CPG มะเร็งปอด

·π«∑“ß°“√√°— …“欓∫“≈

‚√§¡–‡√Áߪե

ªï 2547-2548

 ∂“∫π— ¡–‡√ßÁ ·Àßà ™“µ‘
°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢

·π«∑“ß°“√√°— …“欓∫“≈

‚√§¡–‡√ßÁ ªÕ¥

ªï 2547-2548

∫√√≥“∏‘°“√

Õ“§¡ ‡™¬’ √»≈‘ ªá »ÿ≈æ’ √ · ß°√–®“à ß

Õ“§¡ ™—¬«√’ –«≤— π– ∏√’ «≤ÿ ‘ §ÀŸ –‡ª√¡–

 ∂“∫π— ¡–‡√Áß·Àßà ™“µ‘

°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢

§≥–º‡Ÿâ ™Ë¬’ «™“≠

æ≠. °π°æ√ „® ∂“æ√ πæ. «™‘ µ‘ Õ“¿√≥«å √‘ µ— πå
¡–‡√Áß«∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬ ¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬

√».πæ. °‘µµ‘™¬— ‡À≈◊Õß∑«’∫≠ÿ ».æ≠. «¡‘ ≈  ¢ÿ ∂¡¬“
 ¡“§¡»—≈¬·æ∑¬∑å √«ßÕ°·Ààߪ√–‡∑»‰∑¬  ¡“§¡√ß—  √’ °— …“·≈–¡–‡√ßÁ «∑‘ ¬“·Àßà ª√–‡∑»‰∑¬

æ≠. ®“√ÿ«√√≥ ‡Õ°«—≈≈¿ æ.Õ.æ≠. “«µ‘ √’ ‡¡“ðï ≈ÿ ‰æ‚√®πå
¡–‡√Áß«∑‘ ¬“ ¡“§¡·Ààߪ√–‡∑»‰∑¬ ¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬

πæ. ™¬— ¬∑ÿ ∏ ‡®√≠‘ ∏√√¡ æ≠.  √‘ °‘ ≈ÿ »√ƒ∑∏™‘ ß‘ ™¬—
¡–‡√ßÁ «‘∑¬“ ¡“§¡·Ààߪ√–‡∑»‰∑¬ ¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬

º».πæ. ™≈‡°’¬√µ‘ ¢Õª√–‡ √∞‘ ».æ≠.  ¡ÿ µ‘ √“ ∑Õߪ√–‡ √∞‘
 ¡“§¡√—ß √’ °— …“·≈–¡–‡√ßÁ «∑‘ ¬“·Ààߪ√–‡∑»‰∑¬ ¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬

πæ. ≥√ߧ廰— ¥Ï‘ ‡°¬’ √µ‘¢®√∏“¥“ æ≠.  ¥ÿ  «“∑ ‡≈“À«π‘ ®‘
¡–‡√ßÁ «‘∑¬“ ¡“§¡·Ààߪ√–‡∑»‰∑¬ ¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬

º».æ.∑.πæ. ∏µ‘ ‘  «“à ß»‘≈ªá º».πæ.  ¡‡®√≠‘ ·´‡à µßÁ
 ¡“§¡√ß—  ’√—°…“·≈–¡–‡√Áß«∑‘ ¬“·Ààߪ√–‡∑»‰∑¬  ¡“§¡»≈— ¬·æ∑¬∑å √«ßÕ°·Àßà ª√–‡∑»‰∑¬

πæ. π¿¥≈ ‚ ¿“√—µπ“‰æ»“≈ πæ. Õ“§¡ ‡™¬’ √»≈‘ ªá
¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬ ¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬

πæ. ‰æ‚√®πå  ‘π≈“√—µπå æ≠. Õ¥ÿ ¡≈°— …≥å ‡®πæ“π™‘ ¬å
¡–‡√ßÁ «‘∑¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬ ¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬

πæ. ¬ß¬∑ÿ ∏ §ß∏π“√—µπå
 ¡“§¡√—ß √’ °— …“·≈–¡–‡√ßÁ «‘∑¬“·Ààߪ√–‡∑»‰∑¬

§≥–º∑⟠∫∑«π

√».πæ. ™≈‡°¬’ √µ‘ ¢Õª√–‡ √∞‘ º».æ≠. ππ— ∑πå  πÿ ∑√æß»å
§≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈®Ãÿ “≈ß°√≥å §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈»√‘ √‘ “™

».πæ. ™«≈µ‘ ÕÕà ß®√µ‘ πæ. æπ— ∏æåÿ …‘ ≥å  “§√æπ— ∏å
§≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈®ÿÓ≈ß°√≥å ‚√ß欓∫“≈√“™«∂‘ ’

πæ. ‡µ¡Á »°— ¥Ï‘ æßË÷ √»— ¡’ πæ. ‰æ‚√®πå  π‘ ≈“√µ— πå
§≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈ ß¢≈“π§√π‘ ∑√å §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈»√‘ √‘ “™

º».æ≠. ∏µ‘ ¬‘ “  √‘  ‘ ß‘ À ».æ≠. ≈°— …≥“ ‚æ™π°ÿ ≈Ÿ
§≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏∫‘ ¥’ §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏∫‘ ¥’

πæ. π¿¥≈ ‚ ¿“√µ— π‰æ»“≈ æ≠.  ¥ÿ  «“∑ ‡≈“À«π‘ ®‘
§≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈»√‘ √‘ “™ ‚√ß欓∫“≈√“™«∂‘ ’

§≥–∑”ß“π

πæ.  ¡¬» ¥’√»— ¡’ æ≠. «√“¿√≥å ¿Ÿ¡ ‘ « — ¥‘Ï
°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ¢ÿ  ”π—°æ—≤π“«™‘ “°“√·æ∑¬å
°√¡°“√·æ∑¬å
πæ. ∏’√«ÿ≤‘ §ŸÀ–‡ª√¡–
 ∂“∫π— ¡–‡√ßÁ ·Ààß™“µ‘ πæ. Õ“§¡ ‡™’¬√»≈‘ ªá
 ∂“∫—π¡–‡√ßÁ ·Ààß™“µ‘
».æ≠.  ÿ¡µ‘ √“ ∑Õߪ√–‡ √∞‘
¡–‡√ßÁ «∑‘ ¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬ πæ.  ‡ÿ ¡∏ √π‘  √ÿ ߧ«ß»å
 ∂“∫—π¡–‡√Áß·Ààß™“µ‘
πæ. ¬ß¬∑ÿ ∏ §ß∏π“√—µπå
 ¡“§¡√ß—  √’ °— …“·≈–¡–‡√ßÁ «∑‘ ¬“·Ààߪ√–‡∑»‰∑¬ πæ.  ∂“æ√ ≈≈’ “π—π∑°®‘
 ∂“∫—π¡–‡√Áß·Ààß™“µ‘
√».πæ. °µ‘ µ‘™¬— ‡À≈Õ◊ ß∑«’∫ÿ≠
 ¡“§¡»—≈¬·æ∑¬∑å √«ßÕ°·Àßà ª√–‡∑»‰∑¬ πæ. Õ“§¡ ™¬— «√’ –«—≤π–
 ∂“∫—π¡–‡√Áß·Ààß™“µ‘
º».πæ.  ¡‡®√‘≠ ·´‡à µÁß
 ¡“§¡»—≈¬·æ∑¬å∑√«ßÕ°·Àßà ª√–‡∑»‰∑¬ πæ. Õ¥‘»—°¥Ï‘ »√æ√¡
 ∂“∫π— ¡–‡√Áß·Àßà ™“µ‘
√».πæ. «™— √æß»å æ∑ÿ ∏ ‘ «— ¥‘Ï
π“ß»√‘ æ‘ √√≥ æ…‘ “¿“æ
√“™«‘∑¬“≈—¬»—≈¬·æ∑¬·å Ààߪ√–‡∑»‰∑¬  ∂“∫—π¡–‡√Áß·Ààß™“µ‘
·≈–™¡√¡»—≈¬·æ∑¬¡å –‡√Áß
¥√.»≈ÿ æ’ √ · ß°√–®“à ß
».πæ. «‘»…‘ Øå Õ¥ÿ ¡æ“π‘™  ∂“∫π— ¡–‡√Áß·Àßà ™“µ‘
§≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥¡å À“«‘∑¬“≈—¬

 “√∫—≠ Àπâ“

·ºπ¿¡Ÿ ·‘  ¥ß·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ 1

ë Non-Small Cell Lung Cancer (NSCLC) 2
ë Small Cell Lung Cancer (SCLC) 17

·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ 24

ë Non-Small Cell Lung Cancer (NSCLC) 25
- ·π«∑“ß°“√√—°…“¥â«¬»≈— ¬°√√¡„πºŸâªÉ«¬¡–‡√ßÁ ªÕ¥ 28
- ·π«∑“ß°“√√—°…“¥â«¬√—ß ’√—°…“„πºªâŸ É«¬¡–‡√Áߪե 31
- ·π«∑“ß°“√√—°…“¥â«¬¬“‡§¡∫’ ”∫¥— „πºªâŸ É«¬¡–‡√Áߪե
48
ë Small Cell Lung Cancer (SCLC) 50
- ·π«∑“ß°“√√—°…“¥â«¬√ß—  √’ °— …“„πºªâŸ «É ¬¡–‡√ßÁ ªÕ¥
- ·π«∑“ß°“√√—°…“¥«â ¬¬“‡§¡∫’ ”∫—¥„πºâªŸ É«¬¡–‡√Áߪե 58
81
·π«∑“ß°“√√°— …“·∫∫ª√–§—∫ª√–§Õß„πºâªŸ É«¬‚√§¡–‡√Áߪե
¿“§ºπ«° 82
84
ë Staging of Non-small cell lung cancer (NSCLC) 84
ë Staging of Small Cell Lung Cancer* 85
ë NCCN categories of Consensus 87
ë ™π‘¥¢Õߧ”·π–π”
ë Performance status

§”π”

¡–‡√Áߪե‡ªìπ¡–‡√Áß∑’Ëæ∫¡“°‡ªìπÕ—π¥—∫ Õß„πºâŸªÉ«¬™“¬‰∑¬·≈–‡ªìπÀπ÷Ëß„π‚√§¡–‡√Áß∑Ë’Õ¬Ÿà„π
·ºπ°“√ªÑÕß°—π·≈–§«∫§ÿ¡‚√§¡–‡√ÁߢÕߪ√–‡∑»‰∑¬ (National Cancer Control Program) ¥—ßπ—Èπ
‡æË◊Õ„À¡â ’√Ÿª·∫∫ À√◊Õ·ºπ°“√¥·Ÿ ≈√—°…“∑’‡Ë À¡“– ¡  ”À√∫— ºŸâªÉ«¬¡–‡√ßÁ ªÕ¥„πª√–‡∑»‰∑¬ ®÷ß®”‡ªìπµâÕß
‰¥â√—∫§«“¡√à«¡¡◊Õ®“°ºŸâ‡™Ë’¬«™“≠·≈–ºâŸ™”π“≠‡°Ë’¬«°—∫°“√√—°…“¡–‡√ÁߪեÀ≈“¬ “¢“¡“√à«¡ª√–™ÿ¡‡æ◊ËÕ
®—¥∑”·π«∑“ß°“√√—°…“欓∫“≈‡°¬’Ë «°—∫¡–‡√ßÁ ªÕ¥ (CPG) ©∫∫— ∑®Ë’ –„™„â πª√–‡∑»‰∑¬

 ∂“∫—π¡–‡√Áß·Ààß™“µ‘ ‡ªìπÀπ૬ߓπ¢Õß√—∞∑’Ë¡’Àπâ“∑’Ë√—∫º‘¥™Õ∫ ‡°’ˬ«°—∫°“√ªÑÕß°—π·≈–§«∫§ÿ¡
‚√§¡–‡√ÁߢÕߪ√–‡∑»·≈–‡ªìπ°√√¡°“√/ºâŸ™à«¬‡≈¢“πÿ°“√·≈–§≥–°√√¡°“√ªÑÕß°—π·≈–§«∫§ÿ¡‚√§¡–‡√Áß
·Ààß™“µ‘ ®÷ß∑”Àπâ“∑Ë’‡ªìπ·°ππ”„π°“√®—¥∑”·π«∑“ß°“√√—°…“欓∫“≈ ”À√—∫¡–‡√Áߪե ‚¥¬‰¥â
¥”‡π‘π°“√µ“¡¢—ÈπµÕπ¥—ßπ’È

1. «“ß·ºπ„π°“√®—¥∑”§Ÿà¡◊Õ‡«™ªØ‘∫—µ‘‡°’ˬ«°—∫¡–‡√Áߪե ‚¥¬‡™‘≠ºŸâ·∑π¢Õß√“™«‘∑¬“≈—¬
»—≈¬·æ∑¬å·Ààߪ√–‡∑»‰∑¬,  ¡“§¡»—≈¬·æ∑¬å∑√«ßÕ°·Ààߪ√–‡∑»‰∑¬,  ¡“§¡√—ß ’√—°…“·≈–¡–‡√Áß
«‘∑¬“≈—¬·Àßà ª√–‡∑»‰∑¬, ¡–‡√ßÁ «‘∑¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬ ·≈–™¡√¡»—≈¬·æ∑¬¡å –‡√Áß (ª√–‡∑»‰∑¬)
‡æÕË◊ æ‘®“√≥“‡ πÕ™Õ◊Ë ºâŸ‡™’¬Ë «™“≠„π°“√®—¥∑”·π«∑“ß°“√√°— …“欓∫“≈ ”À√∫— ¡–‡√Áߪե

2. ª√–™ÿ¡®—¥∑”·π«∑“ߥ—ß°≈à“«√à«¡°—∫ºâŸ‡™Ë’¬«™“≠ ¢Õß·µà≈–Õߧå°√∑’ˇ°Ë’¬«¢âÕßµ“¡√“¬™◊ËÕ
∑ˇ’  πÕ‡ªπì §≥–ºâ‡Ÿ ™’ˬ«™“≠‚¥¬À≈—°‡°≥±å Non-Small Cell Lung Cancer ·≈– Small Cell Lung Cancer:
CPG version 1. 2005 ¢Õß National Comprehensive Cancer Network (NCCN) ¢Õß À√—∞Õ‡¡√‘°“,
National Cancer Institute (NCI) ·≈– American Society of Clinical Oncology (ASCO) ·µàª√—∫ª√ÿß
¥—¥·ª≈ß„Àâ‡À¡“– ¡°—∫°“√ªØ‘∫—µ‘ß“π„πª√–‡∑»‰∑¬ ‚¥¬ºà“π¢∫«π°“√æ‘®“√≥“·≈–‡ πÕ·π–®“°
ºŸâ¡ª’ √– ∫°“√≥å„π°“√√°— …“欓∫“≈ºâŸªÉ«¬¡–‡√Áߪե„πª√–‡∑»‰∑¬ (Expertûs opinion)

