2009NCCN指南-胸腺瘤

Continue NCCN Clinical Practice Guidelines in Oncology™ Thymic Malignancies V.2.2009 www.nccn.org Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® NCCN Thymic Malignancies Panel Members David S. Ettinger, MD/Chair † The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Wallace Akerley, MD Huntsman Cancer Institute at the University of Utah Gerold Bepler, MD, PhD H. Lee Moffitt Cancer Center & Research Institute Matthew G. Blum, MD Andrew Chang, MD University of Michigan Comprehensive Cancer Center Richard T. Cheney, MD Lucian R. Chirieac, MD Dana-Farber/Brigham and Women's Cancer Center † † ¶ Robert H. Lurie Comprehensive Cancer Center of Northwestern University ¶ Roswell Park Cancer Institute Thomas A. D’Amico, MD ¶ Duke Comprehensive Cancer Center Todd L. Demmy, MD ¶ Roswell Park Cancer Institute Steven J. Feigenberg, MD § Fox Chase Cancer Center Ramaswamy Govindan, MD † Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine � � Raymond U. Osarogiagbon, MD St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute Gregory A. Otterson, MD † Arthur G. James Cancer Hospital & Richard J. Solove Research Institute at The Ohio State University Jyoti D. Patel, MD ‡ Robert H. Lurie Comprehensive Cancer Center of Northwestern University Katherine M Pisters, MD ¶ † The University of Texas M. D. Anderson Cancer Center Karen Reckamp, MD, MS † City of Hope † ¶ Dana-Farber/Brigham and Women's Cancer Center ¶ Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Stephen C. Yang, MD ¶ The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Francisco Robert, MD University of Alabama at Birmingham Comprehensive Cancer Center David J. Sugarbaker, MD Douglas E. Wood, MD Frederic W. Grannis, Jr., MD ¶ City of Hope UCSF Helen Diller Family Comprehensive Cancer Center † † † § Memorial Sloan-Kettering Cancer Center Quynh-Thu Le, MD § Stanford Comprehensive Cancer Center Inga T. Lennes, MD † Massachusetts General Hospital Cancer Center Renato Martins, MD † Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Thierry Jahan, MD † Mohammad Jahanzeb, MD St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute David H. Johnson, MD Vanderbilt-Ingram Cancer Center Anne Kessinger, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Ritsuko Komaki, MD The University of Texas M. D. Anderson Cancer Center Mark G. Kris, MD † * † Medical Oncology ¶ Surgery/Surgical oncology § Radiation oncology/ Pathology ‡ Hematology/Hematology oncology Radiotherapy *Writing Committee Member � Continue NCCN Guidelines Panel Disclosures Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® Table of Contents NCCN Thymic Malignancies Panel Members Summary of Guidelines Updates Initial Evaluation (THYM-1) Initial Management (THYM-2) Postoperative Disease (THYM-3) Unresectable Disease (THYM-4) Principles of Surgical Resection (THYM-A) Principles of Radiation Therapy (THYM-B) Principles of Chemotherapy (THYM-C) � � � � � � � Guidelines Index Print the Thymic Malignancies 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. ©2008. 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 NCCN Categories of Evidence and Consensus Click here to find a clinical trial at an NCCN Center For help using these documents, please click here Staging Discussion References Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® Summary of the Guidelines updates UPDATES Summary of the changes in the 1.2009 version of the Thymic Malignancies Guidelines from the 2.2008 version include: Pulmonary function tests were added to the workup section. “Consider chemotherapy and/or RT” was replaced with “RT ± chemotherapy” for patients with an R2 resection. “Resection of isolated oligometastases” was added as a treatment option for localized tumors. The first bullet was clarified to include medical management of myasthenia gravis for patients presenting with signs and symptoms. The last bullet regarding VATS and VATS-assisted techniques was removed. � � � � � THYM-1 THYM-4 THYM-A THYM-3 The 2.2009 version of the Thymic Malignancies Guidelines represents the addition of the Discussion section correspondent to the changes in the algorithm. Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® 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. THYM-1 Mediastinal Mass � � � � � � CT chest with contrast Serum beta-HCG, AFP, if appropriate CBC, platelets FDG-PET and radiolabeled octreotide scan optional TSH, T3, T4 levels Pulmonary function tests (PFTs) INITIAL EVALUATION Thymic malignancy likely Thymic malignancy unlikely See Initial Management (THYM-2) See disease specific guidelines (NCCN Table of Contents) Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® 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. THYM-2 INITIAL MANAGEMENT Thymic malignancy likely: All patients should be managed by a multidisciplinary team with experience in the management of thymoma Surgically resectable Locally advanced, not resectable Surgical resection (total thymectomy and complete excision of tumor) a Tissue diagnosis with core needle biopsy or open biopsy (Biopsy should not violate the pleural space) See Postoperative Management (THYM-3) See Treatment (THYM-4) a .See Principles of Surgical Resection for Thymic Malignancies (THYM-A) Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® 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. THYM-3 POSTOPERATIVE MANAGEMENTRESECTABLE DISEASE Pathology evaluation R0 resection R1 resection R2 resection Thymoma, no capsular invasion Thymoma or thymic carcinoma, capsular invasion present Thymoma Thymic carcinoma Thymoma or thymic carcinoma Surveillance for recurrence with annual chest CT Postoperative RTb Postoperative RTb Postoperative + Chemotherapy RTb c RT ± chemotherapyb c Surveillance for recurrence with annual chest CT b c . . See Principles of Radiation Therapy for Thymic Malignancies (THYM-B) See Principles of Chemotherapy for Thymic Malignancies (THYM-C) Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® 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. THYM-4 UNRESECTABLE DISEASE Thymoma or thymic carcinoma Localized tumor Evidence of distant metastases Chemotherapy or Resection of isolated oligometastases c Chemotherapyc c .See Principles of Chemotherapy for Thymic Malignancies (THYM-C) Surgical resection and/or RT or RT ± chemotherapyc TREATMENT Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® 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. THYM-A PRINCIPLES OF SURGICAL RESECTION FOR THYMIC MALIGNANCIES � � � � Prior to surgery, patients should be evaluated for signs and symptoms of myasthenia gravis and they should be medically controlled prior to undergoing surgical resection. Goal of surgery is complete excision of the lesion Procedure of choice is total thymectomy and complete resection of contiguous and noncontiguous disease Complete resection may require the resection of adjacent structures including pericardium, pleura, lung, and even major vascular structures. Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® 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. THYM-B PRINCIPLES OF RADIATION THERAPY FOR THYMIC MALIGNANCIES � � � � � � Prior to surgery, all patients should be evaluated by radiation oncologists, surgeons, medical oncologists, diagnostic imaging specialists and pulmonologists for evaluation resectability of the tumor and operability of the patients. Goal of radiation therapy is to reduce local recurrence. Radiation therapy needs to be given for patients with unresectable, incompletely resected and invasive thymoma or thymic carcinoma. Radiation therapy should be given by 3 dimensional radiotherapy or intensity modulated radiotherapy to reduce surrounding normal tissue damage, e.g. heart, lungs, esophagus and spinal cord. Prior radiation therapy, any cardiac, pulmonary and or neurological toxicities related to the paraneoplastic syndrome, surgery or the induction chemotherapy need to be documented as baseline Radiation oncologists need to communicate with the surgeons to investigate the operative findings and the pathologists regarding the detailed pathology report regarding extra-capsular extension and histology. Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® 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. THYM-C PRINCIPLES OF CHEMOTHERAPY FOR THYMIC MALIGNANCIES 1 2 3 4 5 Loehrer, PJ et al. Cisplatin plus doxorubicin plus cyclophosphamide in metastatic or recurrent thymoma: final results of an Intergroup trial. J Clin Oncol 1994; 12:1164, Shin DM, et al. A multidisciplinary approach to therapy for unresectable malignant thymoma. Ann Intern Med 1998; 129: 100–4. Fornasiero, A et al. Chemotherapy for invasive thymoma. A 13-year experience. Cancer 1991; 68:30 Giaccone, G et al. Cisplatin and etoposide combination chemotherapy for locally advanced or metastatic thymoma. A phase II study of the European Organization for Research and Treatment of Cancer Lung Cancer Cooperative Group. Journal of Clinical Oncology 1996; 14:814 Loehrer PJ Sr, et al. Combined etoposide, ifosfamide, and cisplatin in the treatment of patients with advanced thymoma and thymic carcinoma: an intergroup trial. Cancer 2001; 91: 2010–5. FIRST-LINE COMBINATION CHEMOTHERAPY REGIMENS CAP Cisplatin 50 mg/m IV d1 Doxorubicin 50 mg/m IV d1 Cyclophosphamide 500 mg/m2 IV d1 Administered every 3 weeks CAP with Prednisone Doxorubicin, 20 mg/m /d IV continuous infusion on d 1 to 3 Cyclophosphamide 500 mg/m IV on d 1 Prednisone 100 mg/day d1-5 Administered every 3 weeks ADOC Cisplatin 50 mg/m IV d1 Doxorubicin 40 mg/m IV d1 Vincristine 0.6 mg/m IV d3 Cyclophosphamide 700 mg/m IV d4 Administered every 4 weeks PE Cisplatin 60 mg/m IV d1 Etoposide 120 mg/m /d IV d1-3 Administered every 3 weeks VIP Etoposide 75 mg/m on d 1-4 Ifosfamide 1.2 g/m on d 1-4 Cisplatin 20 mg/m on d 1-4 Administered every 3 weeks Carboplatin/Paclitaxel Carboplatin AUC 6 Paclitaxel 200 mg/m administered every 3 weeks 1 2 3 4 5 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Cisplatin 30 mg/m d1-3 SECOND-LINE CHEMOTHERAPY Etoposide Ifosfamide Pemetrexed Octreotide +/- Prednisone 5-Fluorouracil and Leucovorin Gemcitabine Paclitaxel Version 2.2009, 05/20/09 © 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.2.2009 Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic MalignanciesNCCN ® Staging ST-1 Modified Masaoka clinical staging of thymoma* Masaoka stage Diagnostic criteria Stage I Macroscopically and microscopically completely encapsulated Stage II (A) Microscopic transcapsular invasion. (B) Macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardium Stage III Macroscopic invasion into neighboring organs (i.e., pericardium, great vessels, lung). Stage IV (A) Pleural or pericardial dissemination. (B) Lymphogenous or hematogenous metastasis *Masaoka A, Monden Y, Nakahara K, and Tanioka T. Follow-up study of thymomas with special reference to their clinical stages. Cancer 1981;48:2485-2492. 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. Version 2.2009, 10/15/08 © 2008 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. MS-1 Practice Guidelines in Oncology – v.2.2009 NCCN ® Guidelines Index Thymic Table of Contents Staging, Discussion, ReferencesThymic Malignancies Discussion NCCN Categories of Evidence and Consensus Category 1: The recommendation is based on high-level evidence (e.g. randomized controlled trials) and there is uniform NCCN consensus. Category 2A: The recommendation is based on lower-level evidence and there is uniform NCCN consensus. Category 2B: The recommendation is based on lower-level evidence and there is nonuniform NCCN consensus (but no major disagreement). Category 3: The recommendation is based on any level of evidence but reflects major disagreement. All recommendations are category 2A unless otherwise noted. Overview Masses in the anterior mediastinum can be either neoplasms (such as, thymomas, lymphomas, thymic carcinomas) or non-neoplastic conditions (such as, goiter, thymic cysts).1 Many mediastinal masses are benign, especially those occurring in asymptomatic patients; however, symptomatic patients often have malignant mediastinal lesions. Thymomas are the most common tumor in the anterior mediastinum. The NCCN guideline for Thymic Malignancies (see THYM-1) outlines the evaluation, treatment, and management of thymomas and thymic carcinomas (see “Thymic Masses”). Thymic Masses Masses in the anterior mediastinum can be either neoplasms (such as, thymomas, lymphomas, thymic carcinomas, thymic carcinoids, thymolipomas, germ cell tumors, parathyroid adenomas) or non- neoplastic conditions (such as, intrathoracic goiter, thymic cysts, lymphangiomas, aortic aneurysms).1,2 Lymphomas typically manifest as generalized disease but can also be primary anterior mediastinal lesions (such as, nodular sclerosing Hodgkin’s disease, and non- Hodgkin’s lymphomas [large B-cell lymphoma and lymphoblastic lymphoma]); patients typically have lymphadenopathy (see the NCCN Non-Hodgkin’s Lymphomas Guidelines and the NCCN Hodgkin Disease/Lymphoma Guidelines).2,3 Thymic carcinoids are rare tumors that are discussed in the NCCN Neuroendocrine Tumors Guideline. Teratomas are discussed in the NCCN Testicular Cancer Guideline. Alpha-fetoprotein (AFP) and beta—human chorionic gonadotropin (beta-HCG) levels should be obtained to rule out germ cell tumors (see THYM-1). Thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) levels should also be measured to rule out mediastinal goiter. All patients with a mediastinal mass