2010NCCN霍奇金淋巴瘤治疗指南

Continue NCCN Clinical Practice Guidelines in Oncology™ Hodgkin Lymphoma V.1.2010 www.nccn.org Version 1.2010, 02/02/10 © 2010 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 Lymphoma TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Hodgkin Lymphoma NCCN Hodgkin Lymphoma Panel Members Richard T. Hoppe, MD/Chair § Stanford Ranjana Hira Advani, MD † Stanford Comprehensive Cancer Center Weiyun Z. Ai, MD UCSF Helen Diller Family 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 † ‡ ‡ ‡ Þ † 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 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 Craig H. Moskowitz, MD † Þ Memorial Sloan-Kettering 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 † ‡ � � 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 1.2010, 02/02/10 © 2010 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 Lymphoma TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Hodgkin Lymphoma This discussion 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 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. ©2010. Table of Contents Primary Treatment Classical Hodgkin Lymphoma: Lymphocyte-predominant Hodgkin Lymphoma: NCCN Hodgkin 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 Lymphoma Guidelines Diagnosis and Workup (HODG-1) CS IA-IIA Favorable (HODG-2) CS I-II Unfavorable (Bulky disease) (HODG-4) CS I-II Unfavorable (Non-bulky disease) (HODG-6) CS III-IV (HODG-8) CS I-IV (HODG-10) Follow-up After Completion of Treatment and Monitoring For Late Effects (HODG-11) Relapse (HODG-12) 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 1.2010, 02/02/10 © 2010 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 Lymphoma TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Hodgkin Lymphoma Summary of the Guidelines updates Summary of changes in the 1.2010 version of the Hodgkin Disease/Lymphoma guidelines from the 2.2009 version include: Global Changes Title of Guidelines was changed from Hodgkin Disease/Lymphoma to Hodgkin Lymphoma. The typical immunophenotype for Hodgkin Lymphoma is now described in footnote “a”. Pulmonary function tests were moved from the “Useful in selected case” to “Essential” and clarified for “if ABVD or BEACOPP are being used.” Evaluation of ejection fraction was clarified for “doxorubicin- containing regimens.” � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � This is a new page detailing the treatment and restaging for treatment with ABVD alone for stage IA-IIA (favorable). Stage I-II (unfavorable) divided into “bulky disease” ( ) and “non-bulky disease” ( ). Primary treatment now includes restaging after ABVD x 2 cycles, treatment and restaging detailed on . Primary treatment now includes restaging after ABVD x 2 cycles, treatment and restaging detailed on . “Restage after chemotherapy with PET-CT” was changed to “Restage with PET-CT or diagnostic CT, repeat PFTs.” “Selected cases” was added to “Escalated BEACOPP.” For patients with a PR after 4 cycles of ABVD, ”biopsy” was added as an alternative to 2 additional cycles of ABVD. For patients that are PET negative after 6 cycles of ABVD, ”2 more cycles of ABVD” was removed as a treatment option. “Observe in selected circumstances” was added as a recommendation for patients that are PET positive after treatment for a PR. “Selected cases” was added to “Escalated BEACOPP.” For patients with a PR after 4 cycles of escalated BEACOPP, “biopsy” was added as an alternative to 4 additional cycles of BEACOPP. For patients with a CR after 4 cycles of escalated BEACOPP, RT was changed to optional after 4 additional cycles of baseline BEACOPP. For stage I-IIB, “chemotherapy followed by IFRT” was changed to “Chemotherapy ± IFRT.” “Rituximab ± chemotherapy ± IFRT” was added as a treatment option. For stage III-IVA, “Rituximab ± chemotherapy” was added as a treatment option. For stage III-IVB, “Rituximab ± chemotherapy ± RT” was added as a treatment option. The text of previous footnote “z” was moved to the top of the page. “Consider” was removed from “Consider baseline stress test/echocardiogram at 10 y.” “Pneumococcal revaccination every 5-7 y, was replaced with “after 5 y”. “Non-cross resistant” was replaced with “salvage.” “± RT” was added to HDT/ASCR and salvage chemotherapy. “ 2 extranodal sites” was changed to “> 1 extranodal site.” For stage IA-IIA favorable, a description of the course for chemotherapy alone was added. For Stage I-II unfavorable, the number of ABVD cycles was changed from 4 to 4-6 cycles. For Stage III-IV, the number of cycles of ABVD was changed from 6-8 to 6 cycles. PFTs were added after 4 cycles of ABVD. Nonbulky disease (stage I-II), radiation dose was changed from 30 Gy to 20-30 Gy for patients treated with ABVD. � HODG-1 HODG-3 HODG-4 HODG-6 HODG-8 HODG-9 HODG-10 HODG-11 HODG-12 HODG-A HODG-4 HODG-6 HODG-5 HODG-7 HODG-9 HODG-B 1 of 3 HODG-C Version 1.2010, 02/02/10 © 2010 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 Lymphoma TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Hodgkin 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 lymphomaa Essential Useful in selected cases : 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 ( ) Pulmonary functions tests (PFTs incl. DLCO) if ABVD or BEACOPP are being used : 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 for doxorubicin-containing regimens � � � � � � � � � � � � � � � � � � b c see Distress Management Guidelines HODG-1 a b c Typical immunophenotype for Classical Hodgkin lymphoma: CD30+, CD15+ (majority); CD3-, CD45-,; CD20+ (<40%). Lymphocyte-predominant Hodgkin lymphoma: CD20+, CD45+; CD3-, CD15-, CD30-. An expanded panel of markers may be required especially if equivocal diagnosis. . 