2010NCCN指南-睾丸癌

Continue NCCN Clinical Practice Guidelines in Oncology™ Testicular Cancer V.1.2010 www.nccn.org Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® NCCN Testicular Cancer Panel Members Continue Testicular Cancer * † Medical oncology ‡ Hematology/hematology oncology § Radiotherapy/Radiation oncology Diagnostic Radiology £ Supportive Care including Palliative, Pain Management, Pastoral care and Oncology social work Þ Internal medicine Urology * Writing committee member ф � NCCN Guidelines Panel Disclosures Robert J. Motzer, MD/Chair Memorial Sloan-Kettering Cancer Center Neeraj Agarwal, MD Huntsman Cancer Institute at the University of Utah Clair Beard, MD St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute Michael A. Carducci, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Sam S. Chang, MD Vanderbilt-Ingram Cancer Center Toni K. Choueiri, MD † Þ ‡ § † † £ † Þ † Þ Dana-Farber/Brigham and Women’s Cancer Center Sam Bhayani, MD Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine Graeme B. Bolger, MD University of Alabama at Birmingham Comprehensive Cancer Center Barry Boston, MD Dana-Farber/Brigham and Women’s Cancer Center � � Thomas Olencki, DO The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute Roberto Pili, MD Roswell Park Cancer Institute UCSF Helen Diller Family Comprehensive Cancer Center Memorial Sloan-Kettering Cancer Center UNMC Eppley Cancer Center at The Nebraska Medical Center ‡ † † † † Bruce G. Redman, DO University of Michigan Comprehensive Cancer Center Cary N. Robertson, MD Duke Comprehensive Cancer Center Charles J. Ryan, MD Lawrence H. Schwartz, MD Joel Sheinfeld, MD Memorial Sloan-Kettering Cancer Center Jue Wang, MD � � � ф Robert A. Figlin, MD City of Hope Comprehensive Cancer Center Mayer Fishman, MD, PhD H. Lee Moffitt Cancer Center & Research Institute Steven L. Hancock, MD Stanford Comprehensive Cancer Center Gary R. Hudes, MD Fox Chase Cancer Center Eric Jonasch, MD The University of Texas M. D. Anderson Cancer Center Timothy M. Kuzel, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Paul H. Lange, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Ellis G. Levine, MD Roswell Park Cancer Institute Kim A. Margolin, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance M. Dror Michaelson, MD, PhD Massachusetts General Hospital Cancer Center † † ‡ Þ § Þ † ‡ ‡ † † ‡ † � Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® This manuscript is being updated to correspond with the newly updated algorithm. These 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 these 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 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. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2009. Table of Contents NCCN Testicular Cancer Panel Members Workup, Primary Treatment and Pathologic Diagnosis (TEST-1 Seminoma: Postdiagnostic Workup and Clinical Stage (TEST-2 Stage IA, IB (TEST-3 Stage IIA, IIB (TEST-3 Stage IIC, III (TEST-3 Nonseminoma: Postdiagnostic Work-up and Clinical Stage (TEST-5 Stage IA, IB, IS (TEST-6 Stage IIA, IIB (TEST-7 Postchemotherapy Management (TEST-8 Postsurgical Management (TEST-9 Stage IIC, IIIA, IIIB, IIIC, and Brain Metastases (TEST-10 Follow-up for Nonseminoma (TEST-11 ) ) ) ) ) ) ) ) ) ) ) ) � � � � � � � � � � Stage IS (TEST-3 Recurrence and Second Line Therapy (TEST-12 Risk Classification (TEST-A Primary Chemotherapy Regimens for Germ Cell Tumors (TEST-B Second Line or Subsequent Chemotherapy Regimens for Metastatic Germ Cell Tumors (TEST-C ) ) ) ) ) Summary of Guidelines Updates For help using these documents, please click here Staging Discussion References Clinical Trials: Categories of Evidence and Consensus: NCCN The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN member institutions, All recommendations are Category 2A unless otherwise specified. See NCCN click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus Testicular Cancer Guidelines Index Print the Testicular Cancer Guidelines Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® 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. UPDATES Summary of the Guidelines updates Summary of changes in the 1.2010 version of the Testicular Cancer Guidelines from the 2.2009 version include: Seminoma � � � � � � � Residual mass, positive PET scan, “salvage therapy’ was clarified as “second line chemotherapy”. Follow-up abdominal/pelvic CT interval was clarified as “4 mo post surgery, then as indicated”. Surveillance after complete response to chemotherapy and/or RPLND and months between abdominal/pelvic CT: For 6 + years, the interval between CT scans was changed from “12- 24 mo” to “as clinically indicated”. Previous footnote was modified as, “CT scans apply only to patients