胸腺瘤和胸腺癌2022.v1（英文）-NCCN腫瘤臨床實(shí)踐指南

ThymomasandThymicNCCNClinicalPracticeGuidelinesinOncologyNCCNThymomasandThymicCarcinomasersionDecemberVersion1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomas*DavidS.Ettinger,MD/Chair?*DouglasE.Wood,MD/ViceChair?GregoryJ.Riely,MD,PhD/Lead?TDaraL.Aisner,MD,PhD≠WallaceAkerley,MD?JessicaR.Bauman,MD??AnkitBharat,MD?DeboraS.Bruno,MD,MS?JoeY.Chang,MD,PhD§LucianR.Chirieac,MD≠ThomasA.D’Amico,MD?MalcolmDeCamp,MD?ThomasJ.Dilling,MD,MS§JonathanDowell,MD?esPanelDisclosuresScottGettinger,MD?TTravisE.Grotz,MD?MatthewA.Gubens,MD,MS?AparnaHegde,MD?RudyP.Lackner,MD?MichaelLanuti,MD?JulesLin,MD?BillyW.Loo,Jr.,MD,PhD§ChristineM.Lovly,MD,PhD?RenatoG.Martins,MD,MPH?ErminiaMassarelli,MD,PhD?DanielMorgensztern,MD?ThomasNg,MD?TnUniviyotT9nn92299JoseM.Pacheco,MD?SandipP.Patel,MD??TJonathanRiess,MD?StevenE.Schild,MD§resaAShapiroMDPhDAditiP.Singh,MD?JamesStevenson,MD?AldaTam,MDфTaweeTanvetyanon,MD,MPH?JaneYanagawa,MD?StephenC.Yang,MD?EdwinYau,MD,PhD?HughesPhDloeybiloeybiiononooloeydln才91n6lm9bioin9岡6bio才n916qytM9bio6lonooloeyP2u1e91y\2u1eio6lonooloeyyPrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexFindanNCCNMemberInstitution:/home/member-institutions.dNCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.fGuidelinesUpdatesementTHYMeTHYMPrinciplesofSurgicalResection(THYM-A)PrinciplesofRadiationTherapy(THYM-B)WorldHealthOrganizationHistologicClassification(THYM-D)Staging(ST-1)TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatment.AnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicaltancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanyway.TheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2021.Version1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexersionoftheNCCNGuidelinesforThymomasandThymicCarcinomasfromVersionincludeTHYM-1?Footnoteamodified:Whenassessingamediastinalmass,detectionofthymicmalignancyversusthymiccystorthymichyperplasiacanbebetterdiscriminatedwithchestMRIcomparedtochestCT,potentiallyavoidinganunnecessarythymectomy.THYM-2?Footnotecmodified:Determinationofresectabilityshouldbemadebyathoracicsurgeon,withprimaryfocusonthoraciconcologyandinmultidisciplinaryconsultationwithmedicaloncologyasneeded.Resectabilityisdefinedascomplete(R0)resection.(alsoappliestoTHYM-4)THYM-B2of3?RadiationTechniquespBullet3modified:ComparedtoIMRT,protontherapyhasbeenshowntoimprovethedosimetryallowingbettersparingofthenormalorgans(lungs,heart,andesophagus)withfavorablelocalcontrolandtoxicity,andisappropriateforcertainpatients.THYM-C2of3?ThymicCarcinoma;OtherRecommendedpThefollowingregimenwasremoved:Octreotide(includingLAR)±prednisoneTHYM-D?Referenceupdated:MarxA,DetterbackF,MaromEM,etal.Tumoursofthethymus.In:WHOClassificationofTumoursEditorialBoard.Thoracictumours[Internet].Lyon(France):InternationalAgencyforResearchonCancer;2021[2021912].