2011胃间质瘤指南

2011胃间质瘤指南 中国胃肠间质瘤诊断治疗专家共识(2011年版) 中国CSCO胃肠间质瘤专家委员会 【关键词】 胃肠间质瘤; 诊断; 治疗; 共识 近年来,胃肠间质瘤(gastrointestinal stromal tumor,GIST)诊断,治疗和研究进步迅速:为了推动GIST的规范化诊断和治疗,建立包括病理科,放射科,外科和肿瘤内科等临床多学科的合作模式,有必要制定专家共识或临床实践指南作为重要参考:对此,既往的中国GIST诊断治疗专家共识(2009年版)曾经发挥了积极作用:2010年9月,在CSCO学术年会期间,胃肠间质瘤专家委员会建议对于该专家共识(2009年版)进行更新,之后广泛征求意见,多次组织讨论和进行修改,最近又根据2011年的最新资料进一步补充,形成本文,现予公布: 一, 病理诊断原则 (一)GIST的定义 GIST是胃肠道最常见的间叶源性肿瘤,由突变的c-kit或血小板源性生长因子受体?琢(PDGFRA)基因驱动;组织学上多由梭形细胞,上皮样细胞,偶或多形性细胞,排列成束状或弥漫状图像,免疫组化检测通常为CD117或DOG-1表达阳性: (二)对标本的要求 手术后的标本必须及时固定,标本离体后应在30 min内送至病理科,采用足够的中性10%甲醛液(至 [1]少3倍于标本体积)完全浸泡固定:对于长径大于或等于2 cm的肿瘤组织,应该每隔1 cm予以切开,达到充分固定:固定时间应为12~48 h,以保证后续的免疫组化和分子生物学检测的可行性和准确性:有条件的单位,应留取新鲜组织妥善冻存,以备日后进行分子遗传学研究之用: (三) GIST的病理诊断依据 1. 基本诊断:在组织学上,依据细胞形态可将GIST分为3大类:梭形细胞型(70%),上皮样细胞型(20%)和梭形细胞(或上皮样细胞)混合型(10%):免疫组化检测CD117阳性率约95%,DOG-1阳性率application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical [2-4]98%,CD34阳性率70%,α-SMA阳性率40%,S-100蛋白阳性率5%,以及Desmin阳性率2%:诊断思路和 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 :(1)对于组织学形态符合GIST,同时CD117阳性的病例,可以做出GIST的诊断;(2)对于组织学形态符合GIST,但是CD117阴性和DOG-1阳性的肿瘤,可以做出GIST的诊断;(3)组织学形态符合GIST,CD117和DOG-1均为阴性的肿瘤,应交由专业的分子生物学实验室检测是否存在c-kit或PDGFRA基因的突变,以协助明确GIST的诊断:如果存在该基因的突变,则可做出GIST的诊断;(4)对于组织学形态符合GIST,但CD117和DOG-1均为阴性,并且无c-kit或PDGFRA基因突变的病例,如果能够排除平滑肌肿瘤,神经源性肿瘤等其他肿瘤,可以做出GIST可能的诊断:见图1: 2.基因检测:应该在符合资质的实验室进行基因检测,推荐采用聚合酶链式反应(PCR)扩增-直接测序的方法,以确保检测结果的准确性和一致性:基因突变检测十分重要,有助于一些疑难病例的诊断,预测分子靶向治疗药物的疗效和指导临床治疗:专家委员会推荐存在以下情况时,应该进行基因学分析:(1)所有初次诊断的复发和转移性GIST,拟行分子靶向治疗;(2)原发可切除GIST手术后,中-高度复发风险,拟行伊马替尼辅助治疗;(3)对疑难病例应进行c-kit或PDGFRA突变分析,以明确GIST的诊断;(4)鉴别NF1型GIST,完 [5]全性或不完全性Carney三联症,家族性GIST以及儿童GIST;(5)鉴别同时性和异时性多原发GIST: 检测基因突变的位点,至少应包括c-kit基因的第11,9,13和17号外显子以及PDGFRA基因的第12 [6-8]和18号外显子:大多数GIST(65%~85%)的基因突变发生在c-kit基因的第11号或第9号外显子:对于经济承受能力有限的患者,在鉴别诊断时,可优先检测这两个外显子;但是,对于继发耐药的患者,宜增加检测c-kit基因的13,14,17和18外显子: 3. 