂量及用法 | 推荐级别 |
|---|---|---|
| 一线方案 | ||
| 顺铂+氟尿嘧啶/卡培他滨/替吉奥 | 顺铂75 mg/m2d1，亚叶酸钙200 mg/m2d1，氟尿嘧啶750~1 000 mg/m2CIV d1~4，q3w；或顺铂50 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶400 mg IV，2 400 mg/m2CIV 46 h，q2w | 腺癌Ⅰ级推荐，1A类证据； 鳞癌Ⅰ级推荐，2A类证据 |
| 顺铂80 mg/m2d1，卡培他滨1 000 mg/m2bid d1~14，q3w | ||
| 顺铂80 mg/m2d1，替吉奥40~60 mg bid d1~14，q3w | ||
| 奥沙利铂+氟尿嘧啶类（腺癌） | 奥沙利铂85 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶400 mg/m2IV d1，2 400 mg/m2CIV 46 h，q2w；或奥沙利铂85 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶2 400 mg/m2CIV 46 h，q2w | Ⅰ级推荐，2A类证据 |
| 奥沙利铂130 mg/m2d1，卡培他滨1 000 mg/m2bid d1~14，q3w | ||
| 多西他赛+顺铂+氟尿嘧啶（腺癌） | 多西他赛40 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶400 mg/m2IV d1，2 400 mg/m2CIV 46 h，顺铂40 mg/m2d3，q2w | Ⅰ级推荐，1A类证据 |
| 多西他赛+奥沙利铂+氟尿嘧啶 （腺癌） |
多西他赛50 mg/m2d1，奥沙利铂85 mg/m2d1，氟尿嘧啶2 400 mg/m2CIV 46 h，q2w | Ⅰ级推荐，1A类证据 |
| 紫杉醇/多西他赛+顺铂/奈达铂 | 紫杉醇175 mg/m2d1，顺铂75 mg/m2d1，q3w | Ⅱ级推荐，2A类证据 |
| 紫杉醇175 mg/m2d1，奈达铂80~100 mg/m2d1，q3w | ||
| 多西他赛70~85 mg/m2d1，顺铂70~75 mg/m2d1，q3w | ||
| 多西他赛70~85 mg/m2d1，奈达铂80~100 mg/m2d1，q3w | ||
| 长春瑞滨+顺铂/奈达铂 | 长春瑞滨25 mg/m2d1、8，顺铂80 mg/m2d1，q3w | Ⅱ级推荐，2A类证据 |
| 长春瑞滨25 mg/m2d1、8，奈达铂80~100 mg/m2d1，q3w | ||
| 伊立替康+氟尿嘧啶/卡培他滨/ 替吉奥 |
伊立替康180 mg/m2d1，亚叶酸钙400 mg/m2d1，氟尿嘧啶400 mg/m2IV d1，2 400 mg/m2CIV 46 h，q2w；或伊立替康80 mg/m2d1，亚叶酸钙500 mg/m2d1，氟尿嘧啶1 200 mg/m2CIV d1，qw，连续6周后停2周（仅限于腺癌） | Ⅱ级推荐，2A类证据 |
| 卡培他滨800 mg/m2bid d1~14，伊立替康200 mg/m2d1，q3w | ||
| 伊立替康160 mg/m2d1，替吉奥40~60 mg bid d1~10，q2w | ||
| 二线及以上方案 | ||
| 紫杉类单药 | 紫杉醇175 mg/m2d1，q3w，或80 mg/m2d1、8、15、22，q4w，或80 mg/m2d1、8、15，q4w | 腺癌Ⅰ级推荐，1A类证据； 鳞癌Ⅱ级推荐，2A类证据 |
| 多西他赛75~100 mg/m2d1，q3w | ||
| 脂质体紫杉醇175 mg/m2d1，q3w | ||
| 白蛋白结合型紫杉醇100~150 mg/m2d1、8，q3w | ||
| 伊立替康单药 | 伊立替康150~180 mg/m2d1，q2w，或125 mg/m2d1、8，q3w | 腺癌Ⅰ级推荐，1A类证据； 鳞癌Ⅱ级推荐，2A类证据 |
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