treated with chemotherapy . For patients who are post RPLND, a postoperative baseline CT scan is recommended ” and moved under surveillance for clarification. Second line therapy for favorable prognosis, “high-dose chemotherapy” was added as a treatment option. Second line therapy, incomplete response or relapse, “high-dose chemotherapy” was modified by adding “if not previously given” to preferred. : High-dose chemotherapy regimens were added to the page. � � alone and additional CT scans as clinically indicated Nonseminoma, “post-orchiectomy” was added to markers for clarification for each risk status TEST-4 TEST-11 TEST-12 TEST-A TEST-C Nonseminoma Testicular Cancer Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® 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. WORKUP PRIMARY TREATMENT PATHOLOGIC DIAGNOSIS a b Quantitative analysis of beta subunit. This includes seminoma histology with elevated AFP. Suspicious testicular mass Seminoma (AFP negative; may have elevated beta-hCG) Nonseminomatous germ cell tumorb � � � Discuss sperm banking Radical inguinal orchiectomy Consider open inguinal biopsy of contralateral testis if: Suspicious ultrasound for intratesticular abnormalities Cryptorchid testis Marked atrophy � � � � � � � � � � H&P Alpha-fetoprotein (AFP) beta-hCG Chemistry profile Chest x-ray Optional: Testicular ultrasound a LDH � See Postdiagnostic Workup and Clinical Stage (TEST-2) See Postdiagnostic Workup and Clinical Stage (TEST-5) TEST-1 Testicular Cancer Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® 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. PATHOLOGIC DIAGNOSIS POSTDIAGNOSTIC WORKUP CLINICAL STAGE Seminoma (AFP negative ; may have elevated beta-hCG) c d � � � � � � Abdominal/pelvic CT Chest CT if: Positive abdominal CT or abnormal chest x-ray Repeat beta-hCG, LDH, AFP (if elevated preoperatively) Brain MRI, if clinically indicated Bone scan, if clinically indicated Discuss sperm banking � e Stage IA, IB Stage IIA, IIB Stage IIC, III See Primary Treatment and Follow-up (TEST-3) See Primary Treatment and Follow-up (TEST-3) See Primary Treatment and Follow-up (TEST-3) c d e Mediastinal seminoma should be treated as good risk nonseminomatous germ cell tumor with etoposide/cisplatin for 4 cycles or bleomycin/etoposide/cisplatin for 3 cycles. If positive, treat as nonseminoma. Elevated values should be followed with repeated determination to allow precise staging. TEST-2 Testicular Cancer Seminoma Stage IS See Primary Treatment and Follow-up (TEST-3) Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® 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. CLINICAL STAGE Stage IA, IB Stage IIA, IIB RT: Infradiaphragmatic (35-40 Gy) to include para-aortic and ipsilateral iliac nodes Consider p EP for 4 cycles for selected stage IIB patients rimary chemotherapy:g FOLLOW-UPPRIMARY TREATMENT Surveillance if: Horseshoe or pelvic kidney Inflammatory bowel disease Prior RT Consider surveillance if: (category 2B) T1 or T2 histology in selected patients committed to long-term follow-up or Single agent carboplatin (AUC=7 x 1 cycle or AUC=7 x 2 cycles) (category 1) (category 1) or RT: Infradiaphragmatic (20-30 Gy) to include para-aortic ± ipsilateral iliac nodes (category 1) � � � � � � H&P + chest x-ray, AFP, beta-hCG, LDH: every 3-4 mo for year 1, every 6 mo for year 2, then annually Pelvic CT annually for 3 years (for patients status post only para-aortic RT) � � H&P + chest x-ray for year 4, then annually Abdominal CT at month 4 of year 1 , AFP, beta-hCG, LDH: every 3-4 mo for years 1-3, every 6 mo � � H&P, AFP, beta-hCG, LDH: every 3-4 mo for years 1-3, every 6 mo for years 4-7, then annually Abdominal/pelvic CT at each visit, chest x-ray at alternative visits (up to 10 y) TEST-3 Recurrence, treat according to extent of disease at relapse Recurrence, treat according to extent of disease at relapse Recurrence, treat according to extent of disease at relapse See Post Chemotherapy Management and Follow-up (TEST-4) fSee Risk Classification (TEST-A See Primary Chemotherapy Regimens for Germ Cell Tumors (TEST-B ) ) . .g Stage IIC, III Primary chemotherapy: EP for 4 cycles (category 1) or BEP for 3 cycles (category 1) g Good riskf Intermediate riskf Primary chemotherapy:g BEP for 4 cycles (category 1) See Post Chemotherapy Management and Follow-up (TEST-4) EP = Etoposide/cisplatin BEP = Bleomycin/etoposide/cisplatin Testicular Cancer Seminoma Stage IS RT: Infradiaphragmatic (25-30 Gy) to include para-aortic ± ipsilateral iliac nodes or Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® FOLLOW-UP � � � H&P + chest x-ray every 2 mo for for for year 4, then annually Abdominal/pelvic CT 4 mo post surgery, then as indicated PET scan as clinically