原发完全切除GIST的危险度评估:对于局限性GIST危险度的评估,应该包括原发肿瘤的部位, [3]肿瘤的大小,核分裂像以及是否发生破裂等:既往采用2002版美国国立卫生署(NIH)的危险度分级,包括肿瘤的大小和每50个高倍镜视野下的核分裂数(表1的数据依据物镜数值孔径为0.65的显微镜镜头;强调必须计数核分裂像较丰富的50个高倍视野):多项回顾性研究业已证实,上述两项指标与GIST的预后明显相关;同时也发现,仅仅依赖这两项指标预测GIST患者的预后是不充分的:因此,2008年4月,NIH专家组重新讨论了application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 原发GIST切除后的风险分级,并达成新的共识;在2008版新的危险度分级中,将原发肿瘤部位(非原发于胃的 [9]GIST较原发胃的GIST预后差)和肿瘤破裂也作为预后的基本评估指标:见表1: 有些专家认为:在临床实际工作中,仅依靠上述因素去评估GIST危险分级仍然可能存在不足,其他肿瘤病理学特征,比如瘤细胞显著异型,肿瘤侵犯深度,周围脏器受侵程度(注意:周围脏器浸润不属于局限性GIST,而是进展性GIST),脉管和神经浸润以及瘤栓形成等,对于GIST生物学行为的评估,分期以及分级等也 [10-14]具有重要的参考价值: 完全切除的局限性GIST,可以依据形态学特征区分为良性,潜在恶性和恶性:诊断恶性GIST的最低标准为出现以下形态特征之一:(1)瘤细胞显著异型,肿瘤性坏死,肌层浸润,围绕血管呈古钱币样生长,核分裂像大于或等于10个/50 HPF;(2)黏膜浸润,神经浸润,脂肪浸润,血管浸润和淋巴结转移等;具有以上指征越多,其恶性程度越高:如果没有上述形态学特点,但是瘤体较大,细胞较丰富和出现少量核分裂像者,可视为潜在恶性GIST:至于瘤体积小,细胞稀疏和无异型的GIST,往往合并于消化道上皮性恶性肿瘤,可视为良性GIST:这一形态学规律与生物学行为的关系有助于指导辅助治疗和评估预后,但是还需要进一步的循证医学证据的充分支持和结合临床情况: (四) 规范GIST病理诊断 报告 软件系统测试报告下载sgs报告如何下载关于路面塌陷情况报告535n,sgs报告怎么下载竣工报告下载 病理报告应该规范和细致,必须准确地描述原发部位,肿瘤大小,核分裂像和肿瘤破裂,还要记录其他提示恶性的指标,包括切缘情况,危险度评估,免疫组化检测以及与预后相关的其他病理参考指标等重要信息(穿刺标本除外):对于手术中影响预后的指标,外科手术医师应该注意描述和提供: 二, 外科治疗原则 (一) 活检原则 估计手术能够完整切除且不严重影响相关脏器的功能者,可以直接进行手术:近年的NCCN指南已 [15]经明确,如果要进行新辅助治疗,需要取活检:应该注意不适当的活检可能引起肿瘤的破溃,出血和增加肿瘤播散的危险性;尤其对于部位较深的,如肿瘤位于十二指肠,进行活检需慎重: application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 1. 手术前活检:(1)对于大多数可以完整切除的GIST,手术前不推荐常规活检或穿刺:(2)需要联合多脏器切除者,或手术后可能影响相关脏器功能者,术前可考虑行活检以明确病理诊断,且有助于决定是否直接手术,还是术前先用药物治疗:(3)对于无法切除或估计难以获得R0切除的病变,拟采用术前药物治疗者,应先进行活检:(4)经皮穿刺,适用于肿瘤已经播散或复发的患者:(5)初发且疑似GIST者,术前如需明确性质(如排除淋巴瘤),首选超声内镜引导下穿刺活检;超声内镜引导下进行的穿刺活检,造成脓内种植的概率甚小:(6)对于直肠和盆腔肿物,如需术前活检,推荐经直肠前壁穿刺活检:(7)活检应该由富有经验的外科医师操作: 2. 