2010NCCN指南-原发部位不明的肿瘤

Continue NCCN Clinical Practice Guidelines in Oncology™ Occult Primary (Cancer of Unknown Primary [CUP]) V.1.2010 www.nccn.org Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® NCCN Occult Primary Panel Members David S. Ettinger, MD/Chair † The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Mark Agulnik, MD † Robert H. Lurie Comprehensive Cancer Center of Northwestern University Mihaela Cristea, MD † City of Hope Comprehensive Cancer Center Keith Eaton, MD, PhD † Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Panagiotis M. Fidias, MD ¶ † Massachusetts General Hospital Cancer Center David Gierada, MD Siteman Cancer Center at Barnes- Jewish Hospital and Washington University School of Medicine ф Asif Rashid, MD, PhD The University of Texas M. D. Anderson Cancer Center Leonard Saltz, MD † ‡ Memorial Sloan-Kettering Cancer Center Lawrence N. Shulman, MD ‡ Dana-Farber/Brigham and Women’s Cancer Center Jonathan S. Zager, MD ¶ H. Lee Moffitt Cancer Center & Research Institute Weining Zhen, MD § UNMC Eppley Cancer Center at The Nebraska Medical Center � Gauri Varadhachary, MD † The University of Texas M. D. Anderson Cancer Center Mary Kay Washington, MD, PhD Vanderbilt-Ingram Cancer Center � * † Medical Oncology * Writing committee member ‡ Hematology/Hematology Oncology Pathology § Radiotherapy/Radiation Oncology Diagnostic Radiology ¶ Surgery/Surgical Oncology � ф Continue Jon P. Gockerman, MD † ‡ Duke Comprehensive Cancer Center Omar Hameed, MD University of Alabama at Birmingham Comprehensive Cancer Center � Charles Handorf, MD, PhD St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute Charlotte D. Jacobs, MD † Stanford Comprehensive Cancer Center Nikhil I. Khushalani, MD † Roswell Park Cancer Institute Larry Kvols, MD † H. Lee Moffitt Cancer Center & Research Institute Renato Lenzi, MD † ‡ The University of Texas M. D. Anderson Cancer Center � NCCN Guidelines Panel Disclosures Occult Primary Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® 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 Occult Primary Panel Members Initial Evaluation (OCC-1 Epithelial Occult Primaries (OCC-2 Adenocarcinoma or Carcinoma Not Otherwise Specified (OCC-3 Squamous Cell Carcinoma (OCC-11 Neuroendocrine Tumors (OCC-16 Follow-up for All Occult Primaries (OCC-20 Immunohistochemistry Markers for Unknown Primary Cancers (OCC-A Principles of Chemotherapy (OCC-B Guidelines Index Print the Occult Primary Guideline Summary of the Guidelines Updates ) ) ) ) ) ) ) ) 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 For help using these documents, please click here Discussion References Occult Primary (Cancer of Unknown Primary [CUP]) Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® Summary of the Guidelines Updates OCC-1 OCC-3 OCC-5 OCC-8 OCC-9 OCC-17 OCC-20 OCC-B OCC-6 � � � � � � � � � � � � � � � � Under initial evaluation, “chest/abdominal/pelvic CT scan” was added and “chest x-ray” was removed. Under workup, “preferred” was added to core needle biopsy. Additional workup for supraclavicular nodes, “if not done” was added to “neck/chest/abdominal/pelvic CT scan”. Additional workup for retroperitonal mass, “consider upper endoscopy” was added. Additional workup for inguinal nodes, “proctoscopy if clinically indicated” was added and “cytoscopy” was removed. Additional workup for liver, “upper and/or lower endoscopy” was added. Additional workup, bullet regarding mammogram was clarified as, “Mammogram/breast ultrasound; if negative and histopathologic evidence for breast cancer, breast MRI indicated” throughout the guidelines. if PET-CT scan not previously done” was added to “bone scan”. Also for bone on OCC-11. Axillary for men, “consider RT if 2 lymph nodes positive or extra capsular extension, ± subsequent chemotherapy was clarified as “consider RT if clinically indicated ± chemotherapy.” Also for inguinal node, both unilateral and bilateral on OCC-10, for axillary, localized on OCC-13 and inguinal node, both unilateral and bilateral on OCC-15. Footnotes g, “PET-CT scan can be useful in the diagnosis of an occult primary mediastinal adenocarcinoma” was added to the page. Lung nodules, “If resectable, consider surgery” was added as a management option. Neuroendocrine tumor descriptor, “high-grade” was clarified as “Poorly differentiated (high grade or anaplastic) or small cell subtype other than lung.” Also for OCC-18 and OCC-19. Follow-up for all occult primaries was clarified as “H&P every 3-6 mo for first 3 y, then as indicated”. Principles of chemotherapy, the performance status (PS) was clarified as PS 1-2 for considering chemotherapy in symptomatic