3.  ∂“∫—π¡–‡√Áß·Ààß™“µ‘ ∑”°“√√«∫√«¡¢âÕ¡Ÿ≈∑—ÈßÀ¡¥·≈–¥”‡π‘π°“√®—¥∑”‡ªìπ·π«∑“ß°“√
√—°…“欓∫“≈‡°Ë’¬«°—∫¡–‡√Áߪե©∫—∫√à“ß ‡æË◊Õ àß„À⺟⇙˒¬«™“≠·µà≈– “¢“µ√«®·≈–·°â‰¢‡æË‘¡‡µ‘¡°àÕπ®–
 ßà „À§â ≥–ºŸâ∑∫∑«π (Peer reviewers) æ‘®“√≥“·≈–«‘‡§√“–À«å ‘®“√≥å

4. „Àâ§≥–ºâ∑Ÿ ∫∑«π¥”‡ππ‘ °“√«æ‘ “°…§å Ÿà¡Õ◊ ‡«™ªØ∫‘ —µ‡‘ °Ë’¬«°∫— ¡–‡√ßÁ ªÕ¥
5.  ∂“∫—π¡–‡√Áß·Ààß™“µ‘¥”‡π‘π°“√·°â‰¢·≈–®—¥æ‘¡æ凪ìπ√Ÿª‡≈ࡇæ◊ËÕ„À⇪ìπ‡Õ° “√Õâ“ßÕ‘ß
„π°“√√—°…“欓∫“≈ºªâŸ «É ¬¡–‡√ßÁ ªÕ¥„πª√–‡∑»‰∑¬µàÕ‰ª

§≥–ºŸâ®—¥∑”¡’§«“¡‡ÀÁπ«à“ ·π«∑“ß°“√√—°…“欓∫“≈ ”À√—∫¡–‡√Áߪե§«√¡’°“√∑∫∑«π
·≈–ª√—∫ª√ÿß·°â‰¢„Àâ∑—π ¡—¬∑ÿ°ªï ‡πË◊Õß®“°¢âÕ¡Ÿ≈‡°Ë’¬«°—∫°“√√—°…“欓∫“≈ºŸâªÉ«¬¡–‡√Áߪե¡’°“√
‡ª≈’ˬπ·ª≈ßլൟ ≈Õ¥‡«≈“

¢Õ¢Õ∫§ÿ≥∑ÿ°∑à“π∑’Ë¡’ à«π√à«¡„π°“√®—¥∑”§àŸ¡◊Õ‡≈à¡π’È ·≈–§≥–∑”ß“π¬‘π¥’√—∫§”«‘®“√≥åµà“ßÊ
∑Ë’®–™à«¬„À⧟à¡◊Õ‡≈à¡π’ȉ¥â√—∫°“√æ—≤π“·≈–ª√—∫ª√ÿß·°â‰¢ Õ—π®–‡ªìπª√–‚¬™πå„π°“√√—°…“欓∫“≈ºŸâªÉ«¬
¡–‡√Áߪե„πª√–‡∑»‰∑¬µàÕ‰ª

·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548 1

·ºπ¿Ÿ¡‘· ¥ß·π«∑“ß

°“√√—°…“欓∫“≈
‚√§¡–‡√Áߪե

™π‘¥ Non-Small Cell Lung Cancer (NSCLC)

Non-Small Cell Lung Cancer 2 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

«π‘ ‘®©—¬ °“√µ√«®¢È—πµâπ °“√®—¥√–¬–∑“ߧ≈π‘ °‘
Stage I, peripherala T1-2, N0
Non-Small ë Pathology review Mediastinal CT negative (lymph node < 1 cm) ¥Ÿ°“√µ√«®¢π—È µàÕ‰ª Àπâ“ 3
Cell Lung ë H&P (include Stage I, centrala T1-2, N0 and stage II, T1-2, N1 ¥°Ÿ “√µ√«®¢È—πµàÕ‰ª Àπ“â 3
Cancer Mediastinal CT negative(lymph nodes < 1 cm) ¥Ÿ°“√µ√«®¢πÈ— µÕà ‰ª Àπâ“ 5
(NSCLC) performance Stage IIB,b T3, N0, Stage IIIA, T3, N1 ¥Ÿ°“√µ√«®¢—ÈπµàÕ‰ª Àπâ“ 8
status + weight by CT or bronchoscopy ¥°Ÿ “√µ√«®¢πÈ— µÕà ‰ª Àπ“â 8
loss) Stage IIIA,b T1-3, N2, mediastinal CT positive ¥Ÿ°“√µ√«®¢πÈ— µÕà ‰ª Àπ“â 10
Ipsilateral (lymph nodes < 1 cm) ¥Ÿ°“√µ√«®¢πÈ— µÕà ‰ª Àπâ“ 11
ë Chest x-ray Stage IIIB,b T4, N0-1 (Possibly resectable) ¥°Ÿ “√µ√«®¢—πÈ µàÕ‰ª Àπâ“ 11
Stage IIIB,b T1-3, N3, mediastinal CT positive ¥Ÿ°“√µ√«®¢—ÈπµàÕ‰ª Àπ“â 12
ë CT chest and upper Contralateral (lymph nodes > 1 cm ) or ¥°Ÿ “√µ√«®¢πÈ— µàÕ‰ª Àπâ“ 12
abdomen, including Palpable supraclavicular lymph nodes ¥°Ÿ “√µ√«®¢È—πµàÕ‰ª Àπâ“ 16
adrenals Stage IIIB,b T4, N2-3 on CT
Stage IIIB,b T4 (pleural or pericardial effusion)
ë CBC, platelets Stage IV, M1
Solitary metastasis with resectable lung lesion
ë Chemistry profile Stage IV, M1
Disseminated metastases
ë Smoking cessation Occult TX, N0, M0
counseling

a

„™â CT Chest ‡ªπì ‡°≥±°å “√·∫ßà

Peripheral = Outer half of lung

Central = inner (central) half of lung

b

°“√√—°…“ºâŸªÉ«¬√–¬–IIB ·≈– III ¡°— ®–‡ªìπ°“√√°— …“·∫∫º ¡º “πÀ≈“¬«∏‘ ’

(ºà“µ—¥, ©“¬· ß, ‡§¡∫’ ”∫¥— ) ¥ß— ππ—È §«√ª√–‡¡π‘ ¥â«¬ À “¢“«™‘ “™’æ

√–¬–¢Õß‚√§ Non-Small Cell Lung Cancer

°“√µ√«®ª√–‡¡‘π°àÕπ°“√√—°…“

Stage I ë Bronchoscopy Negative ¥Ÿ·π«∑“ß°“√√—°…“À≈°— ·≈–‡ √¡‘ Àπ“â 4 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 3
(peripheral T1-2, N0) ë Mediastinoscopyc mediastinal
nodes ¥·Ÿ π«∑“ß°“√¥·Ÿ ≈√—°…“√–¬– IIIA Àπ“â 9
Stage I (central T1-2, N0) ë Bronchoscopy À√◊Õ
Stage II (T1-2, N1) ë Mediastinoscopy c Positive ¥·Ÿ π«∑“ß°“√¥·Ÿ ≈√°— …“√–¬– IIIB Àπâ“ 10
ë Brain MRI/CT* mediastinal
nodes
(Stage II only)
ë Plain film or Bone

scan

C Mediastinoscopy æ‘®“√≥“‡ªπì option ∂“â ∑”‰¥â
* If clinically indicated

Non-Small Cell Lung Cancer 4 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

°“√√°— …“À≈°— º≈À≈—ß°“√ºà“µ—¥ °“√√—°…“‡ √‘¡

Surgical Margins (R0)e Observe
explorationd negative À√Õ◊
and Chemotherapy in high risk patients
resection T1, N0 Reresection
À√◊Õ
Margins RTf

positive Chemotherapyg À√Õ◊
(R1, R2)e Observe

Margins Reresection À√◊Õ
negative (R0)e RTf + Chemotherapyg

T2, N0 Margins
positive
(R1, R2)e

Margins Chemotherapyg À√◊Õ
negative (R0)e RTf + Chemotherapyg

T1-2, N1

Margins Reresection À√◊Õ
positive RTf + chemotherapyg
(R1, R2)e
Chemotherapyg
Margins
negative (R0)e

T1-2, N2

d¥Ÿ·π«∑“ß°“√√°— …“¥«â ¬»≈— ¬°√√¡„πºâŸª«É ¬¡–‡√Áߪե Àπâ“ 25 Margins positive RTf+ Chemotherapyg
(R1, R2)e

eR0 = no residual tumor, R1 = microscopic residual tumor, R2 = macroscopic residual tumor.

f¥·Ÿ π«∑“ß°“√√—°…“¥“â π√—ß „’ πºŸâªÉ«¬¡–‡√ßÁ ªÕ¥ Àπ“â 28

g殑 “√≥“„™â Platinum-based therapy

√–¬–¢Õß‚√§ Non-Small Cell Lung Cancer ·π«∑“ß°“√¥Ÿ·≈√°— …“µàÕ‰ª

°“√µ√«®ª√–‡¡π‘ °Õà π°“√√°— …“

Stage IIB (T3, N0) ë Bronchoscopy Superior sulcus tumor ¥·Ÿ π«∑“ß°“√¥Ÿ·≈√°— …“ Àπâ“ 6 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 5
Stage IIIA (T3, N1) ë Mediastinoscopyc ¥Ÿ·π«∑“ß°“√¥Ÿ·≈√—°…“ Àπ“â 7
ë Brain MRI/CT* Chest wall ¥·Ÿ π«∑“ß°“√¥Ÿ·≈√—°…“ Àπâ“ 7
ë Plain film or Bone scan
Proximal airway ¥Ÿ·π«∑“ß°“√¥·Ÿ ≈√—°…“ Àπâ“ 14
À√Õ◊ mediastinum
Metastatic disease

c Mediastinoscopy 殑 “√≥“‡ªìπ option ∂“â ∑”‰¥â
*If clinically indicated

√–¬–¢Õß‚√§ Non-Small Cell Lung Cancer °“√√—°…“‡ √¡‘ 6 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

°“√√°— …“À≈—° Surgery
RTf + chemotherapy
Superior Resectable Chemotherapy À√◊Õ
Sulcus tumorh Unresectable Concurrent Surgery
(T3-4, N0-1) Chemoradiation Complete definitive RTf
(Preferred) + chemotherapy
Resectable
À√Õ◊ RTf
À√Õ◊ Surgery

Definitive
concurrent
chemoradiationf
À√◊Õ Definitive RT

Marginally Concurrent Surgical Resectable
resectable Chemoradiationf Reevaluation Unresectable

f¥Ÿ·π«∑“ß°“√√—°…“¥â«¬√—ß √’ —°…“„πºŸâª«É ¬¡–‡√Áߪե Àπ“â 28
h‡ªπì °“√¬“°∑’Ë®–·¬°√–À«à“ß T3 ·≈– T4 „π superior sulcus tumors

√–¬–¢Õß‚√§ Non-Small Cell Lung Cancer °“√√—°…“‡ √‘¡

°“√√°— …“À≈°—

Chest wall Surgery Surgery Margins negative Chemotherapyg
T3, N0-1 (R0)e („π°√≥’‰¡à‰¥â Preop
Proximal airway À√◊Õ Margins positive Chemotherpy)
or mediastinum RTf (R1, R2)e
T3, N0-1 Reresection + Chemotherapy
À√Õ◊ („π°√≥’∑Ë’ RT ¡“·≈«â )
À√◊Õ ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 7
Chemotherapy RTf + chemotherapy
(„π°√≥∑’ ¬’Ë ß— ‰¡‰à ¥â Preop
À√◊Õ RT ¡“°Õà π)
Chemotherapy+RTf

eR0 = no residual tumor, R1 = microscopic residual tumor, R2 = macroscopic residual tumor.
f¥Ÿ·π«∑“ß°“√√—°…“¥“â π√—ß ’√—°…“„πºªŸâ «É ¬¡–‡√ßÁ ªÕ¥ Àπ“â 28
g殑 “√≥“„™â Platinum-based doublet therapy

Non-Small Cell Lung Cancer 8 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

√–¬–¢Õß‚√§ °“√µ√«®ª√–‡¡π‘ °Õà π°“√√°— …“ º≈°“√ª√–‡¡‘π

Stage IIIA ë Bronchoscopy N2, N3 nodes negative ¥·Ÿ π«∑“ß°“√¥·Ÿ ≈√—°…“Àπ“â 9
(T1-3, N2) ë Mediastinoscopyc N2 nodes positive ¥·Ÿ π«∑“ß°“√¥Ÿ·≈√—°…“Àπâ“ 9
ë Brain MRI/CT* N3 nodes positive ¥·Ÿ π«∑“ß°“√¥·Ÿ ≈√°— …“Àπâ“ 10
ë Plain film or Metastatic disease ¥Ÿ·π«∑“ß°“√¥Ÿ·≈√°— …“Àπâ“ 12

Bone scan ¥Ÿ·π«∑“ß°“√¥·Ÿ ≈√°— …“Àπ“â 10
¥·Ÿ π«∑“ß°“√¥·Ÿ ≈√°— …“Àπ“â 10
Stage IIIB ë Bronchoscopy Resectable: ¥·Ÿ π«∑“ß°“√¥Ÿ·≈√°— …“Àπ“â 10
(T4, N0-1) ë Mediastinoscopyc satellite lesion ¥·Ÿ π«∑“ß°“√¥Ÿ·≈√—°…“Àπâ“ 11
¥Ÿ·π«∑“ß°“√¥Ÿ·≈√—°…“Àπâ“ 12
ë Brain MRI/CT* Resectable other
than satellite
ë Plain film or Bone scan
Unresectable
(without effusion)

Unresectable
(pleural effusion)

Metastatic disease

c

Mediastinoscopy 殑 “√≥“‡ªπì option ∂“â ∑”‰¥â
*If clinically indicated

Mediastinal Biopsy findings Non-Small Cell Lung Cancer °“√√°— …“‡ √¡‘

°“√√—°…“À≈—° ¥·Ÿ π«∑“ß°“√√°— …“ Àπ“â 4 À√Õ◊ 5

Surgical N0-1 Chemotherapyg

Clinical: Resectable resectiond + RTf+chemotherapy
T1-3, N2, N3 mediastinal lymph Surgery
Pathologic: node dissection Margins Chemotherapy RT
nodes negative (R0)e (∂“⠬ߗ ‰¡à‡§¬√—∫ RT ¡“°àÕπ)
negative Thoracotomy RTf (∂“â ¬—߉¡à‡§¬√∫— RT
N2 ¡“°àÕπ) chemotherapy
Clinical: T1-3, ë MBrRaIi/nCT*
Pathologic: ë Plain film Unresectable ¥Ÿ·π«∑“ß°“√√—°…“ Margins
N2 nodes µ“¡√–¬–¢Õß‚√§ Àπ“â 2 positive (R1, R2)e
positive À√◊Õ Bone Negative
scan Positive Induction RTf No ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 9
Chemotherapy progression

