2010NCCN指南--胃癌

Continue NCCN Clinical Practice Guidelines in Oncology™ Gastric Cancer V.1.2010 www.nccn.org Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric Cancer NCCN Gastric Cancer Panel Members NCCN Guidelines Panel Disclosures Continue † Medical oncology ¤ Gastroenterology ¶ Surgery/Surgical oncology Þ Internal medicine § Radiotherapy/Radiation oncology ‡ Hematology/Hematology oncology *Writing committee member � Pathology Jaffer A. Ajani, MD/Chair † ¤ The University of Texas M. D. Anderson Cancer Center James S. Barthel, MD H. Lee Moffitt Cancer Center & Research Institute Tanios Bekaii-Saab, MD † The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute David J. Bentrem, MD ¶ Thomas A. D’Amico, MD ¶ Duke Comprehensive Cancer Center Prajnan Das, MD, MS, MPH § The University of Texas M. D. Anderson Cancer Center Crystal Denlinger, MD † Fox Chase Cancer Center † ¤ Þ James A. Hayman, MD, MBA § University of Michigan Comprehensive Cancer Center ¤ Þ Robert H. Lurie Comprehensive Cancer Center of Northwestern University Charles S. Fuchs, MD, MPH Dana-Farber/Brigham and Women’s Cancer Center Hans Gerdes, MD Memorial Sloan-Kettering Cancer Center James A. Posey, MD † University of Alabama at Birmingham Comprehensive Cancer Center Aaron R. Sasson, MD ¶ UNMC Eppley Cancer Center at The Nebraska Medical Center Walter J. Scott, MD ¶ Fox Chase Cancer Center Stephen Shibata, MD City of Hope Comprehensive Cancer Center Vivian E. M. Strong, MD Memorial Sloan-Kettering Cancer Center Mary Kay Washington, MD, PhD Christopher Willett, MD § Gary Yang, MD § † ¶ ¶ � Vanderbilt-Ingram Cancer Center Duke Comprehensive Cancer Center Douglas E. Wood, MD ¶ Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Cameron D. Wright, MD Massachusetts General Hospital Roswell Park Cancer Institute Lisa Hazard, MD § Huntsman Cancer Institute at the University of Utah Wayne L. Hofstetter, MD The University of Texas M. D. Anderson Cancer Center David H. Ilson, MD, PhD † Þ Memorial Sloan-Kettering Cancer Center Rajesh N. Keswani, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Lawrence R. Kleinberg, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins ¶ Mary F. Mulcahy, MD ‡ Robert H. Lurie Comprehensive Cancer Center of Northwestern University Mark B. Orringer, MD ¶ University of Michigan Comprehensive Cancer Center Raymond U. Osarogiagbon, MD † Þ ‡ St. Jude Children’s Research Hospital/ University of Tennessee Cancer Institute ¶ ¤ § Kenneth Meredith, MD H. Lee Moffitt Cancer Center & Research Institute * * * * Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric Cancer NCCN Gastric Cancer Sub-Committee Members Continue ¤ Gastroenterology ¶ Surgery/Surgical oncology Þ Internal medicine § Radiotherapy/Radiation oncology ‡ Hematology/Hematology oncology *Writing committee member NCCN Guidelines Panel Disclosures Principles of Surgery Aaron R. Sasson, MD ¶/Lead UNMC Eppley Cancer Center at The Nebraska Medical Center David J. Bentrem, MD ¶ Robert H. Lurie Comprehensive Cancer Center of Northwestern University Vivian E. M. Strong, MD Memorial Sloan-Kettering Cancer Center ¶ Principles of Best Supportive Care James S. Barthel, MD H. Lee Moffitt Cancer Center & Research Institute Mary F. Mulcahy, MD ‡ Robert H. Lurie Comprehensive Cancer Center of Northwestern University ¤ Þ/LeadGary Yang, MD §/Lead Roswell Park Cancer Institute Prajnan Das, MD, MS, MPH § The University of Texas M. D. Anderson Cancer Center James A. Hayman, MD, MBA § University of Michigan Comprehensive Cancer Center Lisa Hazard, MD § Huntsman Cancer Institute at the University of Utah Lawrence R. Kleinberg, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Christopher Willett, MD § Duke Comprehensive Cancer Center Principles of Radiation Therapy § Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric Cancer This manuscript is being updated to correspond with the newly updated algorithm. Table of Contents NCCN Gastric Cancer Panel Members Workup and Evaluation (GAST-1) Postlaparoscopy Staging and Treatment (GAST-2) Surgical Outcomes (GAST-3) Adjunctive Treatment (GAST-4) Follow-up and Palliative Therapy (GAST-5) Principles of Surgery (GAST-B) Principles of Systemic Therapy (GAST-C) Principles of Radiation Therapy (GAST-D) Principles of Best Supportive Care (GAST-E) Summary of Guidelines Updates Principles of Multidisciplinary Team Approach (GAST-A) Guidelines Index Print the Gastric 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. For help using these documents, please click here Staging Discussion References 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 Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric 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. Summary of the Guidelines Updates UPDATES ( ) ( ) ( ) ( ) ( ) GAST-1 GAST-5 GAST-A GAST-B GAST-C ( )GAST-3 : Workup; Fourth bullet: Clarified “Abdominal CT with contrast”. Last bullet: “H.pylori test, treat if positive,” changed to “H.pylori test, if patient symptomatic from H.pylori, then treat”. concurrent 5-FU-based radiosensitization”. : H&P c every 4 - 6 mo for 3 y, then annually” to every 3-6 mo for 1-3 y, every 6 mo for 3-5 y, then annually”. : Principles of Multidisciplinary Team Approach Sentence that states, “The NCCN panel believes in an infrastructure that discourages unilateral treatment decision-making...” changed to “The NCCN panel believes in an infrastructure that treatment decision-making.” : Principles of Gastric Cancer Surgery The entire Principles of Surgery page was revised. : Principles of Systemic Therapy There is no longer a separate category for “Postoperative Chemotherapy”. The agents are now listed under “Preoperative and Postoperative chemotherapy”. Preoperative Chemoradiation: “Cisplatin plus fluoropyrimidine (category 2B)” was added. � � � � � IV : After R1 resection: Removed the phrase “preferred” after “...+ Follow-up: hanged from “ “ � � � � encourages multidisciplinary Summary of changes in the 1.2010 version of the Gastric Cancer guidelines from the 2.2009 version include: ( ) ( ) ( ) GAST-C GAST-D GAST-E : Principles of Systemic Therapy (continued) Metastatic or Locally advanced cancer: “Trastuzumab” with corresponding footnote that states “Used in combination with systemic chemotherapy for the treatment of patients with advanced gastric cancer or GE junction adenocarcinoma that is HER-2-positive as determined by a standardized method” was added. Footnote that states “Leucovorin or levoleucovorin is indicated with certain infusional 5-FU-based regimens” changed to “Leucovorin is indicated with...” : Principles of Radiation Therapy Target Volume; Preoperative and Postoperative: “EGD” was added as an example of Pre-treatment diagnostic studies. Supportive Therapy; Fourth bullet: “Intravenous hyperalimentation” was removed from the first sentence. “Nasogastric feeding tube” was added to the second sentence. New bullet added that states “Adequate enteral and/or IV hydration is necessary throughout chemoradiation and early recovery”. : Principles of Best Supportive Care for Gastric Cancer Principles of Best Supportive Care for Gastric Cancer is a new page that provides specific recommendations for gastric cancer best supportive care throughout the guidelines. The new page replaces the “Best Supportive Care” table that was on page . � � � � � � GAST-5 Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric 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. CLINICAL PRESENTATION ADDITIONAL EVALUATION WORKUP � � � � � � � � � � Multidisciplinary evaluation H&P CBC and chemistry profile Abdominal CT with IV contrast CT/ultrasound pelvis (females) Chest imaging Esophagogastroduodenoscopy PET-CT or PET scan (optional) Endoscopic ultrasound (EUS) (optional) H.pylori test, if patient symptomatic from H.pylori, then treat a b Locoregional (M0) Stage IV (M1) Medically fit, potentially resectable d Palliative Therapy (see GAST-5) Medically fit, unresectable d Medically unfit a d May not be appropriate for T1 or M1 patients. Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102(8):1808-1825 . Medically able to tolerate major abdominal surgery. Laparoscopy is performed to evaluate for peritoneal spread when considering chemoradiation or surgery. Laparoscopy is not indicated if a palliative resection is planned. b e cTis or T1a: Defined as tumors involving the mucosa, but not invading the submucosa. Postlaparoscopy Staging (see GAST-2) Consider Laparoscopy (category 2B) e GAST-1 Tis or T1ac Medically fit Medically unfit Primary Treatment (see GAST-2) Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric 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. POSTLAPAROSCOPY STAGING PRIMARY TREATMENT Medically fit, potentially resectable d Surgical Outcomes (see GAST-3) RT, 45–50.4 Gy + concurrent 5-FU-based radiosensitization (category 1) or Palliative Therapy (see GAST-5) RT, 45-50.4 Gy + concurrent 5-FU-based radiosensitization (category 1) or Chemotherapyj Post Treatment Assessment/ Adjunctive Treatment (see GAST-4) Medically fit, unresectable d Medically unfit Palliative Therapy (see GAST-5) Palliative Therapy (see GAST-5) M0 M1 M0 M1 GAST-2 c d g Tis or T1a: Defined as tumors involving the mucosa, but not invading the submucosa.. Medically able to tolerate major abdominal surgery. T1b: Tumors invading the submucosa. fSee Principles of