细针活组织检查:在超声引导下细针穿刺(EUS-FNA),与手术标本的免疫组化染色表达一致性可以达到91%,诊断准确性达到91%:对有高危EUS特征的患者不行穿刺活检,直接手术切除病灶: 3. 内镜活组织检查:依靠内镜下引导活检常难以明确病理诊断,因为只有GIST累及黏膜时才有可能取到肿瘤组织,且偶可导致肿瘤严重出血,需要慎行: 4.术中冰冻活检:不推荐常规进行术中进行冰冻活检,除非手术中怀疑GIST有周围淋巴结转移或不能排除其他恶性肿瘤: (二) GIST的手术适应证 (1)对于肿瘤最大径线超过2 cm的局限性GIST,原则上可行手术切除;而不能切除的局限性GIST,或临界可切除,但切除风险较大或严重影响脏器功能者,宜先行术前药物治疗,待肿瘤缩小后再行手术:(2)对于肿瘤最大径线小于或等于2 cm的可疑局限性GIST,有症状者应进行手术:位于胃的无症状GIST,一旦确诊后,应根据其表现确定超声内镜风险分级(不良因素为边界不规整,溃疡,强回声和异质性):如合并不良因素,应考虑切除;如无不良因素,可定期复查超声内镜:位于直肠的GIST,由于恶性程度较高,且肿瘤一旦增大,保留肛门功能的手术难度相应增大,倾向于及早手术切除:(3)复发或转移性GIST,分以下几种情况区别对待:?未经分子靶向药物治疗,但估计能完全切除且手术风险不大,可推荐药物治疗或考虑手术切除全部病灶:?分子靶向药物治疗有效,且肿瘤维持稳定的复发或转移性GIST,估计在所有复发转移病灶均可切除的情况下,建议考虑手术切除全部病灶:?局限性进展的复发转移性GIST,鉴于分子靶向药物治疗后总体控制比较满意,application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 常常只有单个或少数几个病灶进展,可以考虑谨慎选择全身情况良好的患者行手术切除:术中将进展病灶切除,并尽可能切除更多的转移灶,完成较为满意的减瘤手术:?分子靶向药物治疗下广泛性进展的复发转移性GIST,原则上不考虑手术治疗:?姑息减瘤手术只限于患者能耐手术并预计手术能改善患者生活质量的情况:(4)急诊手术适应证:在GIST引起完全性肠梗阻,消化道穿孔,保守治疗无效的消化道大出血以及肿瘤自发破裂引起腹腔大出血时,须行急诊手术: (三) GIST的手术原则 1. 手术原则:(1)手术目标是尽量争取达到R切除:如果初次手术仅为R切除,预计再次手术难度低01 并且风险可以控制,不会造成主要功能脏器损伤的,可以考虑二次手术:在完整切除肿瘤的同时,应避免肿瘤破裂和术中播散:GIST很少发生淋巴结转移,除非有明确淋巴结转移迹象,一般情况下不必常规清扫:(2)肿瘤破溃出血原因之一为较少发生的自发性出血,另外是手术中触摸肿瘤不当造成破溃出血,因此术中探查要细心轻柔:(3)对于术后切缘阳性,目前国内,外学者倾向于采用分子靶向药物治疗: 2. 腹腔镜手术:腹腔镜手术容易引起肿瘤破裂和导致腹腔种植,所以不推荐常规应用:如果肿瘤直径小于或等于5 cm,可以考虑在有经验的中心进行腹腔镜切除[16]:推荐术中使用“取物袋”,特别注意避免 [17]肿瘤破裂播散:对于大于5 cm的肿瘤,除了临床研究需要外,原则上不推荐进行腹腔镜手术: 3. 胃GIST手术:一般采取局部切除,楔形切除,胃次全切除或全胃切除,切缘1~2 cm,满足R0切除要求即可:近端胃切除术适用于GIST切除缝合后可能造成贲门狭窄者:多病灶,巨大的GIST或同时伴发胃癌时,可以采取全胃切除,否则应尽量避免全胃切除术:单灶性病变,估计需全胃切除者可先行术前药物治疗;联合脏器切除应该在保障手术安全和充分考虑脏器功能的前提下,争取达到R切除:胃GIST很少发生淋巴0 [18]结转移,一般不推荐常规进行淋巴结清扫: 4. 