À√Õ◊ Progression

CDheefimniotitvheerapy/RTf

¥·Ÿ π«∑“ß°“√√°— …“√–¬–·æ√à°√–®“¬ Àπâ“ 14

d ¥Ÿ·π«∑“ß°“√√°— …“¥«â ¬»—≈¬°√√¡„πºâŸªÉ«¬¡–‡√ßÁ ªÕ¥ Àπâ“ 25

e

R0 = no residual tumor, R1 = microscopic residual tumor, R2 = macroscopic residual tumor.

f

¥·Ÿ π«∑“ß°“√√—°…“¥â«¬√—ß √’ °— …“„πºŸâª«É ¬¡–‡√ßÁ ªÕ¥ Àπ“â 28

g

殑 “√≥“„™â Platinum-based doublet therapy

*

If clinically indicate

Non-Small Cell Lung Cancer 10 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

√–¬–¢Õß‚√§ °“√√—°…“À≈°— °“√√—°…“‡ √‘¡

Stage IIIB (T4, N0-1) Surgery Chemotherapy
Resectable: Chemotherapy RTf,**
satellite lesion
RTf,** (∂“â ¬—߉¡‡à §¬√∫— RT ¡“°Õà π)
Stage IIIB (T4, N0-1) Surgery
Resectable other
than satellite À√Õ◊

Induction Surgery
Chemotherapy

À√◊Õ
Chemotherapy + RTf

Stage IIIB (T4, AnyN, RTf+chemotherapy
AnyT N3) À√Õ◊
Unresectable Concurrent chemoradiation
(without effusion)

eR0 = no residual tumor, R1 = microscopic residual tumor, R2 = macroscopic residual tumor.
f
¥Ÿ·π«∑“ß°“√√—°…“¥â«¬√ß—  √’ —°…“„πºŸâª«É ¬¡–‡√Áߪե Àπâ“ 28
** Case by case

√–¬–¢Õß‚√§ Non-Small Cell Lung Cancer ·π«∑“ß°“√¥·Ÿ ≈√°— …“

°“√µ√«®ª√–‡¡‘π°àÕπ°“√√°— …“

Stage IIIB: Thoracentesis or Negativei ¥·Ÿ π«∑“ß°“√¥·Ÿ ≈√—°…“Àπâ“ 2 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 11
T4: pleural Positivei
or pericardiocentesis if Local therapy if necessary (eg, pleurodesis,
pericardial indicated thoracoscopy ambulatory small catheter drainage,
effusion if thoracentesis pericardial window) + treatment as for stage
indeterminate IV disease (¥ŸÀπ“â ∑’Ë 14)

iPleural effusions ∑æ’Ë ∫„πºâŸª«É ¬ «à π¡“°‡°‘¥®“°‚√§¡–‡√Áß ·µà∂“â °“√µ√«®∑“߇´≈≈«å ‘∑¬“¢Õßπ”È ‡¬’ËÕÀ¡ÿâ ªÕ¥‰¡àæ∫‡´≈≈¡å –‡√ßÁ ª√–°Õ∫°∫— π”È ‡¬◊ËÕÀâ¡ÿ ªÕ¥ ‰¡à¡’‡≈◊Õ¥À√Õ◊ ≈°— …≥–
exudate ·≈–ª√–‡¡π‘ ∑“ߧ≈π‘ ‘°·≈â««“à πÈ”®“°‡¬ÕË◊ Àâ¡ÿ ªÕ¥‰¡‰à ¥‡â °¬Ë’ «°—∫¡–‡√Áߪե ¥ß— πÈπ— Pleural effusion §«√æ‘®“√≥“ÕÕ°®“°°“√„™â„π°“√®—¥√–¬–¢Õß‚√§§«√æ‘®“√≥“«à“
ºŸªâ É«¬‡ªπì √–¬– T1, T2 ·≈– T3 Pericardial effusion °Á殑 “√≥“‡™àπ‡¥’¬«°—π

Non-Small Cell Lung Cancer 12 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

«‘π®‘ ©—¬ °“√µ√«®ª√–‡¡‘π°àÕπ°“√√°— …“ ·π«∑“ß°“√¥·Ÿ ≈√—°…“

Resect brain lesion + T1-2, Surgical Chemotherapy
whole-brain RT N0-1; resection of
À√Õ◊ T3, N0 lung lesion Surgical
Stereotactic resection of
Rediosurgery*** whole- À√◊Õ lung lesion
brain RT (category 2B)
Chemotherapy

Brain

Stage IV T1-2, N2; T3 ¥Ÿ·π«∑“ß°“√¥·Ÿ ≈√°— …“·∫∫
M1: N1-2; Any T, Systemic Therapy Àπâ“ 14
Solitary N3; T4, Any N
site

Contralateral lung Treat as two primary lung
(solitary nodule) tumors if both curable
or ipsilateral lung
(other lobe)

Stage IV Workup as ¥Ÿ·π«∑“ß°“√¥Ÿ·≈√°— …“·∫∫ Systemic Therapy Àπâ“ 14
M1: clinically
disseminated indicated

*** - Mass 3 cm
- Number of metastasis nodules 4

Non-Small Cell Lung Cancer

°“√µ√«®‡Ω“Ñ √–«ß— À≈—ß°“√√°— …“ °“√√°— …“„π°√≥‡’ ªπì ´È”À√◊Õ√–¬–°√–®“¬

Locoregional Endobronchial ë Laser/stent/other sugery
recurrence obstruction ë Brachytherapy
ë External-beam RT
ë Physical exam +
chest x-ray every Resectable ë Reresection No evidence Observation
3-4 mo for 2 y, then recurrence ë External-beam RT of À√◊Õ
every 6 mo for 3 y Superior vena disseminated Systemic
then annually cava (SVC) ë External-beam RT disease chemotherapy
obstruction ë Stent
ë Low dose spiral Evidence of ¥Ÿ·π«∑“ß°“√¥·Ÿ ≈ ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 13
chest CT annually Severe ë External-beam RT disseminated √—°…“¢π—È µàÕ‰ª
(optional) hemoptysis ë Brachytherapy disease Àπ“â 14
ë Laser
ë Smoking cessation Localized ë Photodynamic therapy
counseling symptoms ë Embolization
ë Surgery
Distant
metastasis Palliative external-beam RT

Diffuse brain Palliative external-beam RT ¥·Ÿ π«∑“ß°“√¥Ÿ·≈
metastasis √°— …“¢Èπ— µÕà ‰ª
Palliative external-beam RT Àπâ“ 14
Symptomatic + orthopedic stabilization
bony
metastases if risk of fracture

Solitary ¥Ÿ·π«∑“ß°“√√°— …“√–¬–·æ√à°√–®“¬Àπâ“ 14
metastasis ¥Ÿ·π«∑“ß°“√√—°…“Àπ“â 14
Disseminated
metastases

Non-Small Cell Lung Cancer 14 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

°“√√—°…“„π°√≥‡’ ªìπ´È”À√◊Õ·æ√à°√–®“¬

Performance Chemotherapy Course 1-2 Tumor Progression ¥·Ÿ π«∑“ß°“√¥·Ÿ ≈
status 0-2k (category1) response √°— …“¢È—πµÕà ‰ª Àπâ“
Response À√Õ◊ 15
evaluation Stable disease
¥Ÿ·π«∑“ß°“√¥·Ÿ ≈
Course 3-4
Progression √°— …“¢Èπ— µÕà ‰ª Àπâ“
Systemic
Chemotherapyj 15
and/or
supportive care Response À√Õ◊
Stable disease

6 cycles (total)

Relapse ¥Ÿ·π«∑“ß°“√¥·Ÿ ≈
√°— …“¢Èπ— µÕà ‰ª Àπ“â
15

Performance Best supportive care
status 3,4

j¥Ÿ·π«∑“ß°“√√°— …“¥â«¬¬“‡§¡∫’ ”∫—¥„πºªâŸ É«¬¡–‡√ßÁ ªÕ¥ Àπ“â 31
kºªâŸ É«¬°≈ÿ¡à ∑’Ë¡’ Performance status (PS) 2 Õ“®‰¥√â —∫ª√–‚¬™π®å “°°“√√°— …“πâÕ¬°«à“·≈–¡’Õ“°“√¢â“߇§¬’ ß¡“°°«à“°≈¡àÿ ºªŸâ É«¬∑Ë¡’ ’ PS 0-1

Non-Small Cell Lung Cancer

Progressive disease

Performance Best supportive care
status 3, 4
Performance Second-line Progression Performance Best
status 0-2k chemotherapyj Performance status 3, 4 supportive
or Tyrosine status 0-2k Third-line care ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 15
Performance kinase inhibitors therapyj Performance
status 3, 4 (Tyrosine status 0-2k Best
kinase Progression supportive
inhibitors) care or
Phase I/II
clinical trial

Best supportive care

j ¥·Ÿ π«∑“ß°“√√°— …“¥â«¬¬“‡§¡∫’ ”∫¥— „πºâªŸ É«¬¡–‡√Áߪե Àπ“â 31

k

ºâŸªÉ«¬°≈¡ÿà ∑Ë¡’ ’ Performance status (PS) 2 Õ“®‰¥â√∫— ª√–‚¬™π宓°°“√√—°…“πâÕ¬°«à“·≈–¡’Õ“°“√¢â“߇§’¬ß¡“°°«à“°≈ÿࡺŸâªÉ«¬∑’¡Ë ’ PS 0-1

º≈°“√µ√«®µ¥‘ µ“¡ Non-Small Cell Lung Cancer °“√√—°…“ 16 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

Sputum cytology °“√µ√«®ª√–‡¡‘π
positive;
chest x-ray and Bronchoscopy T1-3 ¥·Ÿ π«∑“ß°“√¥Ÿ·≈√—°…“ Àπ“â 2
CT negative Tis
Negative ë Endobronchial ablation: Laser
ë Surgical resection
ë Brachytherapy
ë Photodynamic therapy
À√◊Õ
Rebronchoscope ´È”∑°ÿ 3 ‡¥Õ◊ π

Rebronchoscope ´”È ∑ÿ° 3 ‡¥◊Õπ

·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 17

·ºπ¿Ÿ¡·‘  ¥ß·π«∑“ß

°“√√°— …“欓∫“≈
‚√§¡–‡√Áߪե

™π¥‘ Small Cell Lung Cancer (SCLC)

Small Cell Lung Cancer 18 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

«π‘ ®‘ ©¬— °“√µ√«®¢—πÈ µπâ a √–¬–b

Small Cell or ë H&P Limited ¥Ÿ°“√µ√«®‡æ‘Ë¡‡µ‘¡Àπâ“ 19
Combined Small ë Pathology review stage ¥°Ÿ “√µ√«®‡æ¡Ë‘ ‡µ¡‘ Àπ“â 21
Cell/Non-Small Cell ë Chest x-ray
Lung Cancer on ë Chest/liver/adrenal CT Extensive
biopsy ë Head MRI/CT* stage
or ë Bone scan
cytology of primary ë CBC, platelets
or metastatic site ë Electrolytes, liver funtion tests

(LFT)
ë BUN, creatinine
ë Smoking cessation counseling

and intervention

a ∂“â ‡ªπì ¡–‡√ßÁ √–¬–≈ÿ°≈“¡ §«√æ‘®“√≥“°“√µ√«®§πâ À“‡æ‘Ë¡‡µ‘¡‡æ◊ËÕ®¥— √–¬–¢Õß‚√§∑’Ë∂°Ÿ µÕâ ß
b (1) Limited disease: disease confined to the ipsilateral hemithorax within a single rediation port.

(2) Extensive disease: disease beyond ipsilateral hemithorax or malignant pleural effusion or obvious metastatic disease.
* If clinically indicated

Small Cell Lung Cancer

√–¬– °“√µ√«®«‘π®‘ ©¬— ‡æË¡‘ ‡µ¡‘

Limited ë If pleural effusion is seen in Limited disease ¥·Ÿ π«∑“ß°“√¥Ÿ·≈ ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 19
stage chest x-ray, thoracentesis is √°— …“¢πÈ— µàÕ‰ª
recommended, if Thoracentesis, Àπâ“ 20
thoracoscopy inconclusive, À√◊Õ bone studies
consider thoracentesisc consistent with ¥Ÿ·π«∑“ß°“√¥·Ÿ ≈√°— …“ ”À√—∫
malignancy extensive-stage disease
ë Bone radiographs of areas (¥ÀŸ πâ“∑’Ë 21)
showing uptake or
abnormalities on bone scan

c

Pleural effusions ∑Ëæ’ ∫„πºâŸªÉ«¬ «à π¡“°‡°‘¥®“°‚√§¡–‡√ßÁ °√≥’º≈°“√µ√«®∑“߇´≈≈å«∑‘ ¬“ ‰¡àæ∫‡´≈≈¡å –‡√ßÁ ·≈–π”È „π‡¬Õ’Ë À¡ÿâ ªÕ¥ ‰¡à¡’≈—°…≥–‡ªπì À√Õ◊ exudate ·≈–ª√–‡¡π‘
 ¿“æ∑“ߧ≈π‘ °‘ ‰¡‰à ¥â‡°¬’Ë «°∫— ¡–‡√ßÁ ªÕ¥ ‡æ√“–©–πÈ—π‰¡à§«√æ‘®“√≥“ Pleural effusion „π°“√®—¥√–¬–¢Õß‚√§

Small Cell Lung Cancer 20 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

º≈°“√ª√–‡¡π‘ °“√√—°…“

Limited disease Good performance Chemotherapyd
status Concurrent RTi (category 1)

Poor performance Chemotherapyd or RTe
status due to
comorbidity

d¥·Ÿ π«∑“ß°“√√—°…“¥«â ¬‡§¡’∫”∫—¥„πºâŸª«É ¬¡–‡√ßÁ ªÕ¥ Àπ“â 50
e¥·Ÿ π«∑“ß°“√√°— …“¥«â ¬√ß—  √’ °— …“„πºªâŸ «É ¬¡–‡√ßÁ ªÕ¥ Àπâ“ 48

Small Cell Lung Cancer

√–¬– °“√µ√«®‡æ¡Ë‘ ‡µ¡‘ °“√√—°…“

Extensive stage ë Performance Combination chemotherapyd,f
without localized status (PS) 3-4 including supportive care
symptomatic regimens
sited or brain ë Severely
metastases debilitated Individualized therapy including
supportive care regimens

ëSVC syndrome Chemotherapyd ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 21
ëLobar obstruction
Extensive Plain-film x-rays Extensive stage + ëBone metastases
stage of bone scan localized
abnormalities of symptomatic
weight-bearing sites
areas

Spinal cord RT+Chemotherapyd
compression
Whole-brain RT followed by
Extensive stage with chemotherapyd, unless
brain metastases immediate systemic therapy is
required
d ¥·Ÿ π«∑“ß°“√√°— …“¥«â ¬‡§¡∫’ ”∫¥— „πºâªŸ É«¬¡–‡√ßÁ ªÕ¥ Àπâ“ 50 ë If asymptomatic, may administer
RT after chemotherapy
f

Sequential radiotherapy to thorax in selected patients with low-bulk metastatic disease and CR or near CR after systemic therapy.

