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非小细胞肺癌NCCN指南2017第7版更新

发表者:张品良 人已读

Non-Small Cell Lung Cancer非小细胞肺癌

2017第7版—2017年6月22日山东省肿瘤医院呼吸肿瘤内科张品良

Updates in Version 7.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 6.2017 include:
非小细胞肺癌NCCN指南2017第7版较2017第6版的更新包括:

NSCL-20

ALK rearrangement discovered prior to first-line chemotherapy: Alectinib added as a category 1 treatment option and preferred.
在一线化疗前发现ALK重排:增加阿雷替尼作为一个1类治疗选择和首选。

ALK rearrangement discovered during first-line chemotherapy: Complete planned chemotherapy, including maintenance therapy, or interrupt, followed by alectinib or crizotinib or ceritinib.
在一线化疗期间发现ALK重排:完成计划的化疗,包括维持治疗;或中断,然后阿雷替尼或克唑替尼或色瑞替尼。

NSCL-21

Asymptomatic, Brain and Systemic isolated lesions: "continue alectinib" added as a treatment option.
无症状的脑及全身孤立性病变:增加“继续阿雷替尼”为一个治疗选择。

MS-1

The discussion section was updated based on the recent changes to the Guidelines.
基于指南的最新变化更新了讨论部分。

                                                  

Updates in Version 6.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 5.2017 include:
非小细胞肺癌NCCN指南2017第6版较2017第5版的更新包括:

NSCL-21

Asymptomatic progression; Symptomatic progression - brain or multiple systemic lesions: Brigatinib added as a treatment option.
无症状进展;症状性进展——脑或多发的全身性病变:增加了布加替尼作为一个治疗选择。

Footnote "rr" modified: Patients who are intolerant to crizotinib may be switched to ceritinib, alectinib, or brigatinib.
脚注“rr”修改为:无法耐受克唑替尼的患者可转换至色瑞替尼、阿雷替尼或布加替尼

Footnote "tt" added: Alectinib or brigatinib are treatment options for patients with ALK-positive metastatic NSCLC that have progressed on crizotinib.
脚注“tt”增加了:阿雷替尼或布加替尼作为克唑替尼已经进展的、ALK阳性的转移性非小细胞肺癌患者的治疗选择。

MS-1

The discussion section was updated based on the recent changes to the Guidelines.
基于指南的最新变化更新了讨论部分。

                                                   

Updates in Version 5.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 4.2017 include:
非小细胞肺癌NCCN指南2017第5版较2017第4版的更新包括:

NSCL-20

ALK rearrangement discovered prior to first-line chemotherapy: Ceritinib added as a category 1 treatment option.
在一线化疗前发现ALK重排:增加色瑞替尼为一个1类治疗选择。

ALK rearrangement discovered during first-line chemotherapy: Complete planned chemotherapy, including maintenance therapy, or interrupt, followed by crizotinib or ceritinib.
在一线化疗期间发现ALK重排:完成计划的化疗,包括维持治疗;或中断,然后克唑替尼或色瑞替尼

NSCL-21

Asymptomatic, Brain and Systemic isolated lesions: "continue ceritinib" added as a treatment option.
无症状的脑及全身孤立性病变:继续色瑞替尼”增加为一个治疗选择。

Footnote "ss" added: If not previously given.
脚注“ss”增加了:如果未曾给予。

MS-1

The discussion section was updated based on the recent changes to the Guidelines.
基于指南的最新变化更新了讨论部分。

                                                   

Updates in Version 4.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 3.2017 include:
非小细胞肺癌NCCN指南2017第4版较2017第3版的更新包括:

NSCL-9

Separate pulmonary nodules; N2, R0 after surgery: Adjuvant treatment recommendation clarified as chemotherapy (category 1) or sequential chemotherapy + RT. Previously noted as sequential chemotherapy (category 1) + RT.
分散肺结节;术后N2、R0:辅助治疗推荐明确为化疗(1类)或序贯化疗+放疗。既往所述为序贯化疗(1类)+放疗。

NSCL-19

Osimertinib changed from a category 2A to a category 1 recommendation.
奥希替尼从2A类改为1类推荐。

Footnote "nn" modified with this addition: Consider reflex to tissue-based testing, if plasma test is negative for the T790M mutation.
脚注“nn”补充修改为:如果血浆T790M突变检测阴性,考虑可反过来进行基于组织的检测。