小肠GIST手术:对于直径2~3 cm的位于小肠的GIST,如包膜完整,无出血坏死者可适当减少切缘距离:小肠间质瘤相对较小,切除后行小肠端端吻合即可,有时肿瘤与肠系膜血管成为一体,以空肠上段为多见,无法切除者,可药物治疗后再考虑二次手术:10%~15%的病例出现淋巴结转移,要酌情掌握所属淋巴结application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 清扫范围:小肠GIST可有淋巴结转移,宜酌情清扫周围淋巴结: 5. 十二指肠和直肠GIST手术:十二指肠和直肠GIST手术应根据原发肿瘤的大小,部位,肿瘤与周围脏器的粘连程度以及有无瘤体破裂等情况综合考虑,决定手术方式:十二指肠的GIST,可行胰十二指肠切除术,局部切除及肠壁修补,十二指肠第3,4段及近端部分空肠切除,胃大部切除等:直肠的GIST,手术方式一般分为局部切除,直肠前切除和直肠腹会阴联合根治术:近年来,由于分子靶向药物的使用,腹会阴根治术日益减少,推荐适应证为:(1)药物治疗后肿瘤未见缩小;(2)肿瘤巨大,位于肛门5 cm以下,且与直肠壁无法分离;(3)复发的病例,在经过一线,二线药物治疗后,未见明显改善影响排便功能者: 6. 胃肠外GIST手术:目前认为,胃肠外GIST对于常规的放疗和化疗均不敏感,外科手术仍为首选 [19-21]的治疗方式,手术治疗的彻底性与疾病预后密切相关,推荐行病灶的整块完整切除:在部分患者中,肿瘤可与周围组织广泛粘连或播散,有时也可采用活检术或姑息性手术,以达到明确诊断或减瘤而缓解症状的目[1]的: 7. GIST内镜下治疗原则:由于GIST起源于黏膜下,生长方式多样,内镜下恐难行根治性切除,且并发症高,不常规推荐: 三, 分子靶向药物治疗原则 (一) GIST术前治疗 1. 术前治疗的意义:目前,有关GIST术前治疗的临床试验,多为小规模的回顾性研究或病例报道:在2010年NCCN第2版软组织肉瘤临床实践指南中,专家组建议将“新辅助治疗”改名为“术前治 [15,17,22]疗”,2011年NCCN指南予以沿用,经过讨论,专家共识同意采用后一术语:术前治疗的主要意义:减小肿瘤体积,降低临床分期;缩小手术范围,避免不必要的联合脏器切除,降低手术风险,同时增加根治性切除机会;对于特殊部位的肿瘤,可以保护重要脏器的结构和功能;对于瘤体巨大,术中破裂出血风险较大的患者,可以减少医源性播散的可能性: [15,17,22] 2. 术前治疗的适应证:(1)术前估计难以达到R切除;(2)肿瘤体积巨大(大于10 cm),术中易0 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 出血,破裂,可能造成医源性播散;(3)特殊部位的肿瘤(如胃食管结合部,十二指肠,低位直肠等),手术易损害重要脏器的功能;(4)肿瘤虽可以切除,但估计手术风险较大,术后复发率,死亡率较高;(5)估计需要进行多脏器联合切除手术: 3. 术前治疗时间,治疗剂量及手术时机选择:在药物治疗期间,应定期(每3个月)评估治疗效果,推荐 [23][24]使用Choi标准或参考RECIST(Response Evaluation Criteria in Solid Tumors)标准:对于术前治疗时 [17]间,专家委员会尚未获得一致的共识:一般认为,给予伊马替尼术前治疗6个月左右施行手术比较适宜:过度延长术前治疗时间可能会导致继发性耐药: [25] 术前治疗时,推荐伊马替尼的初始剂量为400 mg/d:对于肿瘤进展的患者,应综合评估病情,尚可手术者(有可能完整切除病灶),应及时停用药物,及早手术干预;不能手术者,可以按照复发转移患者采用二线治疗: 4. 