(WHOclassificationoftumoursseries,5thed.;vol.5).Availablefrom:/chapters/35.THYM-D2of2?ThymomaCarcinomaSubtypesupdated.PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexINITIALEVALUATION?ChestCTwithcontrasta?Serumbeta-HCG,AFP,ifappropriate?CBC,platelets?FDGPET/CTscan(whole-bodyorskullbasetomid-thigh),asclinicallyindicated?Pulmonaryfunctiontests,asclinicallyindicated?ChestMRIwithcontrast,asmictumorlikelybitialManagementmictumorlikelybnesasappropriatenesasappropriatehymictumoridelinesforhymictumoridelinesforaWhenassessingamediastinalmass,detectionofthymicmalignancyversusthymiccystorthymichyperplasiacanbebetterdiscriminatedwithchestMRIcomparedtochestCT,potentiallyavoidinganunnecessarythymectomy.bWell-definedanteriormediastinalmassinthethymicbed,tumormarkersnegative,absenceofotheradenopathy,andabsenceofcontinuitywiththethyroid.MaromEM,etal.JThoracOncol2011;6:S1717-S1723.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.THYM-1Version1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.yisnotfeasiblePrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.yisnotfeasibleNCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexINITIALMANAGEMENTThymictumorlikelybAllpatientsshouldbemanagedbyamultidisciplinaryteamwithexperienceinthemanagementofthymomasandthymiccarcinomasllyresectablecllyLocallyadvanced,Surgicalresectiond(totalhymectomyandcompletesionoftumornbiopsynbiopsyornotdiagnostic(avoidtranspleuralapproach)SeePostoperativeManagement(THYM-3)bWell-definedanteriormediastinalmassinthethymicbed,tumormarkersnegative,absenceofotheradenopathy,andabsenceofcontinuitywiththethyroid.MaromEM,etal.JThoracOncol2011;6:S1717-S1723.cDeterminationofresectabilityshouldbemadebyathoracicsurgeon,withprimaryfocusonthoraciconcologyandinmultidisciplinaryconsultationwithmedicaloncologyasneeded.Resectabilityisdefinedascomplete(R0)resection.dSeePrinciplesofSurgicalResection(THYM-A).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.THYM-2Version1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexPOSTOPERATIVETREATMENTPOSTOPERATIVEMANAGEMENTionR0resectioneR1resectioneR2resectioneThymoma,nocapsularinvasionorthymiccarcinoma,Masaoka-KogastageIchestCTiwithcontrasteverychestCTiwithcontrasteveryfor5yforthymiccarcinomaanddisease,seeTHYM-4momaorthymicinomacapsulartmaThymiccarcinomamaThymiccarcinomaConsiderPostoperativeRTfiveRTfiveRTfmotherapyghapyghDeinitiveapyghDeinitiveRTf+chemotherapyg,hhenannuallyjforyforthymiccarcinomaand10yformomachestCTiwithcontrastchestCTiwithcontrastevery6disease,seeTHYM-4eR0=noresidualtumor,R1=microscopicresidualtumor,R2=macroscopicresidualtumor.fSeePrinciplesofRadiationTherapy(THYM-B).gSeePrinciplesofSystemicTherapyforThymomasandThymicCarcinomas(THYM-C).hThereisadiversityofopinionontreatmentapproach.RuffiniE,etal.EurJCardiothoracSurg2019;55:601-609.iMRIisanappropriatealternativetoCTincertainclinicalsituations.jThedurationforsurveillancehasnotbeenestablished.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.THYM-3Version1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.eillanceforhntchemoradiationfgchestCTiwithteveryResectablec,dtCTiforyenannuallyjforyforthymicwithcontrastFDGPETCTChemotherapyg-ltomid-thigh)asclinicallyeillanceforhntchemoradiationfgchestCTiwithteveryResectablec,dtCTiforyenannuallyjforyforthymicwithcontrastFDGPETCTChemotherapyg-ltomid-thigh)asclinicallyindicatedRTf±nresectablecapygsralsNCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasLOCALLYADVANCED,ADVANCED,ORRECURRENTDISEASETREATMENTThymomaorthymiccarcinoma:Allpatientsshouldbemanagedbyamultidisciplinaryteamwithexperienceinthemanagementofthymomasandthymiccarcinomaslresectiondofprimarytumorandisolatedmlrnomaand10ynomaandPotentiallyresectablec,dSurgerydConsiderchemotherapygEvidenceofextrathoracicmetastasesChemotherapygqeeebL!uc!bIe2oLenLa!cgI匕e2ec在!ou(」H人W-V).LeeebL!uc!bIe2oL匕gq!g在!ou」peLgb入(」H人W-B).aeeebL!uc!bIe2oLe入2在e山!c」peLgb入LoL」p入山o山g2guq」p入山!cCgLc!uo山g2(」H人W-C).CuceLgucIucgIngouNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.THYM-4八eL2!ou).s0ss,)s\ss\s)Qs0s)dg在!ougICo山bLepeu2!^eCguceLde在MoLk(dCCd),VIIL!ap在2Le2eL^eq.dCCdCn!qeI!ue2guq在p!2!IIn2在Lg在!ou山g入uo在peLebLoqnceq!ugu入LoL山M!在pon在在peexbLe22ML!在在eubeL山!22!ouoLdCCd.PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexPRINCIPLESOFSURGICALRESECTION?Surgicalresectionshouldbeperformedoncarefullyevaluatedpatientsbythoracicsurgeonswithexperienceinmanagingthymomasandthymiccarcinomas.Locallyadvanced(unresectable)andresectablestage≥IIcasesshouldbediscussedandevaluatedbyamultidisciplinaryteam.?Surgicalbiopsyshouldbeavoidedifaresectablethymomaisstronglysuspectedbasedonclinicalandradiologicfeaturesbecauseofthesubstantialpotentialoftumorseedingwhenthetumorcapsuleisviolated.?BiopsyofapossiblethymomashouldavoidatranspleuralapproachbecauseofthesubstantialriskofconvertingastageIthymomatoastageIVthymomabyspreadingtumorwithinthepleuralspace.?Priortosurgery,patientsshouldbeevaluatedforsignsandsymptomsofmyastheniagravisandshouldbemedicallycontrolledpriortoundergoingsurgicalresection.?Goalofsurgeryiscompleteexcisionofthelesionwithtotalthymectomyandcompleteresectionofcontiguousandnoncontiguousdisease.?Completeresectionmayrequiretheresectionofadjacentstructures,includingthepericardium,phrenicnerve,pleura,lung,andevenmajorvascularstructures.Bilateralphrenicnerveresectionshouldbeavoidedduetosevererespiratorymorbidity.?Surgicalclipsshouldbeplacedatthetimeofresectiontoareasofclosemargins,residualdisease,ortumoradhesiontounresectednormalstructurestohelpguideaccurateradiationtherapywhenindicated.?Duringthymectomy,thepleuralsurfacesshouldbeexaminedforpleuralmetastases.Iffeasible,resectionofpleuralmetastasestoachievecompletegrossresectionisappropriate.?Minimallyinvasiveproceduresarenotroutinelyrecommendedduetothelackoflong-termdata.However,minimallyinvasiveproceduresmaybeconsideredforclinicalstageI–IIifalloncologicgoalscanbemetasinstandardprocedures,andifperformedinspecializedcentersbysurgeonswithexperienceinthesetechniques.1-61PennathurA,QureshiI,SchubertMJ,etal.Comparisonofsurgicaltechniquesforearlystagethymoma:feasibilityofminimallyinvasivethymectomyandcomparisonwithopenresection.JThoracCardiovascSurg2011;141:694-701.2YeB,TantaiJC,GeXX,etal.Surgicaltechniquesforearly-stagethymoma:video-assistedthorascopicthymectomyversustranssternalthymectomy.JThoracCardiovascSurg2014;147:1599-1603.3SakamakiY,OdaT,KanazawaG,etal.Intermediate-termoncologicoutcomesaftervideo-assistedthorascopicthymectomyforearly-stagethymoma.JThoracCardiovascSurg2014;148:1230-1237.4ManolyI,WhistanceRN,SreekumarR,etal.Earlyandmid-termoutcomesoftrans-sternalandvideo-assistedthoracoscopicsurgeryforthymoma.EurJCardiothoracSurg2014;45:e187-193.5LiuTJ,LinMW,HsiehMS,etal.Video-assistedthoracoscopicsurgicalthymectomytotreatearlythymoma:acomparisonwiththeconventionaltranssternalapproach.AnnSurgOncol2014;322-328.6FriedantAJ,HandorfEA,SuS,ScottWJ.Minimallyinvasiveversusopenthymectomyforthymicmalignancies:systematicreviewandmeta-analysis.JThoracOncol2016;11:30-38.