Footnote removed: Osimertinib is an option for patients with metastatic EGFR T790M mutation-positive tumors, as determined by an FDA-approved test or other validated laboratory-developed test performed in a CLIA-approved laboratory.
删除了脚注:对于经过FDA批准的或其他实验室验证过的由CLIA批准的实验室开发的检测方法测定的EGFR T790M突变阳性的转移性肿瘤患者,奥希替尼是一个选择。

NSCL-24

Atezolizumab changed from a category 2A to a category 1 recommendation. (also applies to NSCL-25)
阿特珠单抗从2A类更改为1类推荐。(也适用于NSCL-25)

                                                  

Updates in Version 3.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 2.2017 include:
非小细胞肺癌NCCN指南2017第3版较2017第2版的更新包括:

MS-1

The Discussion section has been updated to reflect the changes in the algorithm.
讨论部分已经更新为反映出工作步骤方面的变化。

Updates in Version 2.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 1.2017 include:
非小细胞肺癌NCCN指南2017第2版较2017第1版的更新包括:

NSCL-17

Testing results modified: "PD-L1 positive and EGFR, ALK, ROS1 negative or unknown."
检测结果修改为:PD-L1阳性和EGFR、ALK、ROS1阴性或未知。”

NSCL-24

Subsequent Therapy; PS 0-2: Atezolizumab added as a treatment option. Reference added: Barlesi F, Park K, Ciardiello F, et al. Primary analysis from OAK, a randomized phase III study comparing atezolizumab with docetaxel in 2L/3L NSCLC [abstract]. ESMO Congress; Copenhagen. ESMO 2016: LBA44. (also applies to NSCL-25)
后续治疗;PS 0-2:增加了阿特珠单抗作为一个治疗选择。增加了参考文献:Barlesi F, Park K, Ciardiello F,等。OAK,对比阿特珠单抗与多西他赛治疗2L/3L非小细胞肺癌的一项随机Ⅲ期研究初步分析 [摘要]。ESMO大会;哥本哈根。ESMO 2016:LBA44。(也适用于NSCL-25)

Erlotinib removed as a treatment option in subsequent therapy and maintenance therapy.
删除了厄洛替尼作为后续和维持治疗的一个选择。

Footnote "ww" modified: Pembrolizumab is approved for patients with NSCLC tumors with PD-L1 expression levels 1%, as determined by an FDA-approved test. for PD-L1 with use of pembrolizumab. (also applies to NSCL-25)
脚注“ww”修改为:FDA已批准派姆单抗用于经FDA批准的检验测定的肿瘤PD-L1表达水平≥1%的非小细胞肺癌患者的治疗。对于PD-L1使用派姆单抗。(也适用于NSCL-25)

Footnote "aaa" modified: If not already given, options for PS 0-2 include (nivolumab, pembrolizumab, or atezolizumab), erlotinib, docetaxel (category 2B), pemetrexed (category 2B), gemcitabine (category 2B), or ramucirumab + docetaxel (category 2B); options for PS 3-4 include best supportive care. Options for further progression are best supportive care or clinical trial.
脚注“aaa”修改为:如果未曾给予,对于PS 0-2患者的选择包括(尼鲁单抗、派姆单抗或阿特珠单抗)、厄洛替尼、多西他赛(2B类)、培美曲塞(2B类)、吉西他滨(2B类)或雷莫芦单抗+多西他赛(2B类);PS 3-4患者的选择包括最佳支持治疗。进一步进展患者的选择是最佳支持治疗或临床试验。

NSCL-25

Footnote "bbb" modified: If not already given, options for PS 0-2 include (nivolumab, pembrolizumab, or atezolizumab), docetaxel (category 2B), gemcitabine (category 2B), or ramucirumab + docetaxel (category 2B); options for PS 3-4 include best supportive care. Options for further progression are best supportive care or clinical trial.
脚注“bbb”修改为:如果未曾给予,对于PS 0-2患者的选择包括(尼鲁单抗、派姆单抗或阿特珠单抗)、多西他赛(2B类)、吉西他滨(2B类)或雷莫芦单抗+多西他赛(2B类);PS 3-4患者的选择包括最佳支持治疗。进一步进展患者的选择是最佳支持治疗或临床试验。

                                                   

Updates in Version 1.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 4.2016 include:
非小细胞肺癌NCCN指南2017第1版较2016第4版的更新包括:

