2023 NCCN V1围手术期诊断、评估和治疗更新（全文）.docx

2023NCCNV1围手术期诊断、评估和治疗更新（全文）近日，非小细胞肺癌（NSCLC）NCCNV1版更新，此版更新（对比2022V6版）针对早期和局部晚期NSCLC的诊断、治疗等领域进行了大篇幅的更新。详情如下：DIAG-A1/3诊断评估原则NCCNNationalComprehensive Cancer Network*NCCNGuidelines Version 1.2023Non-Small Cell Lung CancerNCCNGmctofcneB IndexTable of Contents DiscussionPRINCIPLESOFDIAGNOSTICEVALUATIONPatientswithastrongclinicalsuspicion0mU90IAungcancer(basedonriskfactorsandradk>k>gicappearance)donotrequireabiopsybeforesurgery.Abiopsyaddstime,costs,andproceduralriskandmaynotbneededfortreatmentdecisions.，ApreoperativbiopsymaybeappropriateHanonJungcancerdiagnosisisstronglysuspctedthatcanbediagnosedbycorebiopsyorfiGdlaspiration(FNALttvbk>psymaybeusfulforpatintsvvtthclinicalstgIBorhigherwhomaybcandidatesforsystemictherapypriorto»AprooperativobiopsymayboappropriaterfanIntraoperativodiagnosisappearsdifficultorveryrisky?IfapreopratrvtissudiagnosishasnotboonobUind.thnanitrx>prativdiagnosis(i.wdgrsction.ndlbiopy)isnecessary*preoperativebronchoscopymayaobepreferredfortiuedia90sand/ormediatalstaging(endobroncaluttraound(EBUS).ITabronchoscopyhasnotbeenpreviouslypertornedtordiagnosisorstaging,bronchoscopyshouldbeperformedduringtheplannedsurgicalresection,ratherthanasaseparateprocedure.»Bronchoscopyisrequiredbeforesurgicalresection(NSCV2). AsparatbronchoscopymaynotbnMddfortreatmentdecisionsbforttimofsurgeryandaddstime,costs,andproceduralrisk. ApreoperativebronchoscopymaybeappropriateIfacentraltumorrequirespre-reMctionevaluationforbiopsy,surgicalplanning(g.potentialsgerMCtio),orproprativoairwaypropartion(g.coringoutanobstructivelsion). InvasivomediastinalstagingisrecommendedbeforesurgicalresectionformostpatientswithclinicalstageIorHlungcancer(NSCL2).FOfpatientsundergoingEBUSndoscopicultrasound(EUS)staging,thismostcommonlyshouldbasoparatproceduretoallowpathologicvaluation. PatientshavingmediastinoscopyshouldpreferablyUndergOInvasivemediastinalstaging(mediastinoscopy)astheinitialstpbeforetheplannedresection(duringthesameanestheticprocedure),ratherthanasaseparateprocedure. aahpro£6durdosiig.cost,drAAthotcr.idovo6d6.artand>oaanestnttcrliik. PreopQrativoinvasivemediastinalstagingmaybeappropriateforastrongCMniSlsuspicionofN2ocN3nodaldisoaMorwhenintraoperativecytologyorfrozensectionanalysisisnotavailable.修改第1点：临床强烈怀疑（由I或改为）IA期肺癌患者（基于危险因素和放射学表现）手术前不需要组织活检。新增第3行描述：术前活检可能对IB期或以上患者更有价值，这部分患者可能是术前全身治疗的适合人群。新增第2点：术前支气管镜检查也可能是组织诊断和/或纵隔分期（超声支气管镜EBUS）的首选。修改第3点：如果先前未通过支气管镜检查进行诊断或分期，（优选改为应）应在计划手术切除期间进行支气管镜检查，而不是单独进行。修改并移至第4点：对于大多数I或II期肺癌患者，建议在手术切除前进行侵入性纵隔分期。对于接受EBUS/超声内镜（EUS）进行分期的患者，通常应单独操作以进行评估。修改第1行描述：在计划切除之前，应首选侵入性纵隔分期（纵隔镜检查）作为初始选择（同一麻醉过程），不应单独进行。NSCL-1NSCLC的病理诊断、初始评估和临床分期NationalComprehensive Cancer Network,NCCNGuidelines Version 1.2023Non-Small Cell Lung CancerNCCNGUideIineSlndeX Tbe “ COnteOtS DtcwonPATHOLOGICINITIAL EVALUATION DIAGNOSISOF NSCLCNSCLCPathologyrovi。