膀胱癌2022.v1（英文）-NCCN腫瘤臨床實(shí)踐指南

ForForimportantinformationregardingtheBCGshortageseeMS-10.AlsoseetheAUABCGShortageNotice.NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)BladderCancerNCCNGuidelinesforPatients?availableat/patientsVersion1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:36:57AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dex*ThomasW.Flaig,MD?/ChairUniversityofColoradoCancerCenter*PhilippeE.Spiess,MD,MS??/ViceChairMoffittCancerCenterstituteNeerajAgarwal,MD??HuntsmanCancerInstituteattheUniversityofUtahMBAeephenABoorjianMDCancerCenterMarkK.Buyyounouski,MD,MS§StanfordCancerInstituteKevinChan,MD?CityofHopeNationalMedicalCenterSamChang,MD,MBA??Vanderbilt-IngramCancerCenterTerenceFriedlander,MD?UCSFHelenDillerFamilyComprehensiveCancerCenterchardEGreenbergMDerCenterGuruMDComprehensiveCancerCenterloanKetteringCancerCenterJeanHoffman-Censits,MD?TheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsesPanelDisclosuresAmarKishan,MD§UCLAJonssonComprehensiveCancerCenterShilajitKundu,MD?rieComprehensiveCancerCenterrthwesternUniversitySubodhM.Lele,MD≠Fred&PamelaBuffettCancerCenterRonacMamtani,MD,MSCE?AbramsonCancerCenterattheUniversityofPennsylvaniaVitalyMargulis,MD?UTSouthwesternSimmonsComprehensiveCancerCenterOmarY.Mian,MD,PhD§CaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerInstituteJeffMichalski,MD,MBA§SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineJeffreyS.Montgomery,MD,MHSA?UniversityofMichiganRogelCancerCenterLakshminarayananNandagopal,MD?O'NealComprehensiveCancerCenteratUABLanceC.Pagliaro,MD?MayoClinicCancerCenterMamtaParikh,MD,MS?UCDavisComprehensiveCancerCenterAnthonyPatterson,MD?St.JudeChildren’sResearchHospital/TheUniversityofTennesseeeCenterElizabethR.Plimack,MD,MS?TFoxChaseCancerCentereOhioStateUniversityComprehensivecerCenterJamesCancerHospitaldSoloveResearchInstituteMarkA.Preston,MD,MPH?Dana-Farber/BrighamandWomen’senterKyleRichards,MD?UniversityofWisconsinCarboneCancerCenterWadeJ.Sexton,MD?MoffittCancerCenterArleneO.Siefker-Radtke,MD?TheUniversityofTexasJonathanTward,MD,PhD§HuntsmanCancerInstituteattheUniversityofUtahJonathanL.Wright,MD,MS?FredHutchinsonCancerResearchCenter/SeattleCancerCareAllianceLisaGurski,PhDMaryDwyer,MSCarlyJ.Cassara,MSc?Hematology/HematologyoncologyTInternalmedicine?Medicaloncology≠Pathology§Radiotherapy/Radiationoncology?Surgery/SurgicalOncology?Urology*DiscussionwritingcommitteememberVersion1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?UrothelialCarcinomaoftheUreter(UTT-2)?UrothelialCarcinomaoftheProstate(UCP-1)?PrimaryCarcinomaoftheUrethra(PCU-1)Staging(ST-1)rinciplesof?UrothelialCarcinomaoftheUreter(UTT-2)?UrothelialCarcinomaoftheProstate(UCP-1)?PrimaryCarcinomaoftheUrethra(PCU-1)Staging(ST-1)rinciplesofPathologyManagementBLCdexFindanNCCNMemberInstitution:/home/member-institutions.NCCNCategoriesofEvidenceandConsensus:Allrecommendationsarecategory2Aunlessotherwiseindicated.SeeNCCNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.ryoftheGuidelinesUpdates?ClinicalPresentationandInitialEvaluation(BL-1)?Non-MuscleInvasiveorTis,PrimaryEvaluation/SurgicalTreatment(BL-1)pRiskStratificationofNMIBC(BL-2)pManagementperNMIBCRiskGroup(BL-3)pManagementofPositiveUrineCytology(BL-4)?MuscleInvasiveorMetastatic,PrimaryEvaluation/SurgicalTreatment,AdditionalWorkup(BL-1)pStageII(cT2,N0)PrimaryandSubsequentTreatment(BL-5)pStageIIIBcTcTaNPrimaryandSubsequentTreatmentBLpStageIIIA(cT3,N0;cTpStageIIIBcTcTaNPrimaryandSubsequentTreatmentBLntBLPrinciplesofSurgicalManagementBLBinciplesofPrinciplesofSurgicalManagementBLB?BladderCancer:Non-UrothelialandUrothelialwithVariantHistology(BL-D)?Follow-up(BL-E)inciplesofRadiationManagementofInvasiveDiseaseBLH-lhL-F)linciplesofRadiationManagementofInvasiveDiseaseBLHTheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.endometrialcancer)FootnoteswvolumeTaurothelialcancerPostTURintravesicalchemotherapyshouldnotbeutilizedifconcernforbladderperforationisidentifiedSeePrinciplesofIntravesicalTreatmentBLFHeadermodified:AdjuvanttreatmentSubsequenttreatmentendometrialcancer)FootnoteswvolumeTaurothelialcancerPostTURintravesicalchemotherapyshouldnotbeutilizedifconcernforbladderperforationisidentifiedSeePrinciplesofIntravesicalTreatmentBLFHeadermodified:AdjuvanttreatmentSubsequenttreatmentPreferredregimenmodifiedPembrolizumab(category1post-platinum)blenomaofthebladderaddedAmetaanalysisofindividualpatientdatafromtworandomizedphaseIIIstudiesBCandBCONfoundthatahypofractionatedscheduleofGyin20fractionsover4weeksisnoninferiortothestandardfractionationscheduleof64Gyin32fractionsover6.5weeksforbothinvasivelocalcontrolandtoxicityandthatthehypofractionatedscheduleissuperiorregardinginvasivelocalcontrol.extentpossibleOnthispage,thetermsmaleandfemalerefertosexChemotherapyrecommendationswererevisedtorefertotheSCLCguidelinesforbothneoadjuvantandmetastaticferenceswereadjustedaccordinglywhenfeasible.SubsequenttreatmentmodifiedObservationSurveillanceforLynchsyndromeyatpresentation,personalhistoryofcolon/FootnoteaddedlinkingtotheColorectalGeneticsGLforlynchsyndromeBLGofandBL-G7of7dexVersionoftheNCCNGuidelinesforBladderCancerfromVersionincludeBL-1BulletBulletaddedFamilyhistory;forthoseathighrisk,considerevaluationurrenceratebyforselectedpatientsMosturrenceratebyforselectedpatientsMostefficaciousinpatientsBL-4SubSubbulletadded:Considernonurinarytractsource(eg,vagina,cervix,ctumandctumandreferraltogynecologyorotherspecialistasappropriate?IfpatientprefersbladderpreservationorisunabletoundergoententtreatmentBL-8?SubsequentBullet5modified:AdditionalstagingifprimaryBullet5modified:Additionalstagingifprimarycarcinomaofnon-RadicalCystectomy/Cystoprostatectomythatpreservetheuterus,vagina,and/orovariesshouldbeemployed?Bulletthatpreservetheuterus,vagina,and/orovariesshouldbeemployedlusiveofindividualsofallsexualandgenderidentitiestolusiveofindividualsofallsexualandgenderidentitiestothegreatestassignedatbirth.AnySmallCellComponentassignedatbirth.AnySmallCellComponent(orneuroendocrinefeatures)BL-E4of6Bullet2modified:Bullet2modified:CTchest(preferred)orchestx-rayorevery3–6moearsBulletmodifiedearsBulletmodifiedCTchest(preferred)orchestx-rayannuallyBullet2modified:Bullet2modified:CTchest(preferred)orchestx-rayevery3–6moforMIBCearsBulletmodifiedearsBulletmodifiedCTchest(preferred)orchestx-rayannuallyLGofLGoftastaticDiseaseStageIVpostplatinumorotherchemotherapytastaticDiseaseStageIVpostplatinumorotherchemotherapyplatinumoranimmunecheckpointinhibitorinfirst-line.?Footnoteremoved:Alsoforplatinumoranimmunecheckpointinhibitorinfirst-line.BL-G5of7PreferredRegimensModified:isplatinandFU?Preferredregimens(doubletchemotherapyisplatinandFU?CisplatinandpaclitaxelOtherRecommendedRegimensModified:?Cisplatinand5-FULowdosegemcitabine(Lowdosegemcitabine(category2Bcategory2A)LHofLHofVersion1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.nt?Footnoteadded:NCCNrecommendationshavebeendevelopedtobelusiveofindividualsofallsexualandgenderidentitiestothegreatestextentpossibleOnthispage,thetermsmaleandfemalent?Footnoteadded:NCCNrecommendationshavebeendevelopedtobelusiveofindividualsofallsexualandgenderidentitiestothegreatestextentpossibleOnthispage,thetermsmaleandfemalerefertosexassignedatbirth.nectomyandconsiderneoadjuvantchemotherapyinselectedextentpossibleOnthispage,thetermsmaleandfemalerefertosexdexVersionoftheNCCNGuidelinesforBladderCancerfromVersionincludeBL-H2of3Footnoteslusiveofindividualsofallsexualandgenderidentitiestolusiveofindividualsofallsexualandgenderidentitiestothegreatestassignedatbirth.assignedatbirth.BulletBulletmodifiedUreteroscopyandbiopsyorpercutaneousbiopsyand/orselectivewashingsUTT-2BulletBulletmodified:UreteroscopyandbiopsyorpercutaneousbiopsyUpperpathmodifiedEndoscopicresection(lowgrade)UpperpathmodifiedEndoscopicresection(lowgrade)ithhighgradediseasePCUithhighgradediseaseFootnotesINTROVersion1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:36:57AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexINTRODUCTIONNCCNandtheNCCNBladderCancerPanelbelievethatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged. colon/endometrialMetastaticbcancer)h colon/endometrialMetastaticbcancer)h(StageIVBSeeBL-10Suspiciontumor(TURBT)chemotherapywithin24collectingsystem(bimanual)dexCLINICALINITIALPRESUMPTIVECCLINICALINITIALPRESUMPTIVECLINICALADDITIONALSTAGINGWORKUPPRESENTATIONEVALUATIONaSURGICALTREATMENTHPHPcTagConsidercytologyNon-muscleinvasiveupperurinarytractanesthesia(EUA)TiscTagConsidercytologyNon-muscleinvasiveupperurinarytractanesthesia(EUA)TisaFortoolstoaidoptimalassessmentandmanagementofolderadultswithcancer,seeNCCNGuidelinesforOlderAdultOncology.bSeePrinciplesofImagingforBladder/UrothelialCancer(BL-A).cSeePrinciplesofSurgicalManagement(BL-B).dImmediateintravesicalchemotherapyreducestherecurrencerateby35%forselectedpatients.Mostefficaciousinpatientswithlow-grade,low-volumeTaurothelialcancer.Post-TURBTintravesicalchemotherapyshouldnotbeutilizedifconcernforbladderperforation.SeePrinciplesofIntravesicalTreatment(BL-F).ePrinciplesofPathologyManagement(BLSee-C).fSeeBladderCancer:Non-UrothelialandUrothelialwithVariantHistology(BL-D).gThemodifier“c”referstoclinicalstagingbasedonbimanualEUA,endoscopicsurgery(biopsyortransurethralresection),andimagingstudies.Themodifier“p”referstopathologicstagingbasedoncystectomyandlymphnodedissection.hSeeNCCNGuidelinesforGenetic/FamilialHigh-RiskAssessment:Colorectal.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.BL-1Version1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.orsuallyincompletemoriMIBCPrintedbyMinTangon3/14/20227:36:57AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.orsuallyincompletemoriMIBCBladderCancerdexRISKSTRATIFICATIONOFNMIBCLow-gradeNMIBCuallycompletesituCISuallycompletesituCISorTajResidualhgradeNMIBCwsNMIBC selectTajRepeatTURBTkhgradeNMIBCwsNMIBC selectTajRepeatTURBTkAUARiskStratificationforNonMuscleInvasiveBladderCancer*ManagementperNMIBCriskgroup(BL-3)teRisk?Papillaryurothelialneoplasmoflowmalignantpotential?Lowgradeurothelialcarcinomap≤3cmandpSolitary?LowgradeurothelialcarcinomapT1orp>3cmorpMultifocalorpRecurrencewithin1year?Highgradeurothelialcarcinomap≤3cmandpSolitaryniskfeaturesReproducedwithpermissionfromChangSSBoorjianSAChouRetalDiagnosisandtreatmentofnonmuscleinvasivebladdercancerAUA/SUOguideline.JUrol2016;196:1021.*Withineachoftheseriskstrataanindividualpatientmayhavemoreorlessconcerningfeaturesthatcaninfluencecare.ijHigh-volumetumors(largeorhighlymultifocal)areathighriskofresidualtumor.ConsiderrepeatTURBTforhigh-gradeTaparticularlyiflarge,and/ornomuscleinspecimen.kMuscleshouldbepresentinrepeatTURBTpathologyspecimenifpossible.lKamatAM,etal.JClinOncol2016;34:1935-1944.mMontironiR,etal.IntJSurgPathol2005;13:143-153.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.BL-2Version1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.toscopypositiveGroupandglyPrintedbyMinTangon3/14/20227:36:57AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.toscopypositiveGroupandglyBladderCancerdexMANAGEMENTPERNMIBCRISKGROUPAUARISKINITIALMANAGEMENTGROUP(SEEBL-2)LowSurveillanceo (preferred)IntermediateorS (preferred)IntermediateorSurveillancehnriskGp(preferred)FOLLOW-UP?Cytologypositivestoscopynegative?Imagingnegative?CytologypositivestoscopynegativelowBCGReclassify(preferred)BCGReclassify(preferred)AUARisknLymphovascularinvasion,prostaticurethralinvolvementoftumor,varianthistology(eg,micropapillary,plasmacytoid,sarcomatoid),T1withextensiveCIS.oShouldconsidersingleperioperativeinstillationofintravesicalchemotherapyattimeofTURBT.pSeePrinciplesofIntravesicalTherapy(BL-F).qOptionsforintravesicaltherapyforintermediate-riskdiseaseincludeBCGandchemotherapy;shouldconsiderBCGavailabilityindecision-making.rValrubicinisapprovedforBCG-refractoryCIS.sPembrolizumabisindicatedforthetreatmentofpatientswithBCG-unresponsive,high-riskNMIBCwithTis(withorwithoutpapillary)tumorswhoareineligiblefororhaveelectednottoundergocystectomy.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.embrolizumabinselectpatientssPrintedbyMinTangon3/14/20227:36:57AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.embrolizumabinselectpatientssNCCNGuidelinesVersion1.2022ManagementofPositiveUrineCytologydexRECURRENTORRECURRENTORPERSISTENTDISEASEFOLLOW-UPRESULTSEVALUATIONfinitialpositiveFollow-upat3mo,thenIfIfpriorBCG,maintenanceBCGp(optional)gativeologytestwithin3monthsfologytestwithin3monthsfrepeatedpositivePersistentPersistentPembrolizumab(inselectpatients)ssiesortransurethralbiopsystatecand?Cytologypositive?Imagingnegative?CystoscopynegativepCytologyofuppertractandtransurethralbiopsystatecand?Cytologypositive?Imagingnegative?CystoscopynegativepCytologyofuppertractandandcystoscopyc(andcystoscopyc(iflableandinarytractsourceeglableandinarytractsourceegvaginacervix,ectumandreferraltogynecologyortherspecialistasappropriate.iactSeeUpperGUTractTumorsUTT1)cSeePrinciplesofSurgicalManagement(BL-B).pSeePrinciplesofIntravesicalTreatment(BL-F).rValrubicinisapprovedforBCG-refractoryCIS.sPembrolizumabisindicatedforthetreatmentofpatientswithBCG-unresponsive,high-risk,non-muscleinvasivebladdercancerwithTis(withorwithoutpapillary)tumorswhoareineligiblefororhaveelectednottoundergocystectomy.tSeeFollow-up(BL-E).uIfnotacystectomycandidate,andrecurrenceiscTaorcT1,considerconcurrentchemoradiotherapy(category2BforcTa,category2AforcT1)oraclinicaltrial.SeePrinciplesofSystemicTherapy(BL-G5of7).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.BL-4Version1.2022,2/11/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.suspicionselectedpatientswithsolitarylesionPrintedbyMinTangon3/14/20227:36:57AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.suspicionselectedpatientswithsolitarylesiondderCancerdexCLINICALSTAGINGgStageII????ADDITIONALWORKUPbAbdominal/pelvicCTorMRIb,vifnotAbdominal/pelvicpreviouslydoneBonescanbBonescanbiforsymptomsofbonemetastasesEstimateGFRtoassesseligibilityforcisplatinwPRIMARYTREATMENTNeoadjuvantcisplatin-basedbyradicalcystectomycbyradicalcystectomyc(category1)Neoadjuvantcisplatin-basedcystectomyccystectomychighlyinasuitablelocation;noTis)orCystectomyaloneforthosenoteligibletoreceivecisplatin-basedchemotherapychemoradiotherapyyzaacategorychemoradiotherapyyzaacategory)Ifpatientprefersbladderpreservationorisunabletoundergocystectomy,Concurrentchemoradiotherapyy,z(preferred,category1)orRTzcctumorstatus2–3monthsafter treatmentcompletionztumorstatus2–3months aftertreatmentcompletionzTumorumorppSurgicalconsolidationcorTreatasmetastaticdisease(BL-10)anceSystemictherapyccorConcurrentchemoradiotherapyorRTalone(ifnopriorRT)y,zorapypTURBT±apypBestsupportivecare(SeeNCCNGuidelinesforPalliativeCare)HYPERLINK\l"_bookm