Small Cell Lung Cancer 22 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

°“√ª√–‡¡‘πÀ≈—ß°“√√°— …“ °“√√°— …“‡ √‘¡ °“√‡ΩÑ“√–«ß—

Complete response ë Limited disease: After recovery from primary
or radiation PCIg (category 1) therapy:
scarring on chest ë Oncology follow-up visits
imaging studies or ë Extensive every 2-3 mo during year 1,
10% of original disease: PCIg every 3-4 mo during years
mass on CT scan 2-3, every 4-6 mo during
ë Chest x-ray years 4-5, then annually °“√°≈∫— ¡“‡ªπì ´”È „À⥟
ë Head MRI or CT, if Partial response ·π«∑“ß°“√√°— …“
At every visit: H&P, Àπ“â 23
prophylactic cranial chest imaging,
irradiation (PCI) to be bloodwork as clinically
given indicated
ë Other imaging ë New pulmonary nodule after
studies, to assess 2 y follow-up should initiate
prior sites of work-up for potential new
involvement, as primary
clinically indicated ë Smoking cessation
ë CBC, platelets intervention
ë Electrolytes, LFTs,
BUN, creatinine

Primary ¥·Ÿ π«∑“ß°“√√°— …“·∫∫ª√–§∫— ª√–§Õß„πºâŸªÉ«¬¡–‡√Áߪե Àπ“â 58

progressive

disease

gPCI: °“√©“¬· ß∑’Ë ¡Õ߇æËÕ◊ ªÑÕß°—π°“√°√–®“¬ππÈ— æ‘®“√≥“„Àâ PCI ‡©æ“–ºŸªâ «É ¬´ß÷Ë ‰¥â Complete response ®“° Chemotherapy „™ªâ √‘¡“≥· ß∑ßÈ— À¡¥ 24-36 Gy (‡™àπ 30 Gy„π

15 fractions, 36 Gy „π 18 fractions, 25 Gy „π 10 fractions, 24 Gy „π 8 fractions) ·≈–·π–π”„Àâ„™â Lower fraction regimens (1.8-2.0 Gy/fraction) ‰¡·à π–π”°“√©“¬· ßπÈ„’ Àâ

ºŸâª«É ¬ multiple comorbidities, poor performance status À√◊Õ ¿“«– ¢ÿ ¿“殑µº‘¥ª°µ‘

Small Cell Lung Cancer

Relapse Second-lin Continue until Clinical trial
Chemotherapyd maximal benefit or or
or refractory to Best supportive
Clinical trial therapy or care
or development of
Best supportive unacceptable
care toxicity

Primary Palliative symptom management, Including localized RT ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 23
progressive or
disease Clinical trial
or
Second-line chemotherapyd (PS 0-2)

d¥Ÿ·π«∑“ß°“√√—°…“¥«â ¬‡§¡’∫”∫¥— „πºâŸª«É ¬¡–‡√ßÁ ªÕ¥ Àπâ“ 50

24 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

·π«∑“ß

°“√√°— …“欓∫“≈
‚√§¡–‡√Áߪե

™π‘¥ Non-Small Cell Lung Cancer (NSCLC)

·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548 25

·π«∑“ß

°“√√—°…“¥â“π»≈— ¬°√√¡
„πºâŸª«É ¬¡–‡√Áߪե

™π¥‘ Non-Small Cell Lung Cancer (NSCLC)

®¥— ∑”‚¥¬  ¡“§¡»—≈¬·æ∑¬å∑√«ßÕ°·Ààߪ√–‡∑»‰∑¬
§≥–Õπ°ÿ √√¡°“√ºŸâ®—¥∑”
√».πæ. °µ‘ µ™‘ —¬ ‡À≈◊Õß∑«∫’ ÿ≠
º».πæ  ¡‡®√≠‘ ·´à‡µÁß

26 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

∫∑∫“∑∑“ߥâ“π»—≈¬°√√¡¢Õß°“√√°— …“¡–‡√ßÁ ªÕ¥
™π‘¥ Non-Small Cell Lung Cancer (NSCLC)

1. ¡–‡√ßÁ ªÕ¥ ™π‘¥ NSCLC √–¬–∑Ë’ I (stage I)
ë T1 N0 M0
ë T2 N0 M0
æ‘®“√≥“∑” Curative lung resection with systematic lymph node dissections „π°√≥∑’ ’Ë
ºâŸªÉ«¬‰¡à¡’¢âÕÀâ“¡µàÕ°“√ºà“µ¥—

2. ¡–‡√ßÁ ªÕ¥ ™π‘¥ NSCLC √–¬–∑’Ë II (stage II)
ë T1 N1 M0
ë T2 N1 M0
æ‘®“√≥“∑” Curative lung resection with systematic lymph node dissections
ë T3 N0 M0
殑 “√≥“∑” Curative enbloc chest well and lung resection with systematic lymph node
dissections

3. ¡–‡√Áߪե ™π¥‘ NSCLC √–¬–∑Ë’ IIIA (stage IIIA)
ë T1 N2 M0
ë T2 N2 M0
ë T3 N2 M0
3.1 æ‘®“√≥“∑” mediastinoscope ( „π ∂“π∑’∑Ë ’Ë “¡“√∂∑”‰¥â ) ‡æÕË◊ À“ true N2
- ∂â“ N2 positive 殑 “√≥“„Àâ pre-op Chemoradiation ·≈⫵àÕ¥«â ¬ surgery
- ∂â“ N2 negative „Àâ°“√√—°…“‡À¡◊Õπ stage II
3.2 °√≥’∑Ë’‰¡à “¡“√∂∑” mediastinoscope ‰¥â „Àâ¢÷ÈπÕ¬àŸ°—∫¥ÿ≈¬æ‘π‘®¢Õß·æ∑¬åºŸâ√—°…“
«à“®–ºà“µ—¥·≈⫵“¡¥â«¬‡§¡’∫”∫—¥°√≥’∑Ë’ º≈欓∏‘«‘∑¬“æ∫«à“ N2 positive
À√Õ◊ „Àâ chemo-radiation ·≈«â µ“¡¥«â ¬ surgery

4. ¡–‡√ßÁ ªÕ¥ ™π‘¥ NSCLC √–¬–∑Ë’ IIIB (stage IIIB)

}ë T4 N0 M0
∑Ë’¡’°“√ª√–‡¡‘π·≈â«æ∫«“à  “¡“√∂º“à µ—¥‰¥â
ë T4 N1 M0

4.1 °√≥’∑’ˇªìπ satellite lesion æ‘®“√≥“∑” lobectomy with systematic node
dissection

4.2 °√≥’∑Ë’ T4 ‡ªπì ™π¥‘ ∑Ë’ limited involvement of carcinoma æ‘®“√≥“º“à µ¥— ∑” Sleeve
resection ·≈⫵“¡¥â«¬°“√©“¬√—ß ’·≈–/À√◊Õ ‡§¡’∫”∫—¥ À√◊Õ„À⇧¡’∫”∫—¥
°àÕπÀ√◊Õ °“√©“¬√—ß ’°àÕπ À√◊Õ °“√©“¬√—ß ’√à«¡°—∫‡§¡’∫”∫—¥°àÕπ·≈⫵“¡¥â«¬
°“√º“à µ¥— ¢Èπ÷ Õ¬Ÿà°—∫§«“¡‡ÀπÁ ¢Õߧ≥–∑¡’ ·æ∑¬åºŸ√â °— …“∑—ßÈ 3 ΩÉ“¬ª√–‡¡π‘ √à«¡°π—

·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 27

5. √–¬–∑’Ë 4 (Any T Any N M1)
æ‘®“√≥“°“√ºà“µ—¥„π°√≥’∑Ë’√Õ¬‚√§∑Ë’ªÕ¥ “¡“√∂ºà“µ—¥ÕÕ°‰¥â·≈–‰¡à¡’°“√°√–®“¬‰ª∑’Ë

Õ◊ËπÊ ¬°‡«πâ
ë °“√°√–®“¬‰ª∑ ’Ë ¡Õß¡’‡æ’¬ß√Õ¬‚√§‡¥¬’ «·≈–¡¢’ π“¥πÕâ ¬°«“à 3 ´¡.

6. superior sulcus tumor
æ‘®“√≥“„À⇧¡’∫”∫—¥√à«¡°—∫°“√©“¬√—ß ’ ·≈⫵“¡¥â«¬°“√ºà“µ—¥„π°√≥’∑’˪√–‡¡‘π·≈â«æ∫

«à“πà“®– “¡“√∂ºà“µ¥— ‰¥â
7. °√≥∑’ º’Ë “à µ¥— ·≈«â √“¬ß“π∑“ß欓∏«‘ ∑‘ ¬“æ∫«“à ¢Õ∫‡¢µ¢Õß°“√º“à µ¥— ¬ß— ¡√’ Õ¬‚√§Õ¬àŸ
( margin positive ) „Àâ殑 “√≥“‡ªπì °√≥¥’ —ßπÈ’
7.1 T1N0 殑 “√≥“º“à µ—¥´È” ( re-resection ) À√Õ◊ °“√©“¬√—ß ’
7.2 T2N0 æ‘®“√≥“ºà“µ—¥´È” √à«¡°—∫°“√„À⇧¡’∫”∫—¥ À√◊Õ °“√©“¬√—ß ’√à«¡°—∫
°“√„À‡â §¡’∫”∫¥—
7.3 T1-2 N1 æ‘®“√≥“ºà“µ—¥´”È √à«¡°—∫°“√„À⇧¡’∫”∫—¥ À√◊Õ °“√©“¬√—ß ’√à«¡°—∫
°“√„À⇧¡’∫”∫¥— À√Õ◊ °“√„À⇩擖‡§¡’∫”∫¥—
7.4 T1-2 N2 æ‘®“√≥“„À‡â §¡∫’ ”∫—¥√à«¡°∫— °“√©“¬√ß—  ’
7.5 T3 N0-1 æ‘®“√≥“ºà“µ—¥´È” √à«¡°—∫°“√„À⇧¡’∫”∫—¥ À√◊Õ °“√©“¬√—ß ’√à«¡°—∫
°“√„À‡â §¡’∫”∫¥—
7.6 T3 N2 殑 “√≥“„À⇧¡∫’ ”∫¥— √à«¡°∫— °“√©“¬√ß—  ’

‡Õ° “√Õâ“ßÕß‘
1. Bermard J Park, Nasser K Altorki. Diagnosis and management of early lung cancer.
The Surgical Clinic of north America 2002; 457-476.
2. Frank C, Detterbeck M. Patricia Revera et al. Diagnosis and treatment of Lung
cancer An evidence based guide for the practicing clinician. WB Saunders Philadelphia.
2001 .
3. F Griffith Pearson, Joel D Cooper, et al. Thoracic Surgery 2nd ed. Churchill USA. 2002.
4. American society of clinical oncology 39th 2003 annual meeting..
5. National comprehensive Cancer network. Practice guidelines in oncology. Non-small
cell lung cancer version1. 2004.

28 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

·π«∑“ß

°“√√—°…“¥â«¬√ß—  √’ —°…“
„πºâŸª«É ¬¡–‡√Áߪե

™π¥‘ Non-Small Cell Lung Cancer (NSCLC)

®¥— ∑”‚¥¬  ¡“§¡√—ß √’ °— …“·≈–¡–‡√ßÁ «∑‘ ¬“·Àßà ª√–‡∑»‰∑¬
§≥–Õπ°ÿ √√¡°“√ºâ®Ÿ ¥— ∑”

πæ. ¬ß¬ÿ∑∏ §ß∏π“√µ— πå
º».πæ. ™≈‡°¬’ √µ‘ ¢Õª√–‡ √‘∞
».æ≠. «¡‘ ≈  ¢ÿ ∂¡¬“
º».æ.∑.πæ. ∏‘µ‘  «“à ß»≈‘ ªá

·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 29

·π«∑“ß°“√„™√â —ß √’ —°…“„πºâªŸ «É ¬¡–‡√Áߪե
™π‘¥ Non-Small Cell Lung Cancer (NSCLC)

1. ¡–‡√Áߪե™π¥‘ NSCLC √–¬–∑Ë’ I (Stage I)
ë T1 N0 M0
ë T2 N0 M0
1.1 °“√√—°…“À≈—°¢ÕߺŸâªÉ«¬§◊Õ°“√ºà“µ—¥ ·µà„π°√≥’∑’˺⟪ɫ¬¡’¢âÕÀâ“¡µàÕ°“√ºà“µ—¥À√◊Õ
ªØ‡‘  ∏°“√ºà“µ—¥ ®–æ‘®“√≥“„Àâ√—ß √’ °— …“
1.2 Postoperative radiation „π√“¬∑’Ë margin + positive (æ‘®“√≥“‡ªπì √“¬Ê)

2. ¡–‡√Áߪե™π¥‘ NSCLC √–¬–∑Ë’ II (Stage II)
ë T1 N1 M0
ë T2 N1 M0
ë T3 N0 M0
°“√√—°…“‡À¡◊Õπ Stage I

3. ¡–‡√ßÁ ªÕ¥™π¥‘ NSCLC √–¬–∑’Ë IIIA (Stage IIIA)
ë T1 N2 M0
ë T2 N2 M0
ë T3 N1 M0
ë T3 N2 M0
3.1 √ß—  √’ —°…“(·≈–/À√◊Õ√«à ¡°—∫¬“‡§¡∫’ ”∫—¥) ·≈–æ‘®“√≥“º“à µ¥— „πºªâŸ «É ¬‡ªπì √“¬Ê
3.2 √—ß √’ —°…“√à«¡°∫— ¬“‡§¡∫’ ”∫¥—
3.3 °“√„™â√ß—  ’√—°…“‡æ’¬ßÕ¬à“߇¥¬’ «‡æ◊ÕË ∫√√‡∑“Õ“°“√

Superior sulcus tumor (T3 N0 or N1, M0)
1. √—ß √’ °— …“µ“¡¥â«¬°“√º“à µ¥— (pre operative radiation)
2. °“√„™√â —ß ’√°— …“√à«¡°∫— ¬“‡§¡∫’ ”∫¥— ·≈«â µ“¡¥«â ¬°“√º“à µ¥—
3. °“√„™√â —ß ’√—°…“‡æ¬’ ßÕ¬“à ߇¥’¬«

Chest wall (T3 N0 or N1, M0)
1. ºà“µ¥— µ“¡¥«â ¬√ß—  ’√—°…“ ‡¡Õ◊Ë margin / positive
2. √ß—  √’ °— …“√à«¡°∫— ¬“‡§¡∫’ ”∫¥— ¥Ÿ°“√µÕ∫ πÕß«“à ®–æ‘®“√≥“º“à µ—¥µÕà À√◊Õ‰¡à
3. °“√„™â√ß—  ’√°— …“‡æ¬’ ßÕ¬à“߇¥¬’ «

30 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

4. ¡–‡√ßÁ ªÕ¥™π‘¥ NSCLC √–¬–∑’Ë IIIB (Stage IIIB)
ë AnyT, N3, M0
ë T4, anyN, M0
4.1 √ß—  ’√°— …“√à«¡°—∫¬“‡§¡∫’ ”∫¥—
4.2 √ß—  √’ °— …“‡æ’¬ßÕ¬“à ߇¥¬’ «

5. ¡–‡√ßÁ ªÕ¥™π‘¥ NSCLC √–¬–∑’Ë IV (Stage IV)
ë AnyT, anyN, M1
5.1 √—ß ’√—°…“®–„™„â π°“√∫√√‡∑“Õ“°“√‡©æ“–∑’Ë

‡Õ° “√Õ“â ßÕß‘

1. National Comprehensive Cancer Network. Practice Guidelines in oncology. Non Small
Cell Lung Cancer version 1, 2004 www.nccn.org Accessed 1 July 2004.