Wa H&P (include performance status weight lott)b CT ChMt and upper abdomen with contrast, including adrenals CBC1 platelets Chemistry profile Smoking cessation advice, counsoling, and pharmacotherapy > Uie the 5 A,s Frarmwortc Ask, Advise. Assess. Assist. Arrange http WWWhrq .goWdinlc/ tobacco5steps.htmIntograto 网HatiVO crc NCCN Guidelines forPalliativo CaroFor tools to aid in th。 optimal assessment and mnagOmnt of NSCLC In older adults, see the NCCN Guidelines for Older Adult OnCOIOqyClinicalstageSta9eIA. POriPhor.2 (T1abc. NO) Stago IB. POriPhorrd (T2, NO);Stage I. central4 (T1abc-T2a. NO); Stago U (T1abc-T2b, N1; T2b. NO);Stage IIB (T3. N0); Stage IIIA (T3t N1)Stage IIBr (T3 invasion, NO);Stage IIIAf (T4 extension. NO-1; T3t N1;T4, NO-1)Stage IIIAf (Tl-Z N2); Stage IIIB (T3t N2)Pretreatment副副 UMiQnlNSCkaPretrMtmwlEvaluation (NSCL-3)PwttwrtmentEvglMation (NSCL-S)PretreetmentEvaluation (NSCL)Multiplelung SnCorSPrtr<tmftEvaIMon(NSCLW)StageIIIBf (T1- N3); Stage IIIC (T3t N3)Stage IIIBf (T4. N2); Stog IIIC (T4, N3)Stage IVA (MIa)C (ptoural or pericardial effu¾k>)EyaluatiQn(NSGhJl)Evaluation(NSCL-13)PretreatrMntEflstlo (NSe3 3)StageIVA(M1b)cdPwttMttMfltEvgIuMion (NSCL-14)StageIVB (M1c)c disseminated metastasesSxfttfimicTbaaDy(NSCL 18)dBased on the CTcrfIhe cest Penpheral outer thrd of lung; Central« inner two PnnaDieSo(PathotoycReVMyW(NSCH).bEnhancedfra<tyOfgeratncasses5m0ntsmaypredictCompbcabonsbetterfo(Mmgtreatmentmodames.part>culartysurgeryApreferredfraMryassessmentsystemhasnotbeenestabitsbedstagA(priphral T1abc, No)。Tng悔 no< hMd G order o< Pbodty and dependent on dhH rcumtuoe, mntut>o<w pcoctss. and judtos uw Ot mourcsh Methods tor valudt>o rk>d mdasnoscopy. mdstmofny. EBUS. EUS. and CTumM trtopey. An EBUSTBNA ne9w Icx mfcgrncy S *9y (PET nd0f CT) pomv mdtMttnum should UMer90 sutaquntCCnnfmabOn1rrmm. & SUnKtf TTmcwy (NSCL-lneris kx IIKeilhood of POewve medaMa rymph nodes when these nodes are CT and PET rwgav tn PenPMrai tuxx> (outer trwd of IUng) <3 cm Thus. prHratwt PelhQk> mduMftnal vakMon is Opbonal m 9wm smngs kwsv meaMa* staging 0 recommended for central HxnortIn PatWntB who ar medcaty moperaNe, wh< mediasbna btcsy ts gncaity prrrd. tw nsks m s0cSd pbnU may outweigh 9w bntCIm9e-9uded Tierfnal bfat>n (KnA) therapy (eg. CryO(hera力.xrowav. r8dcfrQuncy) may b an OPOon for M*d PaXnU not rctvtg SABR of Ocfintive RT；PeS c< It-c-GuQM IbcfT8. Aiatcn T*cay NwL-j0 If mprtc therapy 9 COntem*ated *<houl tissue COnftrmaOon. muttk>80pary vaua*on M at Kast nduds EfVeno2 radtok>gy. <horac surgery, and w<cvntxxai PUlrnonCiogy ts rqured to (Mn t sa¼st and mort ont approach k CHoy. or Io Pfgde consensus tha( a MPey 椎 too Efcy <x difncuit and M the patent can proceed with ttwrapy without Crssue Connrma&on (UssMfk MAaMaI J ThOraC Onool 2019:14 5595 )脚注f修改：对于（删除'考虑IIB和III期患者）接受了一种以上治疗方式（手术、放疗和全身治疗由全身化疗改为全身治疗）的患者），应进行多学科评估。