PREV-1

Link added to the NCCN Guidelines for Smoking Cessation.
增加了至NCCN戒烟指南的链接。

DIAG-2 and DIAG-3
These pages were revised and adapted from the Fleischner Society Guidelines.
修订了这些页,改编自Fleischner协会指南。

NSCL-2

Stage IA: “Consider” added to “pathologic mediastinal lymph node evaluation.”
A期:“考虑”增加到“纵隔淋巴结病理评估。”

Stage IB; Brain MRI: category 2B removed and “optional” listed.
B期;脑MRI:删除了2B类,列为“可选”。

Medically inoperable; N0: Consider adjuvant chemotherapy for high-risk stages IB-IIIA clarified as stages IB-IIB.
因内科因素不能手术;N0:对于高危IB-ⅢA期澄清为IB-ⅡB期考虑辅助化疗。

Footnote "j" modified with addition of first sentence: PET/CT performed skull base to knees or whole body. (also applies to NSCL-4, NSCL-7, NSCL-9, NSCL-11 through NSCL-13)
脚注“j”修改并加入了第一句:颅底到膝关节或全身PET/CT检查。(同样适用于NSCL-4、NSCL-7、NSCL-9、NSCL-11至NSCL-13)

Footnote "p" modified: Examples of high-risk factors may include poorly differentiated tumors (including lung neuroendocrine tumors [excluding well-differentiated neuroendocrine tumors]), vascular invasion, wedge resection, tumors >4 cm, visceral pleural involvement, and incomplete lymph node sampling unknown lymph node status (Nx). These factors independently may not be an indication and may be considered when determining treatment with adjuvant chemotherapy. (also applies to NSCL-3)
脚注“p”修改为:典型的高危因素包括低分化肿瘤(包括肺神经内分泌肿瘤[不包括分化良好的神经内分泌肿瘤])、血管侵犯、楔形切除、肿瘤>4cm、脏层胸膜受累和淋巴结取样不彻底淋巴结状态不明(Nx)。单独这些因素可能不是一个指征,但当确定辅助化疗治疗时可以考虑。(也适用于NSCL-3)

NSCL-5

Surgical reevaluation clarified: including chest CT with or without contrast ± PET/CT.
明确了手术重新评估:包括胸部强化或平扫CT±PET/CT

NSCL-8

T1-3, N0-1: Surgery removed, as this is already noted in the Initial Treatment column.
T1-3N0-1:手术切除,如同在初始治疗中指出的。

Adjuvant treatment linked back to NSCL-3 for N0-1 and N2.
对于N0-1与N2的辅助治疗链接回NSCL-3。

T1-2, T3 (other than invasive), N2 nodes positive and T3 (invasion), N2 nodes positive changed to include M0.
T1-2、T3(除外侵袭性)N2阳性和T3(侵袭性)N2阳性更改为包括M0。

Brain MRI and FDG PET/CT removed, as they are already noted on previous page.
删除了脑MRI及FDG PET/CT,因为已在上一页提到。

Metastatic disease removed, as this is already noted on previous page.
删除了转移性病变,因为已经在上一页提到。

Footnote "w" is new to the page: "Chest CT with contrast and/or PET/CT to evaluate progression."
脚注“w”对于该页是新的:“胸部强化CT和/或PET/CT以评估进展。”

NSCL-10

Definitive local therapy not possible: "Consider" removed from "palliative chemotherapy ± local palliative therapy" and "Observe" added.
不可能根治性局部治疗:从“姑息化疗±局部姑息治疗”中去除了“考虑”并增加了“观察”。

Footnote "aa" modified: "Lung-sparing resection is preferred, but tumor distribution and institutional expertise should guide individual treatment planning. Patients should be evaluated in a multidisciplinary setting (ie, surgery, radiation oncology, medical oncology)."
脚注“aa”修改为:“首选保留肺切除术,但应该使用肿瘤分类和学会专家的意见指导个体化的治疗计划。应该对患者进行多学科(即外科、放射肿瘤学、内科肿瘤学)评估。

NSCL-13

Significant revisions for the management of limited metastases. Now covers pages NSCL-13 and NSCL-14.
对局限转移的管理进行了重大修改。目前包括NSCL-13和NSCL-14页。

                                                  

Updates in Version 1.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 4.2016 include:
非小细胞肺癌NCCN指南2017第1版较2016第4版的更新包括:

