2011NCCN+恶性胸膜间皮瘤临床实践指南

NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion NCCN Guidelines Index Small Cell Lung Table of Contents Staging, Discussion, References NCCN.org Continue NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) Malignant Pleural Mesothelioma Version 1.2011 NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion Continue David S. Ettinger, MD/Chair † The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Wallace Akerley, MD Huntsman Cancer Institute at the University of Utah Hossein Borghaei, DO, MS Fox Chase Cancer Center Andrew Chang, MD University of Michigan Comprehensive Cancer Center Richard T. Cheney, MD Lucian R. Chirieac, MD Dana-Farber/Brigham and Women's Cancer Center † † ‡ ¶ Roswell Park Cancer Institute Thomas A. D’Amico, MD ¶ Duke Comprehensive Cancer Center Todd L. Demmy, MD ¶ Roswell Park Cancer Institute Ramaswamy Govindan, MD † Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine Frederic W. Grannis, Jr., MD ¶ City of Hope Comprehensive Cancer Center Leora Horn, MD, MSc † Vanderbilt-Ingram Cancer Center � � Gregory A. Otterson, MD † Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University Jyoti D. Patel, MD ‡ Robert H. Lurie Comprehensive Cancer Center of Northwestern University Mary Pinder-Schenck, MD † H. Lee Moffitt Cancer Center & Research Institute Katherine M. Pisters, MD † The University of Texas MD Anderson Cancer Center Karen Reckamp, MD, MS † ‡ City of Hope Comprehensive Cancer Center † Memorial Sloan-Kettering Cancer Center The University of Texas MD Anderson Cancer Center ¶ Dana-Farber/Brigham and Women's Cancer Center ¶ Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Stephen C. Yang, MD ¶ The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Gregory J. Riely, MD, PhD Eric Rohren, MD, PhD Scott J. Swanson, MD Douglas E. Wood, MD ф * † Medical Oncology ¶ Surgery/Surgical oncology § Radiation oncology/ Pathology ‡ Hematology/ Hematology oncology Radiotherapy *Writing Committee Member� ф Diagnostic/ Interventional Radiology NCCN Guidelines Panel Disclosures * NCCN Kristina Gregory, RN, MSN Miranda Hughes, PhD NCCN Guidelines™ Version 1.2011 Panel Members Malignant Pleural Mesothelioma Thierry M. Jahan, MD † Anne Kessinger, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Ritsuko Komaki, MD The University of Texas MD Anderson Cancer Center Feng-Ming (Spring) Kong, MD, PhD, MPH University of Michigan Comprehensive Cancer Center Mark G. Kris, MD † ‡ UCSF Helen Diller Family Comprehensive Cancer Center † § § Memorial Sloan-Kettering Cancer Center Lee M. Krug, MD † Memorial Sloan-Kettering Cancer Center Inga T. Lennes, MD † Massachusetts General Hospital Cancer Center Billy W. Loo, Jr., MD, PhD § Stanford Comprehensive Cancer Center Renato Martins, MD † Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Janis O’Malley, MD University of Alabama at Birmingham Comprehensive Cancer Center Raymond U. Osarogiagbon, MD St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute ф † Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion NCCN Malignant Pleural Mesothelioma Panel Members Summary of Guidelines Updates Initial Evaluation (MPM-1) Pretreatment Evaluation (MPM-2) Clinical stage I, Treatment (MPM-3) Clinical stage II-III, Treatment for Medically Inoperable (MPM-3) Clinical stage II-III, Treatment for Medically Operable (MPM-4) Principles of Surgical Resection (MPM-B) Principles of Radiation Therapy (MPM-C) Staging (ST-1) Principles of Chemotherapy (MPM-A) The NCCN Guidelines™ are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2010. NCCN Guidelines™ Version 1.2011 Table of Contents Malignant Pleural Mesothelioma Clinical Trials: Categories of Evidence and Consensus: NCCN All recommendations are Category 2A unless otherwise specified. See The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. NCCN To find clinical trials online at NCCN member institutions, click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion NCCN Guidelines™ Version 1.2011 Updates Malignant Pleural Mesothelioma FDG-PET changed to PET-CT. Note also added that this should be performed prior to pleurodesis. Clinical stage I-III: note added that this is epithelial or mixed histology. Clinical stage I, medically inoperable: Chemotherapy was added as a