NSCL-2临床评估和治疗前评估INITIALTREATMENTClinicalassessmentpretreatmentevaluation Pulmonaryfunctiontests(PFTt)(ifnotpreviouslydone) Bronchoicopy(intraoprativPre(OrrOd) ConsiderpathologicmediastinallymphnodeOntMJ FDGPeiTCTscm(ifnotpreviouslydon)脚注i修改：当周围肿瘤（位于肺外三分之一）3cm处淋巴结CT和PET阴性时（删除：1cmandpurelynon-solidtumors）,纵隔淋巴结阳性的可能性较小。因此，在这些情况下，可选择治疗前的纵隔病理学评估。建议对中心肿瘤进行侵入性纵隔分期。新增脚注j：对于医学上无法手术的患者，虽然通常首选纵隔活检，但有些筛选患者的风险可能大于获益。NSCLC-3临床评估.治疗前评估CLINICALASSESSMENTPRETREATMENTEVALUATION9OprablEvaluateforPeriOPTtlve tropyPJurgIcMexploration and section1 mediastinal ymph node dssaction or systematic lymph node HmMng after proprativo BystOEic thrapy. if PUnnQd_ABuvtETrWvmfoiSCk4)Sta9IB (priphral T2a, NO)St>9 1(central T1bc-T2, NO)Stag Il (TlabC-2a> N1;T2b. NO) Stago IIB (T3, N0) Sta9 IIIA (T3. NI)don) Bronchoscopy Pathologicmdiastinal lymph node valuation11FOG PET/CT gn. (H not previously done) Brain MRI with contrast (Stag II. IIIA) (Stage IB optional)IBflnitis RT. NO preferably SABRmQIPositive mediastinal InodesDeftnitiveChefnoalCfiatio2Conskterduvt chemot h«capyp for highUk stages IB-IIBrDurvalufnab1category2A stage II),SurveiIUncetteCLdfi)T3.NO EMed to sin or saMlo odus9 Tsu>g t not UMed m ord，of 即Onty and ts dependent On CMCal rcumsUncs. GSMgonai rocMSM. and udboo<A us of resourcesh Methods tor vauat>n mcAxto e<a8nscopy. md8Mmotomy. BUS. EUS. and CT-uried bicpy. An EBUS*TBNA negative for malignancy G CWWCa(PET an6,0f CT) PaMrVe meOasbnixn tftodd Under90 subsequent me<astrx>tcopy prior Io surgical mectton* PET心T pdormed3lbaM to knees or wt>o body Positive PET/CT scan rdgs for dsum disease need pathologic Of OChef raddogtc co1iabon If PET/CT scan is p<Mnr in th mdstrum. lymph node status nods PamOIOgiC ConArmBtaonI PrwwirAM r Ci>A PrVKof of Ration Thcaoy INSCL LoIf Om(NnC therapy is ContempAated IMthOUt tasue Corlirmalton. mu!MscIlnary va>uat) that at least includes HerWlgnal rad*o<ogjf. oraoc surgery, and ntcvtMxal pulmonology ts rqurd k> dtrmno the sast and most Mkxnt appcoac tor t×M>*y. or Io pcov) COnSnWS that a hcpy «too m«y or <MAcult and Ihat ttw ptnt can CMd with Iherapy w4hol ta confirmat> (USMW犷 MA. < J Tcrac Oncol 2019.14 583-595 )Q Perioperative Sytefc Therapy (NSCL-El.Qtf ZRl P no俯件呻f T ” Mad加中(yv叫lung neuroedocnno tumor* (xcgng weHMlefentatd nuroendocne tumofs), vascular nvgo. Qdge resection, visceral Pieural involvement. «nd unknown *ymp node status (Nx) Ths UaOrS ndepdny may not be an ndbc0bon and my X constdrd wn dto<nMw>g tralmfM wt adjuvant治疗前评估新增：围手术期治疗的评估（适用于NSCL-5、NSCL-8）o初始治疗对于纵隔淋巴结阴性患者可手术患者的治疗修改：若计划手术，手术探查和切除+纵隔淋巴结清扫术或术前全身治疗后系统性淋巴结取样（适用于NSCL-7、NSCL-9sNSCL-10）脚注移至NSCL-E:手术评估后，可能接受辅助化疗的患者可接受全身诱导治疗作为替代选择（适用于NSCL-7、NSCL-9和NSCL-10）o脚注修改并移至NSCL-E:检测PD-L1状态、EGFR突变和ALK重排（IB-InA期）（删除：使用手术组织或活检检测PD-L1状态II-HIA期）（适用于NSCL-6、NSCL-7）修改脚注r：高危因素可能包括低分化肿瘤（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）、血管浸润、楔形切除、（删除：肿瘤4cm）、脏层胸膜受累和淋巴结状态不明（Nx）。