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NCCN临床实践指南汨非小细胞肺癌(2020.V6)要点NCCNClinicalPracticeGuidelinesinOncology(NCCNGuidelines3}Non-SmallCellLung

CancerVersion2.2020—December23,2019NCCN.org2019年12月,美国国家综合癌症网络(NCCN)发布了非小细胞肺癌(NSCLC)指南2020年第2版,相对于2019版,新版指南系统性治疗方面又有哪些变化呢?让我们一探究竟。1、靶向治疗EGFR突变阳性患者的一线治疗(NSCLC-19)Th^raigyfIMSGLQtHElrrwrlini沪{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讯啦仪询汕眄“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氓轨:LG和k泡PT町肓M袖d»aila「耳叱BoqijTKtif帥冊帼isfiN9CL~0).0£讯MratiteiiEE=rapY心.3阳佃甜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临centhislaryafliernoptjaj&蚩■站FC^^pprqvcd&KJ5m|gF15.gnflporgpr^K?SUftSliMcMbwiCEurrflb,(2020.V2)

新增:厄洛替尼+雷莫芦单抗作为“其他推荐”治疗方案,属于2A类。厄洛替尼+贝伐珠单抗作为“特殊情况下有用”的治疗选择,属于 2B类。(2020.V1)新增了一条关于系统性治疗的脚注说明:如果系统性治疗方案中包含免疫检查点抑制剂,则医生应注意此类药物的半衰期较长,并且当将检查点抑制剂与奥西替尼联合使用时应报告不良事件的数据。奥西替尼治疗中进展的后续治疗(NSCLC-20)・Conode『deflnMvelocaltherapySABRorcurg^ry)forlimited归石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!凤叩伫/比勺凹时”电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应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)对于有症状的多发病灶,新增1条脚注说明:在进展时考虑进行活检以排除SCLC转化。厄洛替尼、阿法替尼、吉非替尼或达克替尼治疗中进展的后续治疗(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蓟从曲亡阪m由orar-atlnlbwgentlnlbofdacomltJnlb11-麻也斛£(州0口阳£|締6忌fChT^iW吕匚■GonslderdeHniUve1loc^lIh&rapy(eg,吕悶RorsupgerylTa亡口rrilnuoo>rl口tinlb1[ramuclrurnjibarliMvacIz*umab^lorafjtlnlborgefltlnlbordJic<»nh:lnibIfprogrosalion,,fan-[N$CL-2p)tfprograssKin.sce111。2呻刊**tarmultiplyfifllcT口gJg*ForniijgiJp層iMlon呂belowtfprogresskin.see■Iwrsg甲刊tormuhiph加lcm・.nowdbelowS«i»lFiJliafli&ysliifnicItierapyoptlonfi^*1™口ESiEinixr.gi问SifIoriilBMn口HS■£屉I0电FPirngTHYN&tLrjlI阿Forpfli sUiLuhCH."€rtBnaivIr-MlmHilbevacuumgbrwn-K|mrTWUQ-nSClC.am#nohistorydfwmoptynis11Be*^rc打帘砂RenomenoirEdbKlofpalB<f3-*twdrsconUnunEGFRTKI.ffdneoseftnre-ooan.re^iriECfRTH.UJCoriHcfeiabDfH^XUnWof芦轉曲ibnLbluitfDuISCLCb^mf&rma'kiii.^AlKhts+ainuMmai!mayfc-c-oon^seredInpatentsm±i比竺^孟pfagr«5M3nanEGFRTKJ也巴r寻yeTrwdaLainUid-^eand-hnaNtlup Ib^lPD-1iFD-LI州biarrnonoltiar^yfciId込arhadne仍皑琴代cbw&PC-L1npnai^n.mEGFff+is>U-K+N5CLCM kh^uldbA砂曲二■■»!*越些1百阳i&i5E^RRTKH.巾fEhATT⑷MMiXd£iWiIIplriAriU-bAi^d[&^巧tfir刪pliM;IiMuA4lAAMI .th閹t■琴AyE南唱埠pUpngl-f喲:4ynmenjJ詞曰卫如<旳詩呻丫岬何H)妙沁rQRng曲亦諏辟哄叶喻plppn?.伽叩F^ngJ"Gon&dcfasrirf^ltii](re^nleu口fTTMMi lexprogreu^w曆phinwinin^Hdisease-.InIheBkxim^liidy,a»mcnnt)wotu»dat1€Dmg."InTiibF*idETiijMphodiOIII*UUiof日阳pui/Mnl&wWibi*dhmftUdrija£Ac\w>關曲耳起曲ksrHY^ilnunlIn1hA■MdlM&twainnwaulAu^3n±jdmiolhar住p&uii(2020.V1)对于有症状的多发病灶,脚注说明作了修改:对于进行性软脑膜病,考虑给予奥希替尼(无论T790M状态如何)或厄洛替尼脉冲式给药。在Bloom研究中,奥西替尼的使用剂量为160mg。