2012NCCN小细胞肺癌指南

Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC Table of Contents Discussion NCCN.org Continue NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) Small Cell Lung Cancer Version 2.2012 Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC Table of Contents Discussion Gregory P. Kalemkerian, MD University of Michigan Comprehensive Cancer Center Wallace Akerley, MD /Chair † † Huntsman Cancer Institute at the University of Utah Paul Bogner, MD Roswell Park Cancer Institute Hossein Borghaei, DO, MS Fox Chase Cancer Center Laura Chow, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Center Alliance ¶ † † ‡ † Robert J. Downey, MD Memorial Sloan-Kettering Cancer Center Leena Gandhi, MD, PhD � Dana-Farber/Brigham and Women's Cancer Center UNMC Eppley Cancer Center at the Nebraska Medical Center Apar Kishor P. Ganti, MD † Þ Harvey B. Niell, MD University of Tennessee Cancer Institute Janis O’Malley, MD University of Alabama at Birmingham Comprehensive Cancer Center Jyoti D. Patel, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University † † † Þ ‡ ф Neal Ready, MD, PhD Duke Cancer Institute Charles M. Rudin, MD, PhD Charles C. Williams, Jr., MD H. Lee Moffitt Cancer Center and Research Institute † † Þ The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Kristina Gregory, RN, MSN, OCN Miranda Hughes, PhD NCCN Ramaswamy Govindan, MD John C. Grecula, MD James Cancer Hospital and Solove Research Institute James Hayman, MD, MBA University of Michigan Comprehensive Cancer Center Rebecca Suk Heist, MD, MPH Massachusetts General Hospital Cancer Center Leora Horn, MD, MSc Vanderbilt-Ingram Cancer Center Thierry Jahan, MD UCSF Helen Diller Family Comprehensive Cancer Center Marianna Koczywas, MD City of Hope Comprehensive Cancer Center † Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine § † † † † ‡ ‡ Þ The Ohio State University Comprehensive Cancer Center - Cesar A. Moran, MD The University of Texas MD Anderson Cancer Center § � † Medical Oncology ¶ Surgery/Surgical oncology § Radiation oncology/ Þ Internal medicine Radiotherapy ‡ Hematology/hematology oncology Pathology *Writing Committee Member � ф Diagnostic/Interventional Radiology Continue * NCCN Guidelines Panel Disclosures NCCN Guidelines™ Version 2.2012 Panel Members Small Cell Lung Cancer Printed by fang jian on 10/13/2011 10:50:29 PM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC Table of Contents Discussion Small Cell Lung Cancer: Lung Neuroendocrine Tumors: NCCN Small Cell Lung Cancer Panel Members Initial Evaluation and Staging (SCL-1) Limited Stage, Workup and Treatment Summary of the Guidelines Updates � � � � � � � � � � (SCL-2) Extensive Stage, Workup and Treatment (SCL-4) Response Assessment after Initial Therapy (SCL-5) Surveillance (SCL-5) Subsequent Therapy and Palliative Therapy (SCL-6) Principles of Surgical Resection (SCL-A) Principles of Chemotherapy (SCL-B) Principles of Radiation Therapy (SCL-C) Principles of Supportive Care (SCL-D) Workup and Primary Treatment (LNT-1) High-grade neuroendocrine carcinoma (large cell neuroendocarcinoma) Intermediate-grade neuroendocrine carcinoma (atypical carcinoid) Low-grade neuroendocrine carcinoma (typical carcinoid) Combined SCLC and NSCLC Staging (ST-1) � � � � � Clinical Trials: Categories of Evidence and Consensus: NCCN All recommendations are Category 2A unless otherwise specified. 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 See NCCN Categories of Evidence and Consensus 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. ©2011. NCCN Guidelines™ Version 2.2012 Table of Contents Small Cell Lung Cancer Printed by fang jian on 10/13/2011 10:50:29 PM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC Table of Contents Discussion UPDATES General - Initial Evaluation Additional Workup ”If pleural effusion is seen on chest x-ray” changed to “If pleural effusion is present”. Footnote “e”: number associated with cytological examinations removed. Combined 3rd and 4th bullets dealing with bone mets: “Bone radiographs of areas showing abnormal uptake on PET/CT or bone scan ; consider MRI of bony lesions .” Bone radiographs removed as additional workup. Initial Treatment For management of osseous structural impairment: “Consider palliative external-beam RT and orthopedic stabilization if risk of fracture” added. PET scan was changed to PET/CT scan. ”Differential” was added to CBC. Chest x-ray was removed. Bone scan was moved from the algorithm and added as footnote “c”: “If PET/CT is not available, a bone scan may be used to identify metastases. Pathologic confirmation is recommended for lesions detected by PET/CT that alter stage.” PET/CT was clarified by adding “if limited stage is suspected.” Footnote “a”modified: “...further . ” Stage Limited stage: “that do not fit in a tolerable radiation field” added. Changed oncology follow-up visits to the following: 3-4 mo during y 1-2 and every 6 mo during y 3-5. Added 4th bullet under surveillance “PET/CT is not recommended for routine follow-up.” Last bullet added, “PCI is not recommended in patients with poor performance status or impaired mental functioning.” References 3 and 4 are new to the page. Limited stage: “The use of myeloid growth factors is not recommended during concurrent chemotherapy plus radiotherapy” added to chemotherapy + RT. References added for subsequent chemotherapy options. References added for subsequent chemotherapy options. Limited stage: Bullet 3 modified: Radiation target volumes should be defined based on the CT scan obtained at the time of radiotherapy planning, following ICRU definitions (Reports 50 and 62). Radiation doses should be calculated with inhomogeneity corrections. Bullet 4 modified: Three-dimensional conformal radiation techniques are preferred. Four-dimensional imaging should also be performed to assess tumor movement less than 1 cm . Prophylactic cranial radiotherapy: “For extensive-stage patients, 20 Gy in 5 fractions may be considered” is new to the page. References 11, 12 are new to the page. Footnote “d” modified: cisplatin/etoposide, . References added for systemic chemotherapy options. � � � � � � � � � � � � � � � � � � � � � � staging evaluation is optional However, head MRI (preferred) or CT should be obtained in all patients. pretreatment PET scan and In selected patients, IMRT may be considered ( ). and/or other available techniques and motion management should be used to achieve movement of or the PTV margin should be increased appropriately Options include temozolomide, sunitinib and everolimus to evaluate potential metastases if radiographs are equivocal 11 � SCL-1 SCL-2 SCL-4 LNT-1SCL-5 SCL-5 SCL-A SCL-B 1 of 2 SCL-B 2 of 2 SCL-C 1 of 2 SCL-C 2 of 2 http://www.icru.org/index.php?option=com_content&task=view&id=171 NCCN Guidelines™ Version 2.2012 Updates Small Cell Lung Cancer Summary of changes in the 1.2012 version of the NCCN Small Cell Lung Cancer Guidelines from the 2.2011 version include: Summary of changes in the 2.2012 version of the NCCN Small Cell Lung Cancer Guidelines from the 1.2012 version include: � The discussion section was updated to reflect the changes in the algorithm ( ).MS-1 Printed by fang jian on 10/13/2011 10:50:29 PM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC 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. DIAGNOSIS INITIAL EVALUATIONa STAGE Limited stage except T3-4 due to multiple lung nodules that do not fit in a tolerable radiation field) d (T any, N any, M0; See Additional Workup (SCL-4) See Additional Workup (SCL-2) Extensive staged (T any, N any, M1a/b; T3-4 due to multiple lung nodules) � � � � � � � H&P Pathology review Chest/liver/adrenal CT with IV contrast whenever possible Head MRI (preferred) or CT PET/CT scan (if limited stage is ) Smoking cessation counseling and intervention CBC with differential, platelets Electrolytes, liver function tests (LFTs), Ca, LDH BUN, creatinine suspected � � a,c b Small cell or combined Small cell/non-small cell lung cancer on biopsy or cytology of primary or metastatic site a b c d If extensive stage is established, further staging evaluation is optional. However, head MRI (preferred) or CT should be obtained in all patients. Head MRI is more sensitive than CT for identifying brain metastases and is preferred over CT. If PET/CT not available, bone scan may be used to identify metastases. Pathologic confirmation is recommended for lesions detected by PET/CT that alter stage. See Staging on page ST-1. SCL-1 NCCN Guidelines™ Version 2.2012 Small Cell Lung Cancer Printed by fang jian on 10/13/2011 10:50:29 PM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC 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. e g h i Most pleural effusions in patients with lung cancer are due to cancer; however, if the effusion is too small to allow image-guided sampling, then the effusion should not be considered in staging. If cytological examination of pleural fluid is negative for cancer, fluid is not bloody and not an exudate and clinical judgment suggests that the effusion is not directly related to the cancer, then the effusion should not be considered evidence of extensive stage disease. PET scan to identify distant disease and to guide mediastinal evaluation, if not previously done. . Mediastinal staging procedures include mediastinoscopy, mediastinotomy, endobronchial or esophageal ultrasound-guided biopsy, and video-assisted thoracoscopy. If endoscopic lymph node biopsy is positive, additional mediastinal staging is not required. fSelection criteria include: nucleated RBCs on peripheral blood smear, neutropenia, or thrombocytopenia. See Principles of Surgical Resection (SCL-A) Clinical stage T1-2, N0 Bone marrow biopsy, thoracentesis, or bone studies consistent with malignancy Limited stage in excess of T1-T2, N0 Pathologic mediastinal staging