patients. Neuroendocrine tumor regimens were replaced with links to appropriate NCCN guidelines, “For poorly differentiated (high grade or anaplastic) or small cell subtype other than lung neuroendocrine tumors, see NCCN Small Cell Lung Guidelines” and “For moderate and well differentiated neuroendocrine tumors, see NCCN Neuroendocrine Tumors Guidelines-Carcinoid Tumors”. The Eastern Cooperative Oncology Group (ECOG) performance status was defined and added to the page. Additional workup for bone, “ � UPDATES 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. Summary of changes in the 1.2010 version of the Occult Primary Guidelines from the 1.2009 version include: Occult Primary Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® 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. � � � � � � � � � � � Complete H&P, including breast, genitourinary, pelvic, and rectal exam, with attention to and review of: Past biopsies or malignancies Removed lesions Spontaneously regressing lesions Existing imaging studies CBC Electrolytes Liver function tests Creatinine Calcium Urinalysis bdominal/pelvic CT scan Hemoccult Symptom directed endoscopy PET-CT scan (category 2B) � � � � Chest/a b INITIAL EVALUATION PATHOLOGIC DIAGNOSIS Biopsy: Core needle biopsy (preferred) FNA Most accessible site Consult pathologist for adequacy of specimen and additional studies including immunohistochemical stains � � � and/or c Epithelial; not site specific Melanoma Sarcoma Germ-cell Nonmalignant diagnosis Suspected metastatic malignancya Lymphoma and other hematologic malignancies See Clinical Presentation (OCC-2) See NCCN Guidelines Table of Contents See NCCN Melanoma Guidelines See NCCN Soft Tissue Sarcoma Guidelines Further evaluation and Appropriate follow-up See NCCN Testicular Cancer Guidelines Thyroid See NCCN Thyroid Carcinoma Guidelines OCC-1 a b c For many patients the apparent uncertainties surrounding the diagnosis of an unknown primary cancer may result in significant psychosocial distress and increased difficulty in accepting treatment options. Empathetic discussion about the natural history of these types of cancer and their prognosis, and the provision of support and counseling both by the primary oncology team and specialized services may help to alleviate this distress. . Many patients are referr be warranted in some situations, even in patients with unknown primary, especially when considering local/regional therapy. . See NCCN Distress Management Guidelines See Immunohistochemistry Markers for Unknown Primary Cancers (OCC-A) ed with PET-CT scans. Routine use is not recommended. PET-CT scans may WORKUP Occult Primary Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® 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. Epithelial; not site specific CLINICAL PRESENTATION Squamous cell carcinoma Neuroendocrine tumor See Clinical Presentation (OCC-11) See Clinical Presentation (OCC-16) Adenocarcinoma or Carcinoma not otherwise specified � � � Cervical nodes Supraclavicular nodes Axillary nodes � � � Mediastinum Chest (multiple nodules) or pleural effusions Peritoneal � � � Retroperitoneal mass Inguinal nodes Liver � � � Bone Brain Multiple, including skin See Clinical Presentation (OCC-3) See Clinical Presentation (OCC-4) See Clinical Presentation (OCC-5) See Clinical Presentation (OCC-6) OCC-2 PATHOLOGIC DIAGNOSIS Occult Primary Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® 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. Adenocarcinoma or Carcinoma not otherwise specified Cervical nodes Supraclavicular nodes Men and women: Neck/chest/abdominal/pelvic CT (if not done) Consider symptom directed endoscopy Women: Attention to appropriate (eg, ER/PR, HER2) � � � � � Mammogram/breast ultrasound; if negative and histopathologic evidence for breast cancer, breast MRI indicated immunohistochemistry Men: > 40 y: PSA d Axillary nodes Men and women: Chest/abdominal CT Women: Attention to appropriate immunohistochemistry (eg, ER/PR, HER2) Men: > 40 y: PSA � � � � Mammogram/breast ultrasound; if negative and histopathologic evidence for breast cancer, breast MRI indicated d See NCCN Head and Neck- Occult Primary Guidelines ADDITIONAL WORKUP See Management Based on Workup Findings (OCC-7) CLINICAL PRESENTATION OCC-3 dAn expanded panel of immunohistochemical markers may be used as appropriate. See Immunohistochemistry Markers for Unknown Primary Cancers (OCC-A). Occult Primary Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® 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. ADDITIONAL WORKUP Adenocarcinoma or Carcinoma not otherwise specified Mediastinum Chest (multiple nodules) or Pleural