卵巢癌2022.v2（英文）-NCCN腫瘤臨床實踐指南

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)OvarianCancerIncludingFallopianTubeCancerandPrimaryPeritonealCancerersionJulyNCCNGuidelinesforPatients?availableat/patientsVersion2.2022,07/13/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon7/14/20229:23:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.ncerdex*DeborahK.Armstrong,MD/Chair??TheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsBAViceChairngramCancerCenterrJBackesMDheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchInstituteJamieN.Bakkum-Gamez,MD?CancerCenterLisaBarroilhet,MD?UniversityofWisconsinCarboneCancerCenterKianBehbakht,MD?UniversityofColoradoCancerCenterAndrewBerchuck,MD?stituteLee-mayChen,MD?UCSFHelenDillerFamilyComprehensiveCancerCenterfHopeelaCristeafHopecalCenterRNDeneralHospitalenterDavidM.Gershenson,MD?TheUniversityofTexasMDAndersonCancerCenterCancerResearchCenterianceesPanelDisclosuresGrishamMDloanKetteringCancerCenternterArdeshirHakamnterAngelaJain,MD?FoxChaseCancerCenterAmerKaram,MD??StanfordCancerInstitutecnyMDeCancerCenterCharlesA.LeathIII,MD,MSPH?O'NealComprehensiveCancerCenteratUABGaryLeiserowitzMDprehensiveCancerCenterighamandJoyceLiu,MD,MPHighamandnsCancerCenterAbramsonCancerCenterattheAbramsonCancerCenteratthensylvaniaDanielaMatei,MD???RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversityMichaelMcHale,MD?oMooresCancerCenternMcLeanMDPhDchiganenternsComprehensiveenterSanjaPercac-Lima,MD,PhDTeneralHospitalenterStevenW.Remmenga,MD?Fred&PamelaBuffettCancerCenterJohnSchorge,MD?St.JudeChildren'sResearchHospital/TheUniversityofTennesseeHealthScienceCenteryofHopeNationalMedicalCenteryofHopeNationalMedicalCenterPremalH.Thaker,MD?SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineRobertoVargas,MD?CaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerInstituteAndreaWahnerHendrickson,MD?MayoClinicCancerCenterTheresaL.Werner,MD??HuntsmanCancerInstituteattheUniversityofUtaheZsirosMDPhDomprehensiveCancerCenterhD?Gynecologyoncology?Hematology/HematologyoncologyTInternalmedicine?Medicaloncology≠Pathology￥Patientadvocacy*DiscussionwritingcommitteememberVersion2.2022,07/13/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon7/14/20229:23:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.ncerdexlievesthatthebestlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.aryoftheGuidelinesUpdatesEpithelialOvarianCancer/FallopianTubeCancer/PrimaryPeritonealCancer:ClinicalPresentation,Workup,ClinicalStage,PrimaryTreatment(OV-1)PoorSurgicalCandidateorLowLikelihoodofOptimalCytoreduction(OV-2)DiagnosisbyPreviousSurgery:FindingsandPrimaryTreatment(OV-3)PathologicStaging,PrimaryChemotherapy/PrimaryAdjuvantTherapy(OV-4)PostPrimaryTreatment:MaintenanceTherapy(OV-5)Monitoring/Follow-Up,RecurrentDisease(OV-6)DiseaseStatus,TherapyforPersistentDiseaseorRecurrence(OV-7)arianCancersDiagnosis(LCOC-1)Carcinosarcoma(MalignantMixedMüllerianTumors)(LCOC-2)ClearCellCarcinomaoftheOvary(LCOC-3)MucinousCarcinomaoftheOvary(LCOC-4)Grade1EndometrioidCarcinoma(LCOC-5)Low-GradeSerousCarcinoma(LCOC-6)OvarianBorderlineEpithelialTumors(LowMalignantPotential)(LCOC-8)MalignantSexCord-StromalTumors(LCOC-11)MalignantGermCellTumors(LCOC-12)?SystemicTherapyRegimens-MalignantGermCell/SexCord-StromalTumors(LCOC-A)?Surveillance-MalignantGermCell/SexCord-StromalTumors(LCOC-B)ogyOVBrapyOVConsOVDogicClassificationOVETheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version2.2022,07/13/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.caparibwaschangedfromacategoryApreferredregimentoacategoryotherrecommendedregimencumstancesrecommendationwithacaparibwaschangedfromacategoryApreferredregimentoacategoryotherrecommendedregimencumstancesrecommendationwithacorrespondingreferenceSalamaALiS,MacraeE,etal.DabrafenibandtrametinibinpatientswithtumorswithBRAFV600EmutationsResultsoftheNCIMATCHtrialsubprotocolHJClinOncol;38:3895-3904."3,OV-5,OV-6,andfootnoteoonLCOC-7,LCOC-10,andLCOC-13)IBandIC1.OV-6sparingsurgeryforselectpatients(ifnotpreviouslydone)markers.Morecomprehensivetestingmaybeparticularlyimportantof(unlesscontraindicated)andrectalcontrastasneeded.(AlsoforOV-?Stagesmodifiedtoincludeobserveasanadjuvantoptionforstage sChemistryprofilesifindicatedpAdjuvantoptionremovedforstageIAIBandstageICFertilityHRstatus,MSI,TMB,NTRKifpriortestingdidnotincludetheseexemestane),leuprolideacetate,tamoxifen.(AlsoonLCOC-6)identifygeneticalterationsforwhichFDA-approvedtumor-specificObserveormaintenanceletrozole(category2B)orotherncerdexsionoftheNCCNGuidelinesforOvarianCancerfromVersionincludeLCOC-7recommendation.?Low-GradeSerousCarcinoma,RecurrenceTherapy:Dabrafenib+trametinib(forBRAFV600E-positivetumors)wasaddedasacategory2recommendation.OV-B(1of3)?Tumormolecularanalyses,2ndsub-bulletrevised:"...mismatchrepair(MMR),tumormutationalburden(TMB),BRAF,andNTRK..."SimilarrevisionmadetofootnotexonOV-C(8of11)andOV-C(9of11).OV-C(8of11)UpdatesinVersion1.2022oftheNCCNGuidelinesforOvarianCancerfromVersion3.2021include:?Footnoteamodified:Imagingperformedwithoraland?Footnoteamodified:ImagingperformedwithoralandIVcontrastLCOC-3OV-8ecurrencePlatinumSensitiveDisease?Headingmodifiedforclarity:ecurrencePlatinumSensitiveDiseaseUPDATESVersion2.2022,07/13/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion2.2022,07/13/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.LinkaddedtonewpageSeeMonitoring/Follow-upforRecurrentorTMBHervecontinuousLinkaddedtonewpageSeeMonitoring/Follow-upforRecurrentorTMBHervecontinuousinfusion,toallowforrenalprotectionduringHIPEC.ncerdexsionoftheNCCNGuidelinesforOvarianCancerfromVersioninclude?StageII-IVtherapyforrecurrent/persistentLCOC.FootnoteremovedDataaretherapyforrecurrent/persistentLCOC.Newpageaddedwithrecommendationsformonitoring/follow-up,andtreatmentforrecurrentlow-gradeserouscarcinoma.iorcompletesurgicalresection?Footnoteiimodified:Pediatric/adolescentpatientswiththefollowingclinicalpresentationsmayconsiderobservationorchemotherapyastreatmentoptions:stageIA,IBdysgerminoma;stageIA,grade1immatureteratoma;stageIAembryonaltumorscarcinomas;orstageIAyolksactumors.ThereareongoingstudiesevaluatingobservationforstageIAandIB,grade2/3pureimmatureteratomas(maycontainmicroscopicfociofyolksactumor),yolksactumor,embryonalcarcinoma,andchoriocarcinoma(pureormixed)inadults.LCOC-A?RecurrenceTherapypRegimenmodified:Etoposide/cisplatin(EP),used?RecurrenceTherapyforMalignantSexCord-StromalTumorspVAChasbeenchangedfromacategory2A/otherrecommendedregimen,toacategory2B/usefulincertaincircumstancesoption.pAdded"ifnotpreviouslyused"toEPandBEP.OV-A(3of4)beadministeredatthestartofperfusionfollowedbyabeadministeredatthestartofperfusionfollowedbyaOV-A(4of4)?SpecialcircumstancespFourthbullet,lastlineadded:Considerusingvalidatedscoringmethodstoassesssuitabilityforsecondarycytoreduction.OV-B(1of3)?Sectionontumormolecularanalyseshasbeenmodifiedtoincludethefollowing:pIntheup-frontsetting,choiceofsomatictestingshould,ataminimum,optimizeidentificationofmolecularalterationsthatcaninformuseofinterventionsthathavedemonstratedbenefitinthissetting,includingBRCA1/2,lossofheterozygosity(LOH),orhomologousrecombination(HR)statusintheabsenceofagermlineBRCAmutation.pIntherecurrencesetting,tumormolecularanalysisisrecommendedtoinclude,ataminimum,teststoidentifypotentialbenefitfromtargetedtherapeuticsthathavetumor-specificortumor-agnosticbenefitincluding,butnotlimitedto,BRCA1/2,HRstatus,microsatelliteinstabilityUPDATESVersion2.2022,07/13/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon7/14/20229:23:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.ncerdexsionoftheNCCNGuidelinesforOvarianCancerfromVersioninclude(MSI),tumormutationalburden(TMB),andNTRKifpriortestingdidnotincludethesemarkers.Morecomprehensivetestingmaybeparticularlyimportantinlesscommonhistologieswithlimitedapprovedtherapeuticoptions.Itisrecommendedthatsuchtestingbeperformedonthemostrecentavailabletumortissue.pValidatedmoleculartestingshouldbeperformedinaCLIA-approvedfacility.OV-C(4of11)?RecurrentOvarian,FallopianTube,orPrimaryPeritonealCancerpThirdbulletmodified:Tumormoleculartestingisrecommended ifnotpreviouslydonepriortoinitiationoftherapyforpersistent/ recurrentdisease.OV-C(5of11)andOV-C(6of11)?Tableheadingsupdated:pPrimaryTherapyforStageIDiseasepPrimaryTherapyforStageII–IVDisease(SeePrinciplesofMaintenancePARPiTherapyonOV-C,3of11)?PrimarytherapyforstageI–IVdiseasepOptionremoved:Carboplatin(ifelderly[age>70]and/orforthosewithcomorbidities)?Low-gradeserous(stageIC-IV)/Grade1Endometrioid(stageIC-IV)pPreferredregimens,firstbulletmodifiedforconsistencywithrecommendationsonLCOC-5/6:Paclitaxel/carboplatinq3weeks±m(xù)aintenanceletrozole(category2B)orotherhormonaltherapy(category2B)?Footnotefadded:Albumin-boundpaclitaxelmaybesubstitutedforthoseexperiencingahypersensitivityreactiontopaclitaxel.However,albumin-boundpaclitaxelwillnotovercomeinfusionreactionsinallpatients.(AlsoonOV-C,6–9of11)?Footnotehadded:Otherhormonaltherapyoptionsinclude:aromataseinhibitors(anastrozole,exemestane),leuprolideacetate,tamoxifen.OV-C(7of11)?Removed:CarboplatinAUC5IVgivenevery21dayspIndicationsmodifiedforthefollowingimmunotherapyoptions:?Pembrolizumab(formicrosatelliteinstability-high[MSI-H]ormismatchrepair-deficient[dMMR]solidtumors,orpatientswithtumormutationalburden-high[TMB-H]tumors≥10mutations/megabaseandnosatisfactoryalternativetreatmentoptions)?Dostarlimab-gxly(fordMMR/MSI-Hrecurrentoradvancedtumorsifdiseaseprogressionandnosatisfactoryalternativetreatmentoptions)pOptionadded:Binimetinib,forlow-gradeserouscarcinoma(category2B)OV-C(11of11)?Referencesadded:pMonkBJ,GrishamRN,BanerjeeS,etal.MILO/ENGOT-ov11:Binimetinibversusphysician'schoicechemotherapyinrecurrentorpersistentlow-gradeserouscarcinomasoftheovary,Fallopiantube,orprimaryperitoneum.JClinOncol.2020Nov10;38:3753-3762.pGrishamRN,VergoteI,BanerjeeSN,etal.MolecularresultsandpotentialbiomarkersidentifiedfromMILO/ENGOT-ov11phase3studyofbinimetinibversusphysicianschoiceofchemotherapy(PCC)inrecurrentlow-gradeserousovariancancer(LGSOC).JournalofClinicalOncology,2021;39(15_suppl),5519-5519.OV-D(3of7)?Referenceadded:RosePG,MetzC,LinkN.Desensitizationwithoxaliplatininpatientsintolerantofcarboplatindesensitization.IntJGynecolCancer.2014;24:1603-1606.atusandnutritionalsIevaluationasclinicallyefgertogynecologicgistforclinicallyiciouslesionshUltrasoundandornicallyindicatedablyindicatedactryprofilewithiontestLFTCA5atusandnutritionalsIevaluationasclinicallyefgertogynecologicgistforclinicallyiciouslesionshUltrasoundandornicallyindicatedablyindicatedactryprofilewithiontestLFTCA5orothertumorCLINICALPRESENTATIONSuspicious/palpablepelvicmassonabdominal/pelvicexamand/orascites,abdominaldistentionrSymptomswithoutsourceofmalignancy(ie,bloating,pelvic/abdominalpain,difficultyeatingorfeelingfullquickly,urinarysymptoms[urgencyorfrequency])WORKUPbdominalpelvicexamminalpelvicCTMRIChestCTorchestx-rayassclinically?EvaluateperformancewithovarianlopianprimaryitonealcancerouldhaveneticriskluationicForlesscommonovariancancers(LCOC),nseeLCOC-1linetictingifnotfgjEpithelialOvarianCancer/FallopianTubeCancer/TableEpithelialOvarianCancer/FallopianTubeCancer/TableinesIndex PrimaryPeritonealCancerCLINICALSTAGEhIA(fertilitydesired)IB(fertilitydesired)PRIMARYTREATMENTh,i,jcandidate,optimalcytoreductionlikely(fertilitynotdesired)rectomyBSOnsivestagingijrectomyBSOSeeNeoadjuvantTherapy(OV-2)mDiagnosisbyprevioussurgeryycytopathologyDiagnosisbyprevioussurgeryycytopathology?Allpatientswithsuspectedovarianmalignancies;publisheddatacChestCTpreferredifconcernformetastaticordisseminateddisease.cChestCTpreferredifconcernformetastaticordisseminateddisease.??ConsiderationkMaybeanoptionforselectpatientswithstagenancetherapylUterinepreservationforpotentialfutureassistedreproductivenancetherapyepithelial,malignantsexcord-stromaltumors,andgermcelltumors.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.OV-1Version2.2022,07/13/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.herapyforPersistentDiseaseorRecurrence(OV-7)PrintedbyMinTangon7/14/20229:23:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.herapyforPersistentDiseaseorRecurrence(OV-7)EpithelialOvarianCancer/FallopianTubeCancer/TableEpithelialOvarianCancer/FallopianTubeCancer/TableinesIndex PrimaryPeritonealCancerPOORSURGICALCANDIDATEORLOWLIKELIHOODOFOPTIMALCYTOREDUCTIONNEOADJUVANTTHERAPYEvaluationbysthsthionj,o(biopsypreferred)and/orLaparoscopicevaluationtodeterminefeasibilityofresectiondateorihoodltionPRIMARYTREATMENTtegoryctegorycriskuationandneandtictestingyfgjerapyherapyhmpResponseStablediseaseIntervaldebulkingsurgery(IDS)SOiSOijqoreductionhysterectomy/BSOi,j,hysterectomy/BSOi,j,qandcytoreductionContinuecurrenttherapy(foratotalofatleast6cycles)morSeeTherapyforPersistentDiseaseorRecurrence(OV-7)AdjuvantapymenancepyAdjuvantapymetionoreductionetionoreductionProgressiveSeeTherapyforPersistentdiseaseDiseaseorRecurrence(OV-7)eSeeNCCNGuidelinesforGenetic/FamilialHigh-RiskAssessment:Breast,Ovarian,andPancreaticandNCCNGuidelinesforGenetic/FamilialHigh-RiskAssessment:Colorectal.fGermlineandsomaticBRCA1/2statusinformsmaintenancetherapy.gIntheabsenceofaBRCA1/2mutation,HRstatusmayprovideinformationonthemagnitudeofbenefitofPARPitherapy(SeeOV-B).hEvaluationbyagynecologiconcologistisrecommendedfor:?Allpatientswithsuspectedovarianmalignancies;publisheddatademonstratethatprimaryassessmentanddebulkingbyagynecologiconcologistresultsinasurvivaladvantage.?Patientsbeingevaluatedforneoadjuvanttherapypriortobeingconsideredapoorsurgicalcandidate.?Managementofoccultseroustubalintraepithelialcarcinomas.?Considerationoflaparoscopicevaluationtodeterminefeasibilityofdebulkingsurgeryinselectpatients.iSeePrinciplesofSurgery(OV-A).jSeePrinciplesofPathology(OV-B).mSeePrinciplesofSystemicTherapy(OV-C)andManagementofDrugReactions(OV-D).oIfbiopsyisnotfeasible,cytopathologyfromascitesorpleuraleffusioncombinedwithCA-125:CEAratioof>25canbeused.pCompletionsurgeryafter3–4cyclesispreferred;however,surgerymaybeperformedafter4–6cyclesbasedontheclinicaljudgmentofthegynecologiconcologist.qHyperthermicintraperitonealchemotherapy(HIPEC)withcisplatin(100mg/m2)canbeconsideredatthetimeofIDSforstageIIIdisease.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.OV-2Version2.2022,07/13/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.Geneticriskevaluationandgermlineandsomatictestinge,f,g(ifnotpreviouslydone),aImagingasclinicallyindicated(eg,chest/abdominal/pelvicCT/MRI,PET/CT,and/orultrasound)CBC,chemistryprofilewithLFTsrkIIikeu–duualctivetva4)umorsseeLCOCaImagingperformedwithoralGeneticriskevaluationandgermlineandsomatictestinge,f,g(ifnotpreviouslydone),aImagingasclinicallyindicated(eg,chest/abdominal/pelvicCT/MRI,PET/CT,and/orultrasound)CBC,chemistryprofilewithLFTsrkIIikeu–duualctivetva4)umorsseeLCOCaImagingperformedwithoralandIVcontrastunlessorcontraindicatedandrectalcontrastasneededMalignantsexcord-stromaltumors(seeLCOC-12)dOthertumormarkersmayincludeinhibin,β-hCG,alpha-fetoprotein,LDH,CEA,andCA19-9.SeeDiscussionforhEvaluationbyagynecologiconcologistisrecommendedfor:usefulnessofdiagnostictests.?Allpatientswithsuspectedovarianmalignancies;publisheddatademonstratethatprimaryassessmenteSeeNCCNGuidelinesforGenetic/FamilialHigh-Riskanddebulkingbyagynecologiconcologistresultsinasurvivaladvantage.Assessment:Breast,Ovarian,andPancreaticandNCCN?Patientsbeingevaluatedforneoadjuvanttherapypriortobeingconsideredapoorsurgicalcandidate.GuidelinesforGeneticFamilialHighRiskAssessment:?Managementofoccultseroustubalintraepithelialcarcinomas.Colorectal.?Considerationoflaparoscopicevaluationtodeterminefeasibilityofdebulkingsurgeryinselectpatients.fPathologyOVBhemagnitudeofbenefitofPARPitherapy(SeeOV-B).oncologisthSee?ltimarkerstaseSeeNeoadjuvantTherapy(OV-2)nosarcomaseeLCOCEpithelialOvarianCancer/FallopianTubeCancer/TableEpithelialOvarianCancer/FallopianTubeCancer/TableinesIndex PrimaryPeritonealCancer