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首页 2009NCCN指南-梅克尔细胞癌

2009NCCN指南-梅克尔细胞癌.pdf

2009NCCN指南-梅克尔细胞癌

hyx5415
2010-05-26 0人阅读 举报 0 0 暂无简介

简介:本文档为《2009NCCN指南-梅克尔细胞癌pdf》,可适用于自然科学领域

ContinueNCCNClinicalPracticeGuidelinesinOncology™MerkelCellCarcinomaVwwwnccnorgVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®NCCNMerkelCellCarcinomaPanelMembers*StanleyJMiller,MDChairTheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsMuradAlam,MDRobertHLurieComprehensiveCancerCenterofNorthwesternUniversityJamesAndersen,MDCityofHopeDanielBerg,MDFredHutchinsonCancerResearchCenterSeattleCancerCareAllianceChristopherKBichakjian,MDUniversityofMichiganComprehensiveCancerCenterGlenBowen,MDHuntsmanCancerInstituteattheUniversityofUtahRichardTCheney,MDRoswellParkCancerInstituteLFrankGlass,MDHLeeMoffittCancerCenterResearchInstitute����������¶¶¶RoyCGrekin,MDUCSFHelenDillerFamilyComprehensiveCancerCenterDennisEHallahan,MDVanderbiltIngramCancerCenterAnneKessinger,MDUNMCEppleyCancerCenteratTheNebraskaMedicalCenterNancyYLee,MDMemorialSloanKetteringCancerCenterNanetteLiegeois,MD,PhDTheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsDanielDLydiatt,DDS,MDUNMCEppleyCancerCenteratTheNebraskaMedicalCenterJeffMichalski,MD,MBASitemanCancerCenteratBarnesJewishHospitalandWashingtonUniversitySchoolofMedicineWilliamHMorrison,MDTheUniversityofTexasMDAndersonCancerCenter���¶§†§¶¶§§KishwerSNehal,MDMemorialSloanKetteringCancerCenterKellyCNelson,MDDukeComprehensiveCancerCenterPaulNghiem,MD,PhDFredHutchinsonCancerResearchCenterSeattleCancerCareAllianceThomasOlencki,DOArthurGJamesCancerHospitalRichardJSoloveResearchInstituteatTheOhioStateUniversityAllanROseroff,MD,PhDRoswellParkCancerInstitute�������¶¶¶¶‡CliffordSPerlis,MD,MBeFoxChaseCancerCenterEWilliamRosenberg,MDStJudeChildren’sResearchHospitalUniversityofTennesseeCancerInstituteAshokRShaha,MDMemorialSloanKetteringCancerCenterMarshallMUrist,MDUniversityofAlabamaatBirminghamComprehensiveCancerCenterLindaCWang,MD,JDDanaFarberBrighamandWomen’sCancerCenter���Dermatology¶SurgerySurgicaloncologyOtolaryngologyPathologyDermatopathology†Medicaloncology§RadiotherapyRadiationoncology‡HematologyHematologyoncology*WritingCommitteeMemberContinueNCCNGuidelinesPanelDisclosuresVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®TableofContentsNCCNMerkelCellCarcinomaPanelMembersGuidelinesIndexPrinttheMerkelCellCarcinomaGuidelinesSummaryofGuidelinesUpdatesClinicalPresentation,PreliminaryWorkup,andClinicalFindings(MCC)PrimaryTreatmentofClinicalN(MCC)PrimaryTreatmentofClinicalN(MCC)TreatmentofClinicalM(MCC)FollowupandRecurrence(MCC)PrinciplesofRadiationTherapy(MCCA)PrinciplesofExcision(MCCB)ChemotherapyAgents(MCCC)MerkelCellCarcinomaTheseguidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheseguidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicalcircumstancestodetermineanypatient'scareortreatmentTheNationalComprehensiveCancerNetworkmakesnorepresentationsnorwarrantiesofanykindwhatsoeverregardingtheircontent,use,orapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheseguidelinesarecopyrightedbyNationalComprehensiveCancerNetworkAllrightsreservedTheseguidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN©Forhelpusingthesedocuments,pleaseclickhereDiscussionReferencesClinicalTrials:NCCNCategoriesofEvidenceandConsensus:ThebelievesthatthebestmanagementforanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedTofindclinicaltrialsonlineatNCCNmemberinstitutions,AllrecommendationsareCategoryAunlessotherwisespecifiedSeeNCCNclickhere:nccnorgclinicaltrialsphysicianhtmlNCCNCategoriesofEvidenceandConsensusVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®SummaryofchangesintheversionoftheMerkelCellCarcinomaguidelinesfromtheversioninclude:ClinicalN:Anewpathwayfor“Headandneckcases”wasaddedAfterSLNPositive:PreviouslytheGuidelinesstated“Consideranyofthefollowingtherapiesorcombinationsof:Nodedissection,Adjuvantradiationtherapy,Adjuvantchemotherapy”Theguidelinesnowstate“Nodedissectionradiationtherapyadjuvantchemotherapy”(ALSOforMCC)AfterSLNNegativeRadiationtherapyrecommendation:FootnoteregardingradiationtherapytoprimarysitewasremovedPrinciplesofExcisionFootnote“”regardingtheusesofthemohstechniqueisnewtothepageChemotherapyAgentsEntirepagerevisedandnowcontainschemotherapyrecommendationsforLocaldisease,Regionaldisease,andDisseminateddisease���������Footnoteb:Changedto,“Imagingmaybeindicated,especially”Footnotem:“extentoflymphnodeandvisceralorganinvolvement”waschangedto“extentoflymphnodevisceral”After“Multidisciplinarytumorboardconsultation”:Thephrase“Clinicaltrial”wasremovedPrinciplesofRadiationTherapy“PrinciplesofRadiationTherapy”isanewpagethatprovidesspecificrecommendationsformerkelcellcarcinomaradiationtherapythroughouttheguidelinestoevaluateforthepossibilityofaskinmetastasisfromanoncutaneousprimaryneuroendocrinecarcinomaandorandorMayconsider()()()()():MCCMCCMCCMCCMCCA():():MCCBMCCCSummaryoftheGuidelinesupdatesUPDATESNote:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®MCCNote:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedCLINICALPRESENTATIONPRELIMINARYWORKUPCLINICALFINDINGSSuspiciouslesionHPCompleteskinandregionallymphnodeexamination��BiopsyHEImmunopanel��a��ImagingstudiesasclinicallyindicatedConsidermultidisciplinarytumorboardconsultationbClinicalNClinicalNClinicalMMerkelcellcarcinomaSeePrimaryandAdjuvant(MCC)TreatmentSeePrimaryandAdjuvant(MCC)TreatmentSeeTreatment(MCC)DIAGNOSISADDITIONALWORKUPabAnappropriateimmunopanelshouldpreferablyincludeCKandthyroidtranscriptionfactor(TTF)Imaging(CT,MR,orPET)maybeindicatedtoevaluateforthepossibilityofaskinmetastasisfromanoncutaneousprimaryneuroendocrinecarcinoma(eg,smallcelllungcancer),especiallyincaseswhereCKisnegativeVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®MCCNote:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedClinicalNPriorwidelocalexcisioncNopriorwidelocalexcisionSentinellymphnodebiopsywithappropriateimmunopanel(SLN)ghExcisioniNegativemarginsSeeFollowup(MCC)SLNpositiveSLNnegative�Multidisciplinarytumorboardconsultation��NodedissectionandorradiationtherapyMayconsideradjuvantchemotherapye,jk,lRadiationtherapyorConsiderobservationefPRIMARYANDADJUVANTTREATMENT:CLINICALNDISEASEckAfterwidelocalexcision,sentinellymphnodebiopsymaybeconsideredinselectedpatients,althoughaccuracyofresultsmaybecompromised,especiallyinnonextremityregionsRadiationtherapytoprimarysite,intransitlymphatics(whenfeasible