术前停药时间及术后治疗时间:建议术前停药1周左右,待患者的基本情况达到要求,即可考虑进行手术:术后,原则上只要患者胃肠道功能恢复且能耐受药物治疗,应尽快进行药物治疗:对于R切除者,术后0药物维持时间可以参考辅助治疗的标准;对于姑息性切除或转移,复发患者(无论是否达到R切除),术后治疗0与复发转移未手术的GIST患者相似: (二) GIST术后辅助治疗 1. 辅助治疗适应证:目前推荐有中,高危复发风险患者作为辅助治疗的适合人群:美国外科协会(ASOCOG)Z9001研究证明,具有复发危险因素的GIST完整切除后,应用伊马替尼辅助治疗1年可明显改 [26][27-28]善患者的无复发生存率:国内学者的两项研究也证实,伊马替尼辅助治疗在中高危GIST患者中获益:ASOCOG Z9001亚组分析提示,不同基因突变类型患者应用辅助治疗的获益存在差异,c-kit外显子11突变与PDGFRA非D842V患者行辅助治疗可以获益;同时,尚没有充分证据显示c-kit外显子9突变GIST能否从辅 [29]助治疗中获益;而PDGFRA D842V突变与野生型GIST行辅助治疗未能获益:SSGXVIII/AIO研究结果也重复证实了这一结论: application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical [26,30] 2.辅助治疗剂量和时限:根据ASOCOG Z9001以及SSGXVIII/AIO研究结果,目前推荐伊马替尼辅助治疗的剂量为400 mg/d;治疗时限:对于中危患者,应至少给予伊马替尼辅助治疗1年;高危患者,辅助治疗时间为3年:ASCOGZ9000与Z9001研究中,患者接受伊马替尼辅助治疗1年停药后,GIST复发率明显 [26,31]升高;而SSGXVIII/AIO研究结果显示,高度复发风险GIST患者术后接受伊马替尼辅助治疗3年与1年比 [30]较,可以进一步改善无复发生存率与总生存期:国内研究提示,中,高危的GIST患者采用伊马替尼辅助治疗 [28]3年与单独接受手术患者相比,可以改善3年无复发生存率与总生存期: (三) 转移复发或不可切除GIST的治疗 1. 伊马替尼一线治疗:伊马替尼是转移复发或不可切除GIST的一线治疗药物,初始推荐剂量为400 mg/d:B2222试验结果表明,伊马替尼治疗转移复发GIST的客观疗效高,并且能够明显地改善患者的中位总 [32]生存期: EORTC62005研究中,c-kit外显子9突变患者的初始治疗,应用伊马替尼800 mg/d与400 mg/d [33]比较获得了更长的无进展生存期:推荐初始治疗给予高剂量伊马替尼:鉴于国内临床实践中多数患者无法耐受伊马替尼800 mg/d治疗,因此,对于c-kit外显子9突变的国人GIST患者,初始治疗可以给予伊马替尼600 mg/d: 对于转移复发或不可切除GIST,如伊马替尼治疗有效,应持续用药,直至疾病进展或出现不能耐受 [34]的毒性:法国肉瘤协作组的BFR14临床研究结果表明,中断伊马替尼治疗将导致病情反复,肿瘤快速进展: [32-33] 伊马替尼的常见不良反应有水肿,胃肠道反应,白细胞减少,贫血,皮疹,肌肉痉挛以及腹泻等:大多数不良反应为轻至中度,多在用药的前8周出现,呈一过性和自限性,对症支持治疗即可改善: 2. 