Multidisciplinary Team Approach (GAST-A). T1bg Surgeryh,i T2 or higher (by clinical staging or N+) Surgery or Preoperative chemotherapy (category 1) or Preoperative chemoradiation (category 2B) i j,k j M0 M1 Surgeryh,i Palliative Therapy (see GAST-5) Medically fit Medically unfit h j k Surgery as primary therapy is appropriate for T1 cancer or actively bleeding cancer, or when postoperative therapy is preferred. iSee Principles of Surgery (GAST-B) See Principles of Systemic Therapy (GAST-C) See Principles of Radiation Therapy (GAST-D) . . . Endoscopic mucosal resection (EMR) or Surgeryi EMR Tis or T1ac Multi- disciplinary evaluation preferredf Multi- disciplinary evaluation preferredf Multi- disciplinary evaluation preferredf Multi- disciplinary evaluation preferredf Post Treatment Assessment/ Adjunctive Treatment (see GAST-4) Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric 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. Surgical outcomes POSTOPERATIVE TREATMENT RT, 45–50.4 Gy + concurrent 5-FU-based radiosensitization + 5-FU ± leucovorin RT, 45–50.4 Gy + concurrent 5-FU-based radiosensitization or Chemotherapy or Best supportive care j n Palliative Therapy (see GAST-5) Follow-up (see GAST-5) Follow-up (see GAST-5) Tis or T1, N0 T3, T4 or Any T, N+ RT, 45–50.4 Gy + concurrent 5-FU-based radiosensitization (preferred) + 5-FU ± leucovorin or ECF if received preoperatively (category 1) M1 R0 resectionl R1 resectionl R2 resectionl GAST-3 T2, N0 Observe Observe or Chemoradiation (Fluoropyrimidine for selected patients j,k m -based) or ECF if received preoperatively (category 1) SURGICAL RESECTION j k lR0= No cancer at resection margins, R1= Microscopic residual cancer, R2= Macroscopic residual cancer or M1B. m n High risk features include poorly differentiated or higher grade cancer, lymphovascular invasion, neural invasion, or < 50 years of age. See Principles of Systemic Therapy (GAST-C) See Principles of Radiation Therapy (GAST-D) . . See Principles of Best Supportive Care for Gastric Cancer (GAST-E). Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric Cancer � � � � � � Restaging (preferred): Chest imaging Abdominal CT with contrast Pelvic imaging (females) CBC and chemistry profile PET-CT or PET scan (optional) Complete or major response Follow-up (see GAST-5) or Surgery, if appropriate i Residual, unresectable locoregional and/or metastatic disease Palliative Therapy (see GAST-5) Medically fit, unresectable or Medically unfit patients following primary treatment POST TREATMENT ASSESSMENT/ADJUNCTIVE TREATMENT GAST-4 iSee Principles of Surgery (GAST-B). 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, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric 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. FOLLOW-UP Best supportive caren Chemotherapy or Clinical trial or j Best supportive caren PALLIATIVE THERAPY Karnofsky performance score < 60 % or ECOG performance score 3� Karnofsky performance score 60 % or ECOG performance score 2 � � � � � � H&P every 3-6 mo for 1-3 y, every 6 mo for 3-5 y, then annually CBC and chemistry profile as indicated or endoscopy, as clinically indicated Monitor for vitamin B deficiency in surgically resected patients and treat as indicated Radiologic imaging 12 GAST-5 j n See Principles of Systemic Therapy (GAST-C) See Principles of Best Supportive Care for Gastric Cancer (GAST-E) . . Recurrence PERFORMANCE STATUS Version 1.2010, 11/23/09 © 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 Gastric Table of Contents Staging, Discussion, ReferencesGastric Cancer PRINCIPLES OF MULTIDISCIPLINARY TEAM APPROACH FOR GASTROESOPHAGEAL CANCERS Category 1 evidence supports the notion that the combined modality therapy is effective for patients with localized gastroesophageal cancer. The NCCN panel believes in an infrastructure decision-making by members of any discipline taking care of this group of patients. The combined modality therapy for patients with localized gastroesophageal cancer may be optimally delivered when the following elements are in place: 1,2,3 that encourages multidisciplinary treatment The involved institution and individuals from relevant disciplines are committed to jointly reviewing the detailed data on patients on a regular basis. Frequent meetings (either once a week or once every two weeks) are encouraged. At each meeting, all relevant disciplines should be encouraged to participate and these include: surgical oncology, medical oncology, gastroenterology, radiation oncology, radiology, and pathology. In addition, the presence of nutritional services, social workers, nursing, and other supporting disciplines are also desirable. All