NCCN Guidelines and Compendium Updated
Flash Update Sent February 23, 2012
NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Central Nervous System Cancers. These NCCN Guidelines® are currently available as Version 1.2012:
- Adult Low-Grade Infiltrative Supratentorial Astrocytoma/Oligodendroglioma (excluding astrocytoma):
- After maximal safe resection, the pathway decision point is now based on "Low Risk" versus "High risk". Previously the pathway decision point was based on "Age > 40 y" and "Age ≤ 40 y". Corresponding footnotes regarding definitions for Low Risk features and High Risk features were also added.
- Anaplastic Gliomas/Glioblastoma:
- The following changes have been made for adjuvant treatment options for patients with anaplastic glioma who have good performance status: Chemotherapy can be considered for patients with 1p19q co-deletion. Combined chemoradiation is now listed as category 3. Previously it was listed as category 3 off clinical trial and category 2A on clinical trial.
- The recommendation pathways for the treatment of glioblastoma were extensively revised. The decision points after "Glioblastoma ± carmustine (BCNU) wafer" are now based on "Performance status". Previously, after "Glioblastoma" the decision points were based on whether the patient was treated with or without a carmustine (BCNU) wafer.
- Adult Medulloblastoma and Supratentorial PNET:
- The algorithm now covers the treatment of pineoblastomas.
- Principles of Brain Tumor Imaging:
- "Enhanced MRI of the brain and spine" changed to "MRI of the brain and spine (± contrast)". A similar change was made for "Enhanced CT of the brain and spine".
- Principles of Brain Tumor Surgery:
- Under "Options" a new bullet was added that states, "Chemotherapy implants when indicated".
- Principles of Brain Tumor Radiation Therapy:
- Adult Medulloblastoma and Supratentorial PNET: The standard risk for recurrence section was revised to include recommendations for "Conventional dose" and "Reduced dose".
- Meningiomas: The third bullet changed to "WHO grade 1 meningiomas may also be treated with stereotactic radiosurgery doses of 12-14 Gy in a single fraction when appropriate." Previously this recommendation only applied to "Small WHO grade 1" and the stereotactic radiosurgery dose was 12-15 Gy.
- Principles of Brain Tumor Systemic Therapy:
- Anaplastic Gliomas: For Recurrence/Salvage therapy the option of BCNU was changed to BCNU/CCNU. A similar change was made for the systemic treatment option of recurrence/salvage therapy for Glioblastoma.
- Glioblastoma: For Recurrence/Salvage therapy the option of nitrosourea wafer was added.
- Primary CNS Lymphoma: For Primary treatment, the following options were added:
- High dose methotrexate 3.5 g/m2 combined with the following plus RT:
- Vincristine, procarbazine, cytarabine ± rituximab
- Ifosfamide ± RT
- High dose methotrexate 8.0 g/m2 combined with the following plus deferred RT:
- Rituximab and temozolomide
- Limited (1-3) Metastatic or Multiple (> 3) Metastatic Lesions: For the treatment of recurrent disease, carmustine wafer was added as an option. For the treatment of organ-specific therapy, "Capecitabine" was changed to "Capecitabine ± lapatinib".
- Leptomeningeal Metastases: Topotecan, etoposide, and interferon alfa were added as options for intra-CSF chemotherapy.
- Principles of Brain Tumor Management:
- Under Multidisciplinary care, the following statement was added, "Patients should be informed of the possibility of pseudoprogression, its approximate incidence and potential investigations that may be needed in the event that pseudoprogression is suspected. Close follow-up imaging, MR Spectroscopy, PET/CT imaging, and repeat surgery may be necessary if clinically indicated.
NCCN has published updates to the NCCN Guidelines and NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Myeloid Growth Factors. These NCCN Guidelines are currently available as Version 1.2012:
- For regimens with a high risk for febrile neutropenia, "± rituximab" was added with a corresponding reference to the non-Hodgkin's Lymphoma regimen, CHOP-14.
- For regimens with an intermediate risk for febrile neutropenia, a note was added to the non-small cell lung cancer regimen carboplatin/paclitaxel: "If carboplatin dose is AUC >6 and/or Japanese ancestry."'
- The Discussion section was updated to reflect the changes in the algorithm.
NCCN has published updates to the NCCN Compendium® to reflect updates to the 2012 version of the corresponding NCCN Guidelines:
- Ovarian Cancer V.2.2012
- Epithelial Ovarian Cancer/Fallopian Tube Cancer/Primary Peritoneal Cancer
- Malignant Germ Cell Tumors
- Malignant Sex Cord-Stromal Tumors
Flash Update Sent February 23, 2012
NCCN has published new NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Adolescent and Young Adult Oncology. These NCCN Guidelines® are currently available as Version 1.2012.
The NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology identify issues specific to the AYA population and recommend age-appropriate supportive care services/interventions with the aim of improving treatment tolerance, compliance, and clinical outcomes as well as promote participation in clinical trials.
The NCCN Guidelines for AYA Oncology recommend comprehensive assessment which should include psychosocial assessment, discussion of risks of infertility associated with treatment and options for fertility preservation, and genetic and familial risk assessment (within 2 months after the start of therapy) following the diagnosis of cancer for all patients. The guidelines also outline screening recommendations for late effects in AYA cancer survivors after successful completion of therapy and address palliative and end-of-life needs specific to the AYA population.
