2010NCCN小细胞肺癌治疗指南

Continue www.nccn.org NCCN Clinical Practice Guidelines in Oncology™ Small Cell Lung Cancer V.1.2010 Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer NCCN Small Cell Lung Cancer Panel Members Gregory P. Kalemkerian, MD University of Michigan Comprehensive Cancer Center Wallace Akerley, MD /Chair † † Huntsman Cancer Institute at the University of Utah Matthew G. Blum, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Hossein Borghaei, DO, MS Fox Chase Cancer Center Laurie L. Carr, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Center Alliance ¶ † ¶ † ‡ † Robert J. Downey, MD Memorial Sloan-Kettering Cancer Center David S. Ettinger, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Cesar Moran, MD The University of Texas M.D. Anderson Cancer Center Harvey B. Niell, MD University of Tennessee Cancer Institute Janis O’Malley, MD University of Alabama at Birmingham Comprehensive Cancer Center Charles C. Pan, MD University of Michigan Comprehensive Cancer Center Jyoti D. Patel, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University � † § † † Þ ‡ § ф Neal Ready, MD, PhD Duke Comprehensive Cancer Center Charles C. Williams, Jr., MD H. Lee Moffitt Cancer Center and Research Institute Apar Kishor P. Ganti, MD UNMC Eppley Cancer Center at the Nebraska Medical Center John C. Grecula, MD Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University 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 Bruce E. Johnson, MD Dana-Farber/Brigham and Women's Cancer Center Marianna Koczywas, MD City of Hope Comprehensive Cancer Center † § † † † † † ‡ ‡ Þ † 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 Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer Table of Contents 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 Guidelines Index Print the Small Cell Lung Cancer Guideline � � � � � 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. 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 For help using these documents, please click here Staging Discussion References Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer Summary of the Guidelines updates UPDATES Summary of the changes in the 1.2010 version of the Small Cell Lung Cancer Guidelines from the 2.2009 version include: � � � � � � � � � � � Fourth bullet under Additional Workup, “negative or inconclusive” was replaced with “show no evidence of metastases.” Footnote “e” changes: “multiple” was replaced by “3” “in staging” was replaced by “evidence of extensive stage disease” Footnote “g” - the clarifying statement “if not previously done” added to PET scan. RT to symptomatic sites before chemotherapy unless immediate systemic therapy is required.” Partial response added to Complete response pathway. Pathway added for “stable disease.” Footnote “n”: “multiple comorbidities” removed as a criteria in which PCI is not recommended. The following regimen added for limited stage with applicable reference: Cisplatin 80 mg/m day 1 and etoposide 100 mg/m days 1, 2, 3 x 4 cycles. Category 1 designation added to the radiotherapy dosing listed in the first bullet. The PCI dose of 30 Gy in 10-15 fractions was added to the last bullet. Reference in footnote 7 updated and a new reference added as footnote 8. The following reference was added: Shepherd FA, Crowley J, Van Houtte P, et al. The International Association for the Study of Lung Cancer Staging Project: Proposals regarding the clinical staging of small cell lung cancer in the forthcoming (seventh) edition of the tumor, node, metastasis classification for lung cancer. J Thorac Oncol 2007;2:1067-1077. � � Initial treatment for spinal cord compression was changed from “Chemotherapy + RT to symptomatic sites” to “ The following regimen added for extensive stage with applicable reference: Cisplatin 30 mg/m and irinotecan 65 mg/m on days 1, 8 every 21 days. � � 2 2 2 2 SCL-2 SCL-4 SCL-C SCL-5 SCL-B 1 of 2 ST-1 Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer 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 staged See Additional Workup (SCL-4) See Additional Workup (SCL-2) Extensive staged � � � � � � � � H&P Pathology review Chest x-ray (optional) Chest/liver/adrenal CT Head MRI (preferred) or CT Bone scan (optional if PET scan obtained) PET scan (optional) Smoking cessation counseling and intervention � � � CBC, platelets Electrolytes, liver function tests (LFT), Ca, LDH BUN, creatinine 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 testing for staging is optional. Head MRI is more sensitive than CT for identifying brain metastases and is preferred over CT. PET scan can be used as part of the initial evaluation, in addition to the other recommended studies. See Staging on page ST-1. SCL-1 Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer 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 3 cytological examinations of pleural fluid are 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. . 