NSCL-15

Surveillance title modified: "SURVEILLANCE AFTER COMPLETION OF DEFINITIVE THERAPY"
修改了监测标题:根治性治疗结束后监测”

Recommendations differentiated based on primary therapy.
推荐随初始治疗不同而异。

Stage I-II (primary treatment included surgery ± chemotherapy)
I-(初始治疗包括手术±化疗)

H&P and chest CT ± contrast every 6 mo for 2–3 y, then H&P and a low-dose non-contrast-enhanced chest CT annually
病史与体格检查和胸部CT±强化,最初2-3年每6个月1次,之后每年1次病史与体格检查和胸部低剂量非强化CT

Stage I-II (primary treatment included RT) or Stage III or Stage IV (oligometastatic with all sites treated with definitive intent)
I-(初始治疗包括放疗)或Ⅲ期或Ⅳ期(所有部位的寡转移灶均给予根治性治疗)

H&P and chest CT ± contrast every 3–6 mo for 3 y, then H&P and chest CT ± contrast every 6 mo for 2 y, then H&P and a low-dose non-contrast-enhanced chest CT annually
病史与体格检查和胸部CT±强化,最初3年每3-6个月1次,之后病史与体格检查和胸部CT±强化,最初2年每6个月1次,之后每年1次病史与体格检查和胸部低剂量非强化CT

Residual or new radiographic abnormalities may require more frequent imaging"
残存或新的影像学异常可能需要更频繁的影像学检查

Recommendations for stage IV not included.
不包括期的推荐。

"PET/CT or brain MRI is not routinely indicated"
常规要求PET/CT或脑部核磁共振造影”

NSCL-16

Locoregional recurrence post therapy: The following imaging was added to evaluate for disseminated disease: "Chest CT with contrast; Brain MRI with contrast; PET/CT."
治疗后局部复发:增加了下列影像以评估疾病播散:“胸部强化CT;脑强化磁共振成像;PET/CT。”

Distant metastasis; Bone metastasis; Recommendations reordered: "If risk of fracture, orthopedic stabilization + palliative external-beam RT."
远处转移;骨转移;重新整理了推荐:“如有骨折风险,骨科固定+姑息性外放疗。”

NSCL-17

Testing added for ROS1 and PD-L1.
增加了ROS1和PD-L1检测。

Squamous cell carcinoma: "Consider EGFR mutation testing and ALK testing especially in never smokers or small biopsy specimens, or mixed histology."
鳞状细胞癌:尤其是在从不吸烟者中或小活检标本或混合型组织学,考虑EGFR基因突变检测和ALK检测。”

Footnote "f" added: "If repeat biopsy is not feasible, plasma biopsy should be considered."
脚注“f”增加了:“如果重复活检不可行,应考虑血浆活检。”

Footnote "gg" modified: "The NCCN NSCLC Guidelines Panel strongly endorses advises broader molecular profiling..."
脚注“gg”修改为:“NCCN NSCLC指南小组强烈认同建议更广泛的分子分析…”

Footnote "kk" added: "PD-L1 expression levels of 50% are a positive test for first-line pembrolizumab therapy."
脚注“kk”增加了:“PD-L1表达水平≥50%为阳性检测结果,一线派姆单抗治疗。”

Footnote removed since the content was added to the algorithm: Consider ROS1 testing; if positive, may treat with crizotinib.
由于将内容加入到工作步骤中,因此删除了脚注:考虑ROS1检测;如果阳性,可以用克唑替尼治疗。

NSCL-18

EGFR mutation discovered during first-line chemotherapy: "Interrupt or complete planned chemotherapy, followed by..." changed to "Complete planned chemotherapy, including maintenance therapy, or interrupt, followed by..." (also applies to NSCL-20)
在一线化疗期间发现表皮生长因子受体突变:中断或完成计划的化疗,然后…”更改为“完成计划的化疗,包括维持治疗,或中断,然后…”(也适用于NSCL-20)

NSCL-19

"T790M testing" added with footnote "nn": "If tissue biopsy is not feasible, plasma biopsy should be considered."
“T790M检测”增加了脚注“nn”:“如果组织活检不可行,应考虑血浆活检。”

Asymptomatic: "Consider local therapy" added as a treatment option.
无症状:考虑局部治疗”增加为一个治疗选择。

Brain: "Osimertinib" added as a treatment option.
脑:奥希替尼 "增加为一个治疗选择。

Asymptomatic, brain lesions, or symptomatic and isolated systemic lesions: progression directed to treatment for multiple lesions.
脑部病变无症状或有症状及孤立的全身性病变:对于多发性病变,针对进展病变治疗。