2. National Comprehensive Cancer Network. Practice Guidelines in oncology. Small Cell Lung
Cancer version 1, 2004 www.nccn.org Accessed 1 July 2004.

3. National Cancer Institute. Non small cell lung treatment. www.cancer.gov Accessed
29 September 2003.

4 National Cancer Institute. small cell lung treatment. www.cancer.gov Accessed
29 September 2003.

5. Pfister DG, Johnson DH, Azzoli CG, Sause w, Smith TJ, Jr SB, Olak J, Stover D,
Strawn JR, Turrisi AT and Somerfield MR. American Society of Clinical Oncology
Treatment of Unresectable Non-Small-Cell Lung Cancer Guideline: Update 2003.

* ·π«∑“ß°“√„™√â —ß √’ °— …“π®’È ¥— ∑”¢È÷πµ“¡¢âÕ √ªÿ ¢Õß NCCN, NCI, ASCO µ“¡‡Õ° “√Õ“â ßÕ‘ß·π∫∑“â ¬ °“√π”·π«∑“ßπÈ’
‰ª„™â„π∑“ߪؑ∫—µ‘µâÕ߇ªìπ‰ªµ“¡§«“¡‡À¡“– ¡°—∫ ∂“π°“√≥å·≈–§«“¡æ√âÕ¡¢Õß ∂“π欓∫“≈·µà≈–·Ààß

·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 31

·π«∑“ß

°“√√°— …“¥«â ¬¬“‡§¡∫’ ”∫¥—
„πºâªŸ «É ¬‚√§¡–‡√Áߪե

™π‘¥ Non-Small Cell Lung Cancer (NSCLC)

®¥— ∑”‚¥¬ ¡–‡√ßÁ «‘∑¬“ ¡“§¡·Àßà ª√–‡∑»‰∑¬
§≥–Õπÿ°√√¡°“√º®Ÿâ ¥— ∑”

æ≠. °π°æ√ „® ∂“æ√ æ.Õ.æ≠.  “«µ‘ √’ ‡¡“ðï ≈ÿ ‰æ‚√®πå
æ≠. ®“√ÿ«√√≥ ‡Õ°«—≈≈¿ æ≠.  √‘ ‘°ÿ≈ »√ƒ∑∏‘™‘ß™—¬
πæ. ™—¬¬∑ÿ ∏ ‡®√≠‘ ∏√√¡ æ≠.  ÿ¥ «“∑ ‡≈“À«π‘ ®‘
πæ. ≥√ߧ»å °— ¥‘Ï ‡°’¬√µ‘¢®√∏“¥“ ».æ≠.  ¡ÿ ‘µ√“ ∑Õߪ√–‡ √‘∞
πæ. π¿¥≈ ‚ ¿“√—µπ“‰æ»“≈ πæ. Õ“§¡ ‡™’¬√»‘≈ªá
πæ. ‰æ‚√®πå  π‘ ≈“√µ— πå æ≠. Õÿ¥¡≈—°…≥å ‡®πæ“𑙬å
πæ. «™‘ ‘µ Õ“¿√≥å«‘√µ— πå

32 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

·π«∑“ß°“√√°— …“¥â«¬¬“‡§¡’∫”∫—¥„πºâªŸ É«¬‚√§¡–‡√Áߪե
™π‘¥ Non-Small Cell Lung Cancer

°“√√—°…“‚√§¡–‡√Áߪե™π¥‘ Non-small cell lung cancer (NSCLC) „π√–¬–·√° (√–¬–∑’Ë I ·≈–
II) ·≈–√–¬–∑’Ë IIIA ∫“ß°≈ÿà¡∑Ë’ºà“µ—¥‰¥âæ∫«à“ °“√ºà“µ—¥∂◊Õ‡ªìπ°“√√—°…“À≈—°„πºâŸªÉ«¬°≈àÿ¡π’È ·µàº≈°“√
√—°…“‰¡à¥’‡∑à“∑’˧«√®–¡’°“√°≈—∫¡“¢Õß‚√§À≈—ß°“√ºà“µ—¥1 ®÷ß¡’°“√𔬓‡§¡’∫”∫—¥¡“„™â√à«¡„π°“√√—°…“
‚¥¬·∫ßà ‡ªπì °“√„À⬓‡§¡∫’ ”∫—¥‡ √¡‘ À≈ß— °“√ºà“µ—¥§Õ◊ çAdjuvant chemotherapyé ·≈–°“√„À⬓‡§¡∫’ ”∫—¥
‡ √¡‘ °Õà πºà“µ¥— §Õ◊ çNeoadjuvant chemotherapyé ‡æËÕ◊ ‡æ‘Ë¡Õ—µ√“°“√√Õ¥™’«‘µ¢ÕߺªŸâ «É ¬ NSCLC

 ”À√∫— ‚√§¡–‡√ßÁ ªÕ¥ NSCLC √–¬– IIIA ∑’˺“à µ¥— ‰¡‰à ¥â (N2 disease) ·≈–√–¬– IIIB ´÷Ëߺ“à µ—¥‰¡à
‰¥â ‰¥¡â °’ “√π”‡Õ“¬“‡§¡’∫”∫¥— ¡“„™√â °— …“√à«¡°—∫√ß—  √’ °— …“§◊Õ chemoradiation

¡–‡√ßÁ ªÕ¥ NSCLC √–¬–∑Ë’ IV À√Õ◊ √–¬–·æ√à°√–®“¬π—Èπ®¥ÿ ª√– ß§¢å Õß°“√√°— …“§Õ◊ °“√ª√–§∫—
ª√–§Õß ¬“‡§¡’∫”∫—¥¡∫’ ∑∫“∑„πºŸªâ É«¬√–¬–∑’Ë IV ´÷Ëß¡’ ¿“æ√à“ß°“¬¬ß— ·¢ßÁ ·√ßæÕ§«√§◊Õ¡’ performance
status (PS) 0-1

∫∑§«“¡π®È’ –°≈à“«∂÷ß∫∑∫“∑¢Õ߬“‡§¡∫’ ”∫¥— „πºŸªâ É«¬‚√§¡–‡√ßÁ ªÕ¥ NSCLC

™π¥‘ ¢Õߧ”·π–π” ( Categories of Consensus )

·π«∑“߇«™ªØ‘∫—µ‘ ”À√—∫°“√®—¥∑”§Ÿà¡◊Õ·π«∑“ß°“√¥Ÿ·≈ºŸâªÉ«¬‚√§¡–‡√Áß ∑’˧≥–∑”ß“πœ
‰¥â®—¥∑”¢È÷ππÈ—π ¬÷¥∂◊ÕæÈ◊π∞“π®“°°“√»÷°…“ «‘®—¬ ·≈–§«“¡‡ÀÁπæâÕߢÕߧ≥–ºâŸ‡™’ˬ«™“≠ ‚¥¬™π‘¥¢Õß
§”·π–π”ª√–°Õ∫¥«â ¬ 2  «à πª√–°Õ∫∑Ë’ ”§≠— §◊Õ√–¥—∫§«“¡¡Ë—π„®¢ÕßÀ≈—°∞“π (strength of evidence)
·≈–√–¥∫— §«“¡‡ÀπÁ À√Õ◊ ©—π∑“¡µ‘ (consensus) ¢Õߧ≥–º‡âŸ ™Ë¬’ «™“≠ ¥ß— πÈ’

™π¥‘ ¢Õß §≥ÿ ¿“æ¢ÕßÀ≈—°∞“π √–¥—∫§«“¡‡ÀπÁ À√◊Õ©π— ∑“¡µ‘¢Õß
§”·π–π” §≥–ºâŸ‡™¬Ë’ «™“≠
 ßŸ
1 µ”Ë °«à“ ∑‘»∑“߇¥’¬«°π—
2A µË”°«à“ ∑»‘ ∑“߇¥’¬«°π—
2B ‰¡à¡’ ‰¡à‰ª„π∑»‘ ∑“߇¥¬’ «°—π
3 ¡§’ «“¡‡ÀπÁ ¢¥— ·¬âß¡“°

™π‘¥§”·π–π” 1 : §”·π–π”√–¥—∫π’È ‰¥â®“°À≈—°∞“π§ÿ≥¿“æ Ÿß (‡™àπ ®“° randomized clinical trial
À√◊Õ meta-analysis) √à«¡°—∫§≥–ºâŸ‡™’ˬ«™“≠¡’©—π∑“¡µ‘„π∑‘»∑“߇¥’¬«°—π
‚¥¬ºŸâ‡™’ˬ«™“≠ à«π¡“° π—∫ πÿ𧔷π–π”πÈ’ ·≈–Õ“®¡’ºŸâ‡™’ˬ«™“≠∫“ß∑à“π‰¡àÕÕ°
§«“¡‡ÀÁπ

·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 33

™π‘¥§”·π–π” 2A : §”·π–π”√–¥—∫π’È ‰¥â®“°À≈—°∞“π∑’Ë¡’§ÿ≥¿“æ ∑’˵”Ë °«à“™π‘¥§”·π–π” 1
(‡™àπ®“°°“√»÷°…“ phase II À√◊Õ°“√»÷°…“™π‘¥ Cohort ¢π“¥„À≠à À√◊Õ
ª√– ∫°“√≥åºâŸ‡™Ë’¬«™“≠À√◊Õ retrospective studies ®“°ª√– ∫°“√≥å°“√√—°…“
ºâŸªÉ«¬®”π«π¡“°¢Õߺ⟇™’ˬ«™“≠) √à«¡°—∫§≥–ºŸâ‡™’ˬ«™“≠¡’©—π∑“¡µ‘„π∑‘»∑“ß
‡¥’¬«°—π

™π¥‘ §”·π–π” 2 B : §”·π–π”√–¥∫— π‰’È ¥®â “°À≈°— ∞“π∑¡’Ë §’ ≥ÿ ¿“æµË”°«“à 1 À√Õ◊ 2 A ·≈– §≥–º‡Ÿâ ™¬’Ë «™“≠
¡’§«“¡‡ÀÁπ‰¡à‰ª„π∑‘»∑“߇¥’¬«°—π «à“§”·π–π”πÈ’§«√𔉪„™â§”·π–π”π’ÈÀ≈—°∞“π
‰¡à “¡“√∂ √ªÿ ‰¥â ‚¥¬·µà≈– ∂“∫π— Õ“®¡’«‘∏’°“√√°— …“·µ°µ“à ß°π— ‰¥â ∂ß÷ ·¡â§«“¡
‡ÀπÁ ¢Õߧ≥–º‡Ÿâ ™¬Ë’ «™“≠‰¡‰à ª„π∑»‘ ∑“߇¥¬’ «°π— ·µ‰à ¡¡à §’ «“¡‡ÀπÁ ∑¢Ë’ ¥— ·¬ßâ °π— Õ¬“à ß
¡“° ¥—ßπ—Èπ™π‘¥§”·π–π” 2B ºŸâª√–°Õ∫«‘™“™’懫™°√√¡Õ“® “¡“√∂
‡≈◊Õ°«∏‘ ª’ Ø∫‘ —µ‰‘ ¥â¡“°°«“à 1 «‘∏¢’ π÷È °—∫À≈—°∞“π∑“ߧ≈π‘ °‘ ∑Ë¡’ ’

™π¥‘ §”·π–π” 3 : §”·π–π”√–¥—∫π’È §≥–º‡Ÿâ ™Ë’¬«™“≠¡§’ «“¡‡ÀπÁ ¢¥— ·¬âß¡“° ´ß÷Ë §”·π–π”√–¥∫— 3 π’È
µÕâ ß¡º’ Ÿ‡â ™¬Ë’ «™“≠¡“°°«à“À√Õ◊ ‡∑à“°∫— 2 §π ‡ÀπÁ æâÕß„π§”·π–π” §«“¡¢—¥·¬ßâ „π
§«“¡‡ÀÁπÀ√◊Õ§”·π–π”π’ÈÕ“®‡°‘¥®“°À≈—°∞“π∑Ë’‰¥âπ—Èπ¬—߉¡à‰¥â¡’°“√‡ª√’¬∫‡∑’¬∫
‚¥¬ randomized trial ¥—ßπÈ—π™π‘¥§”·π–π”√–¥—∫ 3 ºâŸª√–°Õ∫«‘™“™’懫™°√√¡
§«√æ‘®“√≥“¢Õâ ¡≈Ÿ „π∫∑§«“¡ ´ß÷Ë ®–°≈à“«∂÷ߧ«“¡§‘¥‡ÀÁπ∑·’Ë µ°µ“à ß°—π

1. ·π«∑“ß°“√√—°…“¥â«¬¬“‡§¡∫’ ”∫¥— „πºâŸªÉ«¬‚√§¡–‡√ßÁ ªÕ¥ NSCLC

√–¬–∑Ë’ I [IA (T1N0M0), IB (T2N0M0)]
1.1 Adjuvant chemotherapy „πºŸâª«É ¬ NSCLC √–¬–∑’Ë I

„π√–¬–·√°°“√»÷°…“ Randomized control trial ‚¥¬„™â cisplatin based-chemotherapy
„πºâªŸ «É ¬√–¬–∑’Ë I-III √«¡∑ßÈ— meta-analysis ¢Õß°“√»°÷ …“ adjuvant chemotherapy æ∫«à“ª√–‚¬™π¢å Õß
adjuvant chemotherapy ‰¡à™¥— ‡®π 2-5