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) STAGE ADDITIONAL WORKUP Clinical stage T1-2, N0 Bone marrow biopsy, thoracentesis, or bone studies consistent with malignancy Limited disease in excess of T1-T2, N0 Limited stage Mediastinoscopy or Surgical or endoscopic mediastinal staging h h,i � � � � � If pleural effusion is seen in chest x-ray, thoracentesis is recommended, if thoracentesis inconclusive, consider thoracoscopy Pulmonary function tests (PFTs) (if clinically indicated) Bone radiographs of areas showing abnormal uptake on bone scan or PET scan MRI of bony lesions, if x-rays show no evidence of metastases 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 scang SCL-2 Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer 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. INITIAL TREATMENTlTESTING RESULTS 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 . j 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) . . . Limited disease in excess of T1-2, N0 Clinical stage T1-2, N0 Mediastinoscopy or mediastinal staging positive Mediastinoscopy or mediastinal staging negative 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) SCL-3 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 Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer 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 Chemotherapy ± RT to symptomatic sites For management of osseous structural impairment, j See NCCN Bone Cancer Guidelines May administer chemotherapy first, with whole-brain RT after chemotherapy j Individualized therapy including supportive care or chemotherapyl See NCCN Palliative Care Guidelines � � Poor PS (3-4) Severely debilitated Extensive stage � � � SVC syndrome Lobar obstruction Bone metastases Spinal cord compression RT to symptomatic sites before chemotherapy unless immediate systemic therapy is required. See NCCN CNS Malignancies Guidelines INITIAL TREATMENTlSTAGE ADDITIONAL WORKUP Bone radiographs of areas showing abnormal uptake on bone scan or PET scan Sequential radiotherapy to thorax in selected patients with low-bulk metastatic disease and CR or near CR after systemic therapy. j l m See Principles of Chemotherapy (SCL-B). See Principles of Supportive Care (SCL-D). Combination chemotherapy including supportive care j,m l See NCCN Palliative Care Guidelines SCL-4 See Response Assessment + Adjuvant Treatment (SCL-5) Symptomatic Asymptomatic Whole-brain RT before chemotherapy, unless immediate systemic therapy is required j Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer 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. SURVEILLANCE � � � � � � 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 RESPONSE ASSESSMENT FOLLOWING INITIAL THERAPY ADJUVANT TREATMENT After recovery from primary therapy: Oncology follow-up visits every 2-3 mo during y 1, every 3-4 mo during y 2-3, every 4-6 mo during y 4-5, then annually New pulmonary nodule after 2 y follow-up should initiate workup for potential new primary Smoking cessation intervention � � � � At every visit: H&P, chest imaging, bloodwork as clinically indicated Complete response or Partial response Primary progressive disease k nNot recommended in patients with poor performance status or impaired mental function. See Principles of Radiation Therapy (SCL-C). See Subsequent Therapy/Palliation (SCL-6) Limited or extensive disease: PCI (category 1)k,n For Relapse, see Second- line Therapy (SCL-6) SCL-5 Stable Disease Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer 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. SUBSEQUENT THERAPY/PALLIATION Continue until maximal benefit or refractory to therapy or development of unacceptable toxicity Relapse Clinical trial or Palliative symptom management, including localized RT to symptomatic sites Palliative symptom management, including localized RT to symptomatic sites or Clinical trial or Subsequent chemotherapy (PS 0–2)j Primary progressive disease Subsequent chemotherapy or Clinical trial or Palliative symptom management, including localized RT to symptomatic sites j jSee Principles of Chemotherapy (SCL-B). SCL-6 PROGRESSIVE DISEASE Version 1.2010, 11/03/09 © 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. NCCN ® Practice Guidelines in Oncology – v.1.2010 Guidelines Index SCLC Table of Contents Staging, Discussion, ReferencesSmall Cell Lung Cancer PRINCIPLES OF SURGICAL RESECTION SCL-A 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. 1 2 Lad T, Piantadosi S, Thomas P, et al. A prospective randomized trial to determine the benefit of surgical resection of residual disease following response of small cell lung cancer to combination chemotherapy. Chest 1994;106:320S-3S. Auperin A, Arriagada R, Pignon JP, et al. Prophylactic cranial irradiation for patients with small-cell cancer in complete remission. Prophylactic Cranial Irradiation Overview Collaborative Group. N Engl J Med 1999;341:476-84. � � � � Stage I SCLC is diagnosed in less than 5% of patients with SCLC. Patients with clinically staged disease in excess of T1-2, N0 do not benefit from surgery. Patients with SCLC that is clinical stage I (T1-2, N0) after standard staging evaluation (including CT of the chest and upper abdomen, bone scan, brain imaging, and PET imaging) may be considered for surgical resection. Prior to resection, all patients should undergo mediastinoscopy or other surgical mediastinal staging to rule out occult nodal disease. This may also include an endoscopic staging procedure. Patients who undergo complete resection (preferably by a lobectomy with either mediastinal nodal dissection or sampling) should be treated with postoperative chemotherapy. Patients without nodal metastases should be treated with chemotherapy alone. Patients with nodal metastases should be treated with postoperative concurrent chemotherapy and mediastinal radiation therapy. Because prophylactic cranial irradiation (PCI) can improve both disease-free and overall survival in patients with SCLC in complete remission, PCI should be considered after adjuvant chemotherapy in patients who have undergone a complete resection. 1 2 � �