Systemic isolated or multiple lesions:
全身孤立性或多发性病变:

T790M+ added with treatment recommendation of osimertinib.
T790M+增加了奥希替尼治疗推荐。

T790M- added with referral to first-line therapy options for adenocarcinoma, squamous cell carcinoma, or PD-L1 expression positive (50%).
对于腺癌、鳞状细胞癌或PD-L1表达阳性(≥50%)的T790M-者,增加了推荐转至一线治疗方案。

Footnote "pp" modified: "Osimertinib is approved an option for patients..."
脚注“pp”修改为:“奥希替尼是被批准…患者的一个选择”

Footnote "qq" added: "For rapid radiologic progression or threatened organ function, alternate therapy should be instituted."
脚注“qq”增加了:“对于影像学快速进展或威胁器官功能者,应开始替代治疗。”

                                                  

Updates in Version 1.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 4.2016 include:
非小细胞肺癌NCCN指南2017第1版较2016第4版的更新包括:

NSCL-21

Asymptomatic: "Consider local therapy" added as an option.
无症状:考虑局部治疗”增加为一个选择。

Brain and systemic isolated lesions: "continue ALK inhibitor" clarified as "continue crizotinib."
脑及全身孤立性病变:继续ALK抑制剂”澄清为“继续克唑替尼。”

Symptomatic systemic progression after local therapies and/or switching to ceritinib or alectinib changed to "progression."
在局部治疗和/或切换到色瑞替尼或阿雷替尼后症状性全身进展更改为“进展”。

NSCL-22

New page added for ROS1 rearrangement positive. Crizotinib is noted as a category 2A recommendation.
ROS1重排阳性添加了新页面。克唑替尼注明为2A类推荐。

NSCL-23

New page added for PD-L1 expression positive. Pembrolizumab is noted as a category 1 recommendation.
PD-L1表达阳性添加了新页面。派姆单抗注明为1类推荐。

NSCL-24

First-line therapy: Doublet chemotherapy and bevacizumab + chemotherapy changed to "Systemic therapy," as specific recommendations are noted on NSCL-F. Associated footnotes moved to NSCL-F.
一线治疗:二联化疗与贝伐单抗+化疗更改为“全身治疗”,作为具体推荐在NSCL-F中注明。相关脚注移至NSCL-F。

Subsequent Therapy; PS 3-4: Erlotinib, afatinib, gefitinib, crizotinib removed as treatment options. Associated footnotes removed.
后续治疗;PS 3-4:删除了厄洛替尼、阿法替尼、吉非替尼、克唑替尼的治疗选择。删除了相关脚注。

Footnote "v" added: "If pembrolizumab not previously given." (also applies to NSCL-25)
脚注“v”增加了:“如果未曾给予派姆单抗。”(也适用于NSCL-25)

Footnote "xx" added: "If not previously given" (also applies to NSCL-25)
脚注“xx”增加了:“如果未曾给予”(也适用于NSCL-25)

NSCL-A (1 of 5)

Pathologic Evaluation, bullet 3 modified: "The pathology diagnostic report should include the histologic classification in resection specimens or small biopsies as described by the WHO for carcinomas of the lung. The recently published classification of adenocarcinoma should be used for this tumor subtype in resection specimens and small biopsies."
病理学评价,第3项修改为:“在切除标本或小活检中病理诊断报告应包括WHO对肺恶性肿瘤描述的组织学分类。在切除标本和小活检中对于这一肿瘤亚型应该使用最近公布的腺癌分类。

Pathologic Evaluation, bullet 6 modified: "Limited use of IHC studies in small tissue samples is strongly recommended in samples that cannot be reliably classified on the basis of routine histology alone, thereby preserving critical tumor tissue for molecular studies, particularly in patients with advanced-stage disease. A limited panel of one squamous cell carcinoma marker (eg, p63, p40) and one adenocarcinoma marker (eg, TTF-1, napsin A) should suffice for most diagnostic problems."
病理学评价,第6项修改为:“在单独基于常规组织学不能可靠分类的标本中,强烈建议在小组织标本中限制使用免疫组化研究,从而保留关键的肿瘤组织用于分子研究,尤其是在晚期疾病患者中。对于大多数诊断问题,一个鳞状细胞癌标记 (如p63、p40) 和一个腺癌标记 (如甲状腺转录因子-1、新天冬氨酸蛋白酶A) 的有限组合应该足够。”

