骨肿瘤指南-NCCN 2010

Continue NCCN Clinical Practice Guidelines in Oncology™ Bone Cancer V.1.2010 www.nccn.org Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® ¶ Surgery/Surgical oncology † Medical oncology ‡ Hematology/Hematology oncology Orthopedics € Pediatric oncology § Radiotherapy/Radiation oncology *Writing committee member � NCCN Bone Cancer Panel Members J. Sybil Biermann, MD/Chair University of Michigan Comprehensive Cancer Center Frank J. Frassica, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins ¶ † † ¶ † ‡ ¶ § ¶ Douglas R. Adkins, MD Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine Robert S. Benjamin, MD The University of Texas M. D. Anderson Cancer Center Brian Brigman, MD Duke Comprehensive Cancer Center Warren Chow, MD City of Hope Comprehensive Cancer Center Ernest U. Conrad, III, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Deborah A. Frassica, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Carol D. Morris, MD ¶ Memorial Sloan-Kettering Cancer Center Richard J. O’Donnell, MD UCSF Helen Diller Family Comprehensive Cancer Center R. Lor Randall, MD Huntsman Cancer Institute at the University of Utah Victor M. Santana, MD St. Jude Children’s Research Hospital/ University of Tennessee Cancer Institute Robert L. Satcher, MD, PhD The University of Texas M. D. Anderson Cancer Center Herrick J. Siegel, MD University of Alabama at Birmingham Comprehensive Cancer Center Neeta Somaiah, MD Fox Chase Cancer Center Alan W. Yasko, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University � ¶ ¶ € ¶ ¶ † ¶ * Suzanne George, MD Dana-Farber/Brigham and Women’s Cancer Center Kenneth R. Hande, MD Vanderbilt-Ingram Cancer Center Robert Heck, Jr., MD St. Jude Children’s Research Hospital/University of Tennessee Cancer Institute Francis J. Hornicek, MD, PhD G. Douglas Letson, MD H. Lee Moffitt Cancer Center & Research Institute Joel Mayerson, MD The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute Sean V. McGarry, MD UNMC Eppley Cancer Center at The Nebraska Medical Center Brian McGrath, MD Roswell Park Cancer Institute † ¶ ¶ † ¶ Massachusetts General Hospital Cancer Center ‡ � � � � � Bone Cancer Continue NCCN Guidelines Panel Disclosures Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® This manuscript 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 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 Ewing’s Sarcoma: Osteosarcoma: NCCN Bone Cancer Panel Members Bone Cancer Workup (BONE-1) Chondrosarcoma (CHON-1) Guidelines Index Print the Bone Cancer Guideline Summary of Guidelines Updates � � � � Workup and Primary Treatment (EW-1) Workup and Primary Treatment (OSTEO-1) Surveillance and Relapse (OSTEO-3) Adjuvant Treatment, Surveillance and Relapse (EW-2) Multidisciplinary Team (BONE-A) Principles of Bone Cancer Management (BONE-B) For help using these documents, please click here Staging Discussion References Clinical Trials: NCCN Categories of Evidence and Consensus: 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 Bone Cancer Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® Summary of changes in the 1.2010 version of the Bone Cancer guidelines from the 1.2009 version include: Summary of the Guidelines updates ( )BONE-1 ( ): ( ): ( ): ( ): CHON-1 EW-1 EW-2 BONE-B � � � � � � � � � � � � 40 pathway: After workup, branch points changed to “No other lesions ” and “Other lesions ”. There is considerable controversy regarding the grading of Chondrosarcoma. In addition to histology, radiologic features, size, and location of tumors should also be considered in deciding local treatment.” is new to the page. Primary Treatment: “Multiagent chemotherapy” changed from category 2A to category 1. Footnote “c” was revised as follows, “Any member of the Ewing’s family of tumors can be treated using this algorithm . ± RT” with corresponding footnote “j” that states,“Chemotherapy regimens can include irinotecan/temozolomide or cyclophosphamide/topotecan” is new to the page. Footnote “h”: “There is category 1 evidence for a total of 36 weeks of chemotherapy including that received prior to local therapy.” changed to “There is category 1 evidence for weeks of chemotherapy .” Footnote “i” is new to the page. : No changes to the Guidelines. Principles of Bone Cancer Management Biopsy; Bullet #7: “Fresh tissue is needed...” changed to “Fresh tissue needed...” (possible bone primary) (non-bone primary suspected) including primitive neuroectodermal tumor, Askin’s tumor, PNET of bone and extraosseous Ewing’s sarcoma between 28 and 49 depending on the chemotherapy and dosing schedule used Osteosarcoma may be Chondrosarcoma Ewing’s Sarcoma : Footnote “c” that states, “ : First column: Top pathway: Changed to “Stable disease following response to primary treatment”. Bottom pathway: The phrase “Unresponsive” was removed from “Unresponsive or progressive disease...” Surveillance: “CBC” changed from annually to every 2-3 months as part of the “Physical exam, chest...” Progressive Disease/Relapse column: Recommendations for “Early relapse and Late relapse” were combined and are now listed as “Clinical trial or Chemotherapy � � UPDATES Bone 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. Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® BONE-1 < 40 � 40 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. Painful bone lesiona Workup for potential bone metastasis a b Painless bone lesions require evaluation by a musculoskeletal radiologist and referral to multidisciplinary teams. . . See Multidisciplinary Team (BONE-A) See Principles of Bone Cancer Management (BONE-B) Abnormal radiograph � � � � � � � H&P As clinically indicated: Bone scan Chest radiograph SPEP/labs Chest/abdominal/ pelvic CT PSA Mammogram No other lesions (Possible bone primary) Other lesions (Non-bone primary suspected) Refer to appropriate NCCN Guideline. Go to NCCN Table of Contents Refer to orthopaedic oncologist Biopsy should be performed at treating institution � WORKUPb Refer to orthopaedic oncologist Biopsy� should be performed at treating institution See specific bone sarcomas Table of Contents Bone Cancer Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® Positive margins Negative margins Observe Consider RT 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. PRESENTATIONa,b,c PRIMARY TREATMENT SURVEILLANCE RELAPSE Low grade and Intracompartmental Dedifferentiated Mesenchymal Treat as osteosarcoma (category 2B) See NCCN Osteosarcoma Guidelines (OSTEO-1) Treat as Ewing’s Sarcoma (category 2B) See NCCN Ewing’s Sarcoma Guidelines (EW-1) Intralesional excision ± surgical adjuvant or Wide excision, if resectable or Consider RT, if unresectable d Physical exam, chest and lesion x-ray every 6-12 mo for 2 y then yearly as appropriate Local recurrence Wide excision, if resectable or RT, if unresectable d CHON-1 a . . There is considerable controversy regarding the grading of Chondrosarcoma. In addition to histology, radiologic features, size, and location of tumors should also be considered in deciding local treatment. Wide excision should provide negative surgical margins for tumor. This may be achieved by either limb-sparing resection or limb amputation. b c d See Multidisciplinary Team (BONE-A) See Principles of Bone Cancer Management (BONE-B) Chondrosarcoma Bone Cancer Positive margins Negative margins Observe Consider RT High grade (grade ll, grade lll) or Clear cell or Extracompartmental Wide excision, if resectable or Consider RT, if unresectable d Local relapse Systemic relapse Wide excision, if resectable or RT, if unresectable d Clinical trial or Surgical excision � � � � Physical exam Primary site radiographs and/or cross-sectional imaging as indicated Chest imaging every 3-6 mo for 5 y, then yearly for a minimum of 10 y Reassess function at every follow-up visit Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® Bone 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. Ewing’s sarcoma � � � � � � � MRI ± CT of primary site Chest CT PET scan and/or bone scan Consider bone marrow biopsy or screening MRI of spine and pelvis Cytogenetics and/or molecular studies (may require re-biopsy) LDH Fertility consultation as appropriate d Multiagent chemotherapye (category 1) for at least 12-24 weeks prior to local therapy For patients with metastatic disease Restage with: Repeat other abnormal studies � � � Chest imaging Local imaging Consider PET scan or bone scanf Response Progressive disease EW-1 a b c d . . Any member of the Ewing’s family of tumors can be treated using this algorithm including primitive neuroectodermal tumor, Askin’s tumor, PNET of bone and extraosseous Ewing’s sarcoma. 