（2024.V1）NCCN临床实践指南：非小细胞肺癌.pdf

Version 1.2024,12/21/23 2023 National Comprehensive Cancer Network(NCCN),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.NCCN Clinical Practice Guidelines in Oncology(NCCN Guidelines)Non-Small Cell Lung CancerVersion 1.2024 December 21,2023ContinueNCCN.orgNCCN Guidelines for Patients available at www.nccn.org/patientsNCCN 授权医脉通提供NCCN指南全文下载。h n z m b p 于2023/12/24,17:42在医脉通平台下载，仅供个人使用，严禁分发。2022 美国国家综合癌症网络版权所有。NCCN Guidelines Version 1.2024Non-Small Cell Lung CancerVersion 1.2024,12/21/23 2023 National Comprehensive Cancer Network(NCCN),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.NCCN Guidelines IndexTable of ContentsDiscussionContinueNCCN Guidelines Panel DisclosuresNCCNKristina Gregory,RN,MSNLisa Hang,PhD Hematology/Hematology oncology Internal medicine Medical oncology Pathology Patient advocacy Radiation oncology/Radiotherapy Surgery/Surgical oncology Diagnostic/Interventional radiology Pulmonary medicine*Discussion Section Writing CommitteeDavid S.Ettinger,MD/Chair The Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsDouglas E.Wood,MD/Vice Chair Fred Hutchinson Cancer CenterGregory J.Riely,MD,PhD/Lead Memorial Sloan Kettering Cancer CenterDara L.Aisner,MD,PhD University of Colorado Cancer CenterWallace Akerley,MD Huntsman Cancer Institute at the University of UtahJessica R.Bauman,MD Fox Chase Cancer CenterAnkit Bharat,MD Robert H.Lurie Comprehensive Cancer Center of Northwestern UniversityDebora S.Bruno,MD,MS Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer InstituteJoe Y.Chang,MD,PhD The University of Texas MD Anderson Cancer CenterLucian R.Chirieac,MD Dana-Farber/Brigham and Womens Cancer CenterMalcolm DeCamp,MD University of Wisconsin Carbone Cancer CenterAakash P.Desai,MD ONeal Comprehensive Cancer Center at UABThomas J.Dilling,MD,MS Moffitt Cancer CenterJonathan Dowell,MD UT Southwestern Simmons Comprehensive Cancer CenterGregory A.Durm,MD,MS Indiana University Melvin and Bren Simon Comprehensive Cancer CenterScott Gettinger,MD Yale Cancer Center/Smilow Cancer HospitalTravis E.Grotz,MD Mayo Clinic Comprehensive Cancer CenterMatthew A.Gubens,MD,MS UCSF Helen Diller Family Comprehensive Cancer CenterRudy P.Lackner,MD Fred&Pamela Buffett Cancer CenterMichael Lanuti,MD Mass General Cancer CenterJules Lin,MD University of Michigan Rogel Cancer CenterBilly W.Loo,Jr.,MD,PhD Stanford Cancer Institute Christine M.Lovly,MD,PhD Vanderbilt-Ingram Cancer CenterFabien Maldonado,MD Vanderbilt-Ingram Cancer CenterErminia Massarelli,MD,PhD,MS City of Hope National Medical CenterDaniel Morgensztern,MD Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of MedicineTrey C.Mullikin,MD Duke Cancer InstituteThomas Ng,MD The University of Tennessee Health Science CenterGregory A.Otterson,MD The Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research InstituteDawn Owen,MD,PhD Mayo Clinic Comprehensive Cancer CenterSandip P.Patel,MD UC San Diego Moores Cancer CenterTejas Patil,MD University of Colorado Cancer CenterPatricio M.Polanco,MD UT Southwestern Simmons Comprehensive Cancer CenterJonathan Riess,MD UC Davis Comprehensive Cancer CenterTheresa A.Shapiro,MD,PhD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Aditi P.Singh,MD Abramson Cancer Center at the University of PennsylvaniaJames Stevenson,MD Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer InstituteAlda Tam,MD The University of Texas MD Anderson Cancer CenterTawee Tanvetyanon,MD,MPH Moffitt Cancer CenterJane Yanagawa,MD UCLA Jonsson Comprehensive Cancer CenterStephen C.Yang,MD The Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsEdwin Yau,MD,PhD Roswell Park Comprehensive Cancer CenterNCCN 授权医脉通提供NCCN指南全文下载。h n z m b p 于2023/12/24,17:42在医脉通平台下载，仅供个人使用，严禁分发。2022 美国国家综合癌症网络版权所有。NCCN Guidelines Version 1.2024Non-Small Cell Lung CancerVersion 1.2024,12/21/23 2023 National Comprehensive Cancer Network(NCCN),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.NCCN Guidelines IndexTable of ContentsDiscussionClinical Trials:NCCN believes that the best management for any patient with cancer is in a clinical trial.Participation in clinical trials is especially encouraged.Find an NCCN Member Institution:https:/www.nccn.org/home/member-institutions.NCCN Categories of Evidence and Consensus:All recommendations are category 2A unless otherwise indicated.See NCCN Categories of Evidence and Consensus.NCCN Categories of Preference:All recommendations are considered appropriate.See NCCN Categories of Preference.NCCN Non-Small Cell Lung Cancer Panel MembersSummary