NSCL-A (3 of 5)

ALK; bullet 1: "alectinib" added to third sentence.
ALK;第1项:“阿雷替尼"添加到第三句。

ALK; bullet 2: "translocations" changed to "rearrangements".
ALK;第2项:“易位”改为“重排”。

ALK; bullet 3 modified: The current standard method for detecting ALK NSCLC is fluorescence in situ hybridization (FISH), although other methods are currently being evaluated, including polymerase chain reaction (PCR) and IHC.
ALK;第3项修改为:用于检测ALK NSCLC现行的标准方法是荧光原位杂交(FISH),尽管目前正在评估其他方法,包括聚合酶链反应(PCR)和免疫组化

NSCL-A (4 of 5)

New sections were added for ROS-1 and PD-L1.
ROS-1和PD-L1增加了新章节。

NSCL-A (5 of 5)

The following references were updated: 6, 7.
更新了以下参考资料:6, 7.

The following references added: 33–38.
增加了下列参考资料:33–38.

NSCL-B 1 of 4

Bullet 6 added: Patients who are active smokers should be provided counseling and smoking cessation support (NCCN Guidelines for Smoking Cessation). While active smokers have a mildly increased incidence of postoperative pulmonary complications, these should not be considered a prohibitive risk for surgery. Surgeons should not deny surgery to patients solely due to smoking status, as surgery provides the predominant opportunity for prolonged survival in patients with early-stage lung cancer."
6项增加了:应对主动吸烟者提供戒烟指导和教育(戒烟NCCN指南)。尽管主动吸烟者略微增加术后肺部并发症的发生率,但这不应视为手术的一个禁止性危险因素。外科医生不应该单纯由于吸烟状态拒绝为患者手术,因为对于延长早期肺癌患者的生存期,手术占主导地位。

                                                  

Updates in Version 1.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 4.2016 include:
非小细胞肺癌NCCN指南2017第1版较2016第4版的更新包括:

NSCL-C (1 of 10)

General Principles; bullet 5 modified: "Useful references include the ACR-ASTRO Practice Guidelines for Radiation Oncology Practice Parameters and Technical Standards..."
一般原则;第5项修改为:“有用的参考包括ACR-ASTRO放射肿瘤学实践指南实践参数与技术标准…

General Principles; bullet 4 modified with addition of sentence: In a prospective trial of definitive chemo/RT for stage III NSCLC (RTOG 0617), IMRT was associated with a nearly 60% decrease in high-grade radiation pneumonitis and similar survival and tumor control outcomes despite a higher proportion of stage IIIB and larger treatment volumes compared to 3D-CRT; as such, IMRT is preferred over 3D-CRT in this setting.
一般原则;第4项修改为另外一句话:在一项根治性化/放疗治疗Ⅲ期非小细胞肺癌的前瞻性试验(RTOG 0617)中,与三维适形放疗相比,尽管调强放疗组ⅢB期比例较高且治疗体积较大,但是,调强放疗降低高级别放射性肺炎近60%而生存和肿瘤控制结果相似;因此,在这种情况下,适形调强放疗优于三维适形放疗。

NSCL-C (3 of 10)

Node-Negative Early-Stage SABR; bullet 2 modified: "In the United States, only regimens of 5 fractions meet the arbitrary billing code definition of SBRT, but slightly more protracted regimens are appropriate as well. For centrally located tumors (defined as within 2 cm of the proximal bronchial tree), 4 to 10 fraction risk-adapted SABR regimens appear to be effective and safe, while 54 to 60 Gy in 3 fractions is unsafe and should be avoided. The dose for 5-fraction regimens is being studied prospectively in RTOG 0813. For centrally located tumors (defined variably as within 2 cm of the proximal bronchial tree and/or abutting mediastinal pleura) and even ultra-central tumors (defined as abutting the proximal bronchial tree), 4 to 10 fraction risk-adapted SABR regimens appear to be effective and safe, while 54 to 60 Gy in 3 fractions is unsafe and should be avoided. The maximum tolerated dose for 5-fraction regimens was studied prospectively in RTOG 0813, preliminarily demonstrating no high-grade toxicities at 50 Gy in 5 fractions while final results are pending."
早期淋巴结阴性的立体定向消融放疗;第2项修改为:“在美国,只有分割≤5的方案才能符合立体定向放疗任意计费代码的定义,但是,更持久的方案同样略微更合适。对于中心型肿瘤(定义为距近端支气管树2cm内),4-10分割风险调整的立体定向消融方案似乎是有效且安全的,而54-60Gy/3f是不安全的,应该避免。前瞻性RTOG 0813正在研究5分割剂量方案。对于中心型肿瘤(定义变为近端支气管树和/或邻接纵隔胸膜2cm内)甚至超中心型肿瘤(定义为紧邻支气管树),4-10分割风险调整的立体定向消融方案似乎是安全有效的,而54-60Gy/3f是不安全的,应该避免。RTOG 0813前瞻性研究了5分割方案的最大耐受剂量,初步显示50 Gy/5f没有高级别的毒性,等待最终结果。