treatment option. Performance status removed from clinical stage. Post-surgical therapy: Sequential RT followed by chemotherapy added as an option for adjuvant treatment. Bullet 2 is new: “For patients being considered for surgery, a single port thoracoscopy on the line of the potential incision is recommended.” Bullet 5: “low nodal burden” changed to “no N2 lymph node involvement” and “EPP is the best option” changed to “EPP may be the best option.” General Principles Bullet 3: “after EPP” was added to the end of the statement. Radiation Dose and Volume Bullet 5: “For prophylactic radiation after surgical procedure...” was changed to “For prophylactic radiation to surgical sites...” Bullet 7: The following sentence was added, “ � � � � � � � � � RT under such circumstances or after pleurectomy/decortication may be considered with caution under strict dose limits of organs at risk or IRB approved protocols.” MPM-2 MPM-4 MPM-B MPM-C 1 of 3 MPM-3 Summary of the changes in the 1.2011 version of the Malignant Pleural Mesothelioma Guidelines from the 1.2010 version include: Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. MPM-1 Recurrent pleural effusion and/or pleural thickening � � � � � CT chest with contrast Thoracentesis for cytologic assessment Pleural biopsy (eg, Abrahms needle, CT-guided core biopsy, thoracoscopic VATS biopsy [preferred], or open biopsy) Talc pleurodesis or pleural catheter, if required for management of pleural effusion Serum mesothelin-related peptide (SMRP) and osteopontin levels optional INITIAL EVALUATION Management by a multidisciplinary team with experience in MPM recommended See Pretreatment Evaluation (MPM-2) Malignant pleural mesothelioma (MPM) confirmed NCCN Guidelines™ Version 1.2011 Malignant Pleural Mesothelioma Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. MPM-2 PATHOLOGIC DIAGNOSIS Malignant pleural mesothelioma � � � � � � Chest/abdominal CT with contrast PET-CT Mediastinoscopy or EBUS FNA of mediastinal lymph nodes (optional) Laparoscopy to rule out transdiaphragmatic extension (optional) Chest MRI (optional) Consider VATS if suspicion of contralateral disease a Clinical stage I-III and Epithelial or Mixed histology Clinical stage IV or Sarcomatoid histology See Surgical Evaluation (MPM-3) Chemotherapya aShould be performed before any pleurodesis. .bSee Principles of Chemotherapy (MPM-A) PRETREATMENT EVALUATION CLINICAL ASSESSMENT NCCN Guidelines™ Version 1.2011 Malignant Pleural Mesothelioma Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. MPM-3 CLINICAL ASSESSMENT CLINICAL STAGE Clinical stage I Clinical stage II-III Operable Medically inoperable � � � PFTs Quantitative V/Q Cardiac stress test Surgical resectionc Observation for progression or Chemotherapyb See Initial Treatment MPM-4 b c . . See Principles of Chemotherapy (MPM-A) See Principles of Surgical Resection (MPM-B) SURGICAL EVALUATION TREATMENT � � � PFTs Quantitative V/Q Cardiac stress test Operable Medically inoperable Chemotherapyb NCCN Guidelines™ Version 1.2011 Malignant Pleural Mesothelioma Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. MPM-4 Clinical stage II-III Medically operable Induction chemotherapy with pemetrexed and cisplatin or Surgery b c Resectable by pleurectomy/ decortication or extrapleural pneumonectomyc Surgical explorationc Hemithoracic radiation after extrapleural pneumonectomyd CLINICAL STAGE INDUCTION THERAPY b c . . .d See Principles of Chemotherapy (MPM-A) See Principles of Surgical Resection (MPM-B) See Principles of Radiation Therapy (MPM-C) Unresectable ADJUVANT TREATMENT Chemotherapyb Adjuvant chemotherapyb d or RT RTd NCCN Guidelines™ Version 1.2011 Malignant Pleural Mesothelioma Chemotherapyb Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. MPM-A PRINCIPLES OF CHEMOTHERAPY 1 2 3 4 5 6 7 8 Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol 2003;21:2636-44. Castagneto B, Botta M, Aitini E, et al. Phase II study of pemetrexed in combination with carboplatin in patients with malignant pleural mesothelioma. Ann Oncol 2008;19:370-3. Ceresoli GL, Zucali PA, Favaretto AG, et al. Phase II study of pemetrexed plus carboplatin in malignant pleural mesothelioma. J Clin Oncol 2006;24:1443-8. Nowak AK, Byrne MJ, Willianson R, et al. A multicentre phase II