indicated , AFP, beta-hCG, LDH: year 1 every 3 mo year 2, every 4 mo for year 3, every 6 mo Recurrence, See Second line Therapy (TEST-12) TEST-4 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. Residual mass (nodes > 3 cm on CT) Residual mass (nodes 3 cm on CT) � Progressive disease (growing mass or rising markers)h Surveillance or Surgery or RT (category 2B) (category 2B) See Second line Therapy for nonseminoma (TEST-12) � � Chest, abdominal, pelvic CT scan Serum tumor markers No residual mass and normal markersh Residual mass and normal markersh Surveillance Consider surgery with biopsy or Biopsy and second line chemotherapy or RT (category 2B) i PET scan (preferred) Positive Negative Surveillance PET scan not feasible hFor persistent elevated beta-hCG which is not rising, repeat serial markers, testosterone suppression test and consider a PET scan iSee Second Line or Subsequent Chemotherapy Regimens for Metastatic Germ Cell Tumors (TEST-C). STAGE IIB, IIC, III AFTER PRIMARY TREATMENT WITH CHEMOTHERAPY Surveillance Testicular Cancer Seminoma POST CHEMOTHERAPY MANAGEMENT Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® 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. PATHOLOGIC DIAGNOSIS Nonseminomatous germ cell tumorb POSTDIAGNOSTIC WORKUP b j This includes seminoma histology with elevated AFP. Treatment may be initiated prior to histology for patients with rising markers and a deteriorating clinical situation. eElevated values should be followed with repeated determination to allow precise staging. � � � � � � Abdominal/pelvic CT Chest CT if: Abnormal abdominal CT Abnormal chest x-ray Repeat beta-hCG, LDH, AFP Brain MRI, if clinically indicated Bone scan, if clinically indicated Discuss sperm banking � � e CLINICAL STAGEj Stage IA, IB, IS: See Primary Treatment (TEST-6) Stage IIA, IIB: See Treatment (TEST-7 Primary ) Stage IIC, IIIA, IIIB, IIIC, and brain metastasis: See Treatment (TEST-10 Primary ) TEST-5 Testicular Cancer Nonseminoma Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® 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. CLINICAL STAGE Stage IA Surveillance (in compliant patients) or Open nerve-sparing RPLNDk Stage IB Open nerve-sparing RPLND or Primary chemotherapy: BEP for 2 cycles (category 2B) or Surveillance (only if T2, compliant patients [category 2B]) k g The EP and BEP chemotherapy regimens have shown survival advantage in randomized clinical trials and may be considered as category 1 compared with other chemotherapy regimens. EP = Etoposide/cisplatin BEP = Bleomycin/etoposide/cisplatin TEST-6 See Follow-up for Nonseminoma (TEST-11) See Follow-up for Nonseminoma (TEST-11) Stage IS Persistent marker elevation Primary chemotherapy: EP for 4 cycles or BEP for 3 cycles g See Postchemotherapy Management (TEST-8) See Postchemotherapy Management (TEST-8) See Postsurgical Management (TEST-9) See Postsurgical Management (TEST-9) Testicular Cancer Nonseminoma g k . Retroperitoneal lymph node dissection (RPLND) is recommended within 4 weeks of CT scan and 7-10 days of markers (category 2B). See Primary Chemotherapy Regimens for Germ Cell Tumors (TEST-B) PRIMARY TREATMENT Version 1.2010, 08/28/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index Testicular Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® 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. CLINICAL STAGE PRIMARY TREATMENT Stage IIA Markers negative Persistent marker elevation Open nerve-sparing RPLND or Primary chemotherapy (category 2B): EP for 4 cycles or BEP for 3 cycles k g Primary chemotherapy: EP for 4 cycles or BEP for 3 cycles g TEST-7 See Postchemotherapy Management (TEST-8) The EP and BEP chemotherapy regimens have shown survival advantage in randomized clinical trials and may be considered as category 1 compared with other chemotherapy regimens. EP = Etoposide/cisplatin BEP = Bleomycin/etoposide/cisplatin See Postchemotherapy Management (TEST-8) See Postsurgical Management (TEST-9) Stage IIB Markers negative Persistent marker elevation Lymph node metastases, within lymphatic drainage sites (landing zone positive) Multifocal symptomatic lymph node metastases with aberrant lymphatic drainage Primary chemotherapy: EP for 4 cycles or BEP for 3 cycles g Primary chemotherapy: EP for 4 cycles or BEP for 3 cycles g Open nerve-sparing RPLND or Primary chemotherapy: EP for 4 cycles or BEP for 3 cycles k g See Postchemotherapy Management (TEST-8) See Postsurgical Management (TEST-9) g . kRetroperitoneal lymph node dissection (RPLND) is recommended within 4 weeks of CT scan and 7-10 days of markers (category 2B). See Primary Chemotherapy Regimens for Germ Cell Tumors (TEST-B) Testicular Cancer Nonseminoma Version 1.2010, 08/28/09 © 2009 National Compreh