伊马替尼标准剂量失败后的治疗选择:如果在伊马替尼治疗期间发生肿瘤进展,首先应确认患者否遵从了医嘱,即在正确的剂量下坚持服药;在除外患者的依从性因素后,应该参照以下原则处理:(1)局限性进展:表现为伊马替尼治疗期间,部分病灶出现进展,而其他病灶仍然稳定甚至部分缓解:局限性进展的GIST,在手术可以完整切除局灶进展病灶的情况下,建议实施手术治疗,术后可继续原剂量伊马替尼或增加剂量治application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 疗:小样本的临床观察提示,局限性进展患者接受肿瘤完整切除术后继续服用伊马替尼,可以有较好的无疾病 [35-37]进展期与总生存期获益:GIST广泛进展时,不建议采取手术;未能获得完整切除时,后续治疗应遵从GIST广泛性进展的处理原则:对于部分无法实施手术的GIST肝转移患者,动脉栓塞与射频消融治疗也可以 [38-39]考虑作为辅助治疗方式;而不宜接受局部治疗的局灶性进展患者,可以增加伊马替尼剂量或者给予舒尼替尼治疗:(2)广泛性进展:对于应用标准剂量的伊马替尼治疗后出现广泛进展者,建议增加伊马替尼剂量或换用舒尼替尼治疗:?伊马替尼增加剂量:EORTC62005和S0033研究均显示,对于广泛进展的GIST的患者, [33,40]增加伊马替尼剂量到800 mg,有1/3的患者可以再次临床获益;2010年NCCN指南第2版指出,可以采用伊马替尼400 mg bid:伊马替尼增加剂量后,有关不良反应会相应增加:我国GIST患者对600 mg/d伊马替尼 [41]的耐受性较好,与国外报道800 mg/d剂量的疗效相似:因此推荐国人GIST患者优先增量为600 mg/d:?舒尼替尼治疗:A6181004研究显示,对于伊马替尼治疗进展或不能耐受的患者,应用舒尼替尼二线治疗仍然有效,能够改善疾病进展时间和总生存期[42-43]:舒尼替尼的用药剂量和方式尚缺乏随机对照研究的证据,37.5 mg/d连续服用与50 mg/d(4/2) 方案 气瓶 现场处置方案 .pdf气瓶 现场处置方案 .doc见习基地管理方案.doc关于群访事件的化解方案建筑工地扬尘治理专项方案下载 均可选择:舒尼替尼的主要不良反应包括贫血,粒细胞减少,血小板减少,手足综合征,高血压,口腔黏膜炎,乏力以及甲状腺功能减退等;多数不良反应通过支持对症治疗或暂时停药可以获得缓解恢复,但是少数严重者需要停用舒尼替尼: 3. 伊马替尼与舒尼替尼治疗失败后的维持治疗:伊马替尼与舒尼替尼治疗均进展的GIST患者,建议参加新药临床研究,或者考虑给予既往治疗有效且耐受性好的药物进行维持治疗;也可以考虑使用其他分 [44]子靶向药物,如索拉非尼可能有一定的治疗效果,但是需要更多的临床研究证据支持: (四) c-kit和PDGFRA基因突变与分子靶向治疗疗效的相关性 一般认为,c-kit和PDGFRA突变类型可以预测伊马替尼的疗效,其中c-kit外显子11突变者的疗效 [32][45]最佳;PDGFRA D842V突变可能对伊马替尼与舒尼替尼治疗原发性耐药:舒尼替尼治疗原发c-kit外显子9突变和野生型GIST患者的生存获益优于c-kit外显子11突变患者;治疗继发性c-kit外显子13,14突变者 [46]疗效优于继发c-kit外显子17,18突变者: application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical (五) 血药浓度的监测 如果有条件,建议对下列患者进行伊马替尼血药浓度检测:(1)伊马替尼400 mg/d一线治疗进展的患者;(2)药物不良反应较重的患者;(3)未遵从医嘱定期,定量服药的患者: B2222研究亚组分析证实,如果GIST患者的血浆伊马替尼浓度低于1100 ng/ml,临床疗效降低,疾 [47]病很快进展:对伊马替尼血药浓度较低的患者增加剂量治疗能否进一步改善疗程效,需要临床研究证实: (六) 药物疗效的判断 1. 原发性耐药与继发性耐药的定义:原发性耐药的定义为接受伊马替尼一线治疗3~6个月之内发生肿瘤进展;如采用Choi标准评估,推荐观察时间为3个月:继发性耐药的定义为初始接受伊马替尼或舒尼替尼治疗获得肿瘤缓解或稳定后,随着治疗时间的延长再次出现肿瘤进展: 2. 