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NCCN臨床實踐指南汨非小細胞肺癌(2020.V6)要點NCCNClinicalPracticeGuidelinesinOncology(NCCNGuidelines3}Non-SmallCellLung

CancerVersion2.2020—December23,2019NCCN.org2019年12月,美國國家綜合癌癥網(wǎng)絡(NCCN)發(fā)布了非小細胞肺癌(NSCLC)指南2020年第2版,相對于2019版,新版指南系統(tǒng)性治療方面又有哪些變化呢?讓我們一探究竟。1、靶向治療EGFR突變陽性患者的一線治療(NSCLC-19)Th^raigyfIMSGLQtHElrrwrlini滬{category' *pr°flresE,w1Th^raigyfIMSGLQtHErtq|inibpp(cvVvgorv1]orAffaftinlb^ 11OfQ^fltinlbP*1<tMegpry卄or0&comiErtq|inibpp(cvVvgorv1]orAffaftinlb^ 11OfQ^fltinlbP*1<tMegpry卄or0&comi,tinil3p,1(category1)W8Erlotinib+iRmninidruntSb!ll苦pfuiin匚£11諒円Ciixon^ianuBsertoiinita+iw訊啦儀詢汕眄“2B}Pro-gr口昭ionCompletepiAnnedlsystemicther^pv^Includingnuilntwan^itharapy,orinleriuplLfollowedbyoskiDBrElnlb(prefairgud^ arEoliiilb0r.afatlnibor^cAtinjbordacomltiini^bwsrifftlnib+nunuciruma^granatinito+(Cfl|pg0ry2B)?iprckgreselon*Prx>gr?ssioniSeeSiJbMquflinl:Tti^r^i^|NSCL^2pF仙令理口uirntTharapy氓軌:LG和k泡PT町肓M袖d?aila「耳叱BoqijTKtif帥冊幗isfiN9CL~0).0£訊MratiteiiEE=rapY心.3陽佃甜o『制匕塗就匕DsassaINSCLJIuPFFarpcrlzirnancE!-AIajx0-4.柬IFsysiftmccihwapyRrgiTBsnsnfnind;Jinirrmure?di-ffrkFoinlrikitafasr.physkian*卡hcmlHhetawaiterfffirlonghnIL山ftcJsuchdnj申and悶Inreadingad^wM:evftfitswTiancoaibinlngiehsckpoincinNbUarB^HtiCBfnerGr^.SctioerTetiAJSArtourKGBRiz/iH.,ei3l.Septra-inmune-fetai&d evenneareKHmusn?罰tiPtl-(L]1blm*曲科hiiJbs-i7iwtint!.Ari仃g出巫山玄側:的亠B4£OslvrnaY,Taiiindlc7,丫磚艮TbjaAEGFR-TKJ'MBauEiatediribfiabtKdJpntuirKMiiiiiiriR/^luniafe-twatedpaiienhwithnofi-smaNodlkmgGanGer」ALIAOnffil20^41112-1115;AhnMdYingJ,YuHield'Dsmerlinbeambinedwthdurv^iijmabinEGFR-muhrtlflan-?iraHcelllurgcancsr:rj^uIbfromtwTATTONphssaibInal.JThoracOnwl2Q-1t.11:$1l£&fEt?!,Cilte個forIrefllrerM#tiBwaoiZKnafr:no^-squafmxjBNSCLCsndlno臨centhislaryafliernoptjaj&蚩■站FC^^pprqvcd&KJ5m|gF15.gnflporgpr^K?SUftSliMcMbwiCEurrflb,(2020.V2)

