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NCCN Flash UpdatesTM: NCCN Guidelines® & NCCN Compendium® Updated

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Head and Neck Cancers. These NCCN Guidelines® are currently available as Version 1.2015.

  • Global Changes
    • Footnote for all cancer sites regarding smoking cessation support and resources revised to include a link to the “NCCN Guidelines for Smoking Cessation.”
    • Under “Clinical Staging”: A new pathway for “Metastatic (M1) disease at initial presentation” was added for most cancer sites.
    • Under “Workup,” the recommendation “Biopsy” was revised to “Biopsy of primary site or fine needle aspiration (FNA) of the neck” for multiple sites within the Guidelines.
  • Cancer of the Oropharynx
    • Principles of Radiation Therapy (ORPH-A)
      • Definitive therapy: Under planning target volume (PTV), a new fractionation schedule was added for high-risk patients: “69.96 Gy (2.12 Gy/fraction) daily Monday–Friday in 6–7 weeks.” (Also for cancers of the hypopharynx [HYPO-A] and nasopharynx [NASO-A])
  • Cancer of the Hypopharynx
    • After “Surgery + neck dissection (preferred),” recommendations were added for adjuvant treatment of stage T4a, any N. (HYPO-5)
    • For stage T4a, any N, a new page was added that provides “Response Assessment” recommendations after treatment with induction chemotherapy. (HYPO-6)
  • Cancer of the Nasopharynx
    • Workup (NASO-1)
      • The second bullet was revised: “Nasopharyngeal fiberoptic examination and biopsy.”
      • The following bullets were added:
        • Biopsy of primary site or FNA of the neck
        • Consider Epstein-Barr virus (EBV)/DNA testing
        • Consider ophthalmologic and endocrine evaluation as clinically indicated.
    • Principles of Radiation Therapy (NASO-A)
      • Definitive therapy
        • The PTV for high-risk patients was revised: “66 Gy (2.2 Gy/fraction) to 70–70.2 Gy (1.8–2.0 Gy/fraction); daily Monday–Friday in 6–7 weeks.”
      • Concurrent Chemoradiation
        • The PTV for high-risk patients was revised: “typically 70–70.2 Gy (1.8–2.0 Gy/fraction); daily Monday–Friday in 7 weeks.”
  • Cancer of the Glottic Larynx
    • Treatment of Primary and Neck
      • For patients amenable to larynx-preserving (conservation) surgery (T1-T2, or select T3), “Neck dissection as indicated” was added as an option. (GLOT-2)
      • For T3 requiring (amenable to) total laryngectomy (N0-1), recommendation revised: “Laryngectomy with ipsilateral thyroidectomy as indicated...” (GLOT-3)
  • Cancer of the Supraglottic Larynx
    • For patients amenable to larynx-preserving (conservation) surgery (Most T1-2, N0; Selected T3 patients), Pathology Stage: Recommendation revised, “Positive node; Adverse features: positive margins or other risk features.” (SUPRA-2)
    • Footnote “k” is new: “Adverse features: extracapsular nodal spread, positive margins, pT4 primary, N2 or N3 nodal disease, perineural invasion, vascular embolism (lymphovascular invasion).” (SUPRA-2)
  • Ethmoid Sinus Tumors
    • Workup
      • Second bullet revised: “CT or MRI skull base through thoracic inlet.” (ETHM-1)
    • Pathology
      • Change made: “Undifferentiated carcinoma (sinonasal undifferentiated carcinoma [SNUC], small cell, or sinonasal neuroendocrine carcinoma [SNEC]).” (ETHM-1) (Also for maxillary sinus tumors)
    • Footnote “e” revised: ““For sinonasal undifferentiated carcinoma (SNUC), and small cell or sinonasal neuroendocrine carcinoma (SNEC) histologies, systemic therapy should be a part of the overall treatment. Consider referral to a major medical center that specializes in these diseases.” (ETHM-1) (Also for maxillary sinus tumors [MAXI-1])
    • Footnote “f” is new: “N+ neck disease is uncommon in ethmoid cancers, but, if present, requires neck dissection and appropriate risk-based adjuvant therapy.” (ETHM-2)
    • Principles of Radiation Therapy (ETHM-A)
      • Definitive therapy
        • The PTV for high-risk patients was revised “66 Gy (2.2 Gy/fraction) to 70–70.2 Gy (1.8–2.0 Gy/fraction); daily Monday–Friday in 6–7 weeks.” (Also for maxillary sinus tumors [MAXI-A])
      • Concurrent Chemoradiation
        • The PTV for high-risk patients was revised, “typically 70–70.2 Gy (1.8–2.0 Gy/fraction); daily Monday–Friday in 7 weeks.” (Also for maxillary sinus tumors [MAXI-A])
  • Maxillary Sinus Tumors
    • Workup
      • “Consider PET/CT for Stage III or IV” added as an option. (MAXI-1)
  • Very Advanced Head and Neck Cancer
    • This section was revised extensively, including adding treatment recommendations for “Metastatic (M1) disease at initial presentation” and “Recurrent or persistent disease with distant metastases.”
  • Occult Primary
    • Workup after pathology findings of “Squamous cell carcinoma, adenocarcinoma, and/anaplastic undifferentiated epithelial tumors”
      • Fifth bullet revised to include “…PAX8, and/or TTF staining..” (OCC-1)
  • Salivary Gland Tumors
    • Footnote “j” regarding treatment revised: “The facial nerve should be preserved if possible; strongly consider referral to a specialized center with reconstructive expertise.” (SALI-3)
  • Follow-up Recommendations (FOLL-A)
    • Second bullet revised: “Further reimaging as indicated based on signs/symptoms; not routinely recommended for patients without worrisome signs/symptoms. Further reimaging as indicated based on worrisome or equivocal signs/symptoms, smoking history, and areas inaccessible to clinical examination.
    • Three new bullets added:
      • “Due to the inaccessibility of the nasopharynx, routine annual imaging may be indicated
      • Nutritional evaluation and rehabilitation as clinically indicated until nutritional status is stabilized
      • Ongoing surveillance for depression (See NCCN Guidelines for Distress Management).”
  • Radiation Techniques (RAD-A)
    • Palliative radiation
      • Bullet revised: “44.4 Gy in 12 fractions, in 3 cycles (for each cycle, give 2 fractions six hours apart for 2 days in a row, and treatments must exclude the spinal cord after second cycle). Reassessment should be done at 1- to 3-week intervals.”
  • Principles of Systemic Therapy (CHEM-A)
    • Squamous cell cancers; Nasopharynx
      • The second bullet was revised for clarity: “Cisplatin + RT without adjuvant chemotherapy“(category 2B).
    • For “Recurrent, unresectable, or metastatic (incurable)” disease, single-agent ifosfamide and bleomycin were removed as treatment options.
  • Principles of Dental Evaluation and Management (DENT-A)
    • Under “Goals of Dental Management Post-treatment, a new recommendation was added: “Consultation with treating radiation oncologist is recommended before considering implants or extraction.”

For the complete updated versions of the NCCN Guidelines, the NCCN Compendium®, and the NCCN Chemotherapy Order Templates (NCCN Templates®), please visit NCCN.org.

To access the NCCN Biomarkers Compendium®, please visit NCCN.org/biomarkers.

To view the NCCN Guidelines for Patients®, please visit NCCN.org/patients.

Free NCCN Guidelines apps iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps

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