血液肿瘤合并实体肿瘤诊疗专家共识（2025年版）

doi:10.19401/j.cnki.1007-3639.2025.10.010

摘要/Abstract

摘要：

血液肿瘤合并实体肿瘤（hematologic malignancies with solid tumor，HM-ST）作为多原发肿瘤（multiple primary malignancies，MPM）的一种特殊类型，在临床实践中日益增多，给诊疗带来严峻挑战。两种肿瘤在生物学行为、治疗策略及患者的预后上差异巨大，治疗决策需综合考虑优先顺序、同步/序贯化疗方案的选择及毒性管理。由于高质量研究证据缺乏，临床实践中常依赖于医师有限的经验。本共识旨在结合国内外最新进展及中国临床实践经验，梳理HM-ST的定义、分类、流行病学、病理学机制[如潜能不明的克隆性造血（clonal hematopoiesis of indeterminate potential，CHIP）、RNA剪接异常]、诊断流程（强调病理学诊断、分子生物学诊断及影像学诊断技术如PET/CT与靶向探针的应用）、治疗原则[突出多学科诊疗团队（multidisciplinary team，MDT）协作、治疗优先级决策、毒性管理、精细化放疗及“异病同治”策略]和随访管理。本共识重点提出了诊断、评估、治疗及随访方面的系列化推荐意见，以期为临床医师提供一套规范化、操作性强的指导依据，优化HM-ST患者的个体化诊疗，改善患者的预后并提高患者的生活质量。本共识已在国际实践指南注册平台（Practice guideline REgistration for transPAREncy，PREPARE）注册，注册号为PREPARE-2025CN1599。

关键词: 血液肿瘤, 实体肿瘤, 多原发肿瘤, 治疗, 专家共识

Abstract:

Hematologic malignancies with solid tumors (HM-ST), a special subtype of multiple primary malignancies (MPMs), are increasingly encountered in clinical practice, posing significant diagnostic and therapeutic challenges. The two types of tumors exhibit vast differences in biological behavior, treatment strategies, and prognosis. Treatment decisions require comprehensive consideration of prioritization, synchronous/metachronous approaches, and toxicity management. Due to the scarcity of high-quality research data, clinical practice often relies on limited experience. This consensus aimed to integrate the latest international advancements with Chinese clinical practice experience to delineate the definition, classification, epidemiology, pathogenesis [e.g., clonal hematopoiesis of indeterminate potential (CHIP), RNA splicing abnormalities], diagnostic workflow (emphasizing pathology, molecular diagnosis, and advanced imaging techniques such as PET/CT with targeted probes), treatment principles [highlighting multidisciplinary team (MDT) collaboration, treatment prioritization, toxicity management, refined radiotherapy, and the strategy of “treating different diseases with the same method” ], and follow-up management for HM-ST. This consensus specifically puts forward a series of recommendations regarding diagnosis, assessment, treatment, and follow-up, intending to provide clinicians with standardized and practical guidance, optimize individualized management for HM-ST patients, and ultimately improve their prognosis and quality of life. This consensus has been registered on the Practice guideline REgistration for transPAREncy (PREPARE) platform (registration number: PREPARE-2025CN1599).

Key words: Hematologic malignancies, Solid tumors, Multiple primary malignancies, Treatment, Expert consensus

中图分类号:

R733

中国抗癌协会多原发和不明原发肿瘤专业委员会, 上海市抗癌协会多原发和不明原发肿瘤专业委员会, 中华医学会血液学分会淋巴细胞疾病学组, 中华医学会血液学分会罕见病学组. 血液肿瘤合并实体肿瘤诊疗专家共识（2025年版）[J]. 中国癌症杂志, 2025, 35(10): 968-985.

Multiple Primary and Unknown Primary Tumors Special Committee of China Anti-Cancer Association , Shanghai Anti Cancer Association Multiple Primary and Unknown Primary Tumor Special Committee , Lymphocytic Disease Group, Hematology Branch, Chinese Medical Association , Rare Disease Group, Hematology Branch, Chinese Medical Association . Expert consensus on diagnosis and treatment of hematologic malignancies with solid tumors (2025 version)[J]. China Oncology, 2025, 35(10): 968-985.