新增:厄洛替尼+雷莫蘆單抗作為“其他推薦”治療方案,屬于2A類。厄洛替尼+貝伐珠單抗作為“特殊情況下有用”的治療選擇,屬于 2B類。(2020.V1)新增了一條關于系統(tǒng)性治療的腳注說明:如果系統(tǒng)性治療方案中包含免疫檢查點抑制劑,則醫(yī)生應注意此類藥物的半衰期較長,并且當將檢查點抑制劑與奧西替尼聯(lián)合使用時應報告不良事件的數(shù)據(jù)。奧西替尼治療中進展的后續(xù)治療(NSCLC-20)?Conode『deflnMvelocaltherapySABRorcurg^ry)forlimited歸石ion評Brain *■S^mptDfnBlic■ContinueBrain *■S^mptDfnBlicProgre&slcn,bbs?therapy1Progre&slcn,bbs?therapy1^1**(crviiiulEliplelaslon^,netedbelow■SeeNCCNGuidelin^isfgrCNSGan^r>-Consjdfirdeflnfivelocaltharapy(eg,SABRorsurgeryeConttnuBwlrueriiniborBSwsubsequentthieiinapyformuhiplelesions,帕啲belowSeaInitialsy&Lernic options**4**SquamansCell.C^rciTOma J*"lni^je?rguid?iiFleiirwl方陽Huriiu-dn4jptO1fbise*K;ltfd 泌也=iSsi!鳳叩佇/比勺凹時”電o」商出町 .削可![N-SGL-^GJ-"■5己己Tar?i*5lBiTiesiBpy『口rMYrHnc皀d口1 0&巫己[hfiULNl.1 nfphrnnrn?nonin;utiseiqipntK'inlswhorincLiri'tinu^E右FFtIWlIf日加heflaredccij^.nft^tariEGFflTKI?*Considerabicris^nAtime*pusgre-KXinnInMe口皿SCLC也JwTnmi&icri■、AtjGffitj*uKimn應mfljftw心ansi伽rdinpatenig dtsetse:Drpgncsgj-cric<iEGFRTKiEhoragy**The曲5intheM^nr-linc-5eBngsuggwlth刖PD-1|PD4J冰hclqimgnq^hcrsipy詬lewcff^drvp.iiTrspecliv?-<rfPO-Ll卵pnwsimirEQFR皿U<4N$<XC(2020.V1)對于有癥狀的多發(fā)病灶,新增1條腳注說明:在進展時考慮進行活檢以排除SCLC轉化。厄洛替尼、阿法替尼、吉非替尼或達克替尼治療中進展的后續(xù)治療(NSCLC-21)

A^^rThpkH'Yiatlc-^ramu匚l「Lm;i口<MTbevMHuimdbLaratlnlls,ril>.ardacamJ-HnlbH-Con&Klerda-fini^velocaltherapy(eg,SAfilRA^^rThpkH'Yiatlc-^ramu匚l「Lm;i口<MTbevMHuimdbLaratlnlls,ril>.ardacamJ-HnlbH-Con&Klerda-fini^velocaltherapy(eg,SAfilR&surgory)torIImtted”QsInwrEJnl13^(11T79D秸料『匚打*g>ory1|igrCanUnuucrloUnlH±fr^nuelrumsborEmvsctzuorafatln血 gefltlnlbardacomrunlb■Considerde41nftlv&localm^rapy(eg,3RS)brIfpmgrosslon?rg口|lN5CL-2C;>ProgrBsslon,sad■h?rapy啊**ligrmiiltJpleles-lonB.flowdb6k>wCantinLMcrl^llriib±iwnu^irurabor薊從曲亡阪m由orar-atlnlbwgentlnlbofdacomltJnlb11-麻也斛£(州0口陽£|締6忌fChT^iW呂匚■GonslderdeHniUve1loc^lIh&rapy(eg,呂悶RorsupgerylTa亡口rrilnuoo>rl口tinlb1[ramuclrurnjibarliMvacIz*umab^lorafjtlnlborgefltlnlbordJic<?nh:lnibIfprogrosalion,,fan-[N$CL-2p)tfprograssKin.sce111。2呻刊**tarmultiplyfifllcT口gJg*ForniijgiJp層iMlon呂belowtfprogresskin.see■Iwrsg甲刊tormuhiph加lcm?.nowdbelowS?i?lFiJliafli&ysliifnicItierapyoptlonfi^*1?