90% of Ewing’s family tumors will have one of four specific cytogenetic translocations. eChemotherapy should include a combination of at least three of the following agents : (ifosfamide and/or cyclophosphamide, etoposide, doxorubicin, vincristine) and growth factor support Use the same imaging technique that was performed in the initial workup.f See Multidisciplinary Team (BONE-A) See Principles of Bone Cancer Management (BONE-B) ( )See Discussion Section MS-5 ( )See NCCN Myeloid Growth Factors Guidelines For patients with localized disease Restage with: Chest imaging Local imaging Consider PET scan or bone scan � � � f Ewing’s Sarcoma PRESENTATIONa,b,c WORKUP PRIMARY TREATMENT RESTAGE See Stable disease following response to Primary Treatment (EW-2) See Progressive disease following Primary Treatment (EW-2) Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® Preoperative RT Bone 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. ADJUVANT TREATMENT/ ADDITIONAL THERAPY Stable disease following response to primary treatment Progressive disease following primary treatment SURVEILLANCE PROGRESSIVE DISEASE/RELAPSE Wide excision Definitive RT and chemotherapyh Amputation in selected cases (such as tumors of the foot) Positive margins Negative marginsg Chemotherapy ± additional RT h Post-operative chemotherapy, consider RT depending on margin status RT and/or surgery to primary site for local control or palliation Chemotherapy (category 1) h Continue chemotherapy (category 1) followed by RT or RT and chemotherapy (category 1, for chemotherapy) h h � � � Physical exam, CBC, chest, and local imaging every 2-3 mo Increase intervals for physical exam, chest and local imaging after 24 mo. Annually after 5 y (indefinitely) Consider PET scan or bone scanf Early relapse Late relapsei Clinical trial or Chemotherapy RT j ± or or EW-2 Wide excision Chemotherapy or Best supportive care or Ewing’s Sarcoma LOCAL CONTROL THERAPY f g Use the same imaging technique that was performed in the initial workup. RT may be considered for close margins. or late relapse, c h i There is category 1 evidence for between 28 and 49 weeks of chemotherapy depending on the chemotherapy and dosing schedule used. F onsider re-treatment with previously effective regimen. Chemotherapy regimens can include irinotecan/temozolomide or cyclophosphamide/topotecan.j Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® Bone 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. WORKUPa,b PRIMARY TREATMENT � � � � � � � Plain films MRI ± CT of primary site Chest imaging including chest CT PET scan and/or bone scan LDH Alkaline phosphatase Fertility consultation as appropriate High grade osteosarcoma: Intramedullary + surface See Surveillance (OSTEO-3) a b c . . Dedifferentiated parosteal osteosarcomas are not considered to be low grade tumors. dChemotherapy may be intravenous or intra-arterial and should include a combination of at least two of the following agents: (doxorubicin, cisplatin, ifosfamide, high- dose methotrexate) and growth factors . See Multidisciplinary Team (BONE-A) See Principles of Bone Cancer Management (BONE-B) (See NCCN Myeloid Growth Factors Guideline) OSTEO-1 Low grade osteosarcoma : Intramedullary + surface c Wide excision High grade Chemotherapyd Periosteal osteosarcoma Consider chemotherapyd Wide excision Low grade Osteosarcoma See Primary Treatment (OSTEO-2) ADJUVANT TREATMENT Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® Bone Cancer Osteosarcoma 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. Positive margins Negative margins � � Chemotherapy Consider additional local therapy d Reassess tumor as appropriate Restage with pretreatment imaging modalities: Chest imaging Local imaging Consider PET scan Consider bone scan � � � � PRIMARY TREATMENT Preoperative chemotherapy (category 1) d,e Wide excision, if resectable Good responsef Poor responsef Chemotherapyd Unresectable � � RT ± sensitizers Samarium Good responsef Poor responsef Consider changing chemotherapy Chemotherapyd � � Consider additional local therapy Consider changing chemotherapy High grade osteosarcoma: Intramedullary + surface See Surveillance (OSTEO-3) d e f Chemotherapy may be intravenous or intra-arterial and should include a combination of at least two of the following agents: (doxorubicin, cisplatin, ifosfamide, high- dose methotrexate) and growth factors . Response defined by pathologic mapping. Selected elderly patients may benefit from immediate surgery. (See NCCN Myeloid Growth Factors Guideline) OSTEO-2 RESTAGENEOADJUVANT TREATMENT ADJUVANT TREATMENT Version 1.2010, 11/12/09 © 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 Bone Cancer Table of Contents Staging, Discussion, ReferencesNCCN ® Surveillance Bone 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 RELAPSE � � � � � � � � Physical exam Chest imaging CBC Local imaging : Consider PET scan and/or bone scan (category 2B) Reassess function every visit Every 3 mo for y 1 and 2 Every 4 mo for y 3 Every 6 mo for y 4 and 5 and yearly thereafter g Follow-up schedule: Relapse Chemotherapy and/or resection if possible Response Relapse Resect or Best supportive