1、NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines)Pancreatic AdenocarcinomaVersion 2.2016NCCN.orgVersion 2.2016, 08/16/16 National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the expres
2、s written permission of NCCN. ContinueNCCN Guidelines for Patients available at www.nccn.org/NCCN Guidelines IndexTable of ContentsDiscussionVersion 2.2016, 08/16/16 National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelinesand this illustration may not be reproduced
3、in any form without the express written permission of NCCN. NCCN Guidelines Version 2.2016 Panel Members Pancreatic Adenocarcinoma*Margaret A. Tempero, MD/Chair UCSF Helen Diller Family Comprehensive Cancer CenterMokenge P. Malafa, MD/Vice Chair Moffitt Cancer CenterMahmoud Al-Hawary, MD University
4、of MichiganComprehensive Cancer CenterHoracio Asbun, MD Mayo Clinic Cancer CenterStephen W. Behrman, MD The University of Tennessee Health Science CenterAl B. Benson III, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern UniversityJordan D. Berlin, MD Vanderbilt-Ingram Cancer CenterChar
5、les Cha, MD Yale Cancer Center/Smilow Cancer HospitalE. Gabriela Chiorean, MD Fred Hutchinson Cancer Research Center/Seattle Cancer Care AllianceVincent Chung, MD City of Hope Comprehensive Cancer CenterSteven J. Cohen, MD Fox Chase Cancer CenterBrian Czito, MD Duke Cancer InstituteMary Dillhoff, MD
6、 The Ohio State University ComprehensiveCancer Center - James Cancer Hospital and Solove Research InstituteMary Feng, MD University of MichiganComprehensive Cancer CenterCristina R. Ferrone, MD Massachusetts General Hospital Cancer CenterJeffrey Hardacre, MD Case Comprehensive Cancer Center/Universi
7、ty Hospitals Seidman Cancer Center andCleveland Clinic Taussig Cancer InstituteWilliam G. Hawkins, MD Siteman Cancer Center at Barnes-Jewish Hospitaland Washington University School of MedicineJoseph Herman, MD, MSc The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins John P. Hoffman, MD F
8、ox Chase Cancer CenterAndrew H. Ko, MD UCSF Helen Diller Family Comprehensive Cancer CenterSrinadh Komanduri, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern UniversityAlbert Koong, MD, PhD Stanford Cancer InstituteAndrew M. Lowy, MD UC San Diego Moores Cancer CenterWen Wee Ma, MD Ros
9、well Park Cancer InstituteCassadie Moravek Pancreatic Cancer Action NetworkSean J. Mulvihill, MD Huntsman Cancer Institute at the University of UtahEric K. Nakakura, MD UCSF Helen Diller FamilyComprehensive Cancer CenterEileen M. OReilly, MD Memorial Sloan Kettering Cancer CenterJorge Obando, MD Duk
10、e Cancer Institute Sushanth Reddy, MD University of Alabama at BirminghamComprehensive Cancer CenterSarah Thayer, MD Fred & Pamela Buffett Cancer CenterColin D. Weekes, MD, PhD University of Colorado Cancer CenterRobert A. Wolff, MD The University of Texas MD Anderson Cancer CenterBrian M. Wolpin, M
11、D, MPH Dana-Farber/Brigham and Womens Cancer CenterNCCNJennifer BurnsSusan Darlow, PhDNCCN Guidelines Panel Disclosures Gastroenterology Surgery/Surgical oncology Radiotherapy/Radiation oncology Medical oncology Hematology/Hematology oncology Internal medicine Interventional radiology Pathology Pati
12、ent advocacy* Discussion Writing Committee MemberContinuePrinted by Maria Chen on 8/18/2016 1:22:44 AM. For personal use only. Not approved for distribution. Copyright 2016 National Comprehensive Cancer Network, Inc., All Rights RClinical Trials: NCCN believes that the best management for any patien
13、t with cancer is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN Member Institutions, click here: nccn.org/clinical_trials/physician.html.NCCN Categories of Evidence and Consensus: All recommendations are category 2A unless other
14、wise specified. See NCCN Categories of Evidence and Consensus.NCCN Pancreatic Adenocarcinoma Panel MembersSummary of Guidelines UpdatesIntroductionClinical Suspicion of Pancreatic Cancer/Evidence of Dilated Pancreatic and/or Bile Duct (PANC-1)No Metastatic Disease on Physical Exam and by Imaging (PA
15、NC-2)Resectable, Workup, Treatment (PANC-3)Borderline Resectable, No Metastases (PANC-4)Postoperative Adjuvant Treatment (PANC-6)Locally Advanced, Unresectable (PANC-7)Metastatic Disease (PANC-9)Recurrence After Resection (PANC-10)Principles of Diagnosis, Imaging, and Staging (PANC-A) Pancreatic Can
16、cer Radiology Reporting Template (PANC-A, 5 of 8)Criteria Defining Resectability Status (PANC-B)Principles of Surgical Technique (PANC-C)Pathologic Analysis: Specimen Orientation, Histologic Sections, and Reporting (PANC-D)Principles of Palliation and Supportive Care (PANC-E)Principles of Radiation