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.THYM-AVersion1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexPRINCIPLESOFRADIATIONTHERAPY1,2GeneralPrinciples?RecommendationsregardingRTshouldbemadebyradiationoncologistswithexperienceinmanagingthymomasandthymiccarcinomas.?DefinitiveRTshouldbegivenforpatientswithunresectabledisease(ifdiseaseprogressesoninductionchemotherapy),incompletelyresectedinvasivethymomaorthymiccarcinoma,orasadjuvanttherapyafterchemotherapyandsurgeryforpatientswithlocallyadvanceddisease.?Radiationoncologistsneedtocommunicatewiththesurgeontoreviewtheoperativefindingsandtohelpdeterminethetargetvolumeatrisk.Theyalsoneedtocommunicatewiththepathologistregardingthedetailedpathologyonhistology,diseaseextentsuchasextracapsularextension,andsurgicalmargins.?Thereviewofpreoperativeimagingandco-registrationofpreoperativeimagingintotheplanningsystemarehelpfulindefiningtreatmentvolumes.?AcronymsandabbreviationsforRTarethesameaslistedinthePrinciplesofRadiationTherapyfortheNCCNGuidelinesforNon-SmallCellLungCancer.e?ThedoseandfractionationschemesofRTdependontheindicationoftheradiationandthecompletenessofsurgicalresectioninpostoperativecases.?Adoseof60to70Gyshouldbegiventopatientswithunresectabledisease.?Foradjuvanttreatment,theradiationdoseconsistsof45to50Gyforclear/closemarginsand54Gyformicroscopicallypositiveresectionmargins.Atotaldoseof60–70Gyshouldbegiventopatientswithgrossresidualdisease(similartopatientswithunresectabledisease),3,4whenconventionalfractionation(1.8–2.0Gyperdailyfraction)isapplied.?Dependingonthetreatmentobjectivesinthepalliativesetting,typicalpalliativedoses(eg,8Gyinasinglefraction,20Gyin5fractions,30Gyin10fractions)uptodefinitivedosesformoredurablelocalcontrolandhighlyconformaltechniquesforlimitedvolumemetastasesmaybeappropriate,giventherelativelylongnaturalhistoryofevenmetastaticthymoma.RadiationVolume?Thegrosstumorvolumeshouldincludeanygrosslyvisibletumor.SurgicalclipsindicativeofgrossresidualtumorshouldbeincludedforpostoperativeadjuvantRT.?Theclinicaltargetvolume(CTV)forpostoperativeRTshouldencompasstheentirethymus(forpartialresectioncases),surgicalclips,andanypotentialsiteswithresidualdisease.TheCTVshouldbereviewedwiththethoracicsurgeon.?Extensiveelectivenodalirradiation(ENI)(entiremediastinumandbilateralsupraclavicularnodalregions)isnotrecommended,asthymomasdonotcommonlymetastasizetoregionallymphnodes.5?Theplanningtargetvolume(PTV)shouldconsiderthetargetmotionanddailysetuperror.ThePTVmarginshouldbebasedontheindividualpatient’smotion,simulationtechniquesused(withandwithoutinclusionmotion),andreproducibilityofdailysetupofeachclinic.chniquesTHYMBofcesonTHYMBofNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