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NCCN Flash Update: NCCN Guidelines for Hepatobiliary Cancers and NCCN Radiation Therapy Compendium

NCCN has updated the NCCN Radiation Therapy Compendium™ to reflect recommendations within the following NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®):

  • Melanoma, Version 2.2018


NCCN has published updates to the NCCN Guidelines® and the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Hepatobiliary Cancers. These NCCN Guidelines are currently available as Version 1.2018.

  • Hepatocellular Carcinoma
  • Screening for patients at risk for HCC (HCC-1)
  • A sub-bullet was amended: "Stage 4 primary biliary cirrhosis cholangitis” with a supporting reference added: "Beuers U, Gershwin M, Gish R, et al. Changing Nomenclature for PBC: From 'Cirrhosis' to ‘Cholangitis' Am J Gastroenterol 2015;110(11):1536–1538."
  • Treatment for patients ineligible for transplant (HCC-4)
  • A bullet was amended: "External-beam radiation therapy (EBRT) (category 2B) Radiation therapy, and accompanying footnote was also amended: "Case series and single-arm studies demonstrate suggest safety and possible efficacy of radiation therapy in selected cases. See Principles of Locoregional Therapy (HCC-E)." (Also for HCC-5 and HCC-6)
  • Principles of Imaging, Extrahepatic Staging (HCC-A)
  • A statement was amended: "Frequent sites of extrahepatic metastases from HCC include lungs, and bone and lymph nodes. Adrenal and peritoneal metastases also may occur. For this reason, chest CT, complete imaging of abdomen and pelvis with contrast-enhanced CT or MRI, and selective use of bone scan when skeletal symptoms are present are recommended at initial diagnosis of HCC and for monitoring disease while on the transplant wait list or during or after treatment for response assessment. Chest CT may be performed with contrast if concurrently acquired with contrast-enhanced abdominal/pelvic CT. If MRI is performed, chest CT may be acquired without contrast."
  • Principles of Locoregional Therapy
  • A sub-bullet was amended: “Arterially directed therapies are relatively contraindicated in highly selected patients have been shown to be safe in the presence of limited tumor invasion with main of the portal vein. thrombosis and Child-Pugh Class C." (HCC-E 1 of 3)
  • The title “External-beam Radiation Therapy (EBRT) was revised. (HCC-E 2 of 3)
  • A bullet was added: “Dosing for SBRT is generally is 30-50 Gy in 3-5 fractions, depending on the ability to meet normal organ constraints and underlying liver function. Other hypofractionated schedules >5 fractions may also be used if clinically indicated."
  • Gallbladder Cancer
  • A bullet was added for unresectable disease, jaundice, and metastatic disease: "Microsatellite instability (MSI) testing" (GALL-1, GALL-2, GALL-3, and GALL-4)
  • Primary treatment, unresectable and metastatic disease
  • A bullet was amended: "EBRT Radiation therapy"(GALL-1, GALL-2, GALL-3, GALL-4, and INTRA-1)
  • A bullet: "Pembrolizumab (Only for MSI-H tumors)" was added a treatment option, with an accompanying footnote: "There are limited clinical trial data to support pembrolizumab in this setting. Personalized, molecularly matched combination therapies for treatment-naïve, lethal malignancies: the I-PREDICT Study. Slickick JK, Leyland-Jones B, Kato S, et al. J Clin Oncol 2017;35:2512." (Also for GALL-2, GALL-3, GALL-4, INTRA-1, and EXTRA-1)
  • Treatment (GALL-5)
  • Resected, positive margin (R1) or Resected gross residual disease (R2) or Positive regional nodes
  • A statement was amended: "Consider Fluoropyrimidine chemoradiation followed by additional fluoropyrimidine-based or gemcitabine-based chemotherapy or Fluoropyrimidine-based or gemcitabine-based chemotherapy+/- fluoropyrimidine chemoradiation for positive regional lymph nodes or Clinical trial" and supporting reference was added: "Ben-Josef E, Guthrie KA, El-Khoueiry AB, et al. SWOG S0809: A phase II intergroup trial of adjuvant capecitabine and ."gemcitabine followed by radiotherapy and concurrent capecitabine in extrahepatic cholangiocarcinoma and gallbladder carcinoma. J Clin Oncol 2015;33(24):2617-2622.” (Also for INTRA-2 and EXTRA-2)
  • For chemotherapy in the adjuvant setting, the footnote was amended: "There are no randomized phase III clinical trial data to support a standard adjuvant regimen. Clinical trial participation is encouraged. There are phase II trials that support the following combinations: gemcitabine/cisplatin, gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin, 5-fluorouracil/oxaliplatin, 5-fluorouracil/cisplatin, and the single agents gemcitabine, capecitabine, and 5-fluorouracil in the unresectable or metastatic setting. (Hezel AF and Zhu AX. Systemic therapy for biliary tract cancers. Oncologist 2008;13:415-423). The phase 3 BILCAP study shows improved overall survival for adjuvant capecitabine in the per-protocol analysis, but the study is not yet published, and the overall survival did not reach statistical significance in the intent-to-treat analysis. Primrose JN, Fox R, Palmer DH, et al: Adjuvant Capecitabine for Biliary Tract Cancer. The BILCAP randomized study. ASCO Meeting 2017. Abstract 4006.” (Also for INTRA-2 and EXTRA-2)
  • Principles of Radiation Therapy (GALL-C)
  • A bullet under “Adjuvant EBRT” was revised: "Target volumes should cover the draining regional lymph nodes to 45 Gy at 1.8 Gy/fraction and 50.4–59.4 at 1.8 Gy at 1.8 Gy/faction 50–60 Gy in 1.8–2 Gy/fraction to the tumor bed depending on margin positivity."
  • A bullet under “Unresectable” was amended: "Dosing for SBRT for biliary tract tumors is generally 30-50 Gy in 3-5 fractions, depending on the ability to meet normal organ constraints and underlying liver function. Other hypofractionated schedules >5 fractions may also be used if clinically indicated. For intrahepatic tumors, SBRT in 1-5 fractions is an acceptable option."
  • Intrahepatic Cholangiocarcinoma
  • A bullet was added for Unresectable and Metastatic disease: "Consider molecular testing, including MSI testing." (INTRA-1, also for EXTRA-1)
  • Primary Treatment, Unresectable and Metastatic disease (INTRA-1)
  • Treatment options statement was revised: "Consider locoregional therapy (category 2B)"
  • "Arterially directed therapies" was added as a treatment option for metastatic disease
  • Extrahepatic Cholangiocarcinoma
  • A primary treatment option was added for unresectable disease: "Radiation therapy" (EXTRA-1)
  • Staging Tables (ST-1)
  • Staging tables have been revised to reflect the 8th edition of the AJCC Cancer Staging System.

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium®), the NCCN Biomarkers Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit

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