The NCCN Guidelines for AYA Oncology can be found under NCCN Guidelines for Supportive Care on NCCN.org or at http://www.nccn.org/professionals/physician_gls/pdf/aya.pdf.
NCCN has published updates to the NCCN Guidelines for Non-Hodgkin's Lymphomas. These NCCN Guidelines are currently available as Version 2.2012.
Mantle Cell Lymphoma
- For stage IIx, III, IV with a complete response to first-line R-CHOP induction, the treatment option for patients who are not candidates for HDT/ASCR was changed to recommend rituximab maintenance based on the following study: Kluin-Nelemans JC, Hoster E, Walewski J, et al. R-CHOP versus R-FC followed by maintenance with rituximab versus interferon-alfa: Outcome of the first randomized trial for elderly patients with mantle cell lymphoma [abstract]. Blood 2011;118:Abstract 439.
Post-Transplant Lymphoproliferative Disorder
- A sequential chemoimmunotherapy regimen was added: "Rituximab 375 mg/m2 weekly x 4 weeks followed by CHOP-21 (cyclophosphamide, doxorubicin, vincristine, prednisone) starting Day 1 of week 9 x 4 cycles."
Flash Update Sent February 29, 2012
NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Soft Tissue Sarcoma. These NCCN Guidelines® are currently available as Version 1.2012.
- Soft Tissue Sarcoma of Extremity/Trunk
- A new footnote was added that states, "All patients, especially those with rhabdomyosarcoma, should be evaluated by institutions with expertise and experience in treating soft tissue sarcoma.
- For follow-up, the recommendation to consider ultrasound has a new footnote that states, "Consider ultrasound for smaller lesions that are superficial. Ultrasound should be done by an ultrasonographer experienced in musculoskeletal disease".
- For patients with stage II, III disease who are potentially resectable and there is concern for adverse functional outcomes, the recommendation for preoperative chemotherapy changed from category 2A to category 2B.
- For metastatic disease, a new pathway for "Isolated regional disease or nodes" was added.
- For patients with single organ and limited tumor bulk, the use of chemotherapy and RT with metastasectomy was clarified as a category 2B recommendation.
- A new footnote to address concerns about the use of re-irradiation for local recurrence was added that states, "If local recurrence can be excised, a decision will need to be made on a case by case basis whether re-irradiation is possible. Some case series suggest benefit with re-irradiation, while others do not, likely reflecting differences in selection of patients for treatment with surgery and radiotherapy or surgery alone. Traditionally, the re-irradiation has been done with post-operative adjuvant brachytherapy, but may now be able to be done as a combination of brachytherapy and IMRT to reduce the risks of morbidity with re-irradiation."
- Gastrointestinal Stromal Tumors (GISTs)
- For patients who have undergone complete resection and did not receive preoperative imatinib, the use of postoperative imatinib for patients with significant risk of recurrence (intermediate or high risk) is now included as a category 1 recommendation with the following revised footnote: "Adjuvant imatinib for at least 36 months should be considered for high risk tumors. The results of a recently completed randomized trial (SSGXVIII/AIO) suggest that adjuvant imatinib administered for 36 months improves relapse free survival (RFS) and overall survival (OS) compared to 12 months of adjuvant imatinib for patients with a high estimated risk of recurrence (tumor greater than 5 cm in size with high mitotic rate (> 5 mitoses/50 HPF) or a risk of recurrence of greater than 50%) after surgery. The results of ACOSOG trial Z9001 showed that adjuvant imatinib improved relapse free survival in patients with GIST ≥ 3 cm in size with the greatest benefit noted in tumors at higher risk of recurrence (intermediate and high-risk)."
- For patients who have undergone complete resection after preoperative imatinib, a new footnote "y" was added that states, "For patients with complete resections following preoperative therapy, continued imatinib is warranted. The length of postoperative imatinib has not been established in randomized trials; there are single and multi-institutional trials supporting the benefit for continuation of imatinib for two years post-surgery."
- Principles of Biopsy for GIST: This page was revised extensively, including the addition of the following statement, "Percutaneous image guided biopsy may be appropriate for confirmation of metastatic disease."
- Desmoid Tumors (Fibromatosis)
- The algorithm name changed to "Desmoid Tumors (Aggressive fibromatosis)".
- Principles of Pathologic Assessment of Sarcoma Specimens: A new bullet was added that states, "Biopsy should establish malignancy, provide a specific diagnosis where possible and provide a grade where appropriate or feasible, recognizing that limited biopsy material may underestimate grade."
- Principles of Surgery: Under "Resection Margins," a new bullet was added that states, "In selected cases where margin status is uncertain, consultation with a radiation oncologist is recommended".
- Systemic Therapy Agents and Regimens with Activity in Soft Tissue Sarcoma
- Extremity, Retroperitoneal, Intra-abdominal: Vinorelbine and Pazopanib were added as single agents with a category 2A recommendation. For pazopanib, footnote "c" was added that states, "Pazopanib should not be used for lipogenic sarcomas."
- Desmoid Tumors (Aggressive fibromatosis): Sorafenib was added as a single agent with a category 2A recommendation.
- Chordoma: Erlotinib, alone or in combination with cetuximab was removed.
- Inflammatory Myofibroblastic Tumor (IMT) with ALK Translocation is a new subtype that was added to the page. Crizotinib was added as a single agent for the treatment of IMT with a category 2A recommendation.
For the complete updated version of these and all NCCN Guidelines, visit NCCN.org.