of Guidelines UpdatesLung Cancer Prevention and Screening(PREV-1)Clinical Presentation and Risk Assessment(DIAG-1)Initial Evaluation and Clinical Stage(NSCL-1)Evaluation and Treatment:Stage IA(T1abc,N0)(NSCL-2)Stage IB(peripheral T2a,N0),Stage I(central T1abcT2a,N0),Stage II(T1abc2ab,N1;T2b,N0),Stage IIB(T3,N0),and Stage IIIA(T3,N1)(NSCL-3)Stage IIB(T3 invasion,N0)and Stage IIIA(T4 extension,N01;T3,N1;T4,N01)(NSCL-5)Stage IIIA(T12,N2);Stage IIIB(T3,N2);Separate Pulmonary Nodule(s)(Stage IIB,IIIA,IV)(NSCL-8)Multiple Lung Cancers(N01)(NSCL-12)Stage IIIB(T12,N3);Stage IIIC(T3,N3)(NSCL-13)Stage IIIB(T4,N2);Stage IIIC(T4,N3);Stage IVA,M1a:Pleural or Pericardial Effusion(NSCL-14)Stage IVA,M1b(NSCL-15)Surveillance After Completion of Definitive Therapy(NSCL-17)Therapy for Recurrence and Metastasis(NSCL-18)Systemic Therapy for Advanced or Metastatic Disease(NSCL-19)Principles of Pathologic Review(NSCL-A)Principles of Surgical Therapy(NSCL-B)Principles of Radiation Therapy(NSCL-C)Principles of Image-Guided Thermal Ablation Therapy(NSCL-D)Perioperative Systemic Therapy(NSCL-E)Concurrent Chemoradiation Regimens(NSCL-F)Cancer Survivorship Care(NSCL-G)Principles of Molecular and Biomarker Analysis(NSCL-H)Emerging Biomarkers to Identify Novel Therapies for Patients with Metastatic NSCLC(NSCL-I)Molecular and Biomarker-Directed Therapy for Advanced or Metastatic Disease(NSCL-J)Systemic Therapy for Advanced or Metastatic Disease(NSCL-K)The NCCN 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 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 regarding 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 the express written permission of NCCN.2023.Staging(ST-1)Abbreviations(ABBR-1)NCCN 授权医脉通提供NCCN指南全文下载。h n z m b p 于2023/12/24,17:42在医脉通平台下载，仅供个人使用，严禁分发。2022 美国国家综合癌症网络版权所有。NCCN Guidelines Version 1.2024Non-Small Cell Lung CancerVersion 1.2024,12/21/23 2023 National Comprehensive Cancer Network(NCCN),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.NCCN Guidelines IndexTable of ContentsDiscussionUPDATESContinuedDIAG-2 Footnote i modifiedFirst sentence modified:FDG-PET/CT performed skull base to mid-thigh knees or whole body.(also applies to DIAG-3,footnote k on NSCL-3,NSCL-5,NSCL-8,NSCL-11,NSCL-13 through NSCL-15)Third sentence modified:A false-positive FDG-PET/CT scan finding can be caused by infection or inflammation,including absence of lung cancer with localized infection,presence of lung cancer with associated(eg,postobstructive)infection,and presence of lung cancer with related inflammation(eg,nodal,parenchymal,pleural).(also applies to DIAG-3)Last sentence added:If a false-negative FDG-PET/CT is due to low tumor avidity and/or low cellularity is suspected,follow-up CT or biopsy are reasonable options.(also applies to DIAG-3)Footnote j modified:If empiric therapy is contemplated without tissue confirmationPrior to treatment,multidisciplinary evaluation that at least includes treating physicians and specialists in obtaining tissue diagnosis(thoracic surgery,interventional pulmonology,and interventional radiology)is required to determine the safest and most efficient approach for biopsy,or to provide consensus that a biopsy is too risky or difficult,that a clinical diagnosis of lung cancer is appropriate,and that treatment is warranted and that the patient can proceed with therapy without tissue confirmation.(IJsseldijk MA,et al.J Thorac Oncol 2019;14:583-595.)(also applies to DIAG-3,footnote o on NSCL-2,NSCL-3)DIAG-A 1 of 3 Bullet 1,including sub-bullets replaced with the followingThe decision to pursue preoperative biopsy of a potential stage I lung cancer should be informed by the pre-test probability of malignancy.Factors that might be considered in pre-test probability assessment include risk factors,radiologic appearance(including comparison to prior chest imaging if available or FDG-PET/CT if performed),and current or prior residence in regions with prevalent endemic infectious lung disease(ie,fungal,mycobacterial),among other potential factors.Patients with very high pre-test probability of stage IA lung cancer do not require a biopsy before surgery.A biopsy adds time,costs,and procedural risk and may not be needed for treatment decisions.If a preoperative tissue diagnosis has not been obtained,then an intraoperative diagnosis(ie,wedge resection,needle biopsy)is necessary before lobectomy,bilobectomy,or pneumonectomy.Situations in which a preoperative biopsy may be appropriate:A non-lung cancer diagnosis that can be diagnosed by minimally invasive