当决定进行辅助化疗时单独因素可能不能作为适应证,但应予以考虑（NSCL-4A）。删除脚注：不推荐度伐利尤单抗用于根治性手术切除后的患者（适用于NSCL-6、NSCL-7xNSCL-9.NScL-12、NSCL-13）NSCL-4术中发现.辅助治疗FINDINGSAT SURGERYADJUVANTTREATMENTStageIA (T1abc, NO) <Marginsnegative (R0)tMarginsPQSIUVo (R1. R2)tStageIB (T21. NO!ObserveMarglnSnegative (R0)«AReT。7史吧竺竺吧en正还UlllfWIUIIIUvr CKJfr UAUII 13 UtfltflIUII Ul UXl IReresection (preferred) ± Chemotherapyp vMargins positive (R1, R2)t » or I RTm!Observe ObserveIRorMoction(profod)I RTm (category 2B)StageIIA (T2b. NO)Marginsngativo (R0)tPhemOtheraPyPfor highrisk PatientS' followed by atezolizuloFs7mrTm!PEOTonTT8TTIoroFG577TTS58!TPrIiZUmabP，TlMarginspositive (R1. R2)tIReresection(prefeed) ± chemotherapy OrI RTm ± ChomothorapyPSurveillance(NSC36)StageIIB (TIabe-T2a, NI)Stage IIB (T3, NO; T2b. N1)Marginsnegative (RO)1yR1tMarginsposttlvo('r2iChemotberapyP(CategOry 1) followed by atez。UZUmaWw> loslrn8TmB78TonylTeoorexCTzLo5oK/ I Reresection chemotherapy!OrChemoradiationrn (sequentialp or concurrent*) IReresection Chemotherapyp I or.Concurrent chmoradiationfns IStagoIIlA I x (TI-2,N2;T3,N1) KStage IIIB (T3, N2) I Marginsnegative (R0)tFtnotes,NSCL-4AMarginspositive <Iosimertinibp(EGFR exon 19 doletion or exon 21 L858R)u orI Soquontlal Chomothorapyp and consider RTmChQmoradiationm (squ«ntialp or concurront9)R2t. Concurrent Chemoradiationm sNot:Alrco<nM<dattonrCirtegocy2AunlsocrwtMlctdCHfuCAlTrUte:NCCNbivMtNMttetmm>9mento<anypetntwttoncftnclin½Altrti.PatlicipMlontoCHnU«1trialsitpcillyne0ur9d.辅助治疗文字修改：IB期（T2a,NO）:对高危患者进行化疗（删除and）序贯奥希替尼（EGFR19外显子缺失或21外显子L858R突变）。IIA期（T2b,NO）:对高危患者进行化疗（删除and）序贯阿替利珠单抗或奥希替尼（EGFR19外显子缺失或21外显子L858R突变）。IIB期（TIabC-T2a、N1;T3、NO;T2b、N1）,IIIA期（Tl-2、N2;T3、N1）,IIIB期（T3、N2）:化疗（1类）（删除and"）序贯阿替利珠单抗或奥希替尼（EGFR19外显子缺失或21外显子L858R突变）oNSCL-9纵隔活检结果、初始治疗MediastinalbiopsyfindingsINITIALTREATMENTADJUVANTTREATMENTT1-3,NO-1 (Including T3 with multiple nodules in same lobe)ResectablelModicallyinoperableSurgicalresection1 ÷ mediastinal lymph node dissection or systematic lymph node sampling after preoperative systemic therapy, if plannedTroatmont according to clinical stage (NSCL-3)Definitiveconcurrent Chemoradiationmi (category 1)T1-2,T3 (other than invasive), N2 nodes positive, MOInductionsystemicIherapyPy ± RNoapparent progrossionDurvalumabs(category 1)'Surgeryl Consider RTmHNSCL4SUryfiiHanCdlNSCLJ)SUrVeiIIanCe(NSCL 16)T3(Invasion), N2 nodos positive, MODefinitiveconcurrentChemoradlationm'9<Local » RTm (if feasible) ± chemotherapyITreatment for MetaEaSi5Systemic - limited SNeS (NSCL-14) orIdiStent di¾w (NSC37)Durvalumab1(category 