2009NCCN指南-霍奇金淋巴瘤

Continue NCCN Clinical Practice Guidelines in Oncology™ Hodgkin Disease/ Lymphoma V.2.2009 www.nccn.org Version 2.2009, 02/25/09 © 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 Hodgkin Disease TOC Staging, Discussion, References Practice Guidelines in Oncology – v.2.2009NCCN ® Hodgkin Disease/Lymphoma NCCN Hodgkin Disease/Lymphoma Panel Members Richard T. Hoppe, MD/Chair § Stanford Ranjana Hira Advani, MD † Stanford Comprehensive Cancer Center Richard F. Ambinder, PhD, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Bouthaina Dabaja, MD The University of Texas M. D. Anderson Cancer Center Comprehensive Cancer Center Philip J. Bierman, MD † ‡ † The Sidney Kimmel Comprehensive Cancer Center at John Hopkins � Kristie A. Blum, MD ‡ Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University § Benjamin Djulbegovic, MD, PhD † ‡ H. Lee Moffitt Cancer Center & Research Institute Andrew M. Evens, DO, MS Robert H. Lurie Comprehensive Cancer Center of Northwestern University ‡ Þ David Mansur, MD Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine Dana-Farber/Brigham and Women's Cancer Center Joseph O. Moore, MD † Duke Comprehensive Cancer Center David Morgan, MD Vanderbilt-Ingram Cancer Center † ‡ ‡ § Peter M. Mauch, MD § Russell J. Schilder, MD Fox Chase Cancer Center Lawrence M. Weiss, MD City of Hope Jane N. Winter, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Joachim Yahalom, MD Memorial Sloan-Kettering Cancer Center Andrew D. Zelenetz, MD, PhD † Þ Memorial Sloan-Kettering Cancer Center † ‡ � � Andres Forero, MD † ‡ University of Alabama at Birmingham Comprehensive Cancer Center Leo I. Gordon, MD ‡ Robert H. Lurie Comprehensive Cancer Center of Northwestern University † Roswell Park Cancer Institute Ephraim P. Hochberg, MD Massachusetts General Hospital Cancer Center Melissa M. Hudson, MD ‡ St. Jude Children's Research Hospital/University of Tennessee Cancer Institute Mark S. Kaminski, MD † University of Michigan Comprehensive Cancer Center † ‡ Francisco J. Hernandez-Ilizaliturri, MD † Gena Love ¥ New Mexico Department of Health Comprehensive Cancer Programs David G. Maloney, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance * Writing Committee Member * § Radiation oncology † Medical Oncology ‡ Hematology/Hematology oncology Bone Marrow Transplantation Pathology Þ Internal medicine ¥ Patient Advocacy � �ContinueNCCN Guidelines Panel Disclosures Version 2.2009, 02/25/09 © 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 Hodgkin Disease TOC Staging, Discussion, References Practice Guidelines in Oncology – v.2.2009NCCN ® Hodgkin Disease/Lymphoma 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 nor warranties of any kind whatsoever 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 Primary Treatment Classical Hodgkin Lymphoma: Lymphocyte-predominant Hodgkin Lymphoma: NCCN Hodgkin Disease/Lymphoma Panel Members Summary of Guidelines Updates Principles of Radiation Therapy (HODG-C) Revised Response Criteria (HODG-D) Principles of Second-line Chemotherapy (HODG-E) Guideline Index Print the Hodgkin Disease/Lymphoma Guidelines Diagnosis and Workup (HODG-1) CS IA-IIA Favorable (HODG-2) CS I-II Unfavorable (HODG-3) CS III-IV (HODG-4) CS IA-IIA (HODG-6) CS IB-IIB (HODG-6) CS IIIA-IVA (HODG-6) CS IIIB-IVB (HODG-6) Follow-up After Completion of Treatment and Monitoring For Late Effects (HODG-7) Relapse (HODG-8) Unfavorable Factors (localized and advanced disease) (HODG-A) Principles of Chemotherapy (HODG-B) � � For help using these documents, please click here Staging Discussion References 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 Version 2.2009, 02/25/09 © 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 Hodgkin Disease TOC Staging, Discussion, References Practice Guidelines in Oncology – v.2.2009NCCN ® Hodgkin Disease/Lymphoma Summary of the Guidelines updates UPDATES HODG-1 HODG-3 HODG-6 HODG-7 HODG-8 HODG-A HODG-B 1 of 3 HODG-E � � � � � � � � � � � � � � � � � � � Diagnostic was added to chest/abdominal/pelvic CT. PET