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. 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 f See Non-Hodgkin’s Lymphoma guidelines See Unfavorable Factors HODG-A see Unfavorable Factors HODG-A See (ST-1) CLINICAL STAGING See Primary Treatment (HODG-2)h See Primary Treatment (HODG-10)h Classical Hodgkin lymphomad Lymphocyte- predominant Hodgkin lymphoma (LPHL)e Stage IA-IIA Favorablef Stage I-II (Bulky disease) Unfavorableg Stage III-IV See Primary Treatment (HODG-4)h See Primary Treatment (HODG-8)h Stage I-II (Non-bulky disease) Unfavorableg See Primary Treatment (HODG-6)h Version 1.2010, 02/02/10 © 2010 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 Lymphoma TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Hodgkin Lymphoma See Follow-up HODG-11 See HODG-12 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. Combined modality therapy (ABVD or Stanford V + involved field RT [IFRT]) category 1 j,k l m or Chemotherapy alone ABVD x 2 cycles (category 2B) j k 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 Systemic Therapy (HODG-B) See (HODG-C). See Revised Response Criteria for Lymphoma (HODG-D) Principles of Radiation Therapy HODG-2 See Follow-up HODG-11 Restage after chemotherapy with PET-CTn Complete response (CR)o IFRTl Stable (PET positive) or progressive disease (PD)o See Progressive Disease or Relapse HODG-12 See Follow-up HODG-11 Partial response (PR)o Biopsy Restage with PET-CTn PET positive PET negative See HODG-12 Observe IFRTl Biopsy or Positive Negative Restage with PET-CTn PET positive PET negative IFRTl IFRTl or See Progressive Disease or Relapse HODG-12 Stage IA- IIA Favorable See Primary Treatment HODG-3 Version 1.2010, 02/02/10 © 2010 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 Lymphoma TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Hodgkin 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. Chemotherapy alone ABVD x 2 cycles (category 2B) j k Restage with PET-CTn CR (with CR on CT) o o ABVD x 2 cycles (total 4) Observe ( ) See Follow-up HODG-11 ABVD x 2 cycles (total 4) d i j k l 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. An integrated PET-CT or a PET with a diagnostic CT is recommended. . See Principles of Systemic Therapy (HODG-B) See (HODG-C). See Revised Response Criteria for Lymphoma (HODG-D) Principles of Radiation Therapy PR or CR (with PR on CT) o o � � Restage with PET-CT Repeat PFTs n Stable (PET positive) PDo ABVD x 2 cycles (total 4) � � Restage with PET-CT Repeat PFTs n PET positive PET negative Biopsy Biopsy HODG-3 Observe ( )See Follow-up HODG-11 CRo PDo PRo ABVD x 2 cycles (total 6) ABVD x 2 cycles (total 6) or Restage with PET-CTn Restage with PET-CTn CRo PDo PRo CRo PDo PRo Biopsy Observe Observe or IFRTl Observe or Biopsy Negative See Follow-up HODG-11 Observe or IFRTl Biopsy Negative IFRTlor Positive Observe ( ) See Follow-up HODG-11 Biopsy ( )See HODG-12 See HODG-12 Biopsy Positive See HODG-12 See Follow-up HODG-11 See HODG-12 See HODG-12 PRIMARY TREATMENTi (continued from HODG-2) CLINICAL PRESENTATION: Classical Hodgkin lymphoma Stage IA-IIA Favorable d ObserveIFRT l Version 1.2010, 02/02/10 © 2010 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 Lymphoma TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Hodgkin Lymphoma Stage I-II (Bulky Disease) Unfavorableg Stanford Vj,p x 12 weeks RT to initial sites > 5 cm and residual PET positive sites (36 Gy begins optimally within 3 weeks) l Progressive diseaseo Follow-up, if progressive disease, see below Biopsy or ABVDj 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 l n o Classical Hodgkin lymphoma (HL) includes nodular sclerosis (NSHL), mixed cellularity (MCHL), lymphocyte-depleted (LDHL) and lymphocyte-rich (LRHL). Bulky 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. . 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. p q ( )see Unfavorable Factors, HODG-A Principles of Radiation Therapy See Principles of Systemic Therapy (HODG-B) See (HODG-C). See Revised Response Criteria for Lymphoma (HODG-D) HODG-4 Restage with PET-CTn Restage with CT (or PET-CT if last PET scan was still positive) after 3 m See Progressive Disease or Relapse HODG-12 See Primary Treatment HODG-5 Version 1.2010, 02/02/10 © 2010 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 Lymphoma TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Hodgkin Lymphoma CRo � � ABVD x 2 cycles (total 4) Repeat PFTs PRo Restage with PET-CTn PDo CRo PDo PRo ABVD x 2 cycles (total 6) ABVD x 2 cycles (total 6) Restage with PET-CTn Negative Positive Biopsy Negative or Biopsy (See HODG-12) Positive ABVD x 2 cycles (total 6) IFRTl or See Follow-up HODG-11 See Follow-up HODG-11 � � ABVD x 2 cycles (total 4) Repeat PFTs See Follow-up HODG-11 Restage with PET-CTn Negative Positive Biopsy (See HODG-12) See Follow-up HODG-11 ABVD x 2 cycles j k Restage with PET-CTn Biopsy (See HODG-12) Note: All recommendations are category 2A unless otherwise