1)对于T1-2zT3（侵入性除外），N2淋巴结阳性，MO患者，初始治疗方案之一为：应给予诱导全身治疗（诱导化疗改为诱导全身治疗）±RToNSCL-10临床表现、辅助治疗ADJUVANTTREATMENTCLINICALPRESENTATIONSoparatoPUlmOE nodule(s)l same l( (T3, NO-1), or ipsilateral nonprt lobe (T4, NO-1)Surgerylafter PreOPOratiVC systemic therapy, if plannedStagoIVA (NO. Mla)ITrMt as two primary lung Contralateral lung p tumors if both curable, (solitary nodule) I IEvaIUation (NSC3)Suspectedmultiple lung cancers (based on the presence of biopsy- proven synchronous lesions or history of lung cancer产4 ChestCT with contrast FDG PETZCT sca not previously de Brain MRI with contrastNodisease OUtsicfo of chestnsnegativeMargins/ positive Chemotherapy(category 1) orSequential chemotherapyp÷ RTfnChemoradiationm (sequential or ConCUrrCntt)R2t. Concurrent ChemoradiationmsDiseaseoutside of chestSurveillanceiuMlMC0Chemotherapypfollowed by atezolizumabp-w or OSimertinibpuSur5irM(NSCL 16)SUrVeiHanCe INSCLdfijSyttsmlcTherapy for Mt*ttic DIm (NSCL18)PathologicI / mediastinal lymph nod。 Ovalustlonh INO-1* Initial TreatimnUNSCLdI)“KKtetastafc Disease (NSCL-18)hMethods for evaluation include mediastinoscopy, mediastinotomy. EBUS. EUS. and CTalded biopsy An EBUS-TBNa negative for malignancy in a cn>caNy (PET and/or CT) PoSltrVe mediastinum should undergo subsequent mediastinoscopy PdOr to surgical resectionh PET/CT Ped(Xmed skull base to knees or Wh* body Powtive PET/CT son findings foe distant disease need pathologic or other radiologic confirmation If PET/CT scan is positive in the mediastinum, lymph node status needs PathoIOgBC confirmationIPnnQPteS Of Surgtcal Thefapy (NSCL向一 m PngDteS o< Radiauon TberaoV (NSCLC). q If MRI is no< possible. CT ot bead with contrast P PertOOeratrVe Sytem Ther¾> (NSCLwLJrreniChemOradlatIoH CeQme5 (CSCLF).1RO residual tumor. R1 = microscopic residual tumor. R2 macroscopic fetdual tumor, For patients wt EGWexofydebon or exon 21 L85 who received previous adjuvant chemotherapy or are nelig<>l to receive platinum-based ChemOtheQPywF<x patients with P0L1 1% and ne9atrve kx EGFR exon 19 deletion Of ex 21 L858R mutations or ALK Teafrangement5 who rece<ved previous ad)uvantce types (egquamous cell cardnoma. adeoca<noma) are usually different primary tumors. This analysis may be limited by small biopsy samples HoWeVef. lesions of the same cell type are not necessanly metastases Single contralateral lung nodules wt CMCaL radolog:. or pathologic features suggestive of a synchronous Pnmary lung cancer (eg. IOng disease-free survival, ground glass components. <M!cen< histologic Chdractenslics) that are amenable to local therapy should be considered as probable separate pmary cancers and eligible for local therapy (NSCL-11). Multiple studies suggest that next-9enerat>0n sequeng (NGS) testing vwth broad gene cove