°“√»÷°…“„π√–¬–À≈ß— æ∫«à“∫∑∫“∑¢Õß adjuvant chemotherapy „πºâªŸ «É ¬√–¬–∑Ë’ I ‡√‘¡Ë ¡∫’ ∑∫“∑¡“°
¢È÷π¥—ß°“√»÷°…“ Randomized phase III adjuvant chemotherapy ¥â«¬¬“ UFT „πºâŸªÉ«¬√–¬–∑’Ë I æ∫«à“
ºŸâªÉ«¬√–¬–∑’Ë IB ¡’Õ—µ√“°“√√Õ¥™’«‘µ∑Ë’ 5 ªï ‡æ‘Ë¡¢È÷πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘6 ·≈–®“°°“√»÷°…“¢Õß
International Adjuvant Lung Cancer Trial (IALT) ¥«â ¬¬“ Cisplatin-based chemotherapy „πºªâŸ «É ¬ NSCLC
√–¬–∑’Ë I- III æ∫«“à Õ—µ√“°“√√Õ¥™’«µ‘ ∑Ë’ 5 ªï ‡æ¡‘Ë ¢Èπ÷ (44.5% vs 40%, p < 0.03)7 °“√»°÷ …“ Adjuvant
chemotherapy ¥â«¬¬“ paclitaxel ·≈– carboplatin „πºŸâªÉ«¬√–¬–∑Ë’ IB8 ·≈–°“√»÷°…“ Adjuvant
chemotherapy ¥«â ¬¬“ vinorelbine ·≈– cisplatin „πºâŸª«É ¬ NSCLC √–¬–∑Ë’ IB ·≈– II ‚¥¬ Intergroup
JBR109 √«¡∑È—ß°“√»÷°…“„πºŸâªÉ«¬ NSCLC √–¬–∑Ë’ I-III Adjuvant Navelbine International Trialist
Association (ANITA)10 æ∫«à“ adjuvant chemotherapy ™à«¬‡æ‘Ë¡°“√√Õ¥™’«‘µÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘
Õ¬à“߉√°Áµ“¡°“√»÷°…“ subgroup analysis æ∫«“à ºªâŸ «É ¬√–¬–∑’Ë I ∑’ˉ¥â Adjuvant vinorelbine ·≈– cisplatin
‰¡‡à æ¡Ë‘ °“√Õ¬àŸ√Õ¥ ¢≥–∑ºË’ ⪟ «É ¬√–¬–∑’Ë II ·≈– III ¡’Õ—µ√“°“√√Õ¥™’æ‡æË¡‘ ¢È÷π 9,10

34 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

Õ¬“à ߉√°µÁ “¡°“√»÷°…“ Randomized study ∂÷ß∫∑∫“∑¢Õß Adjuvant chemotherapy „πºªâŸ É«¬
√–¬– I, II ·≈– IIIA ¥«â ¬¬“ cisplatin-based chemotherapy ‚¥¬°≈¡ÿà Adjuvant Lung Project Study 11 ·≈–
The Big Lung Trial12 ‰¡æà ∫«“à Adjuvant chemotherapy ‡æË¡‘ √–¬–°“√√Õ¥™«’ ‘µ

°“√»÷°…“ meta-analysis „π√–¬–À≈—ß‚¥¬»÷°…“∂÷ß∫∑∫“∑¢Õß Adjuvant chemotherapy
°≈—∫æ∫«à“ Adjuvant chemotherapy ¥â«¬ cisplatin-based chemotherapy ·≈– UFT ¡’ª√–‚¬™πå„π°“√
‡æ‘¡Ë √–¬–‡«≈“°“√√Õ¥™’æÕ¬“à ß¡π’ ¬—  ”§≠— ∑“ß ∂µ‘ ‘ (p = 0.012 ·≈– p = 0.015)13

§”·π–π”
·π–π”„Àâ„™â Adjuvant chemotherapy „πºâªŸ «É ¬ NSCLC √–¬–∑’Ë IB (T2N0M0)

™π‘¥¢Õߧ”·π–π” 2A
1.2 Neoadjuvant chemotherapy „πºªâŸ «É ¬ NSCLC √–¬–∑Ë’ I
°“√»÷°…“ Neoadjuvant chemotherapy „πºâŸªÉ«¬√–¬–∑’Ë I ππ—È ¡’·µà°“√»°÷ …“„πºâŸª«É ¬√–¬– IB
‚¥¬»÷°…“√à«¡°—∫ºŸâªÉ«¬√–¬–∑’Ë II ·≈– IIIA14-17 ·µàº≈°“√»÷°…“·∫∫ àÿ¡®“°°“√»÷°…“¢Õß Depierre14
‡ªπì °“√»°÷ …“‡¥¬’ «∑¡’Ë ·’ π«‚π¡â «“à °“√„Àâ Neoadjuvant chemotherapy ®–‡æ¡Ë‘ °“√√Õ¥™«’ µ‘ „πºªŸâ «É ¬√–¬–∑’Ë IB
·≈– II
§”·π–π”

‰¡·à π–π”„Àâ„™â Neoadjuvant chemotherapy „πºâªŸ «É ¬ NSCLC √–¬–∑’Ë I
™π‘¥¢Õߧ”·π–π” 2A

2. ·π«∑“ß°“√√—°…“¥â«¬¬“‡§¡∫’ ”∫—¥„πºŸâªÉ«¬‚√§¡–‡√ßÁ ªÕ¥ NSCLC √–¬–∑Ë’ II
[IIA(T1N1M0), IIB (T1N1M0, T3N0M0)]

2.1 Adjuvant chemotherapy „πºâŸª«É ¬ NSCLC √–¬–∑’Ë II ®“°°“√»÷°…“∫∑∫“∑¢Õß Adjuvant
chemotherapy „πºŸâªÉ«¬√–¬–∑’Ë II ‚¥¬ Randomized control trial ·≈– meta-analysis ∫“ß°“√
»÷°…“æ∫«à“‰¡à‡æ‘Ë¡Õ—µ√“°“√√Õ¥™’«‘µ 2,5,11,12 ·µàº≈°“√»÷°…“„π√–¬–À≈—ßæ∫«à“ Adjuvant chemotherapy
‚¥¬ cisplatin based chemotherapy7 ·≈– vinorelbine ·≈– cisplatin9,10  “¡“√∂‡æË‘¡√–¬–°“√√Õ¥™’«‘µ
Õ¬“à ß¡π’ ¬—  ”§≠— ∑“ß ∂µ‘ ‘ ´ß÷Ë  π∫—  ππÿ ‚¥¬°“√»°÷ …“ meta-analysis ¢Õß°“√»°÷ …“ Adjuvant chemotherapy
„π√–¬–À≈—ß13

§”·π–π”
·π–π”„À„â ™â Adjuvant chemotherapy „πºâªŸ É«¬ NSCLC √–¬–∑Ë’ II

™π¥‘ ¢Õߧ”·π–π” 1
2.2 Neoadjuvant chemotherapy „πºŸªâ É«¬ NSCLC √–¬–∑Ë’ II ‡™àπ‡¥¬’ «°∫— ºŸªâ É«¬√–¬–∑’Ë I ¢âÕ¡≈Ÿ
∑Ë’ π—∫ ππÿ ∫∑∫“∑¢Õß Neoadjuvant chemotherapy„π°“√‡æ¡‘Ë √–¬–°“√√Õ¥™«’ ‘µ¬ß— ¡’πÕâ ¬14-17
§”·π–π”

‰¡·à π–π”„Àâ„™â Neoadjuvant chemotherapy „πºâªŸ «É ¬ NSCLC √–¬–∑Ë’ II

™π‘¥¢Õߧ”·π–π” 2A

·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548 35

3. ·π«∑“ß°“√√°— …“¥«â ¬¬“‡§¡∫’ ”∫¥— „πºâŸª«É ¬‚√§¡–‡√Áߪե NSCLC √–¬–∑Ë’ III

ºâŸªÉ«¬√–¬–∑Ë’ III ·∫ßà ÕÕ°‡ªìπ IIIA ·≈– IIIB √–¬– IIIA ª√–°Õ∫¥«â ¬ºªŸâ É«¬ T3N1 ·≈–ºŸâª«É ¬∑’¡Ë ’
°“√°√–®“¬¢Õß‚√§‰ª¬ß— mediastinal lymph nodes ¢“â ߇¥¬’ «°∫— primary tumor (N2) §◊Õ T 1-3 N2 ´ß÷Ë
ºâªŸ «É ¬∑¡’Ë ’ N2 Õ“®ºà“µ—¥‰¥âÕÕ°‰¥âÀ¡¥ (Incidental ·≈– Potential resectable N2) À√Õ◊ º“à ‰¡‰à ¥â (bulky N2)

ºŸâªÉ«¬√–¬– IIIB ª√–°Õ∫¥â«¬°≈àÿ¡ N3 À√◊Õ T4 ‰¥â·°à T4 N0-2 M0 ·≈– T1-4 N3 M0
°≈àÿ¡∑¡Ë’ ’ N3 ‰¡ à “¡“√∂ºà“µ—¥ÕÕ°‰¥âÀ¡¥ ·≈–°≈¡àÿ IIIB ∑Ë’¡’ malignant pleural effusion (T4) ´Ëß÷ ¡·’ π«∑“ß
°“√√°— …“‡™àπ‡¥¬’ «°—∫√–¬–∑’Ë IV (M1 disease)

·π«∑“ß°“√√—°…“ºŸâªÉ«¬¥â«¬¬“‡§¡’∫”∫—¥„πºâŸªÉ«¬ NSCLC √–¬–∑’Ë III ®÷ß·∫àßµ“¡ºŸâªÉ«¬
‚¥¬·∫ßà ÕÕ°‡ªìπ 4 °≈ÿ¡à ¥ß— πÈ’

°≈à¡ÿ ∑Ë’ 1 ºâŸªÉ«¬ T3N1M0 ·≈–ºŸâªÉ«¬∑’ˉ¡à‰¥â√—∫°“√«‘π‘®©—¬«à“¡’ N2 disease ·µà¡“æ∫
À≈ß— °“√ºà“µ¥— «à“‡ªìπ N2 disease À√◊Õ Incidental N2

°≈àÿ¡∑’Ë 2 ºâªŸ É«¬√–¬– IIIA ∑’ˉ¥â√—∫°“√«π‘ ‘®©¬— «à“¡’ N2 disease ®“° CT scan ·≈–¡’·π«‚π¡â «à“
 “¡“√∂ºà“µ—¥ÕÕ°‰¥âÀ¡¥ (Potential resectable N2 disease)

°≈¡ÿà ∑’Ë 3 ºŸâªÉ«¬ locally advanced disease ´Ë÷ß unresectable §◊Õ√–¬– IIIA ∑’Ë¡’ bulky N2
disease ·≈–√–¬– IIIB ∑¡Ë’ ’ N3 disease

°≈ÿà¡∑’Ë 4 ºâŸªÉ«¬√–¬– IIIB ∑’Ë¡’ pleural effusion (T4) ´Ë÷ß·π«∑“ß°“√√—°…“‡À¡◊Õπ°—∫ºâŸªÉ«¬
√–¬–∑Ë’ IV (¥·Ÿ π«∑“ß°“√√—°…“„πºªŸâ «É ¬√–¬–∑Ë’ IV)

3.1 °≈¡àÿ ∑Ë’ 1 ºªŸâ É«¬√–¬– IIIA: T3N1M0 À√Õ◊ incidental N2 disease ∑ˉ’ ¥â√∫— °“√ºà“µ—¥°Õà π
¡’·π«∑“ß°“√√°— …“¥—ßπÈ’

3.1.1 Adjuvant chemotherapy
®“°°“√»°÷ …“ Randomized control trial „πºªâŸ É«¬ NSCLC √–¬–∑’Ë I, II, III ´÷ßË ‰¥â√∫—

adjuvant chemotherapy ¥â«¬ cisplatin based chemotherapy7 À√◊Õ vinorelbine ·≈– cisplatin10
·≈– meta-analysis ∑«’Ë ‘‡§√“–Àå∂ß÷ ∫∑∫“∑¢Õß adjuvant chemotherapy13 „πªï §». 2004 æ∫«à“ adjuvant
chemotherapy “¡“√∂‡æ¡‘Ë Õµ— √“°“√√Õ¥™«’ µ‘ Õ¬“à ß¡π’ ¬—  ”§≠— Õ¬“à ߉√°µÁ “¡¡°’ “√»°÷ …“∫“ß°“√»°÷ …“∑æ’Ë ∫«“à
Adjuvant chemotherapy ‰¡‡à æ¡‘Ë √–¬–‡«≈“°“√Õ¬Ÿà√Õ¥2,5,11,12

§”·π–π”
·π–π”„Àâ„™â Adjuvant chemotherapy „πºŸâªÉ«¬ NSCLC √–¬–∑Ë’ IIIA

™π¥‘ §”·π–π” 1

36 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

3.1.2 Adjuvant combination chemoradiotherapy
°“√»÷°…“∂÷ߺ≈¢Õß adjuvant radiotherapy æ∫«à“ “¡“√∂≈¥ local recurrence

‰¥â·µ°à “√‡æ‘Ë¡√–¬–‡«≈“°“√√Õ¥™æ’ ‰¡à™¥— ‡®π18-20
°“√»°÷ …“∂÷ߺ≈°“√„Àâ chemotherapy √à«¡°∫— radiation ‡ √¡‘ À≈ß— °“√ºà“µ¥— æ∫«“à

‰¡‰à ¥â™à«¬„ÀâÕµ— √“Õ¬àŸ√Õ¥¢Õߺ⟪ɫ¬¥¢’ È÷π21-23
§”·π–π”
‰¡·à π–π”„Àâ„™â Adjuvant chemoradiation „πºªŸâ «É ¬ NSCLC √–¬– ∑Ë’ IIIA
™π‘¥§”·π–π” 1

3.2 °≈ÿà¡∑Ë’ 2 ºªâŸ É«¬√–¬– IIIA : Potential resectable N2 disease ¡·’ π«∑“ß°“√√—°…“¥ß— πÈ’
3.2.1 Neoadjuvant chemotherapy µ“¡¥â«¬°“√ºà“µ—¥
°“√„Àâ neoadjuvant chemotherapy ¡’ª√–‚¬™πå„π°“√≈¥¢π“¥¢Õß°âÕπ‡π◊ÈÕßÕ°

„Àâºà“µ—¥‰¥ â ¡∫√Ÿ ≥å¢πÈ÷ ≈¥ micrometastasis ·≈–≈¥ surgical seeding ¢âÕ‡ ’¬§◊Õ ∑”„À°â “√ºà“µ¥— µÕâ ߇≈ÕË◊ π
ÕÕ°‰ª ·≈–‡æË¡‘ ª≠í À“·∑√°´Õâ π®“°°“√ºà“µ—¥ ®“°°“√»÷°…“¢Õß Rosell ·≈–§≥–24 ·≈– Roth ·≈–§≥–25
´Ë÷ß¡’ºŸâªÉ«¬ 60 √“¬„π·µà≈–°“√»÷°…“æ∫«à“°“√„Àâ Neoadjuvant chemotherapy ™à«¬∑”„ÀâÕ—µ√“°“√
Õ¬√àŸ Õ¥¥¢’ ÷Èπ°«à“°“√º“à µ—¥Õ¬“à ߇¥’¬« „π¢≥–∑°’Ë “√»÷°…“®“° Depierre ·≈–§≥–14 ´ß÷Ë √«¡ºâªŸ «É ¬√–¬–∑’Ë I, II
·≈– IIIA ¥«â ¬°—πÀ¡¥ ·≈–∑” subset analysis æ∫«à“ºâŸªÉ«¬√–¬–∑Ë’ N0, N1 ¡’Õµ— √“°“√√Õ¥Õ¬à√Ÿ Õ¥®“°°“√
√—°…“ Neoadjuvant chemotherapy ¥’°«“à °“√ºà“µ—¥Õ¬“à ߇¥¬’ « ·µà„π°≈àÿ¡ √–¬– IIIA ª√–°Õ∫¥â«¬ºâªŸ «É ¬ 92
√“¬¢Õß chemotherapy-surgery ·≈– 75 √“¬ ¢Õß surgery-only º≈¢Õß°“√√—°…“‰¡à‰¥â·µ°µà“ß°—π
·≈–„π°“√»°÷ …“∑ßÈ— 3√“¬°“√¥ß— °≈“à «¡º’ ªâŸ «É ¬∫“ß «à π∑‰’Ë ¥√â ∫— √ß—  √’ °— …“‡ √¡‘ √«à ¡¥«â ¬πÕ°‡ÀπÕ◊ ®“°°“√º“à µ¥—
ÕπË÷ß°“√ºà“µ—¥¡–‡√Áߪե¿“¬À≈—ß Neoadjuvant chemotherapy æ∫«à“°“√ºà“µ—¥‰¡à‰¥â‡°‘¥ª√–‚¬™πåµàÕ
ºâªŸ «É ¬∂Ⓣ¡ à “¡“√∂º“à µ—¥ÕÕ°‰¥Àâ ¡¥·≈–‰¡§à «√∑” debulking ‡æ√“–‰¡‰à ¥â™«à ¬„Àâ°“√Õ¬√àŸ Õ¥¥’¢Èπ÷