ROS1重排阳性患者的一线治疗和后续治疗(NSCLC-25)(pretenr&d)arD&rlOnlbIgriLrtinij口FInltifiJsyeiwnictlie-rapya(pretenr&d)arD&rlOnlbIgriLrtinij口FInltifiJsyeiwnictlie-rapya■曲fix/siyiwins殆―肖小<*rSQmni-cij',Ct-IlCarciBicf7!HiNSCu-J';LoH^llnih□ifSee:IniiLiaJs/sceffikEhtra^y£»pEldriAArRin<x:jirc>n.-rfna^NSCl-jQiC»r呂OzBEdXj/畔剧1£云fCiriMiQ『N!Sd34*」駅rPTrcJptesolMdKbiarand日》om岀唸fAmIfhs:N旳L£ib EeraoF^yjdvmrK与uccMet3gbt!yDBE3flE<N5UL~il却ForpeformarKCSULU'S-(£3-■Beware&Ij>bphenarre*nnins-ubselofiMrterrlsw<iddcconlinue-TKJ.IfaiHascIhrcaccuin.mtiri.TKIvM>bijV(2020.V1)对于一线治疗后进展,新增1条脚注说明:应谨防一些亚群患者在停用TKI抑制剂后出现复燃现象。如果发生复燃,必须重新启用TKI抑制剂。PD匕囂s1£(2」%)lmEGF?°AL厂RosrBRAF蓉^BfflBl^llKWUKAtezo-N'umabsss3»ltt3lffi^Q蓉Bn(NSCLG28.29)stEKIPRfnEim_QIMPDUH一VE詩呂^化Fnw-Llffl^snHg書-jrTogg£s-drtH's.s.lns.nMw_.=.+EA£i«a+p-mibro一llummb-caiaAQV-II-$匚■诒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晋jllr-rLl-JyM**會^nah¥.B岂1.凸1oc■當FCA-^LE也mpzsAs-rcp"置£UF*LUJbMEUMEwFn?3Duf=0rnc3np43o^fi--iBXTB_EQFH3E-严1rfhbnLHHr-Lay-rldkJd^.LWspimu^RHG=0Hfp~hLUUHIILrEc-EtBE»s^SIiawisl-BSS.^-I5w±.e-g电8=-sn^gyflv-44-3』Ha-.185a-Jni<555§SRia-fi3ncrffLXE.JafN3CL•二宫ujmw■呈-3a«§£-E=-X3卡HFrmcPD-L」畫¥魯EHiEGWE»区严FKIDult吧DUH-Q3Dgn量蛊嘗HECM2PO-USEVSIUSPCMJ豐JX畫BoflHals?ffu&nlwC4=nN23nR-uSep5-^bm需ThgrupyIpf^effs^sirjal『*f!r于*Us^a3a£u^aaGalTzQnwE-K:gtH应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岂甲:4rbap4Hrvig4MHMU:blfnn-4MkndPM-I?舍«审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涨。(2020.V2)■f4a*ijp<:ffqAn-^v"一•MM.I6_.3krH^r^lThBcawm-Alc^mdwfg帛.理a-孟门nF"-5JIE电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}删n}臊毬®+Atezo-izumab亠-Tfr凶=»詳®咄"吵询谢删、a4-(宜确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盘一黑叮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壬专En?,FD4lH-f0^-3rEm霽53_KFEFN&一IWJP-TaNivolumab+ipilimumab作为"特殊情况下有用”的治疗选择,属于2A类。a如果给予卡铂+白蛋白紫杉醇+Atezolizumab,则Atezolizumab作为维持治疗选择。(2020.V1)a鳞癌一线治疗方案中,删除了“顺铂+紫杉醇/白蛋白紫杉醇+帕博利珠单抗”,仅推荐首选“卡铂+紫杉醇/白蛋白紫杉醇+帕博利珠单抗”。a对于一线治疗后缓解或稳定的患者,删除了密切观察,建议都继续进行维持治疗。A对于腺癌、大细胞癌或病理类型不确定的NSCLC患者,维持治疗方案删除了“Atezolizumab和/或贝伐珠单抗”,仅推荐“Atezolizumab加贝伐珠单抗双药维持”。初始全身治疗及后续治疗(NSCLC-30)0『曲盯邛对Inou眸创蚀曲|QyDfiBtflWSIOl:cccpfl-mtbFfljcMlwgemclmblrwDrramuClruiti^b*dOCE血包IPnQgrw&lon0『曲盯邛对Inou眸创蚀曲|QyDfiBtflWSIOl:cccpfl-mtbFfljcMlwgemclmblrwDrramuClruiti^b*dOCE血包IPnQgrw&lon|TlMH£Wpgf:跻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+齡撤阳les财bySB),optowtsrPSIncyUttbwIsmprUwhiu0p4un^kHkiilhHrRfDgies'innarebwl密efHtv?uracirckni[ial!t!lalBd£E earoNCCNSsiJltilHlinesrPallialiysCar-gCormnuaOcri血aim的曲恥护"-Ba^^ijuinab(^dilft^ry1)Pfl-nifflrftKiBiCl(cirtWfV1)-BfiYaclzumab♦pemetrexed1^Pbmbralizujnab■+p«me<rrM.«llt個吗凶yTp+Al-oz^illzumabandtMYarClzunn.ab|GatGgpry1)™亠Gamdtablnit^calcgory2B'|orSwNchmikn加畠Mfii闻QPemelrexedT*nwlJ8OfuMfJA.血舉臼闻村Aecal.Early関IMf朋4*尊nw阳關谁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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