),andordrainingnodalbasinsConsiderobservationwithsmalltumors,widelyexcisedwithnootheradverseriskfactorsdefhlgiThepreferredtreatmentsequenceisforthesentinellymphnodebiopsytoprecedetheexcisionForlymphnodesthatarepositiveonlybyimmunohistochemicalmethodsbutnotHE,considerRTasthesoletherapytothedrainingnodalbasin(s)AnappropriateimmunopanelforSLNexaminationshouldpreferablyincludeCK,andpancytokeratins(AEAE)AvailableretrospectivestudiesdonotsuggestprolongedsurvivalbenefitforadjuvantchemotherapyjSeePrinciplesofRadiationTherapy(MCCA)SeeChemotherapyAgents(MCCC)SeePrinciplesofExcision(MCCB)RadiationtherapyorConsiderobservationd,efHeadandneckcases:Widelocalexcision(WLE)withoutsentinellymphnode(SLN)biopsyRadiationtherapytoprimarysite,nodalbedsandintransitlymphaticseVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®MCC���MultidisciplinarytumorboardconsultationNodedissectionandorradiationtherapyMayconsideradjuvantchemotherapyek,lNote:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedClinicalN��FNAImmunopanelhMMSeeTreatmentofMdisease(MCC)FNANegativeOpenbiopsyBiopsypositiveBiopsynegativeFollowappropriateClinicalNpathway(MCC)PRIMARYANDADJUVANTTREATMENT:CLINICALNDISEASEehmAnappropriateimmunopanelforLNexaminationshouldpreferablyincludeCKandpancytokeratins(AEAE)AvailableretrospectivestudiesdonotsuggestprolongedsurvivalbenefitforadjuvantchemotherapyImaging(CT,MR,orPET)maybeindicatedtoevaluateextentoflymphnodeandorvisceralorganinvolvementklSeePrinciplesofRadiationTherapy(MCCA)SeeChemotherapyAgents(MCCC)SeeFollowup(MCC)ImagingstudiesasclinicallyindicatedmFNAPositiveVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®MCCNote:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedClinicalMMultidisciplinarytumorboardconsultationTREATMENT:CLINICALMDISEASESeeFollowup(MCC)BestsupportivecareConsideranyofthefollowingtherapiesorcombinationsof:Chemotherapyand���SurgeryRadiationtherapyek(SeeNCCNPalliativeCareGuideline)ekSeePrinciplesofRadiationTherapy(MCCA)SeeChemotherapyAgents(MCCC)Version,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®MCCNote:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedRecurrenceLocalRegionalDisseminatedIndividualizedtreatmentIndividualizedtreatmentSeeClinicalM(MCC)FOLLOWUPRECURRENCE���EverymoforyearEverymoforyearAnnuallythereafterPhysicalexamincludingcompleteskinandregionallymphnodeexam��ImagingstudiesasclinicallyindicatedVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®Note:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedPRINCIPLESOFRADIATIONTHERAPYMCCA���AlldosesatGydaystandardfractionationBolusisusedtoachieveadequateskindoseWidemargins(cm)shouldbeused,ifpossible,aroundtheprimarysiteIfelectronbeamisused,anenergyandisodoseline(eg,)shouldbeusedthatwilldeliveradequatelateralanddeepmarginsExtremityandtorsoMCC:AfternegativeSLNBandwidelocalexcision(WLE),inmostinstances,radiationtherapyisgiventotheprimarysiteonlySLNBdictatestheneedforregionalirradiationIfSLNBisnegative,thenregionalnodalbasinscanbeobservedIfSLNBisnotperformed,considerirradiatingnodalbedsforsubclinicaldiseaseIrradiationofintransitlymphaticsisusuallynotfeasibleunlesstheprimarysiteisincloseproximitytothenodalbedHeadandneckMCC:Riskoffalsenegativesentinelnodebiopsyishigher,duetoaberrantlymphnodedrainageandfrequentpresenceofmultiplesentinelnodebasinsTheradiationfieldtotreattheprimarysiteisoftenoverlyingthedraininglymphnodebedsTreatmentoptionsforclinicallynodenegativeMCCoftheheadandneckinclude:PerformSLNBandWLEIfSLNBisnegative,optionsaretoirradiatetheprimarysitenodalbedsandintransitlymphaticsorobserveORPerformWLEwithoutperformingSLNBandirradiatetheprimarytumorsite,intransitlymphaticsandregionalnodalsites��±Lymphnodedissectionistherecommendedinitialtherapyforclinicallyevidentadenopathyintheaxillaorgroin,followedbypostoperativeradiationifindicatedConsiderRTwhenthereisapotentialforanatomic(eg,previoushistoryofsurgeryincludingWLE),operator,orhistologicfailure(eg,failuretoperformappropriateimmunohistochemistryonSLNs)thatmayleadtoafalsenegativeSLNBDoserecommendationsforradiationtherapy:PrimarySite:NegativeresectionmarginsGyMicroscopic()resectionmarginsGyGross()resectionmarginsorunresectableGy����AfterSLNBwithoutLNDissection����NegativeSLNbiopsy:axillaorRadiationnotindicatedNegativeSLNbiopsy:headandneck,ifatriskforfalsenegativebiopsyGyMicroscopicNonSLNB:GyMicroscopicNonSLNB:headandneckGygroinaxillaorgroinNodalBed:Clinically()butatriskforsubclinicaldiseaseGyClinicallyevidentadenopathy:headandneckGyClinicallyevidentadenopathy:axillaorgroin––�NoSLNBorLNDissection����AfterLNDissection��Lymphnodedissection:axillaorgroinGyLymphnodedissection:headandneckGyMicroscopicNisdefinedassinglenodeinvolvementthatisneitherpalpableclinicallynorabnormalbyimagingcriteriawhichmicroscopicallyconsistsofsmallmetastaticfociwithoutextracapsularextensionRTmaybeomittedafteraxillarygroinLNdissectionformicroscopicdiseasePostoperativeradiationisindicatedformultipleinvolvednodesandorpresenceofmorethanfocalextracapsularextensionVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®MCCBNote:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofanycancerpatientisinaclinicaltrialParticipationinclinicaltrialsisespeciallyencouragedPRINCIPLESOFEXCISIONGoal:ClearsurgicalmarginswhenclinicallyfeasibleVariedApproaches:cmmarginstoinvestingfasciaofmuscleorpericraniumwithclearpathologicmargins,whenclinicallyfeasibleMohstechniqueModifiedMohs=MohstechniquewithadditionalfinalmarginforpermanentsectionassessmentCCPDMA=CompletecircumferentialandperipheraldeepmarginassessmentReconstruction:ImmediatereconstructioninmostcasesItispreferabletodelayreconstructioninvolvingextensiveunderminingorflapsuntilnegativesurgicalmarginsareassessedandcertifiedpathologicallyclearWhenprimaryclosureisnotpossible,considersplitthicknessskingrafting(STSG)tomonitorforrecurrence��������MohstechniqueisusedprimarilyinMCCtoinsurecompleteremovalandclearmargins,andsecondarilyforitstissuesparingcapabilitiesVersion,©NationalComprehensiveCancerNetwork,IncAllrightsreservedTheseguidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCNGuidelinesIndexMCCTableofContentsDiscussion,ReferencesMerkelCellCarcinomaPracticeGuidelinesinOncology–vNCCN®CHEMOTHERAPYAGENTSMCCCNote:AllrecommendationsarecategoryAunlessotherwiseindicatedClinicalTrials:NCCNbelievesthatthebestmanagementofa

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2009NCCN指南-梅克尔细胞癌

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