§”·π–π”
1. ºªâŸ «É ¬√–¬– IIIA §«√Õ¬„àŸ π‚§√ß°“√«®‘ ¬— ∂“â ‡ªπì ‰ª‰¥Àâ √Õ◊ „À°â “√√°— …“¥«â ¬ bimodality

À√◊Õ trimodality ¥’°«à“°“√ºà“µ¥— Õ¬“à ߇¥’¬«
™π‘¥§”·π–π” 2A
2. „π°√≥’∑Ë’ºà“µ—¥·≈⫬—߇À≈◊Õ residual tumor or residual nodal disease

ºŸâª«É ¬§«√‰¥√â ∫— postoperative radiotherapy
™π¥‘ §”·π–π” 2A

·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548 37

3.2.2 Concurrent chemoradiotherapy √à«¡°∫— °“√º“à µ¥—
º≈°“√»÷°…“ Southwest Oncology Group26 ·≈– Bueno ·≈–§≥–27 ∫àß«à“Õ—µ√“°“√Õ¬àŸ
√Õ¥„πºâªŸ É«¬∑’‰Ë ¥â√∫— chemoradiotherapy √à«¡¥â«¬„Àâº≈¥°’ «“à °“√º“à µ—¥Õ¬à“߇¥¬’ « ·µàºâŸª«É ¬∑¡’Ë ’‡´≈≈å¡–‡√Áß
À≈߇À≈Õ◊ Õ¬à„Ÿ πµàÕ¡π”È ‡À≈◊ÕßÀ≈ß— ®“° induction therapy ¡Õ’ —µ√“°“√Õ¬à√Ÿ Õ¥µ”Ë ¡“° (median survival 10
months, 5-year survival 9%) ‡¡ÕË◊ ‡ª√¬’ ∫‡∑¬’ ∫°∫— °≈¡àÿ ∑‰Ë’ ¡‡à À≈Õ◊ √Õ¬‚√§‡≈¬ (complete pathologic clearing
of residual disease) ∑ß—È  Õß√“¬ß“π„À§â «“¡‡ÀπÁ «“à °“√º“à µ¥— À≈ß— ®“°°“√„Àâ concurrent chemoradiotherapy
„πºªŸâ «É ¬∑¡Ë’ ’ residual nodal disease (æ ‘ ®Ÿ π‚å ¥¬°“√∑” biopsy) ‰¡‰à ¥∑â ”„ÀÕâ µ— √“°“√Õ¬√àŸ Õ¥¥¢’ πÈ÷ °“√»°÷ …“¢Õß
Rusch ·≈–§≥–28 ´÷Ë߇ªπì phase III study (Intergroup 0139, RTOG 9309) „πºªŸâ É«¬√–¬– IIIA (N2)
‚¥¬‡√Ë‘¡„Àâ induction chemoradiatherapy ·≈–·∫àߺ⟪ɫ¬ÕÕ°‡ªìπ Õß°≈àÿ¡§◊Õºà“µ—¥ À√◊Õ„Àâ√—ß ’√—°…“µàÕ
ºŸâª«É ¬∑ßÈ—  Õß°≈ÿࡉ¥â√—∫ adjuvant chemotherapy µàÕ®π§√∫µ“¡°”Àπ¥ ºŸªâ «É ¬∑Ë’‰¥√â —∫°“√ºà“µ¥— ¡’ progres-
sion free survival ¥’°«“à °≈¡ÿà ∑’ˉ¡‰à ¥â√—∫°“√º“à µ¥— ·µà overall survival ‰¡à‰¥â·µ°µ“à ß°π— √–À«“à ߺªâŸ «É ¬ 2 °≈ÿà¡
§”·π–π”

ºâŸªÉ«¬√–¬– IIIA ∑’¡Ë ’ Performance Status (PS) ¥’ ∂÷ß·¡«â “à ®–¡·’ π«‚π¡â «“à  “¡“√∂
º“à µ—¥ÕÕ°‰¥â °“√√—°…“‚¥¬ induction chemoradiotherapy √«à ¡¥«â ¬ „Àºâ ≈¥°’ «“à °“√ºà“µ¥— Õ¬“à ߇¥¬’ «

™π¥‘ §”·π–π” 2A

3.3 °≈ÿà¡∑Ë’ 3 Locally advanced disease √–¬– IIIA (Bulky N2) ·≈–√–¬– IIIB (N3)
¡’·π«∑“ß°“√√°— …“¥—ßπÈ’

3.3.1 Combined chemotherapy with radiation (sequential chemotherapy followed by
radiation) ¬“‡§¡’∫”∫¥— ∑¡Ë’ ’°“√»°÷ …“¡“°∑ Ë’ ¥ÿ ·≈–‰¥âº≈¥’§Õ◊ cisplatin based combination CALGB29 ‰¥â
∑”°“√»÷°…“ sequential chemotherapy followed by radiotherapy (CT/RT) ‡ª√’¬∫‡∑’¬∫°∫— radiotherapy
(RT) Õ¬à“߇¥’¬« æ∫«à“°≈àÿ¡∑Ë’„Àâ°“√√—°…“ CT/RT ¡’Õ—µ√“°“√Õ¬àŸ√Õ¥∑Ë’ 2 ªï ·≈– 5 ªï¥’°«à“
RT Õ¬“à ߇¥¬’ «Õ¬“à ß¡π’ —¬ ”§—≠ (2- year = 26% vs 13% and 5-year = 13% vs 6%) Le Chevalier ·≈–
§≥–30 ‰¥â∑”°“√»÷°…“∑”πÕ߇¥’¬«°—π·≈–‰¥âº≈°“√√—°…“‡™àπ‡¥’¬«°—π πÕ°®“°π’È meta-analysis 3
©∫—∫5,31,32 ‰¥â√“¬ß“π∂÷ßÕ—µ√“°“√Õ¬Ÿà√Õ¥¢Õߺ⟪ɫ¬ locally advanced, unresectable NSCLC ∑Ë’‰¥â√—∫
platinum-based chemotherapy √à«¡°—∫√—ß ’√—°…“æ∫«à“¥’°«à“ºâŸªÉ«¬∑’Ë„Àâ√—ß ’√—°…“Õ¬à“߇¥’¬« ‡ªìπ
∑’Ë —߇°µ«à“ºâŸªÉ«¬∑Ë’∑”°“√»÷°…“π’È„π∑ÿ°√“¬ß“π‰¥â§—¥‡≈◊Õ°‡©æ“–ºŸâ∑’Ë¡’ PS ECOG 0-1 √à«¡°—∫¡’π”È Àπ—°
≈¥‡æ¬’ ߇≈Á°πÕâ ¬‡∑à“ππÈ— ®ß÷ ®– “¡“√∂∑πµàÕ°“√√—°…“π‰’È ¥â

3.3.2 Concurrent chemotherapy and radiotherapy ‰¥â¡’°“√»÷°…“‡ª√’¬∫‡∑’¬∫«à“
concurrent CT/RT ®–„Àâº≈°“√√—°…“¥°’ «à“ sequential CT/RT À√◊Õ‰¡à °“√»°÷ …“®“°ª√–‡∑»≠˪’ ÿÉπ33 ºâªŸ É«¬
320 √“¬æ∫«“à °“√√°— …“·∫∫ concurrent „Àºâ ≈¥°’ «“à ·∫∫ sequential ‚¥¬ 2-year survival 34.6% vs
27.4% ·≈– 5-year survival 15.8% vs 8.8% µ“¡≈”¥∫— º≈¢“â ߇§¬’ ߧ◊Õ ¡°’ “√°¥‰¢°√–¥°Ÿ ¡“°°«“à
RTOG study34 ´ß÷Ë ‡ªπì phase III trial ‡ª√¬’ ∫‡∑’¬∫√–À«à“ß concurrent vs sequential therapy æ∫«“à ºâŸª«É ¬
concurrent CT/RT ¡’ median survival ∑’Ë¥’°«à“ sequential CT/RT §◊Õ 17 ‡¥◊Õπ ·≈– 14.6 ‡¥◊Õπ
µ“¡≈”¥∫— ‡™àπ‡¥’¬«°∫— French cooperative group35 ´Ëß÷ „Àºâ ≈¢Õß median survival „π concurrent CT/RT

38 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

∑’Ë¥°’ «à“§◊Õ 15 ‡¥Õ◊ π ·≈– 13.8 ‡¥◊Õ𠵓¡≈”¥—∫ 2-year survival 35% ·≈– 23% µ“¡≈”¥—∫ ·µ°à ≈àÿ¡∑’Ë
‰¥√â ∫— concurrent CT/RT ¡º’ ≈·∑√°´Õâ π®“° grade 3-4 esophagitis 26% ¥ß— ππ—È ®ß÷ ·π–π”„À°â “√√°— …“·∫∫
concurrent CR/RT ‡©æ“–„πºŸâªÉ«¬∑’Ë¡’ PS 0-1 ‡∑à“πÈ—π Õ¬à“߉√°Áµ“¡ §«√¡’°“√»÷°…“‡æ‘Ë¡‡µ‘¡‡æ◊ËÕ
ª√–‡¡‘πº≈¢â“߇§¬’ ߢÕß concurrent CR/RT ‡ª√’¬∫‡∑’¬∫°π— „Àâ™—¥‡®π°«“à π’È „πª®í ®ÿ∫—𠉥¡â °’ “√»÷°…“¬“
„À¡à ‡™àπ paclitaxel, doxetaxel, gemcitabine √«à ¡°∫— √—ß ’√—°…“ ´ß÷Ë µÕâ ß√Õ phase III trial ÕÕ°¡“„Àâ™—¥‡®π
«à“§«√«“ß·ºπ°“√√—°…“ combination CR/RT ÕÕ°¡“„π√Ÿª·∫∫„¥ ·≈–¬“„¥∑’Ë®–„Àâº≈°“√√—°…“¥’
∑Ë’ ¥ÿ √«à ¡°—∫Õ“°“√¢â“߇§’¬ß∑Ë’µË” ¥ÿ

§”·π–π”
1. ºªâŸ É«¬¡–‡√ßÁ ªÕ¥ unresectable IIIA (Bulky N2) ·≈–√–¬– IIIB (N3) ∑Ë’¡’ PS 0-1

·π–π”„À„â ™â concurrent chemoradiation À√Õ◊ sequential chemotherapy √à«¡°—∫ radiation ‚¥¬ chemo-
therapy §«√‡ªìπ platinum-based

™π‘¥§”·π–π” 1
2. °√≥’∑’˺⪟ «É ¬„π¢Õâ 1 ¡’ PS >2 §«√„À√â ß—  √’ °— …“Õ¬à“߇¥¬’ «

™π‘¥§”·π–π” 2A
3.4 °≈à¡ÿ ∑Ë’ 4 ºâªŸ É«¬√–¬– IIIB ∑¡’Ë ’ malignant plerual effustion (T4) ·π«∑“ß°“√√°— …“
‡À¡◊ÕπºªŸâ «É ¬√–¬–∑Ë’ IV (¥·Ÿ π«∑“ß°“√√°— …“„πºªŸâ É«¬√–¬–∑’Ë IV)

4. ·π«∑“ß°“√√°— …“¥â«¬¬“‡§¡∫’ ”∫¥— „πºªâŸ É«¬‚√§¡–‡√Áߪե NSCLC √–¬–∑Ë’ IV

®“°°“√»÷°…“ Randomized trials ·≈– metaanalysis ∂ß÷ º≈¢Õß°“√√°— …“ºŸâªÉ«¬ NSCLC √–¬–∑Ë’
IV ∑’¡Ë ’ PS 0 À√Õ◊ 1 æ∫«à“¬“‡§¡’∫”∫¥— ™à«¬‡æË¡‘ Õµ— √“°“√√Õ¥™«’ ‘µ¢Õߺ⟪«É ¬‡¡◊ÕË ‡ª√’¬∫‡∑¬’ ∫°—∫°“√√°— …“
¥â«¬ Best supportive care (BSC) Õ¬à“ß¡’π—¬ ”§≠— ∑“ß ∂‘µ5‘ ,36-38 ·≈–æ∫«“à Platinum-based chemo-
therapy ™à«¬≈¥Õ—µ√“°“√‡ ’¬™’«‘µ√âÕ¬≈– 27 ‡∑’¬∫°—∫ BSC (HR 0.73%; 95% CI 0.63-0.85,
P <0.001)5

PS ¡’º≈µàÕ°“√√—°…“ºâŸªÉ«¬ NSCLC √–¬–∑’Ë IV ‚¥¬æ∫«à“ºâŸª«É ¬ PS 2 ‡°¥‘ º≈¢“â ߇§¬’ ß®“°°“√
√°— …“ Ÿß°«“à ·≈–¡Õ’ —µ√“°“√µÕ∫ πÕßµàÕ°“√√—°…“·≈–Õµ— √“°“√√Õ¥™’«µ‘ µË”°«“à ºªâŸ É«¬∑’Ë¡’ PS 0-139 - 42