17、Therapy (PANC-F)Principles of Chemotherapy (PANC-G)American Joint Committee on Cancer (AJCC) TNM Staging of Pancreatic Cancer (2010) (ST-1)The NCCN Guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician s
18、eeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patients care or treatment. The National Comprehensive Cancer Network (NCCN) makes no representations or warranties of any kind regardin
19、g their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without
20、the express written permission of NCCN. 2016.Version 2.2016, 08/16/16 National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelinesand this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Guidelines Version 2.2016 Table
21、 of ContentsPancreatic AdenocarcinomaNCCN Guidelines IndexTable of ContentsDiscussionNCCN Guidelines for Patients available at www.nccn.org/patients.Printed by Maria Chen on 8/18/2016 1:22:44 AM. For personal use only. Not approved for distribution. Copyright 2016 National Comprehensive Cancer Netwo
22、rk, Inc., All Rights RVersion 2.2016, 08/16/16 National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelinesand this illustration may not be reproduced in any form without the express written permission of NCCN. UPDATESNCCN Guidelines Version 2.2016 Updates Pancreatic Ad
23、enocarcinomaUpdates in Version 1.2016 of the NCCN Guidelines for Pancreatic Adenocarcinoma from Version 2.2015 include:Updates in Version 2.2016 of the NCCN Guidelines for Pancreatic Adenocarcinoma from Version 1.2016 include:PANC-1 Under workup, “Obtain family history” has been added with the follo
24、wing footnote: “If pancreatic cancer is diagnosed, consider referral for genetic counseling for patients who are young or who have a family history of cancer.” “Chest imaging” has been changed to “Chest CT (preferred) or x-ray.”PANC-3 Footnote “i” has been revised: “For patients with tumors that are
25、 clearly resectable and who do not have high-risk features, neoadjuvant therapy is only recommended in a clinical trial. For patients with high-risk features (ie, very highly elevated CA 19-9, large primary tumors, large regional lymph nodes, excessive weight loss, extreme pain), neoadjuvant chemoth
26、erapy may be considered, which requires biopsy confirmation of adenocarcinoma (see PANC-4). Acceptable neoadjuvant regimens include FOLFIRINOX or gemcitabine + albumin-bound paclitaxel. Subsequent chemoradiation is sometimes included. Most NCCN Member Institutions prefer neoadjuvant therapy at a hig
27、h-volume center.” In selected patients who appear technically resectable but have poor prognostic features (ie, very highly elevated CA 19-9, large primary tumors, large regional lymph nodes, excessive weight loss, or extreme pain) consider neoadjuvant therapy (clinical trial preferred), which requi
28、res biopsy confirmation of adenocarcinoma (see PANC-4). For patients with biliary obstruction, durable biliary decompression is required.PANC-4 “Baseline CA 19-9” has been added to the initial workup, and “Post-treatment CA 19-9” has been added to the workup following neoadjuvant therapy. After neoa
29、djuvant therapy, the first bullet has been revised and split into two bullets: “Pancreatic protocol CT or MRI (abdomen and pelvis); and, Chest imaging CT (preferred) or x-ray.” If unresectable at surgery, the options for patients with jaundice have been revised: “Self-expanding metal stent or Consid
30、er surgical biliary bypass gastrojejunostomy.”PANC-5 Former algorithm for “Borderline Resectable Disease, Planned Resection” has been removed. New algorithm for “Borderline Resectable, No Metastases, Cancer Not Confirmed” has been added.PANC-6 The second adjuvant therapy option has been revised: “Sy
31、stemic gemcitabine or 5-FU/leucovorin or continuous infusion 5-FU before or and after chemoradiation.” The frequency of surveillance after two years has been changed from “annually” to “every 612 mo.” The following has been added to footnote “o”: “The adjuvant therapy options are dependent on the re
32、sponse to neoadjuvant therapy and other clinical considerations.”PANC-8 The second-line therapy options have been separated into recommendations for those “previously treated with gemcitabine-based therapy” or “previously treated with fluoropyrimidine-based therapy.” (Also on PANC-9) Footnote “v” ha
33、s been added: “FOLFIRINOX should be limited to those with ECOG 0-1. Gemcitabine + albumin-bound paclitaxel is reasonable for patients with KPS 70.” (Also on PANC-9)PANC-9 The following second-line therapy option has been added for patients with metastatic disease previously treated with gemcitabine-