biopsy is at least moderately likelyeg,granulomatous nodule due to endemic fungus).Suspected stage IB or higher lung cancer in patients who may be candidates for systemic therapy prior to surgery.An intraoperative diagnosis appears difficult or very risky.To establish the diagnosis prior to stereotactic ablative radiotherapy(SABR)Footnote 2 added:Prior to treatment,multidisciplinary evaluation that includes treating physicians and specialists in obtaining tissue diagnosis(thoracic surgery,interventional pulmonology,and interventional radiology)is required to determine the safest and most efficient approach for biopsy,or to provide consensus that a biopsy is too risky or difficult,that a clinical diagnosis of lung cancer is appropriate,and treatment is warranted.DIAG-A 2 of 3 Bullet 4;sub-bullet 1Last diamond added:Left anterior mediastinotomy/ChamberlainTerminologies in all NCCN Guidelines are being actively modified to advance the goals of equity,inclusion,and representation.Updates in Version 1.2024 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 5.2023 include:NCCN 授权医脉通提供NCCN指南全文下载。h n z m b p 于2023/12/24,17:42在医脉通平台下载，仅供个人使用，严禁分发。2022 美国国家综合癌症网络版权所有。NCCN Guidelines Version 1.2024Non-Small Cell Lung CancerVersion 1.2024,12/21/23 2023 National Comprehensive Cancer Network(NCCN),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.NCCN Guidelines IndexTable of ContentsDiscussionUPDATESContinuedUpdates in Version 1.2024 of the NCCN Guidelines for Non-Small Cell Lung Cancer from Version 5.2023 include:DIAG-A 3 of 3 Bullet 1;sub-bullet 2Diamond 2 modified:Patients with peripheral(outer one-third)pulmonary nodules may benefit from navigational bronchoscopy(including robotic),radial EBUS,or transthoracic needle aspiration(TTNA).Diamond 3;entry 3 modified with the addition of the 3P nodal stationDiamond 6 modified:Patients with lung cancer with an associated pleural effusion should undergo thoracentesis and cytology.A negative pleural cytology result on initial thoracentesis does not exclude pleural involvement.An additional thoracentesis and/or Thoracoscopic evaluation of the pleura should be considered before starting curative intent therapy if pleural fluid is a lymphocytic exudate with negative pleural fluid cytology.NSCL-2 Medically inoperable category modified(also applies to NSCL-3)Medically inoperable,high surgical risk as determined by thoracic surgeon,and those who decline surgery after thoracic surgical consultation Footnote n modified:Image-guided thermal ablation(IGTA)therapy(eg,cryotherapy,microwave,radiofrequency)may be an option for select patients not receiving SABR or definitive RT.(also applies to NSCL-12,NSCL-16,NSCL-18,NSCL-22,NSCL-23,NSCL-28,NSCL-29,NSCL-31)NSCL-3 Following Pretreatment EvaluationNegative mediastinal nodes changed to No nodal disease Consider adjuvant chemotherapy for high-risk stages IB,II Treatment row for N1 removed,as the category changed to no nodal diseasePositive mediastinal nodes changed to N1 or N2 disease Stage IIB added with a link to NSCL-8 Footnote r modified:Examples of high-risk factors may include poorly differentiated tumors(including lung neuroendocrine tumors excluding well-differentiated neuroendocrine tumors),vascular invasion,wedge resection,visceral pleural involvement,and 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-9)NSCL-4 Footnote l added to Adjuvant Treatment with a link to the Principles of Surgical Therapy.NSCL-5 Proximal airway or mediastinum changed to Trachea/carina or mediastinumNSCL-6 Footnote v added:For patients who have received sequential chemoradiation,durvalumab can be considered as consolidation immunotherapy.(also applies to NSCL-7,NSCL-9,NSCL-13,NSCL-14)NSCL-7 Initial Treatment options modifiedSurgery(preferred)after preoperative systemic therapy,if plannedSystemic therapy or concurrent chemoradiation or chemotherapy Margins negative after surgery;Following reresection after Margins positive Adjuvant Systemic Therapy(NSCL-E)added Footnote x added:Resectability should be determined by thoracic surgery evaluation prior to initiation of any therapy.NCCN 授权医脉通提供NCCN指南全文下载。h n z m b p 于2023/12/24,17:42在医脉通平台下载，仅供个人使用，严禁分发。2022 美国国家综合癌症网络版权所有。NCCN Guidelines Version 1.2024Non-Small Cell Lung CancerVersion 1.2024,12/21/23 2023 National Comprehensive Cancer Network(NCCN),All rights reserved.NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.NCCN Guidelines IndexTable of ContentsDiscussionUPDATESContinuedUpdates in Version 1.2024 of the NCCN Guidelines for Non-Small Cell Lu