scan replaced with PET-CT. IVF or ovarian tissue or oocyte cryopreservation added to “Useful in selected cases”. ”Favorable” and “Unfavorable” replaced “nonbulky” and “bulky” in the clinical staging definitions. Due to this change stage IB-IIB nonbulky are now included with the category of stage I-II unfavorable. Footnote “b” is new to the page to clarify that a diagnostic CT is not needed, if an integrated PET-CT was performed. The factors of ootnote “g”. ESR >50, >3 sites of disease, and >1 extranodal site were added to f Footnote “p” is new to the page “The Stanford V regimen is used in this fashion for patients with bulky mediastinal disease or B symptoms. Patients with other “unfavorable” factors are not treated on this protocol.” For CS I-IIB LPHL, the recommendation for chemotherapy in the combination of chemotherapy + IFRT was deleted. PET-CT was removed from restaging, unlike CHL, most LPHL are overstaged due to PET positivity. Monitoring for Late Effects after 5 Years Aggressive management of cardiovascular risk factors was added to the annual physical history and physical. Annual mammographic/breast MRI screening was changed to annual breast screening. To increase the awareness of the need to be alert for cardiovascular complications, “Cardiovascular symptoms may emerge at an earlier age” was added. The recommendation for a “treatment summary and consideration of transfer to PCP” was also added. The sentence “There are few data to support specific recommendations, these represent the range of practice at NCCN institutions” was added to footnote “z”. ”At relapse, patient should be considered for re-biopsy because of risk for transformation” was added to footnote “dd”. ”In a radiation naive patient, TLI may be an appropriate component of HDT” was added to footnote “gg”. A new table was added with examples of unfavorable risk factors for stage I-II Hodgkin disease according to major clinical trials groups. The following was added, “Routine use of growth factors is not recommended. Leukopenia is not a factor for delay of treatment or reduction of dose intensity.” C-MOPP (cyclophosphamide, vincristine, procarbazine, prednisone), ChlVPP (Chlorambucil, vinblastine, procarbazine, prednisone) were added to the examples of second-line chemotherapy regimens. HODG-2 � � Footnote “k” is new to the page “Interim PET scan after 2-4 cycles has increasingly shown to have a role in management and prognosis. Further management may include IFRT, biopsy, or change in chemotherapy.” The option of “Observe” was added for patients with non-bulky disease in CR following 2 additional cycles. Summary of changes in the 1.2009 version of the Hodgkin Disease/Lymphoma guidelines from the 2.2008 version include: The 2.2009 version of the Hodgkin Disease/Lymphoma represents the addition of the Discussion section correspondent to the changes in the algorithm. There was also a correction on page HODG-6 for stage IB-IIB, chemotherapy was added to the recommendation of IFRT. Version 2.2009, 02/25/09 © 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 Hodgkin Disease TOC Staging, Discussion, References Practice Guidelines in Oncology – v.2.2009NCCN ® Hodgkin Disease/Lymphoma 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 WORKUP � � � � � � Excisional biopsy (recommended) Core needle biopsy may be adequate if diagnostic FNA alone is insufficient Immunohistochemistry highly recommended for Hodgkin lymphoma For typical classical Hodgkin lymphoma, recommend CD3, CD15, CD20, CD30, CD45 For lymphocyte- predominant Hodgkin lymphoma, recommend CD3, CD15, CD20, CD21, CD30, CD57 a a � � � � � � � � � � � � � � H&P including: B symptoms Alcohol intolerance Pruritus Fatigue Performance status Exam lymphoid regions, spleen, liver CBC, differential, platelets Erythrocyte sedimentation rate (ESR) LDH, LFT, albumin BUN, creatinine Pregnancy test: women of childbearing age Chest x-ray Diagnostic chest/abdominal/pelvic CT PET-CT scan Adequate bone marrow biopsy in stage IB-IIB and stage III-IV Counseling: Fertility, smoking cessation, psychosocial ( ) : Semen cryopreservation, if chemotherapy or pelvic RT contemplated IVF or ovarian tissue or oocyte cryopreservation Neck CT, if neck RT planned Pneumococcal, H-flu, meningococcal vaccines, if splenic RT contemplated HIV, if risk factors, unusual disease presentations Evaluation of ejection fraction Pulmonary functions tests (PFTs), Diffusion capacity of the lungs for carbon monoxide (DLCO) � � � � � � � � � � b c Useful in selected cases see NCCN Distress Management Guidelines HODG-1 a b c An expanded panel of markers may be required especially if equivocal diagnosis. . A separate diagnostic CT does not need to be done if it was part of the integrated PET-CT scan. In cases of PET positivity where sites of disease are inconsistent with usual presentation of Hodgkin lymphoma or if an unusual disease presentation (ie, HIV), additional clinical evaluation may be required to upstage patient. . d e g h Classical Hodgkin lymphoma (HL) includes nodular sclerosis (NSHL), mixed cellularity (MCHL), lymphocyte-depleted (LDHL) and lymphocyte-rich (LRHL). Lymphocyte-predominant Hodgkin lymphona (LPHL) has a different natural history and response to therapy than does classical Hodgkin lymphoma, especially stages I- II. For that reason, separate guidelines are presented for LPHL. No unfavorable factors present ( ). Bulky disease, B symptoms, ESR >50, >3 sites of disease, >1 extranodal site ( ). Treatment recommendations for postadolescent Hodgkin lymphoma. f See Non-Hodgkin’s Lymphoma guidelines See Table 1 (ST-1) See Unfavorable Factors HODG-A see Unfavorable Factors HODG-A CLINICAL STAGING See Primary Treatment (HODG-2)h See Primary Treatment (HODG-6)h Classical Hodgkin lymphomad Lymphocyte- predominant Hodgkin lymphoma (LPHL)e Stage IA-IIA Favorablef Stage I-II Unfavorableg Stage III-IV See Primary Treatment (HODG-3)h See Primary Treatment (HODG-4)h Version 2.2009, 02/25/09 © 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 Hodgkin Disease TOC Staging, Discussion, References Practice Guidelines in Oncology – v.2.2009NCCN ® Hodgkin Disease/Lymphoma See Follow-up HODG-7 See HODG-8 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. Chemotherapy + involved-field RT (IFRT) (category 1) j,k l m PRIMARY TREATMENTi CLINICAL PRESENTATION: Classical Hodgkin lymphomad d i j k l m n o Classical Hodgkin lymphoma (HL) includes nodular sclerosis (NSHL), mixed cellularity (MCHL), lymphocyte-depleted (LDHL) and lymphocyte-rich (LRHL). Individualized treatment may be necessary for older patients and patients with concomitant disease. . Interim PET scan after 2-4 cycles has increasingly shown to have a role in management and prognosis. Further management may include IFRT, biopsy, or change in chemotherapy. ma alone may be considered for patients not able tolerate chemotherapy. An integrated PET-CT or a PET with a diagnostic CT is recommended. . Depending upon co-morbidities, subtotal lymphoid irradiation (category 1) or ntle See Principles of Chemotherapy (HODG-B) See (HODG-C). See Revised Response Criteria for Lymphoma (HODG-D) Principles of Radiation Therapy HODG-2 See Follow-up HODG-7 Restage after chemotherapy with PET-CTn Complete response (CR)o Complete IFRT (if part of initial plan Stable (PET positive) or progressive diseaseo See Progressive Disease or Relapse HODG-8 See Follow-up HODG-7 Partial response (PR)o ABVD x 4 cycles (category 2B) j k Restage after chemotherapy with PET-CTn Biopsy Restage with PET-CTn PET positive PET negative See HODG-8 Observe or IFRT Biopsy or Positive Negative Restage with PET-CTn PET positive PET negative IFRT IFRT or See Progressive Disease or Relapse HODG-8 Stage IA- IIA Favorable Version 2.2009, 02/25/09 © 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 Hodgkin Disease TOC Staging, Discussion, References Practice Guidelines in Oncology – v.2.2009NCCN ® Hodgkin Disease/Lymphoma 2 additional cycles or IFRT (category 2B)l 2 additional cycles Stage I-II Unfavorableg Stanford Vj,p x 3 cycles or 12 weeks RT to initial sites > 5 cm and residual PET positive sites (36 Gy begins optimally within 3 weeks) Progressive diseaseo Follow-up, if progressive disease, see below Biopsy or ABVD x 4 cycles j k Restage with PET-CTn Consolidative RT PET Negatives PET Positive Observe (if non-bulky) or IFRT (if bulky)l r See Follow-up HODG-7 Non- progressive diseaseq PRIMARY TREATMENTiCLINICAL PRESENTATION: Classical Hodgkin lymphomad 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. d g i j k l n o Classical Hodgkin lymphoma (HL) includes nodular sclerosis (NSHL), mixed cellularity (MCHL), lymphocyte-depleted (LDHL) and lymphocyte-rich (LRHL). Bulky mediastinal disease, B symptoms, ESR >50, >3 sites of disease, >1 extranodal site . Individualized treatment may be necessary for older patients and patients with concomitant disease. . Interim PET scan after 2-4 cycles has increasingly shown to have a role in management and prognosis. Further management may include IFRT, biopsy, or change in chemotherapy. An integrated PET-CT or a PET with a diagnostic CT is recommended. . The Stanford V regimen is used in this fashion for patients with bulky mediastinal disease or B symptoms. Patients with other “unfavorable” factors are not treated on this protocol. May include patients with residual PET positive sites. Do not add two additional cycles of ABVD. p q r s ( )see Unfavorable Factors, HODG-A Principles of Radiation Therapy See Principles of Chemotherapy (HODG-B) See (HODG-C). See Revised Response Criteria for Lymphoma (HODG-D) See Unfavorable Factors HODG-A. CRo Stable (PET positive) or progressive diseaseo PRo Biopsy See Progressive Disease or Relapse HODG-8 HODG-3 Restage with PET-CTn Restage after chemotherapy with PET-CTn Restage with PET-CT after 3 m n Restage with PET-CTn PET positive PET negative IFRTl Biopsy or See Progressive Disease or Relapse HODG-8 See Follow-up HODG-7 Version 2.2009, 02/25/09 © 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 Hodgkin Disease TOC Staging, Discussion, References Practice Guidelines in Oncology – v.2.2009NCCN ® Hodgkin Disease/Lymphoma ABVD x 4 cycles j PRo Progressive diseaseo 2 additional cycles Observe or IFRT for initial bulky disease or l r 2 more cycles to a total of 8 cycles Biopsy or IFRTl 2 additional cycles Observe or IFRT (especially for initial bulky disease) l r d i j l n o u v Classical Hodgkin lymphoma (HL) includes nodular sclerosis (NSHL), mixed cellularity (MCHL), lymphocyte-depleted (LDHL) and lymphocyte-rich (LRHL). Individualized treatment may be necessary for older patients and patients with concomitant disease. . An integrated PET-CT or a PET with a diagnostic CT is recommended. . If there is bulky mediastinal disease on CT after 6 cycles of ABVD, consolidative RT to mediastinum recommended. It is not known in the context of PET negative whether the outcomes will be altered. RT to residual disease pre or posttransplant. in select patients r t Allotransplant is an option as a category 3.w See Principles of Chemotherapy (HODG-B) See (HODG-C). See Revised Response Criteria for Lymphoma (HODG-D) See Unfavorable Factors HODG-A See International Prognostic Score (IPS) (HODG-A). Principles of Radiation Therapy . Stage III-IV Escalated BEACOPP (especially if IPS 4)� t PET negativeu PET positiveu Biopsy 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. CRo or PRIMARY TREATMENTiCLINICAL PRESENTATION: Classical Hodgkin lymphomad HODG-4 HDT/ASCRv,w See Follow-up HODG-7HDT/ASCRv,w or Stanford V x cycles or 12 weeks j 3 See HODG-5 See HODG-3 Restage after chemotherapy with PET-CTn Restage with PET-CTl Version 2.2009, 02/25/09 © 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 Hodgkin Disease TOC Staging, Discussion, References Practice Guidelines in Oncology – v.2.2009NCCN ® Hodgkin Disease/Lymphoma Escalated BEACOPP x 4 cycles (IPS 4)� t PRIMARY TREATMENTi (continued from HODG-4) CLINICAL PRESENTATION: Classical Hodgkin lymphoma Stage III-IV d Restage with PET-CTn Progressive diseaseo Biopsy HDT/ASCRv,w Note: All recommendations are category 2A unless ot