图/表 7

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表2

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表5

“异病同治”治疗方案示例"

临床情景（HM-ST 组合)	核心药物/机制	推荐方案示例（含具体药物)	关键注意事项
经典型霍奇金淋巴瘤合并PD-L1高表达的NSCLC	免疫检查点抑制剂（PD-1抑制剂）	帕博利珠单抗或纳武利尤单抗单药或联合化疗： ① 序贯策略：先以A-AVD方案（维布妥昔单抗、多柔比星、长春花碱、达卡巴嗪）治疗经典型霍奇金淋巴瘤，待其缓解后，使用帕博利珠单抗单药治疗NSCLC。 ② 同步策略（适用于特定晚期经典型霍奇金淋巴瘤）：可考虑纳武利尤单抗联合AVD方案	严密监测并管理irAE，特别是肺炎、肝炎和内分泌毒性。两种疾病均可能引发irAE，需仔细鉴别
CML合并GIST	TKI	伊马替尼标准剂量治疗： ① CML慢性期：伊马替尼400 mg 每日1次。 ② GIST：根据c-Kit/PDGFRA基因突变类型及治疗目的（辅助/晚期），伊马替尼剂量通常为400 mg 每日1次	伊马替尼可同时高效控制两种疾病。需常规监测血常规、肝功能，并关注水肿、皮疹、肌肉痉挛等常见不良反应
复发/难治性PTCL合并激素受体阳性/HER2阴性晚期乳腺癌	组蛋白去乙酰化酶（HDAC）抑制剂	西达本胺的应用这是一个复杂的场景，通常采用序贯治疗： ① 优先以含吉西他滨或培美曲塞等药物的方案挽救治疗PTCL。 ② 在淋巴瘤病情稳定后，采用西达本胺联合内分泌治疗（如依西美坦）治疗乳腺癌，同时可能对惰性T细胞淋巴瘤有维持作用	同步治疗毒性风险高，需在经验丰富的中心MDT指导下进行。重点关注血液学毒性、心脏毒性（QTc间期延长）和血栓风险
复发难治性DLBCL合并铂类药物敏感的实体瘤（如卵巢癌、肺癌）	铂类化疗药物	基于铂类药物的挽救性化疗方案： ① R-ICE方案（利妥昔单抗、异环磷酰胺、卡铂、依托泊苷)。 ② R-DHAP方案（利妥昔单抗、地塞米松、大剂量阿糖胞苷、顺铂）。以上方案中的铂类药物（卡铂/顺铂）不仅是淋巴瘤挽救治疗的核心，也对多种实体瘤有效	毒性剧烈，需强有力的支持治疗。重点管理肾毒性（尤其是顺铂）、神经毒性和重度、持续的骨髓抑制。需充分水化、预防性使用G-CSF
FLT3突变阳性AML合并VEGF高表达的实体瘤（如肾癌）	多靶点TKI（如索拉非尼）	探索性应用：在标准AML诱导化疗（如“7+3”方案）基础上，联合FLT3抑制剂（如吉瑞替尼）。若患者合并晚期肾癌，也可考虑使用索拉非尼或舒尼替尼这类多靶点TKI，它们既能抑制FLT3，也具有抗血管生成（抑制VEGFR）作用	此为非常规策略，仅限于MDT充分论证且患者无标准治疗选择时考虑，最好在临床试验框架下进行。需严密监测药物相互作用、心脏毒性、高血压和手足综合征

表5

表6

《血液肿瘤合并实体肿瘤诊疗专家共识（2025年版）》内容汇总"

共识内容	证据级别	推荐强度
诊断与鉴别诊断
推荐意见1：确诊HM-ST的核心标准是，必须通过病理学检查（含免疫组织化学检测）和必要的分子生物学检测（如NGS），证实存在两种组织学来源不同的独立原发恶性肿瘤	高	强
推荐意见2：HM-ST的诊断流程应采用多维模式，起始于详细的临床评估，影像学检查推荐以¹⁸F-FDG PET/CT作为基础全身筛查手段，并根据情况辅以局部精查或靶向分子探针PET	中	强
推荐意见3：最终确诊HM-ST必须依赖充分的病理学检查，包括活组织病理学检查、H-E染色和针对性的免疫组织化学检测标志物组合。疑难病例推荐进行NGS分子检测辅助鉴别	高	强
治疗原则
推荐意见4：HM-ST患者的治疗决策应在MDT框架下进行，整合多学科专家意见，全面评估	中	强
推荐意见5：治疗优先级的确定应基于对两种肿瘤侵袭性、对生命威胁程度等的综合评估，通常优先处理威胁更大者	低	强
推荐意见6：治疗方案的选择需严格遵循功能保留和减少毒性叠加的原则，推荐采用现代精细化放疗技术	中	强
推荐意见7：对于同时性HM-ST，推荐MDT评估后决定采取序贯治疗或同步治疗，治疗中需密切监测毒性并个体化调整	中	强
推荐意见8：对于异时性HM-ST，治疗决策需充分考虑首发肿瘤类型及既往治疗史，谨慎选择方案以避免毒性累加	中	强
推荐意见9：建议MDT评估“异病同治”的可能性，个体化选择药物，并警惕相关风险。新兴疗法主要限于临床试验	中	一般
随访与管理
推荐意见10：推荐对HM-ST患者进行长期、规律的随访，内容应包括临床、实验室、影像学及必要的分子监测	中	强
推荐意见11：随访期间应密切监测并积极管理治疗相关毒性，并根据患者情况采取必要的感染预防措施	高	强