effusion Peritoneal Men and women: Chest/abdominal/pelvic CT Beta-hCG, alpha-fetoprotein Women: ER/PR immunohistochemistry Men: > 40 y: PSA � � � � � � Mammogram/breast ultrasound; if negative and histopathologic evidence for breast cancer, breast MRI indicated Testicular ultrasound, if beta-hCG and alpha-fetoprotein markers elevated d Men and women: Women: CA-125 ER/PR immunohistochemistry Consider gynecologic oncologist consult if clinically indicated Mammogram/breast ultrasound; if negative breast Men: > 40 y: PSA � � � � � � Chest/abdominal/pelvic CT and histopathologic evidence for breast cancer, MRI indicated d Men and women: Chest/abdominal/pelvic CT Urine cytology; cystoscopy if suspicious CA-125 ER/PR immunohistochemistry breast ultrasound; if negative and histopathologic evidence for breast cancer, breast MRI indicated � � � � � � � Women: d Mammogram/ Gynecologic oncologist consult Men: > 40 y: PSA See Management Based on Workup Findings (OCC-7) OCC-4 CLINICAL PRESENTATION dAn expanded panel of immunohistochemical markers may be used as appropriate. See Immunohistochemistry Markers for Unknown Primary Cancers (OCC-A). Occult Primary Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® 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. Retroperitoneal mass Inguinal nodes Liver Men and Women: Chest/abdominal/pelvic CT Urine cytology; consider cystoscopy if suspicious Consider upper endoscopy Women: Men: > 40 y: PSA < 65 y: Beta-hCG, alpha-fetoprotein, testicular ultrasound if markers elevated � � � � � � � � � CA-125 ER/PR immunohistochemistry Mammogram/breast ultrasound; if negative and histopathologic evidence for breast cancer, breast MRI indicated Gynecologic oncologist consult if clinically indicated d Men and women: Women: CA-125 Gynecologic oncologist consult Men: > 40 y: PSA � � � � � Abdominal/pelvic CT Proctoscopy if clinically indicated Men and women: Chest/abdominal/pelvic CT Colonoscopy Upper and/or lower endoscopy Alpha-fetoprotein (category 2B) Women: Mammogram/breast ultrasound; if negative and histopathologic evidence for breast cancer, breast MRI indicated � � � � � � ER/PR immunohistochemistryd Adenocarcinoma or Carcinoma not otherwise specified See Management Based on Workup Findings (OCC-7) OCC-5 ADDITIONAL WORKUPCLINICAL PRESENTATION dAn expanded panel of immunohistochemical markers may be used as appropriate. See Immunohistochemistry Markers for Unknown Primary Cancers (OCC-A). Occult Primary Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® 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. Bone Brain Multiple, including skin Men and women: � � � � � � Bone scan (if PET-CT scan not previously done) Radiographic studies for painful lesions and/or bone-scan–positive lesions and/or weight- bearing areas Chest/abdominal/pelvic CT Women: ER/PR immunohistochemistry Men: PSA d Mammogram/breast ultrasound, if negative and histopathologic evidence for breast cancer, breast MRI indicated Men and women: Chest/abdominal CT Women: ER/P � � � � See for Primary Treatment of CNS Metastatic Lesions Mammogram/breast ultrasound, if negative and histopathologic evidence for breast cancer, breast MRI indicated NCCN Cental Nervous System Cancers Guidelines R immunohistochemistryd Men and women Women: ER/PR immunohistochemistry Men: PSA � � � � Chest/abdominal/pelvic CT Mammogram/breast ultrasound, if negative and histopathologic evidence for breast cancer, breast MRI indicated d ADDITIONAL WORKUP Adenocarcinoma or Carcinoma not otherwise specified See Management Based on Workup Findings (OCC-7) CLINICAL PRESENTATION dAn expanded panel of immunohistochemical markers may be used as appropriate. See Immunohistochemistry Markers for Unknown Primary Cancers (OCC-A). OCC-6 Occult Primary Version 1.2010, 11/02/09 © 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. Practice Guidelines in Oncology – v.1.2010 Guidelines Index Occult Primary Table of Contents Discussion, ReferencesNCCN ® 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. Primary found Treat per NCCN disease-specific guidelines NCCN Guidelines Table of Contents Disseminated metastasesa � � � � � Symptom control Clinical trial preferred Consider chemotherapy on an individual basis Specialized approaches Mediastinal: Treat per in young men (category 3) e f NCCN Testicular Cancer Guidelines Localized adenocarcinoma or carcinoma not otherwise specifieda a e f For many patients the apparent uncertainties surrounding the diagnosis of an unknown primary cancer may result in significant psychosocial distress and increased difficulty in accepting treatment options. Empathetic discussion about the natural history