study of cisplatin and gemcitabine for malignant mesothelioma. Br J Cancer 2002;87:491-6. Van Haarst JM, Baas J, Manegold CH, et al. Multicentre phase II study of gemcitabine and cisplatin in malignant pleural mesothelioma. Br J Cancer 2002; 86:342-5. Taylor P, Castagneto B, Dark G, et al. Single-agent pemetrexed for chemonaive and pretreated patients with malignant pleural mesothelioma: results of an International Expanded Access Program. J Thorac Oncol 2008;3:764-771. Muers MF, Stephens RJ, Fisher P, et al. Active symptom control with or without chemotherapy in the treatment of patients with malignant pleural mesothelioma (MS01): a multicentre randomised trial. Lancet 2008;371:1685-94. Jassem J, Ramlau R, Santoro A, et al. Phase III trial of pemetrexed plus best supportive care compared with best supportive care in previously treated patients with advanced malignant pleural mesothelioma. J Clin Oncol 2008;26:1698-1704. Stebbing J, Powles T, McPherson K, et al. The efficacy and safety of weekly vinorelbine in relapsed malignant pleural mesothelioma. Lung Cancer 2009;63:94-7.9 FIRST-LINE COMBINATION CHEMOTHERAPY REGIMENS Pemetrexed 500 mg/m day 1 Cisplatin 75 mg/m day 1 Administered every 3 weeks (category 1) Pemetrexed 500 mg/m day 1 Carboplatin AUC 5 day 1 Administered every 3 weeks Gemcitabine 1000-1250 mg/m day 1, 8, 15 Cisplatin 80-100 mg/m day 1 Administered in 3-4 week cycles Pemetrexed 500 mg/m every 3 weeks Vinorelbine 25-30 mg/m weekly 2 2 2 2 2 2 2 1 2,3 4,5 6 7 SECOND-LINE CHEMOTHERAPY Pemetrexed (if not administered as first-line) Vinorelbine Gemcitabine 8 9 NCCN Guidelines™ Version 1.2011 Malignant Pleural Mesothelioma Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. MPM-B PRINCIPLES OF SURGICAL RESECTION � � � � � � Surgical resection should be performed on carefully evaluated patients by board certified thoracic surgeons. The goal of surgery is complete gross cytoreduction of the tumor. In cases where this is not possible such as multiple sites of chest wall invasion, surgery should be aborted. The surgical choices are (1) pleurectomy/decortication (P/D) which is defined as complete removal of the pleura and all gross tumor; and (2) extrapleural pneumonectomy (EPP) which is defined as en-bloc resection of the pleura, lung, ipsilateral diaphragm, and often pericardium. A mediastinal node dissection should be performed. For early disease (confined to the pleural envelope, no N2 lymph node involvement) with favorable histology (epithelioid) in good risk patients, EPP may be the best option. For advanced disease (high nodal disease, areas of local invasion), mixed histology, and/or high-risk patients, pleurectomy/decortication may be a better choice. After recovery from surgery, patients should be referred for adjuvant therapy which may include chemotherapy and radiation therapy depending on whether any preoperative therapy was used and on the pathological analysis of the surgical specimen. For patients being considered for surgery, a single port thoracoscopy on the line of the potential incision is recommended. NCCN Guidelines™ Version 1.2011 Malignant Pleural Mesothelioma Printed by z z on 1/10/2011 2:16:26 AM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. NCCN ® Version 1.2011, 10/25/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index MPM Table of Contents Discussion Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. MPM-C 1 of 3 PRINCIPLES OF RADIATION THERAPY (1 of 3) General Principles The best timing of delivering RT after surgical intervention and/or in conjunction with chemotherapy, should be discussed in a multidisciplinary team. For patients with resectable MPM, adjuvant RT is recommended after EPP. The goal of adjuvant RT is to improve local control. RT can be used to prevent instrument-tract recurrence after pleural intervention. RT is an effective palliative treatment for relief of chest pain associated with mesothelioma. After extrapleural pneumonectomy, adjuvant RT significantly reduces the local recurrence rate. When there is limited or no resection of disease, delivery of high-dose RT to the entire hemithorax in the setting of an intact lung has not been shown to be associated with significant survival benefit, and the toxicity is significant. RT under such c