h,i � � � � If pleural effusion is present, thoracentesis is recommended; if thoracentesis inconclusive, consider thoracoscopy Pulmonary function tests (PFTs) (if clinically indicated) Bone radiographs of areas showing abnormal uptake on PET/CT or bone scan to evaluate potential metastases; consider MRI of bony lesions if radiographs are equivocal e Unilateral marrow aspiration/biopsy in select patientsf Follow Pathway For Extensive-Stage Disease (See SCL-4) See Initial Treatment (SCL-3) See Initial Treatment (SCL-3) PET/CT scang STAGE ADDITIONAL WORKUP Limited stage except T3-4 due to multiple lung nodules (T any, N any, M0; that do not fit in a tolerable radiation field) NCCN Guidelines™ Version 2.2012 Small Cell Lung Cancer SCL-2 Printed by fang jian on 10/13/2011 10:50:29 PM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC 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. Lobectomy (preferred) and mediastinal lymph node dissection or sampling h Chemotherapy + concurrent RT (category 1) j kGood PS (0-2) Individualized treatment including supportive carel ChemotherapyjN0 N+ Concurrent chemotherapy + mediastinal RT j k h l . k See Principles of Surgical Resection (SCL-A) See Principles of Supportive Care (SCL-D) See Principles of Chemotherapy (SCL-B) See Principles of Radiation Therapy (SCL-C) . . . iMediastinal staging procedures include mediastinoscopy, mediastinotomy, endobronchial or esophageal ultrasound-guided biopsy, and video-assisted thoracoscopy. If endoscopic lymph node biopsy is positive, additional mediastinal staging is not required. j Limited stage in excess of T1-2, N0 Clinical stage T1-2, N0 Pathologic mediastinal staging positive or medically inoperable h,i Pathologic mediastinal staging negative h,i Chemotherapy + concurrent thoracic RT (category 1) j k Good performance status (PS 0-2) Poor PS (3-4) due to SCLC Chemotherapy ± RTj k See Response Assessment + Adjuvant Treatment (SCL-5) Poor PS (3-4) due to SCLC Chemotherapy ± RTj k Poor PS (3-4) not due to SCLC Individualized treatment including supportive carel Poor PS (3-4) not due to SCLC TESTING RESULTS INITIAL TREATMENTl NCCN Guidelines™ Version 2.2012 Small Cell Lung Cancer SCL-3 ADJUVANT TREATMENT See Response Assessment + Adjuvant Treatment (SCL-5) Printed by fang jian on 10/13/2011 10:50:29 PM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC 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. Extensive stage + localized symptomatic sites Extensive stage without localized symptomatic sites or brain metastases Extensive stage with brain metastases May administer chemotherapy first, with whole-brain RT after chemotherapyj Individualized therapy including supportive care or chemotherapyl See NCCN Palliative Care Guidelines � � Poor PS (3-4) Severely debilitated Extensive stage (T any, N any, M1a/b; T3-4 due to multiple lung nodules) � � � SVC syndrome Lobar obstruction Bone metastases Spinal cord compression RT to symptomatic sites before chemotherapy unless immediate systemic therapy is required. k See NCCN Central Nervous System Cancers Guidelines Sequential radiotherapy to thorax in selected patients with low-bulk metastatic disease and CR or near CR after systemic therapy. j m See Principles of Chemotherapy (SCL-B). See Principles of Radiation Therapy (SCL-C) See Principles of Supportive Care (SCL-D). .k l Combination chemotherapy including supportive care j,m l See NCCN Palliative Care Guidelines See Response Assessment + Adjuvant Treatment (SCL-5) Symptomatic Asymptomatic Whole-brain RT before chemotherapy, unless immediate systemic therapy is required j STAGE INITIAL TREATMENTl NCCN Guidelines™ Version 2.2012 Small Cell Lung Cancer SCL-4 Chemotherapy ± RT to symptomatic sites For management of osseous structural impairment, consider palliative external-beam RT and orthopedic stabilization, if risk of fracture j k k Printed by fang jian on 10/13/2011 10:50:29 PM. For personal use only. Not approved for distribution. Copyright © 2011 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 2.2012, 06/23/11 © National Comprehensive Cancer Network, Inc. 2011, 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 SCLC 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. � � � � � � Chest x-ray (optional) Chest/liver/adrenal CT Head MRI or CT, if prophylactic cranial irradiation (PCI) to be given Other imaging studies, to assess prior sites of involvement, as clinically indicated CBC, platelets Electrolytes, LFTs, Ca, BUN, creatinine with IV contrast whenever possible After recovery from primary therapy: Oncology follow-up visits every 3-4 mo during y 1-2, every 6 mo during y 3-5, then annually New pulmonary nodule should initiate workup for potential new primary Smoking cessation intervention PET/CT is not recommended for routine follow-up � � � � � At every visit: H&P, chest imaging, bloodwork as clinically indicated Complete response or Partial response P