.THYM-BOF3THYM-B2OF3PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsTHYM-B2OF3NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexPRINCIPLESOFRADIATIONTHERAPYRadiationTechniques?TargetmotionshouldbemanagedusingthePrinciplesofRadiationTherapyintheNCCNGuidelinesforNon-SmallCellLungCancer.Intravenouscontrastisbeneficialintheunresectablesetting.?InadditiontofollowingthenormaltissueconstraintsrecommendationusingthePrinciplesofRadiationTherapyintheNCCNGuidelinesforNon-SmallCellLungCancer,moreconservativelimitsarerecommendedtominimizethedosevolumestoallthenormalstructures.Sincethesepatientsareyoungerandmostlylong-termsurvivors,themeantotaldosetotheheartshouldbeaslowasreasonablyachievabletopotentiallymaximizesurvival.?AminimumtechnologicalstandardforRTisCT-planned3-Dconformalradiationtherapy(3D-CRT).MoreadvancedtechnologiesareappropriatewhenneededtodelivercurativeRTsafely.Thesetechnologiesinclude(butarenotlimitedto)4D-CTand/orPET/CTsimulation,IMRT/VMAT,IGRT,motionmanagement,andprotontherapy.Inparticular,IMRTispreferredover3D-CRT.ComparedtoIMRT,protontherapyhasbeenshowntoimprovethedosimetryallowingbettersparingofthenormalorgans(lungs,heart,andesophagus)6withfavorablelocalcontrolandtoxicity,andisappropriate.7eneralPrinciplesRadiationDoseandRadiationVolumeTHYMBoferencesonTHYMBofNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdex1234567PRINCIPLESOFRADIATIONTHERAPYREFERENCESGomezD,KomakiR,YuJ,etal.Radiationtherapydefinitionsandreportingguidelinesforthymicmalignancies.JThoracOncol2011;6:S1743-1748.GomezD,KomakiR.Technicaladvancesofradiationtherapyforthymicmalignancies.JThoracOncol2010;5:S336-343.MornexF,ResbeutM,RichaudP,etal.Radiotherapyandchemotherapyforinvasivethymomas:amulticentricretrospectivereviewof90cases.TheFNCLCCtrialists.FederationNationaledesCentresdeLutteContreleCancer.IntJRadiatOncolBiolPhys1995;32:651-659.MyojinM,ChoiNC,WrightCD,etal.StageIIIthymoma:patternoffailureaftersurgeryandpostoperativeradiotherapyanditsimplicationforfuturestudy.IntJRadiatOncolBiolPhys2000;46:927-933.RuffiniE,MancusoM,OliaroA,etal.Recurrenceofthymoma:analysisofclinicopathologicfeatures,treatment,andoutcome.JThoracCardiovascSurg1997;113:55-63.ParikhRR,RhomeR,HugE,etal.Adjuvantprotonbeamtherapyinthemanagementofthymoma:adosimetriccomparisonandacutetoxicities.ClinLungCancer2016;17:362-366.VogelJ,BermanAT,PechetTT,etal.Prospectivestudyofprotonbeamradiationtherapyforadjuvantanddefinitivetreatmentofthymomaandthymiccarcinoma:earlyresponseandtoxicityassessment.RadiotherOncol2016;118:504-509.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2022,12/22/21?2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.THYM-B3OF3PrintedbyMinTangon3/14/20227:50:58AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.NCCNGuidelinesVersion1.2022ThymomasandThymicCarcinomasdexPRINCIPLESOFSYSTEMICTHERAPYOMAPreferred(OtherRecommendedforThymicCarcinoma)?CAP1Cisplatin50mg/m2IVday1Doxorubicin50mg/m2IVday1Cyclophosphamide500mg/m2IVday1Administeredevery3weeksMICCARCINOMAPreferred(OtherRecommendedforThymoma)?Carboplatin/paclitaxel6,7atinAUCtaxelmgmAdministeredevery3weeksOtherRecommendedforThymi