改良的Choi疗效评估标准:GIST靶向治疗有效者的组织成分改变较早,常以坏死,出血,囊变及黏液变为主要表现,有时体积缩小可以不明显甚至增大:以往采用的细胞毒药物疗效 评价 LEC评价法下载LEC评价法下载评价量规免费下载学院评价表文档下载学院评价表文档下载 标准RECIST标准,仅考虑体积变化因素,存在明显的缺陷:Choi等[23]结合长径和CT的Hu值提出新的标准(表2),一些研究表明其评效能力优于RECIST标准:本共识建议对于治疗早期肿瘤体积缩小不明显甚或增大者,应补充测量CT的Hu值,参照Choi标准进行评价: 3. CT扫描和测量规范: (1)扫描范围:应该由膈顶至盆底,包括整个腹,盆腔区域:(2)扫描参数:检查前12 h禁食,禁水;以3~4 ml/s的速度静脉注射非离子造影剂,单排螺旋CT于30,60 s扫描,多排螺旋CT于注药后20,40及60 s分别扫描;要求簿层扫描,层厚小于或等于5 mm:(3)长径和CT值测量方法:轴位图像测量肿瘤最大径线;增强静脉期,于肿瘤最大层面采用曲线边缘描记法获得肿瘤整体CT值(Hu):原则上要求进行增强扫描:如有禁忌,建议改行MRI扫描,可较CT平扫更敏感地检出病变,并可发现囊变,黏液变等早期组织学改变: 4. PET-CT的应用: PET-CT扫描将分子影像学与形态影像学紧密结合,是目前评估分子靶向药物治疗GIST疗效最敏感的手段,具有重要的价值,有条件者应该积极应用;但由于机器设备还不够普及,且价格application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 较昂贵,尚未明确地写入国际指南,暂不作为常规手段: 5. MRI的应用:MRI具有高软组织分辨率和组织含水量敏感的特点,是除PET-CT之外另一项可以提供功能定量指标的影像学手段;磁共振扩散加权成像(DW-MRI)是其中研究较为成熟的技术之一,但其确切的临床意义有待进一步证实: (七) 随访原则 对所有GIST患者均需建立完整的病例档案,进行系统的随访: 1. 术后随访的患者:GIST手术后最常见的转移部位是腹膜和肝脏,故推荐进行腹,盆腔增强CT或MRI扫描作为常规随访项目:(1)中,高危患者应该每3个月进行CT或MRI检查,持续3年,然后每6个月1次,直至满5年;(2)低危患者应每6个月进行CT或MRI检查,持续5年;(3)由于肺部和骨骼转移的发生率相对较低,建议至少每年1次胸部X线检查,在出现相关症状情况下推荐进行ECT骨扫描: 2. 转移复发(或不可切除)或术前治疗患者:(1)治疗前必须行增强CT作为基线和疗效评估的依据:(2)开始治疗后应至少每3个月随访,复查增强CT或MRI;如果涉及治疗决策,可以适当增加随访次数:(3)治疗初期(前3个月)的密切监测非常重要,必要时可以行PET-CT扫描确认肿瘤对治疗的反应:(4)必须时应该监测血药浓度变化,指导临床治疗: [48] 附件 GIST病理学诊断报告推荐格式 临床特征 肿瘤来源:?原发 ?术后复发 ?转移 部 位:?食管 ?胃 ?小肠 ?结肠 ?直肠 ?后腹膜 ?网膜 ?肠系膜 ?肝 ?其他 组织病理 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 肿瘤大小 cm(最大直径) 核分裂像数 /50 HPF 组织学类型:?梭形细胞型 ?上皮样细胞型 ?混合细胞型 手术切缘:?阴性 ?阳性 肿瘤性坏死:?无 ?有 肿瘤细胞显著异形:?无 ?有 肿瘤浸润部位:?无 ?浆膜 ?黏膜 ?脉管 ?神经 ?脂肪 ?其他 肿瘤破裂:?无 ?有 其他特征: 免疫组织化学 CD117 CD34 DOG-1 Ki-67 SMA Desmin S-100 其他 病理诊断(部位,恶性潜能分级和胃肠间质瘤): 注:如果检测c-kit和PDGFRA基因突变的状况,应另附检测报告 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical