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NCCN Flash Update: NCCN Guidelines® and NCCN Compendium® Updated

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Vulvar Cancer (Squamous Cell Carcinoma). These NCCN Guidelines® are currently available as Version 1.2017.

  • A new section for “Principles of Imaging” that includes recommendations for “Initial Workup” and “Follow-up/Surveillance” was added to the Guidelines to clarify recommended modalities wherever imaging is mentioned. Recommendations for specific imaging modalities (ie, CT, PET, MRI) were removed from the algorithms and described in greater detail in the new imaging section. (VULVA-A)
  • The Discussion section was updated to reflect the changes in the algorithm (MS-1)
  • Workup (VULVA-1)
    • New bullet added: “Consider HPV testing.”
  • Evaluation of Response to EBRT + Concurrent Chemotherapy (VULVA-6)
    • “Clinically positive for residual tumor at primary site and/or nodes” pathway
      • After “Resect” and “Positive margins,” recommendation revised, “Consider additional individualized RT surgery, additional EBRT, and/or Chemotherapy Systemic therapy....”
      • After “Unresectable” recommendation revised, “Consider additional individualized RT EBRT, and/or Chemotherapy Systemic therapy....”
    • Footnote “n” regarding the consideration of biopsy of the tumor bed is new: “No sooner than 3 months from completion of treatment.”
  • Surveillance (VULVA-8)
    • Fifth bullet revised: “Patient education regarding symptoms of potential recurrence and vulvar dystrophy,   periodic self-examinations, lifestyle, obesity, exercise, sexual health (including vaginal dilator use and lubricants/moisturizers), smoking cessation, nutrition counseling, potential long-term and late effects of treatment...”
  • Site of Recurrence (VULVA-9)
    • Revised language: “Clinically Vulva-confined recurrence (nodes clinically negative), not previously irradiated.”
    • New pathway added: “Vulva-confined recurrences (nodes clinically negative), previously irradiated.”
  • Therapy for recurrence
    • New treatment option added after “Vulva-confined recurrence (nodes clinically negative), not previously irradiated”: “EBRT ± brachytherapy ± concurrent chemotherapy.” (VULVA-9)
    • After “Margins positive; LN(s) surgically or clinically negative,” recommendation revised, “Re-excision or EBRT ± brachytherapy ± concurrent chemotherapy (category 2B for concurrent chemotherapy)” (VULVA-9)
    • After “Margins positive; LN(s) surgically positive,” recommendation revised, “EBRT ± brachytherapy ± concurrent chemotherapy ± re-excision.” (VULVA-9)
    • Clinical nodal or distant recurrence (VULVA-10)
      • The pathways “Groin” and “Isolated pelvic nodal recurrence and no prior pelvic EBRT” were combined into one “Isolated groin/pelvic recurrence.”
      • Isolated groin/pelvic recurrence
        • After “No prior EBRT”: Recommendations revised:
          • “Consider resection of positive LN(s) ± inguinofemoral LN dissection.”
          • Fixed positive node(s) or large recurrence Unresectable node(s).”
      • After “Prior EBRT” a new option was added for “Consider resection in select cases” followed by “Consider systemic chemotherapy.”
  • Principles of Radiation Therapy (VULVA-C)
    • Under “General Principles” new bullets were added
      • RT is often used in the management of patients with vulvar cancer, as adjuvant therapy following initial surgery, as part of primary therapy in locally advanced disease, or for secondary therapy/palliation in recurrent/metastatic disease.
      • Radiation technique and doses are important to maximize tumor control while limiting adjacent normal tissue toxicity.
      • Historically a widely disparate range of approaches has been described. In an attempt to better standardize RT use and techniques, a recent international survey, with consequent recommendations, has been reported.
      • Acute effects during RT (eg, diarrhea, bladder irritation, fatigue, mucocutaneous reaction) are expected to some degree in most patients, and can be further accentuated by concurrent chemotherapy. These toxicities should be aggressively managed (eg, local skin care, symptomatic medications), and treatment breaks should be avoided or minimized. These acute effects generally resolve several weeks after completion of radiation.
      • Postoperative adjuvant treatment should be initiated as soon as adequate healing is achieved, preferably within 6–8 wks.”
  • Systemic Therapy (VULVA-D)
    • The following regimens were added as options under “Chemotherapy for Advanced, Recurrent/Metastatic Disease”:
      • Carboplatin
      • Carboplatin/paclitaxel (category 2B)
      • Paclitaxel (category 2B)
      • Erlotinib (category 2B)

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, 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.com/patients.

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

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