Journal of International Oncology››2023,Vol. 50››Issue (1): 1-11.doi:10.3760/cma.j.cn371439-20221021-00001
Received:2022-10-21Revised:2022-11-28Online:2023-01-08Published:2023-03-16
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| 患者因素 | 不宜使用标准剂量顺铂治疗 | 需谨慎顺铂治疗 |
|---|---|---|
| 年龄（岁） | N/A | >70 |
| ECOG PS评分 | ≥2 | ≥1 |
| 营养不良（分） | N/A | PG-SGA评分≥3 |
| 合并症 | ||
| 肾功能不全 | Ccr<50 ml/min | Ccr：50~60 ml/min |
| 神经系统疾病 | ≥2级 | 1级 |
| 既往听力丧失/耳鸣 | ≥2级 | 1级 |
| 心功能不全 | NYHA心功能分级≥Ⅱ级 | NYHA心功能分级Ⅰ级 |
| HIV/AIDS | N/A | CD4+T淋巴细胞计数<200个/μl |
| 既往铂类药物治疗（包括诱导化疗） | N/A | 顺铂累积剂量≥200 mg/m2 |
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| 出现次数 | 剂量调整 |
|---|---|
| 第1次 | 暂停西妥昔单抗治疗≤21 d直到皮疹降至2级。如改善，可重新开始250 mg/m2西妥昔单抗治疗；如无改善，暂停治疗 |
| 第2次 | 暂停西妥昔单抗治疗≤21 d直到皮疹降至2级。如改善，调整剂量为200 mg/m2西妥昔单抗治疗；如无改善，暂停治疗 |
| 第3次 | 暂停西妥昔单抗治疗≤21 d直到皮疹降至2级。如改善，调整剂量为150 mg/m2西妥昔单抗治疗；如无改善，暂停治疗 |
| 第4次 | 永久性停用西妥昔单抗 |
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| 分级 | 评判标准 | 基于分级的处理意见 |
|---|---|---|
| 1级 | 轻微红或干性脱皮 | 每周随访1次 |
| 2级 | 中度红斑和（或）干性脱皮；斑片状湿性脱皮，或局限于皮肤皱襞的非出血性结痂 | 每周随访2次 ①干性脱皮无结痂：短期（1~2周）使用糖皮质激素乳膏，怀疑二重感染的使用抗生素；②皮肤皱襞湿性脱皮：每天使用糖皮质激素乳膏（1~2周）减轻炎症反应，出现任何双重感染迹象时，局部使用针对金黄色葡萄球菌的抗生素。如二重感染加重，考虑全身使用抗生素，软锌制剂可用于皮肤皱襞，但应在放疗前将其去除以避免辐射剂量学问题，也可以使用伊红；③皮肤皱襞的非出血性结痂：同②的处理，此外，凝胶可用于结痂处 |
| 3级 | 湿性脱皮或出血性结痂；皮肤皱襞以外的非出血性结痂，但大部分局限于皮肤皱襞；轻微擦伤引起的出血；需要口服抗生素的二重感染 | 评估每天随访的必要性，密切监测局部或全身感染，如发生在<50 Gy，考虑短暂中断治疗 ①无结痂的湿性脱皮：外用抗菌剂，短期（1~2周）使用糖皮质激素乳膏，怀疑二重感染的使用抗生素，口服抗生素无效的考虑改静脉使用，软锌制剂可用于皮肤皱襞，但应在放疗前将其去除以避免辐射剂量学问题，也可以使用伊红；②有结痂的湿性脱皮：外用抗菌剂，怀疑二重感染的使用抗生素，口服抗生素无效的考虑改静脉使用，凝胶可用于结痂处，避免皮肤外伤以防止重复感染，如果使用水胶体敷料，在进行放疗剂量测定时应考虑敷料的厚度。放疗结束后可使用水纤维敷料 |
| 4级 | 危及生命；广泛的出血性结痂或溃疡（面积>50%）；受累部位大量自发性出血（>40%受累部位）；全真皮层皮肤坏死或溃疡或任何大小的溃疡，伴有广泛组织、肌肉、骨骼或支撑结构的坏死，伴有或不伴有全层皮肤受损；有皮肤移植指征；需要静脉使用抗生素的多重感染性溃疡 | 同时中断放疗和西妥昔单抗，西妥昔单抗需中断至皮炎恢复至2级或以下；严重二重感染口服抗生素无效的考虑改静脉使用；住院治疗 |
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