34、based therapy: “5-FU + leucovorin + liposomal irinotecan (category 1).” (Also on PANC-G, 1 of 3)Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical tr
35、ials is especially encouraged.NCCN Guidelines IndexTable of ContentsDiscussionContinued on next pageMS-1 The Discussion section has been updated to reflect the changes in the algorithm.Printed by Maria Chen on 8/18/2016 1:22:44 AM. For personal use only. Not approved for distribution. Copyright 2016
36、 National Comprehensive Cancer Network, Inc., All Rights RVersion 2.2016, 08/16/16 National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelinesand this illustration may not be reproduced in any form without the express written permission of NCCN. UPDATESNCCN Guidelines
37、Version 2.2016 Updates Pancreatic AdenocarcinomaUpdates in Version 1.2016 of the NCCN Guidelines for Pancreatic Adenocarcinoma from Version 2.2015 include:PANC-A The following reference has been added: Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology reporting te
38、mplate: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology 2014 Jan; 270(1):248-260. (Also on PANC-B)PANC-A (2 of 8) The following has been added to #8: “Intraoperative ultrasound can be used as a diagnostic adjunct during staging laparoscopy
39、.” #10 has been added: “For locally advanced/metastatic disease, the panel recommends serial CT (routine single portal venous phase or dedicated pancreatic protocol if surgery is still contemplated) or MRI of known sites of disease to determine therapeutic benefit. It is recognized that patients can
40、 demonstrate progressive disease clinically without objective radiologic evidence of disease progression.”PANC-A (5 of 8) The Pancreatic Cancer Radiology Reporting Template has been included and adapted from: Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology repor
41、ting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology 2014 Jan; 270(1):248-260.PANC-C Under distal pancreatectomy, the following bullet has been removed: “Utilization of radical resection is associated with an increase in blood lo
42、ss, transfusion requirements, operating time, length of stay, and whether morbidity/mortality remains acceptable.”PANC-D (2 of 4) Under histologic sectioning, the last sub-bullet has been revised: “Consider frozen section analysis of the pancreatic neck and bile duct is recommended.”PANC-E The third
43、 bullet has been revised: “Severe tumor-associated abdominal pain that is unresponsive to optimal, around-the-clock narcotic administration, or if patient experiences undesirable narcotic associated side effects (See NCCN Guidelines for Adult Cancer Pain).” Footnote “c” has been added: “A randomized
44、 trial examing the effects of prophylactic low-molecular-weight heparin showed a decrease in VTE but no effect on survival. (Pelzer U, Opitz B, Deutschinoff G, et al. Efficacy of prophylactic lowmolecular weight heparin for ambulatory patients with advanced pancreatic cancer: Outcomes from the CONKO
45、-004 trial. J Clin Oncol 2015;33:20282034.)”PANC-F (2 of 6) The following adjuvant therapy option has been removed: “Upfront fluoropyrimidine- (CI 5-FU or capecitabine) or gemcitabine-based chemoradiation followed by maintenance 5-FU or gemcitabine.” Footnote “b” has been added: “Adjuvant options li
46、sted apply only to patients who did not receive prior neoadjuvant therapy. For those who received prior neoadjuvant therapy, the adjuvant therapy options are dependent on the response to neoadjuvant therapy and other clinical considerations.”PANC-G (1 of 3) After gemcitabine + cisplatin, the text in
47、 parenthesis has been revised: “Can be considered as an alternative to FOLFIRINOX especially for in patients with possible hereditary cancers involving DNA repair mutations.PANC-G (2 of 3) The following bullet has been added: “Recommended adjuvant therapy options apply to patients who did not receiv
48、e prior neoadjuvant therapy. For those who received prior neoadjuvant therapy, the adjuvant therapy options are dependent on the response to neoadjuvant therapy and other clinical considerations.”Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that
49、 the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.NCCN Guidelines IndexTable of ContentsDiscussionPrinted by Maria Chen on 8/18/2016 1:22:44 AM. For personal use only. Not approved for distribution. Copyright 2016 Nation
50、al Comprehensive Cancer Network, Inc., All Rights RNCCN Guidelines Version 2.2016Pancreatic AdenocarcinomaVersion 2.2016, 08/16/16 National Comprehensive Cancer Network, Inc. 2016, All rights reserved. The NCCN Guidelinesand this illustration may not be reproduced in any form without the express wri