NSCL-C (4 of 10)

Locally Advanced Stage/Conventionally Fractionated RT; bullet 2 modified: "Dose escalation in RT alone, sequential chemo/RT, or concurrent chemo/RT is associated with better survival in non-randomized comparisons. While doses of up to 74 Gy with concurrent chemotherapy can be delivered safely when normal tissue dose constraints are respected, results from RTOG 0617, comparing 60 versus 74 Gy with concurrent chemotherapy, found that 74 Gy does not improve overall survival, and might be potentially harmful. While optimal RT dose intensification remains a valid question, higher doses of 74 Gy are not currently recommended for routine use."
局部晚期/常规分割放疗;第2项修改为:“在非随机对照试验中,单纯增加放疗剂量、序贯化/放疗或同步化/放疗与更好的生存相关。当遵守正常组织剂量限制时,尽管剂量高达74Gy同步化疗可以安全实施,但是,RTOG 0617比较60Gy对74Gy同步化疗的结果,发现74Gy不能改善总生存,且可能有害。尽管最佳的放疗剂量强度仍然是一个悬而未决的问题,但是,目前不建议常规使用74Gy的更高剂量。

Advanced Stage/Palliative RT; last sentence modified: "When higher doses (>30 Gy) are warranted, technologies to reduce normal tissue irradiation (at least 3D-CRT and including IMRT or proton therapy as appropriate) should be used."
晚期/姑息性放疗;最后一句修改为:“当使用更高剂量(> 30 Gy)可行时,应该使用技术减少正常组织的照射(至少3D-CRT以及包括IMRT或酌情使用质子治疗)。”

NSCL-C (7 of 10)

"Please note - Tables 2–5 provide doses and constraints used commonly or in past clinical trials as useful references rather than specific recommendations." (also applies to NSCL-C 8 of 10)
请注意-表2-5提供的通常或在过去临床试验中的剂量和使用限制为有用的参考,而不是具体的推荐。”(也适用于NSCL-C 8/10)

NSCL-C (8 of 10)

Table 5: Footnote "*" added: "RTOG 0617 data suggest that even lower radiation doses to the heart than previously appreciated may be detrimental to survival after thoracic RT, and more stringent constraints may be appropriate."
5:脚注“*”增加了:“RTOG 0617数据表明,在胸部放疗后,即使比以前更低的心脏照射剂量也可能不利于生存,因此,更严格的限制可能是合适的。”

NSCL-C (9 of 10)

The following reference was added: 5, 17.
添加了以下参考文献:5, 17.

NSCL-C (10 of 10)

The following references were added: 52, 53, 55, 89.
添加了以下参考文献:52, 53, 55, 89.

                                                  

Updates in Version 1.2017 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 4.2016 include:
非小细胞肺癌NCCN指南2017第1版较2016第4版的更新包括:

NSCL-E

Concurrent Chemotherapy/RT Regimens
同步化/放疗方案

Bullet 4 modified: "Cisplatin 75 mg/m2 on day 1, pemetrexed 500 mg/m2 on day 1 every 21 days for 3 cycles; concurrent thoracic RT (nonsquamous) ± additional 4 cycles of pemetrexed 500 mg/m2
4项修改为:“顺铂75mg/㎡ d1,培美曲塞500mg/㎡ d1,每21天重复共3周期;同期胸部放疗(非鳞癌)±追加4周期的培美曲塞500mg/㎡