口ESiEinixr.gi問SifIoriilBMn口HS■£屜I0電FPirngTHYN&tLrjlI阿Forpfli sUiLuhCH."€rtBnaivIr-MlmHilbevacuumgbrwn-K|mrTWUQ-nSClC.am#nohistorydfwmoptynis11Be*^rc打簾砂RenomenoirEdbKlofpalB<f3-*twdrsconUnunEGFRTKI.ffdneoseftnre-ooan.re^iriECfRTH.UJCoriHcfeiabDfH^XUnWof蘆轉曲ibnLbluitfDuISCLCb^mf&rma'kiii.^AlKhts+ainuMmai!mayfc-c-oon^seredInpatentsm±i比竺^孟pfagr?5M3nanEGFRTKJ也巴r尋yeTrwdaLainUid-^eand-hnaNtlup Ib^lPD-1iFD-LI州biarrnonoltiar^yfciId込arhadne仍皚琴代cbw&PC-L1npnai^n.mEGFff+is>U-K+N5CLCM kh^uldbA砂曲二■■?!*越些1百陽i&i5E^RRTKH.巾fEhATT⑷MMiXd£iWiIIplriAriU-bAi^d[&^巧tfir刪pliM;IiMuA4lAAMI .th閹t■琴AyE南唱埠pUpngl-f喲:4ynmenjJ詞曰衛(wèi)如<旳詩呻丫岬何H)妙沁rQRng曲亦諏辟哄葉喻plppn?.伽叩F^ngJ"Gon&dcfasrirf^ltii](re^nleu口fTTMMi lexprogreu^w曆phinwinin^Hdisease-.InIheBkxim^liidy,a?mcnnt)wotu?dat1€Dmg."InTiibF*idETiijMphodiOIII*UUiof日陽pui/Mnl&wWibi*dhmftUdrija£Ac\w>關曲耳起曲ksrHY^ilnunlIn1hA■MdlM&twainnwaulAu^3n±jdmiolhar住p&uii(2020.V1)對于有癥狀的多發(fā)病灶,腳注說明作了修改:對于進行性軟腦膜病,考慮給予奧希替尼(無論T790M狀態(tài)如何)或厄洛替尼脈沖式給藥。在Bloom研究中,奧西替尼的使用劑量為160mg。ROS1重排陽性患者的一線治療和后續(xù)治療(NSCLC-25)(pretenr&d)arD&rlOnlbIgriLrtinij口FInltifiJsyeiwnictlie-rapya(pretenr&d)arD&rlOnlbIgriLrtinij口FInltifiJsyeiwnictlie-rapya■曲fix/siyiwins殆―肖小<*rSQmni-cij',Ct-IlCarciBicf7!HiNSCu-J';LoH^llnih□ifSee:IniiLiaJs/sceffikEhtra^y£?pEldriAArRin<x:jirc>n.-rfna^NSCl-jQiC?r呂OzBEdXj/畔劇1£云fCiriMiQ『N!Sd34*」駅rPTrcJptesolMdKbiarand日》om岀唸fAmIfhs:N旳L£ib EeraoF^yjdvmrK與uccMet3gbt!yDBE3flE<N5UL~il卻ForpeformarKCSULU'S-(£3-■Beware&Ij>bphenarre*nnins-ubselofiMrterrlsw<iddcconlinue-TKJ.IfaiHascIhrcaccuin.mtiri.TKIvM>bijV(2020.V1)對于一線治療后進展,新增1條腳注說明:應謹防一些亞群患者在停用TKI抑制劑后出現(xiàn)復燃現(xiàn)象。如果發(fā)生復燃,必須重新啟用TKI抑制劑。PD匕囂s1£(2」%)lmEGF?°AL廠RosrBRAF蓉^BfflBl^llKWUKAtezo-N'umabsss3?ltt3lffi^Q蓉Bn(NSCLG28.29)stEKIPRfnEim_QIMPDUH一VE詩呂^化Fnw-Llffl^snHg書-jrTogg£s-drtH's.s.lns.nMw_.=.+EA£i?a+p-mibro一llummb-caiaAQV-II-$匚■詒rwdnIssirx-3MMMl-M4E3?4&r?*3ft94SB£>^ax9KaE$8i空3-3_-s=3s_nwprunornA?

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\n卅THCDfldWErsmD=sr.BI.nncl*"_J3?0-F5LW-F.tfzwn一im£Jb+■豆一-nlL自ab晉jllr-rLl-JyM**會^nah¥.B豈1.凸1oc■當FCA-^LE也mpzsAs-rcp"置£UF*LUJbMEUMEwFn?3Duf=0rnc3np43o^fi--iBXTB_EQFH3E-嚴1rfhbnLHHr-Lay-rldkJd^.LWspimu^RHG=0Hfp~hLUUHIILrEc-EtBE?s^SIiawisl-BSS.^-I5w±.e-g電8=-sn^gyflv-44-3』Ha-.185a-Jni<555§SRia-fi3ncrffLXE.JafN3CL?二宮ujmw■呈-3a?§£-E=-X3卡HFrmcPD-L」畫¥魯EHiEGWE?區(qū)嚴FKIDult吧DUH-Q3Dgn量蠱嘗HECM2PO-USEVSIUSPCMJ豐JX畫BoflHals?ffu&nlwC4=nN23nR-uSep5-^bm需ThgrupyIpf^effs^sirjal『*f!r于*Us^a3a£u^aaGalTzQnwE-K:gtH應Hwb^lrhsMirvpenl菩餐fl5_0£3EIfaildk匸uLF*LM-i*f“rLI1/IJKiillMubc¥IH£.£Er艮<jBnn-=Kxk*r-h3&rBn£^5--.-XH-£-txK-E&PHUtkiH-vti=-;:-_-爼g二i-.333.vnIhrrBpy.,HPHI*n-5d3auu*7£lS3--?9a.=■flT--a■Sj^a-S3-1□1■pe^bi克if豈甲:4rbap4Hrvig4MHMU:blfnn-4MkndPM-I?舍?審r~PFogFmrlErtnurboHarlEnH口筈三卜vaadnssa+pc'mbfqHumubEtgwy1一gEl-alMG宣lYBnd&d"?rbaDs*-*EalmM£4^s.3_s■_5-nHnff-uvsv*ta-b<rn3kaundFurlEE'kai一+UEDeNES^nfinss.-gMnubid*CLg?M”a-gma-ITIDnlflcA-£hnid4n1?<rw-^=3C33_M「rpmRTmw"3lrbQplart132IKK-@"s.LbiJmklfrEnELpac!=E£】+p.frbB-uldnublEbgqJ¥-普□syfiDfnKThndpKc>『^3YC3M-HS3LfgubscnLKrri:Tlwdll劣aNm>&=SUS53亠鄆EE2A漲。(2020.V2)■f4a*ijp<:ffqAn-^v"一?MM.I6_.3krH^r^lThBcawm-Alc^mdwfg帛.理a-孟門nF"-5JIE電E-F*LhyE.芯色uhbbIt-=:^VAB?JA?Gk=Mt9£rOQ-^.k^HvnxF3■-fb-nubriNiCfih尸1W1-U3-qj-1c&4^71_s-a35£4a33aia-n-*31-sJis^—sisiKS1Elgen^<rpf^not巳Ms88S5-fcffJW04JQ.EcdldIxka-¥ss?sex-*IQraHIWvrldlc-stD^ekfE^wltesrwL^l宦一EBMmu-gTn卅曲+n}刪n}臊毬?+Atezo-izumab亠-Tfr兇=?詳?咄"吵詢謝刪、a4-(宜確fflHHNSCL—29)匕5&U-BGc『gjmgpzumEMrwEh^q-^nl??"?-PH亍cir53_alflc3J言Dry8^xs■i『IMTflLLJUTUhllcsrbcfdMIn^MrrMLrwrespm^cflD口^ElufnrrhfiFJP^aruui&MqulThmupyy—dJaluwgMcumaorTu盤一黑叮M聖nrXSJ7nFrR3M_^RK&7-3aassara33f43□■■『mFEr=Eum=Tk±.wi-±,-=qFm」=131=fk3ft-zc*7kukp*-e-7&..&£AUXSETa-x^^.-Br-rlxvrfbx3H■plmpy?=??W_C3S40O733aiITa'^cxr^--if-ff-^_J353--y曇IEnifpenb^-IMTUblurtoIMIJVkHclIga.orLtMJmMnlndPACHaMdv唱呂s-?u£i^sfr-gB壬專En?,FD4lH-f0^-3rEm霽53_KFEFN&一IWJP-TaNivolumab+ipilimumab作為"特殊情況下有用”的治療選擇,屬于2A類。a如果給予卡鉑+白蛋白紫杉醇+Atezolizumab,則Atezolizumab作為維持治療選擇。(2020.V1)a鱗癌一線治療方案中,刪除了“順鉑+紫杉醇/白蛋白紫杉醇+帕博利珠單抗”,僅推薦首選“卡鉑+紫杉醇/白蛋白紫杉醇+帕博利珠單抗”。a對于一線治療后緩解或穩(wěn)定的患者,刪除了密切觀察,建議都繼續(xù)進行維持治療。A對于腺癌、大細胞癌或病理類型不確定的NSCLC患者,維持治療方案刪除了“Atezolizumab和/或貝伐珠單抗”,僅推薦“Atezolizumab加貝伐珠單抗雙藥維持”。初始全身治療及后續(xù)治療(NSCLC-30)0『曲盯邛對Inou眸創(chuàng)蝕曲|QyDfiBtflWSIOl:cccpfl-mtbFfljcMlwgemclmblrwDrramuClruiti^b*dOCE血包IPnQgrw&lon0『曲盯邛對Inou眸創(chuàng)蝕曲|QyDfiBtflWSIOl:cccpfl-mtbFfljcMlwgemclmblrwDrramuClruiti^b*dOCE血包IPnQgrw&lon|TlMH£Wpgf:躋T耽nSubsflQUBnlIhunppyB曲刖尊H,■b?acLzurnabzwlk-k!呼寸ialire-bneperncIre-Hed'pl^inumreijmtmlui,Hnol4A*a3dfgi^en.ophoosforPSD-2hckide(nivtAjrrdb.ps^nbroizuvnab,exabrudDLKTiAiti)iJncrtair-l>;rji1ngnr^!ptmrfrriied慎]alng<i■甲?B|.gerncifcatunr-血和y2B).atrimewunnib+齡撤陽les財bySB),optowtsrPSIncyUttbwIsmprUwhiu0p4un^kHkiilhHrRfDgies'innarebwl密efHtv?uracirckni[ial!t!lalBd£E earoNCCNSsiJltilHlinesrPallialiysCar-gCormnuaOcri血aim的曲恥護"-Ba^^ijuinab(^dilft^ry1)Pfl-nifflrftKiBiCl(cirtWfV1)-BfiYaclzumab?pemetrexed1^Pbmbralizujnab■+p?me<rrM.?llt個嗎兇yTp+Al-oz^illzumabandtMYarClzunn.ab|GatGgpry1)?亠Gamdtablnit^calcgory2B'|orSwNchmikn加畠Mfii聞QPemelrexedT*nwlJ8OfuMfJA.血舉臼聞村Aecal.Early関IMf朋4*尊nw陽關誰E赴口別臨fibiSTrECellhjh^e^kiHr.IWEiHlIJMed3010:363:7&742ThedaLainlheEeoond-linc-seting54jgges1WatPtMiP<inlnhiurmemthergpy0也辭皿二伽程rrei&twlrws咁FOL1?<|

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