表6

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项目	内容
证据级别
高质量	证据基于高水平前瞻性随机对照临床试验或关于其的Meta分析，研究结果具有高度可信性和推广性
中等质量	证据基于低水平随机试验或设计良好的非对照试验或队列研究，可信度一般
低质量	证据基于病例对照研究、回顾性研究、亚组分析、专家共识或科学假设，可信度较低
推荐级别
强推荐	证据级别较高，结果与因素具有显著相关性；或虽然证据级别不高，但干预措施获益明确、风险低，为临床基本原则
一般推荐	证据级别较低，结果与因素相关性不显著或无明确证据显示相关性；或干预措施的获益与风险尚不明确，需个体化决策

探针名称	靶点/机制	主要适应证	成像技术	临床阶段（截至共识制定时）
¹⁸F-FDG	葡萄糖代谢	实体肿瘤	PET/CT	临床常规
⁶⁸Ga-PSMA^[36]	PSMA	前列腺癌	PET/CT/MRI	临床常规
⁶⁸Ga-FAPI^[37]	FAP	多种实体肿瘤（胰腺癌、肉瘤等）	PET/CT	临床试验/部分中心应用
⁶⁸Ga-DOTATATE^[38]	SSTR2	神经内分泌肿瘤	PET/CT	临床常规

探针名称	靶点/机制	主要适应证	成像技术	临床阶段（截至共识制定时）
¹⁸F-FDG	葡萄糖代谢	血液肿瘤	PET/CT	临床常规
⁶⁸Ga-Pentixafor^[39]	CXCR4受体	多发性骨髓瘤，部分淋巴瘤	PET/CT	临床应用/部分中心常规
⁶⁸Ga-DOTATATE^[40]	SSTR2	部分T细胞淋巴瘤	PET/CT	临床常规

肿瘤类型	推荐免疫组织化学检测标志物组合	备注
肺腺癌	TTF-1、napsin A、CK7	TTF-1/napsin A阳性支持肺来源；CK7辅助鉴别腺癌
肺鳞癌	p40、CK5/6、p63	p40/p63强阳性为鳞癌特征；TTF-1通常阴性
乳腺癌	ER、PR、HER2、GATA3、Ki-67增殖指数	ER/PR/HER2指导治疗；GATA3支持乳腺来源；Ki-67增殖指数评估增殖活性
胃癌	CK7、CK20、CDX2、HER2	CK7⁺/CK20-或CDX2⁺支持胃腺癌；HER2检测用于靶向治疗
结直肠癌	CK20、CDX2、SATB2、MLH1/MSH2/MSH6/PMS2（错配修复蛋白）	CK20⁺/CDX2⁺支持肠源性；MMR检测筛选林奇综合征
肝癌	HepPar-1、arginase-1、glypican-3、AFP	HepPar-1/arginase-1特异性高；glypican-3/AFP辅助诊断
前列腺癌	PSA、PSAP、NKX3.1、AMACR	PSA/PSAP/NKX3.1阳性支持前列腺来源；AMACR辅助鉴别癌与良性增生
卵巢癌	CK7、PAX8、WT1、ER、p16、napsinA、HNF1β、p53	PAX8⁺/WT1⁺支持浆液性癌
甲状腺癌	TTF-1、TG、calcitonin（髓样癌）、BRAF V600E（如适用）	TTF-1⁺/TG⁺支持甲状腺滤泡来源；calcitonin诊断髓样癌
淋巴瘤	B细胞：CD20、CD19、PAX5、BCL2、CD10、BCL6等；T细胞：CD3、CD5、CD4、CD8、CD30等；增殖指数：Ki-67；EBER原位杂交	需结合CD系列及分子检测（如MYC/BCL2重排）
黑色素瘤	S100、SOX10、melan-A、HMB45、BRAF V600E（如适用）	S100/SOX10敏感但非特异；melan-A/HMB45特异性高
肾细胞癌	PAX8、CAIX、CD10、RCC	PAX8⁺/CAIX⁺支持透明细胞癌；RCC标志物辅助诊断
神经内分泌肿瘤	Synaptophysin、chromogranin A、CD56、Ki-67增殖指数	Syn/chromogranin A必查；Ki-67增殖指数分级（如G1/G2/G3）