Bullet 5 modified: "Paclitaxel 45–50 mg/m2 weekly; carboplatin AUC 2, concurrent thoracic RT± additional 2 cycles of paclitaxel 200 mg/m2 and carboplatin AUC 6"
5项修改为:“紫杉醇45-50mg/㎡每周1次;卡铂AUC 2,同期胸部放疗±追加2周期紫杉醇200mg/㎡加卡铂AUC 6”

"Concurrent Chemotherapy/RT Followed by Chemotherapy" removed.
“同步化/放疗序贯化疗”被删除。

Cisplatin/etoposide with concurrent RT followed by cisplatin/etoposide removed.
删除了顺铂/依托泊苷同步放疗序贯顺铂/依托泊苷。

NSCL-F (1 of 4)

First-line therapy; bullet 4 modified: "Response assessment after 1-2 cycles, then every 2–4 cycles with CT of known sites with or without contrast or when clinically indicated."
一线治疗;第4项修改为:“1-2周期后疗效评估,然后每2-4周期1次或有临床指征时对已知部位强化或平扫CT检查。

Subsequent therapy; bullets removed for the following agents: nivolumab, pembrolizumab, docetaxel, pemetrexed, ramucirumab + docetaxel, erlotinib. This information is included in detail in the discussion.
后续治疗;删除了下列药物项目:尼鲁单抗、派姆单抗、多西他赛、培美曲塞、雷莫芦单抗+多西他赛、厄洛替尼。此信息在讨论中详述。

Subsequent therapy; bullet added: "Response assessment with CT of known sites with or without contrast every 6–12 weeks."
后续治疗;增加了项目:“每6-12周对已知部位强化或平扫CT检查评估疗效。”

NSCL-F (2 of 4)

First-line Systemic Therapy Options; Adenocarcinoma, Large cell, NSCLC NOS (PS 0-1); the following regimens removed: carboplatin/vinorelbine, cisplatin/vinorelbine.
一线全身治疗方案;腺癌、大细胞肺癌、非特指的NSCLC(PS 0-1);删除了下列方案:卡铂/长春瑞滨、顺铂/长春瑞滨。

First-line Systemic Therapy Options; Adenocarcinoma, Large cell, NSCLC NOS (PS 2); the following regimens removed: carboplatin/vinorelbine, etoposide, irinotecan, vinorelbine.
一线全身治疗方案;腺癌、大细胞肺癌、非特指的NSCLC(PS 2);删除了下列方案:卡铂/长春瑞滨、依托泊苷、伊立替康、长春瑞滨。

NSCL-F (3 of 4)

First-line Systemic Therapy Options; Squamous cell carcinoma (PS 0-1); the following regimens removed: carboplatin/etoposide, carboplatin/vinorelbine, cisplatin/gemcitabine/necitumumab, cisplatin/vinorelbine.
一线全身治疗方案;鳞状细胞癌(PS 0-1);删除了下列方案:卡铂/依托泊苷,卡铂/长春瑞滨、顺铂/吉西他滨/奈昔妥珠单抗、顺铂/长春瑞滨。

First-line Systemic Therapy Options; Squamous cell carcinoma (PS 2); the following regimens removed: carboplatin/vinorelbine, cisplatin/gemcitabine/necitumumab, etoposide, irinotecan, vinorelbine.
一线全身治疗方案;鳞状细胞癌(PS 2);删除了下列方案:卡铂/长春瑞滨、顺铂/吉西他滨/奈昔妥珠单抗、依托泊苷、伊立替康、长春瑞滨。

Footnote added: "Cisplatin/gemcitabine/necitumumab in the first-line setting and erlotinib or afatinib in the second-line setting are not used at NCCN institutions for these indications related to the efficacy  and safety of these agents compared to the efficacy and safety of other available agents."
增加了脚注:在NCCN机构中对于这些适应症,基于这些药物的疗效与安全性和其他可用药物的疗效与安全性相比较,顺铂/吉西他滨/奈昔妥珠单抗不用于一线、厄洛替尼或阿法替尼不用于二线。”

NSCL-H

Emerging Targeted Agents for Patients with Genetic Alterations
具有遗传学改变患者的新兴靶向药物

RET rearrangements: vandetanib added as an option.
RET重排:增加了凡德他尼作为一个选择。

ROS1 rearrangements were removed, as this information has been added to the algorithm.
删除了ROS1重排,因为该信息已增加到工作步骤中。

Footnotes references updated: 3, 4. Footnote references added: 9, 12.
更新了脚注参考资料:3, 4. 增加了脚注参考资料:9, 12.

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