°“√»÷°…“∂ß÷ º≈°“√√—°…“„πºªŸâ É«¬ NSCLC ∑Ë ’ ߟ Õ“¬ÿ (>70 ªï) æ∫«“à platinum based chemo-
therapy „πºâªŸ É«¬∑Ë¡’ ’ PS ¥’‰¥ºâ ≈‰¡·à µ°µà“ß°∫— ºŸªâ «É ¬Õ“¬ÿπÕâ ¬°«à“ 70 ª4ï 3-44 °“√»÷°…“∂÷ߺ≈¢Õ߬“‡¥¬Ë’ «
vinorelbine ‡ª√¬’ ∫‡∑¬’ ∫°∫— BSC („πºªâŸ «É ¬ ßŸ Õ“¬æÿ ∫«“à ºªâŸ «É ¬∑‰’Ë ¥¬â “‡¥¬Ë’ «¡√’ –¬–‡«≈“°“√√Õ¥™æ’ π“π°«“à
°≈¡ÿà ∑‰’Ë ¥â BSC45-46 ·≈–°“√»÷°…“‡ª√’¬∫‡∑’¬∫°“√√—°…“¥â«¬¬“‡§¡’∫”∫—¥µ—«‡¥’¬«§◊Õ¬“ vinorelbine À√◊Õ
gemcitabine ‡ª√¬’ ∫‡∑’¬∫°∫— °“√„™¬â “ 2 µ«— √à«¡°π— §◊Õ vinorelbine √«à ¡°∫— gemcitabine æ∫«à“°“√„™â¬“ 2
µ—«√«à ¡°π— ‰¡à‰¥™â «à ¬‡æË‘¡√–¬–‡«≈“°“√√Õ¥™æ’ ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°∫— °“√„™â¬“µ—«‡¥’¬«47

·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548 39

¬“ Third generation ‰¥â·°à Pacitaxel, Vinorelbine, Docetaxel, Gemcitabine ·≈– Irinotecan
¡°’ “√π”¡“»°÷ …“„π°“√√°— …“‚√§¡–‡√ßÁ ªÕ¥ NSCLC √–¬–∑Ë’ IV ‚¥¬„™‡â ªπì ¬“‡¥¬’ «À√Õ◊ °“√„™√â «à ¡°∫— Cisplatin
À√◊Õ Carboplatin ®“°°“√»÷°…“ prospective randomized study „πºâŸªÉ«¬ NSCLC √–¬–∑Ë’ III À√◊Õ IV
æ∫«à“°“√√°— …“¥«â ¬ Ÿµ√ Cisplatin √«à ¡°—∫ Paclitaxel, Gemcitabine √«à ¡°∫— Cispltain, Docetaxel √à«¡°—∫
Cisplatin À√◊Õ Paclitaxel √à«¡°—∫ Carboplatin ‰¡à¡’§«“¡·µ°µà“ß°—π„πÕ—µ√“°“√µÕ∫ πÕß·≈–√–¬–‡«≈“
°“√√Õ¥™’«µ‘ 39

®”π«π™¥ÿ ¢Õ߬“‡§¡∫’ ”∫¥— ∑§Ë’ «√„™®â “°°“√»°÷ …“‡ª√¬’ ∫‡∑¬’ ∫°“√√°— …“ºªŸâ «É ¬¥«â ¬¬“ Mitomycin/
Vinblastine Cisplatin (MIC) ®”π«π 3 ™ÿ¥ ‡ª√’¬∫‡∑’¬∫°—∫ 6 ™ÿ¥æ∫«à“ºŸâªÉ«¬∑—Èß 2 °≈àÿ¡¡’√–¬–‡«≈“
°“√√Õ¥™’æ·≈–§ÿ≥¿“æ™’«‘µ‰¡à·µ°µà“ß°—π48 Õ’°°“√»÷°…“‚¥¬ Socinski ·≈– §≥–49 ∑’ˇª√’¬∫‡∑’¬∫°“√
√—°…“¥«â ¬ Carboplatin √à«¡°∫— Paclitaxel ®”π«π 4 ™ÿ¥°—∫°“√„Àâ°“√√°— …“¥â«¬ Ÿµ√¬“‡¥’¬«°—π®π°«à“®–¡’
‚√§°”‡√∫‘ º≈°“√»÷°…“æ∫«à“°≈¡ÿà ∑Ë„’ Àâ°“√√°— …“®π°«“à ‚√§°”‡√‘∫‰¥â√∫— ¬“‚¥¬‡©≈¬Ë’ 4 ™¥ÿ ‡™πà °—π ‚¥¬°“√
√°— …“¢ÕߺªâŸ «É ¬∑ß—È 2 °≈¡àÿ ‰¡æà ∫§«“¡·µ°µ“à ߢÕß√–¬–‡«≈“∑√’Ë Õ¥™«’ µ‘ ·≈–º≈°“√ª√–‡¡π‘ §≥ÿ ¿“晫’ µ‘ ∑ßÈ— π’È
æ∫«à“ºâŸªÉ«¬∑’ˉ¥â°“√√—°…“‡°‘π°«à“ 4 ™ÿ¥®–‡°‘¥ª√– “∑ à«πª≈“¬‡ ◊ËÕ¡∑’ˇªìπº≈®“°¬“‡§¡’∫”∫—¥‰¥â Ÿß°«à“
®“°¢âÕ¡Ÿ≈¥—ß°≈à“«®–‡ÀÁπ‰¥â«à“ºŸâªÉ«¬ à«π„À≠à¡—°®–‰¡àµÕ∫ πÕßµàÕ‚√§‡æË‘¡¢È÷πÕ’°À≈—ß®“°∑Ë’‰¥â√—∫°“√√—°…“
¡“·≈â« 3 ∂÷ß 4 ™¥ÿ ·≈–¡—°®–‡ ’ˬߵàÕ°“√‡°¥‘ æ‘…¢â“߇§’¬ß – ¡®“°¬“∑√Ë’ °— …“‡¡Õ◊Ë „À°â “√√—°…“µÕà ‡πË◊Õ߇ªπì
‡«≈“π“π

°“√‡√‘Ë¡µâπ°“√√—°…“¥â«¬¬“‡§¡’∫”∫—¥„πºâŸªÉ«¬√–¬–∑Ë’ IV ®“°¢âÕ¡Ÿ≈∑’Ëæ∫«à“ºâŸªÉ«¬∑’Ë¡’ PS 0-1
¡’º≈°“√√—°…“¥’°«à“ºŸâªÉ«¬∑’Ë PS 2 À√◊Õ¡“°°«à“ ¥—ßπ—Èπ°“√‡√‘Ë¡µâπ°“√√—°…“§«√‡√Ë‘¡À≈—ß®“°°“√«‘π‘®©—¬
‰¡à§«√√Õ®π PS ‡≈«≈ß

°“√„Àâ°“√√—°…“‡¡◊ËÕ‚√§°”‡√‘∫À≈—ß®“°„À⬓‡§¡’∫”∫—¥·≈â«À√◊Õ Second line chemotherapy
§«√„À„â πºŸâª«É ¬∑Ë’ PS ¬ß— ¥Õ’ ¬Ÿà§◊Õ PS 0-1 ·≈–‰¡à§«√‡°π‘ PS 2 ®“°°“√»÷°…“ Randomized phase III
‡ª√’¬∫‡∑’¬∫°“√√—°…“ºâŸªÉ«¬∑’Ë¡’‚√§°”‡√‘∫¥â«¬¬“ Docetaxel °—∫ BSC æ∫«à“¬“ Docetaxel  “¡“√∂‡æ‘Ë¡
√–¬–‡«≈“°“√√Õ¥™’扥⇡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ BSC50 °“√»÷°…“‡ª√’¬∫‡∑’¬∫√–À«à“߬“ Pemetrexed ·≈–
Docetaxel „πºªâŸ «É ¬∑Ë‚’ √§°”‡√‘∫À≈—߬“‡§¡∫’ ”∫¥— æ∫«“à ¬“∑È—ß Õß¡’ª√– ∑‘ ∏‘¿“扡·à µ°µ“à ß°—π51

¡’°“√»÷°…“∂÷ߺ≈¢Õß Tyrosine kinase inhibitors „π°“√√—°…“ºŸâªÉ«¬ NSCLC ∑Ë’‚√§°”‡√‘∫À≈—ß
®“°¬“‡§¡’∫”∫—¥ µŸ √ Platinum-based chemotherapy æ∫«à“º≈°“√»÷°…“ phase II study ¢Õ߬“ Erlotinib
„πºªâŸ «É ¬ NSCLC ∑‡Ë’ §¬‰¥√â ∫— °“√√°— …“¥«â ¬ platinum-based chemotherapy æ∫«“à ¡’ response rate 12.5%52
·≈– phase II study ¢Õ߬“ Gefitinib „πºªŸâ É«¬ NSCLC ∑‡’Ë §¬‰¥√â —∫°“√√—°…“¥â«¬ platinum ·≈– taxane
chemotherapy æ∫ response rate 9.6%-19%53,54 °“√»°÷ …“Placebo-controlled trial ‡ª√¬’ ∫‡∑¬’ ∫ Erlotinib
„π°“√√—°…“ºŸªâ «É ¬ NSCLC ¿“¬À≈ß— first line À√Õ◊ second line chemotherapy ‡ª√’¬∫‡∑’¬∫°∫— ¬“À≈Õ°
æ∫«à“¬“ Erlotinib ‡æ¡‘Ë median overall survival (6.7 ‡¥◊Õπ vs 4.7 ‡¥◊Õπ p = .001) ·≈– ‡æ¡Ë‘ median
progression free survival (2.23 ‡¥◊Õπ vs 1.84 ‡¥Õ◊ π P <.001) Õ¬à“ß¡π’ ¬—  ”§—≠∑“ß ∂‘µ5‘ 5 ·µà°“√
»°÷ …“‡ª√¬’ ∫‡∑¬’ ∫ Gefitinib °—∫¬“À≈Õ°„π°“√√°— …“ºªâŸ É«¬ NSCLC ∑’ˇ§¬‰¥√â —∫¬“‡§¡∫’ ”∫—¥¡“°Õà πæ∫«à“
¬“ Gefitinib ‰¡‡à æ‘¡Ë overall survival (5.6 ‡¥Õ◊ π vs 5.1 ‡¥Õ◊ π P = .11)56

40 ·π«∑“ß°“√√°— …“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548

§”·π–π”
1. ºâŸªÉ«¬¡–‡√Áߪե (NSCLC) √–¬–∑Ë’ IV (√«¡∂÷ß IIIB ∑Ë’¡’ malignant pleural

effusion ·≈–/À√◊Õ malignant pericardial effusion) ∑Ë¡’ ’ performance status 0 À√◊Õ 1 ·π–π”„À„⠙⬓‡§¡’
∫”∫—¥ Ÿµ√∑’Ë¡’ platinum √à«¡„π°“√√—°…“ „π°√≥’ºâŸªÉ«¬ ŸßÕ“¬ÿ > 70 ªï Õ“®æ‘®“√≥“„À⬓‡§¡’∫”∫—¥
™π‘¥‡¥¬’ « (single agent)

™π¥‘ §”·π–π” 1
2. ºŸâªÉ«¬¡–‡√Áߪե (NSCLC) √–¬–∑Ë’ IV (√«¡∂÷ß IIIB ∑Ë’¡’ malignant pleural

effusion ·≈–/À√Õ◊ malignant pericardial effusion) ∑’¡Ë ’ performance status 2 „Àâæ‘®“√≥“°“√√°— …“¥«â ¬
¬“‡§¡’∫”∫—¥‡ªìπ√“¬Ê ‰ª ‚¥¬Õ“®æ‘®“√≥“„™â¬“‡§¡’∫”∫—¥∑Ë’‡ªì𬓇¥Ë’¬«„π°“√√—°…“ ‚¥¬‰¡à§”π÷ß∂÷ßÕ“¬ÿ
¢ÕߺŸâªÉ«¬

™π‘¥§”·π–π” 2A
3. ºâŸªÉ«¬¡–‡√Áߪե (NSCLC) √–¬–∑Ë’ IV (√«¡∂÷ß IIIB ∑’Ë¡’ malignant pleural

effusion À√◊Õ malignant pericardial effusion) ∑Ë’¡’ performance status 3 À√◊Õ 4 ‰¡à·π–π”„Àâ°“√
√°— …“¥â«¬¬“‡§¡’∫”∫—¥ ‚¥¬‰¡§à ”π÷ß∂ß÷ Õ“¬ÿ¢Õߺ⪟ «É ¬

™π¥‘ §”·π–π” 1
4. √–¬–‡«≈“¢Õß°“√„À⬓‡§¡∫’ ”∫¥— „π°“√√—°…“ºâªŸ É«¬¡–‡√Áߪե (NSCLC) √–¬–∑’Ë

IV (√«¡∂÷ß IIIB ∑’Ë¡’ malignant pleural effusion ·≈–À√Õ◊ malignant pericardial effusion) ª√–¡“≥ 3-6 ™ÿ¥
™π¥‘ §”·π–π” 2A
5. ºŸâªÉ«¬¡–‡√Áߪե (NSCLC) √–¬–∑Ë’ IV (√«¡∂÷ß IIIB ∑’Ë¡’ malignant pleural

effusion) ·≈–À√◊Õ malignant pericardial effusion ∑¡Ë’ ’ performance status 0 À√◊Õ 1 ∑Ë’¡‚’ √§°”‡√∫‘ À√◊Õ
°≈∫— ‡ªπì ´”È À≈ß— ®“°‰¥√â ∫— ¬“‡§¡∫’ ”∫¥— ™¥ÿ ·√°‰ª·≈«â ·π–π”„À„â ™¬â “‡§¡∫’ ”∫¥— ∑‡Ë’ ªπì ¬“‡¥¬’Ë «„π°“√√°— …“ ‚¥¬
‰¡§à ”πß÷ ∂÷ßÕ“¬¢ÿ ÕߺŸªâ É«¬ ‚¥¬¬“‡§¡∫’ ”∫—¥‰¥·â °à

5.1 Docetaxel À√Õ◊ Pemetrexed
™π¥‘ §”·π–π” 1

5.2 Erlotinib
™π‘¥§”·π–π” 2A

5.3 Gefitinib
™π‘¥§”·π–π” 2B

·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√ßÁ ªÕ¥ ªï 2547 - 2548 41

5.  Ÿµ√¬“‡§¡∫’ ”∫¥— ∑’Ë·π–π”„À„™â„π Adjuvant chemotherapy
1. Cisplatin based chemotheapy
2. Carboplatin / paclitaxel
3. Vinorelbine / cisplatin

6.  Ÿµ√¬“‡§¡∫’ ”∫¥— ∑Ë’·π–π”„π Advanced NSCLC
1. Cisplatin À√◊Õ Carboplatin based combinations chemotherapy ‚¥¬„™â Cisplatin À√◊Õ

Carboplatin√à«¡°—∫¬“‡§¡’∫”∫¥— ¥ß— π’È
- Etoposide
- Vinblastine
- Mitomycin
- Paclitaxel
- Docetaxel
- Vinorelbine
- Gemcitabine
- Irinotecan
- Ifosfamide
2. °√≥’ºâªŸ «É ¬ ŸßÕ“¬Õÿ “®„™â single agent
3. ¬“∑’Ë·π–π”„Àâ„™â„π second line ·≈– third line ‰¥â·°à Docetaxel (™π‘¥§”·π–π”1),

Pemetrexed (™π¥‘ §”·π–π” 1), Erlotinib (™π¥‘ §”·π–π” 2A), Gefitinib(™π¥‘ §”·π–π” 2B)

42 ·π«∑“ß°“√√—°…“欓∫“≈‚√§¡–‡√Áߪե ªï 2547 - 2548

‡Õ° “√Õâ“ßÕß‘

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