结肠癌2022.v1-NCCN（英文版）

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines®)ColonCancerersionFebruaryNCCNGuidelinesforPatients®availableat/patientsVersion1.2022,02/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:29:16AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdex*AlB.Benson,III,MD/Chair†RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversity*AlanP.Venook,MD/Vice-Chair†‡UCSFHelenDillerFamilyComprehensiveCancerCenteryofMichiganRogelCancerCenteryofMichiganRogelCancerCenterNiloferAzad,MD†TheSidneyKimmelComprehensiveCancerCenteratJohnsHopkins*Yi-JenChen,MD,PhD§CityofHopeNationalMedicalCenterngramCancerCenterngramCancerCenterStaceyCohen,MD†FredHutchinsonCancerResearchCenter/SeattleCancerCareAllianceHarryS.Cooper,MD≠FoxChaseCancerCenteryofWisconsinCarboneCanceryofWisconsinCarboneCancerCenterLindaFarkas,MD¶UTSouthwesternSimmonsComprehensiveCancerCenterIgnacioGarrido-Laguna,MD,PhD†HuntsmanCancerInstituteattheUniversityofUtahfettCancerfettCancerCenterAndrewGunn,MDфONealComprehensiveCancerCenteratUABJ.RandolphHecht,MD†UCLAJonssonComprehensiveCancerCenternterSarahHoffenteresPanelDisclosuresJoleenHubbard,MD†‡MayoClinicCancerCenternCancerCenteratBarnesnCancerCenteratBarnesJewishHospitalandWashingtonUniversitySchoolofMedicineWilliamJeck,MD≠DukeCancerInstitutenterSmilowCancerHospitalimberlyLnterSmilowCancerHospitalNatalieKirilcuk,MD¶StanfordCancerInstituteSmithaKrishnamurthi,MD†ÞCaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerInstituteofColoradoCancerCenterWellsAofColoradoCancerCenterandWomens*JeffreyandWomenstalandWashingtontalandWashingtonoolofMedicineMassachusettsGeneralHospitalCancerCenterHitendraPatel,MD†UCSanDiegoMooresCancerCenternCancerCenteratBarnesrinanCancerCenteratBarnesElizabethRaskin,MD¶UCDavisComprehensiveCancerCenter*LeonardSaltz,MD†‡ÞMemorialSloanKetteringCancerCenterCharlesSchneider,MD†AbramsonCancerCenterattheUniversityofPennsylvaniaTheUniversityofTennesseeHealthScienceTheUniversityofTennesseeHealthScienceCenterTheUniversityofTexasMDAndersonCancerTheUniversityofTexasMDAndersonCancerCenternosTnosTSofocleousMDPhDloanKetteringCancerCenterenaMloanKetteringCancerCenterenaMStoffelMDMPHTheOhioStateUniversityComprehensiveyofMichiganRogelCancerCenteryofMichiganRogelCancerCentertotskyHimelfarbBSNRNandSoloveResearchInstituteeSidneyKimmelComprehensiveMaryF.MulcahyeSidneyKimmelComprehensiverCenteratJohnsHopkins*ChristopherrCenteratJohnsHopkins*ChristopherG.Willett,MD§CenterofNorthwesternUniversitystitutestituteiPhDRoswellParkComprehensiveCancerCenterTheUniversityofTexasMDAndersonCancerCenterTheUniversityofTexasMDAndersonCancerCenterфDiagnostic/Interventional≠Pathologyradiology¥Patientadvocacy¤Gastroenterology§Radiotherapy/Radiation‡Hematology/Hematologyoncologyoncology¶Surgery/SurgicaloncologyÞInternalmedicine*DiscussionSectionWriting†MedicaloncologyCommitteeVersion1.2022,02/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.NCCNColonCancerPanelMembersSummaryoftheGuidelinesUpdatesClinicalPresentationsandPrimaryTreatment:•PedunculatedPolyp(Adenoma)withInvasiveCancer(COL-1)•SessilePolyp(Adenoma)withInvasiveNCCNColonCancerPanelMembersSummaryoftheGuidelinesUpdatesClinicalPresentationsandPrimaryTreatment:•PedunculatedPolyp(Adenoma)withInvasiveCancer(COL-1)•SessilePolyp(Adenoma)withInvasiveCancer(COL-1)•ColonCancerAppropriateforResection(COL-2)•SuspectedorProvenMetastaticSynchronousAdenocarcinoma(COL-4)PathologicStage,AdjuvantTreatment(COL-3)Surveillance(COL-8)RecurrenceandWorkup(COL-9)MetachronousMetastases(COL-9)PrinciplesofImaging(COL-A)PrinciplesofPathologicandMolecularReview(COL-B)PrinciplesofSurgery(COL-C)SystemicTherapyforAdvancedorMetastaticDisease(COL-D)PrinciplesofRadiationandChemoradiationTherapy(COL-E)PrinciplesofRiskAssessmentforStageIIDisease(COL-F)PrinciplesofAdjuvantTherapy(COL-G)PrinciplesofSurvivorship(COL-H)Staging(ST-1)rdexlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNationalComprehensiveCancerNetworkAllrightsreservedTheNCCNGuidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.©2022.Version1.2022,02/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:29:16AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexVersionoftheNCCNGuidelinesforColonCancerfromVersionincludeGeneral--FOLFOXIRIreplacedwithFOLFIRINOXCOL-2pThefollowingoptionadded:([Nivolumab±ipilimumab]orpembrolizumab)(dMMR/MSI-Honly)COL-4•WorkuppBullet5modified:NGSPanelclarifiedastissue-orblood-based(alsoappliestofootnotew)(alsoaddedtofoonotekkonCOL-9)COL-5•TreatmentpResectionnotedaspreferredandlocaltherapyaddedasanadditionaloralternateoptiontoresection.COL-6•Re-evaluateforconversiontoresectablepConvertedtoresectable◊Resectionnotedaspreferredandlocaltherapyaddedasanadditionaloralternateoptiontoresection.(alsoappliestoCOL-11)◊Footnotezadded:Resectionispreferredoverlocallyablativeprocedures(eg,image-guidedablationorSBRT).However,theselocaltechniquescanbeconsideredforliverorlungoligometastases(COL-CandCOL-E).(alsoappliestoCOL-11)pRemainsunresectable◊Systemictherapyandconsiderlocaltherapyforselectpatients(alsoappliestoCOL-11)◊Footnoteyadded:Hepaticarteryinfusion±systemic5-FU/leucovorin(category2B)isalsoanoptionatinstitutionswithexperienceinboththesurgicalandmedicaloncologicaspectsofthisprocedure.•Footnoteeemodified:Cetuximaborpanitumumabshouldonlybeusedforleft-sidedtumors.Thepaneldefinestheleftsideofthecolonassplenicflexuretorectum.Evidencesuggeststhatpatientswithtumorsoriginatingontherightsideofthecolon(hepaticflexurethroughcecum)areunlikelytorespondtocetuximabandpanitumumabinfirst-linetherapyformetastaticdisease.Dataontheresponsetocetuximabandpanitumumabinpatientswithprimarytumorsoriginatinginthetransversecolon(hepaticflexuretosplenicflexure)arelacking.(alsoappliestofootnotegonCOL-D7of13;footnoteaddedtoCOL-11)COL-8•TimingofChest/abdominal/pelvicCTclarifiedwithadditionof“fromdateofsurgery”PrinciplesofImagingCOL-A2of2•StageIVdiseasepSub-bullet2modified:PET/CTcanbeconsideredforassessmentofresponseandliverrecurrenceafterimage-guidedliver-directedtherapies(ie,ablation,radioembolization)orserialCEAelevationduringfollow-upPrinciplesofPathologicandMolecularReviewCOL-B4of8•MethodsforTestingaddedpBulletmovedfromunderKRAS,NRAS,BRAFMutationTesting:Thetestingcanbeperformedonformalin-fixedparaffin-embeddedtissue(preferred)orblood-basedassay.COL-B5of8pBullet1modified:ThesedatasupportlimitingthesubpopulationofcolorectalcancersthatshouldbetestedforNTRKfusionstothosewithwildtypeKRAS,NRAS,BRAF,andarguablytothosethatareMMRdeficient(dMMR)/MSI-HNTRKfusionsaremorefrequentlyfoundamongpatientswithdMMR.UPDATESVersion1.2022,02/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2022,02/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:29:16AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexVersionoftheNCCNGuidelinesforColonCancerfromVersionincludeSystemicTherapyforAdvancedorMetastaticDiseaseCOL-D1of13•PatientappropriateforIntensivetherapyrecommendedpFootnotedaddedtoallFOLFOX,CAPEOX,andFOLFIRINOXregimens(appliestoCOL-D2of13throughCOL-D6of13)•PatientNOTappropriateforIntensivetherapyNOTrecommendedpThefollowingInitialTherapyoptionsremoved:Fam-trastuzumabderuxtecan-nxki(HER2-amplifiedandRASandBRAFWT)•Cetuximaborpanitumumab:restrictionforleft-sidedtumorsextendedthroughoutallguidelinesettings.QualificationonthispageasitisaddressedinfootnotegandCOL-D8of13throughCOL-D11of13COL-D2of13•SubsequentTherapypFootnotegaddedtoallanti-EGFRbasedregimens(appliestoCOL-D3of13throughCOL-D6of13)COL-D7of13•Footnotedadded:Discontinuationofoxaliplatinshouldbestronglyconsideredafter3to4monthsoftherapy(orsoonerforunacceptableneurotoxicity)whilemaintainingotheragentsuntiltimeofprogression.Oxaliplatinmaybereintroducedifitwasdiscontinuedforneurotoxicityratherthanfordiseaseprogression.COL-D8of13•Cetuximabevery2weekdosingnotedaspreferred(alsoappliestoCOL-D9of13,COL-D10of13)COL-D9of13•DosingaddedforFOLFIRINOXandmodifiedFOLFIRINOX(referencesaddedtoCOL-D12of13)•Footnoteeeadded:FOLFIRINOXisrecommendedinsteadofFOLFOXIRIbecauseFOLFOXIRIusesahighdoseoffluorouracil(3,200mg/m²over48hours).PatientsintheUnitedStates(U.S.)havebeenshowntohavegreatertoxicitywithfluorouracil.Thedoseoffluorouracil(2,400mg/m²over46hours)isastartingdoseconsistentwiththedoserecommendedinFOLFOXorFOLFIRIandshouldbestronglyconsideredforU.S.patients.PrinciplesofRadiationandChemoradiationTherapyCOL-E1of2•TreatmentInformationpBullet1modified:Ifradiationtherapyistobeused,conformalexternalbeamradiationshouldberoutinelyusedandIMRTshouldbereservedonlyispreferredforuniqueclinicalsituationssuchasreirradiationofpreviouslytreatedpatientswithrecurrentdiseaseandoruniqueanatomicalsituationswhereIMRTfacilitatesthedeliveryofrecommendedtargetvolumedoseswhilerespectingacceptednormaltissuedose-volumeconstraints(eg,coverageofexternaliliacoringuinallymphnodesoravoidanceofsmallbowel).•TargetVolumespSub-bullet2◊Diamond1modified:Considerboostforcloseorpositivemarginsorunresectablecasesafterevaluatingthecumulativedosetoadjacentorgansatrisk.◊Diamond2modified:Smallboweldoseshouldbelimitedto4550Gy.pSub-bulletremoved:IfIORTisnotavailable,additional10–20Gyexternalbeamradiationtherapyand/orbrachytherapycouldbeconsideredtoalimitedvolume.COL-E2of2•SupportiveCarepTerminologiesmodifiedtobemoreinclusiveofallsexualandgenderidentities.pBullet2added:Patientsofchildbearingpotentialshouldbecounseledabouttheeffectsofprematuremenopauseandconsiderationshouldbegiventoreferralfordiscussionofhormonereplacementstrategies.pBullet3added:Patientsofchildbearingpotentialshouldbecounseledthatanirradiateduteruscannotcarryafetustoterm.pBullet4modified:Patientsshouldbecounseledonsexualdysfunction,potentialforfuturelowtestosteronelevels,andinfertilityrisksandgiveninformationregardingspermbankingoroocyte,egg,orovariantissuebanking,asappropriate,priortotreatment.PrintedbyMinTangon3/14/20227:29:16AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.rdexCLINICALWORKUPbPRESENTATIONaeolypadenoma)withinvasivecancer•Pathologyreviewc,d•ColonoscopyMSItestinge•Markingofcancerouspolypsite(attimeofcolonoscopyorwithin2weeksifdeemednecessaryMSItestingeSmallboweladenocarcinomaFINDINGSFINDINGS specimen specimenelyremovederwithfavorablewithfavorablefeaturesflearmarginsColectomyhlearmarginsColectomyhwithenblocremovalofnallymphnodeswithinvasive•ConsiderpelvicMRIb•CBC,chemistryprofile,CEAColectomyhColectomyhwithenblocremovalofnallymphnodesspecimenormargin•Chest/abdominal/•Chest/abdominal/pelvicCTb•PET/CTscanisnotfeaturesffeaturesfindicatedcNCCNGuidelinesforSmallBowelAdenocarcinomaStage,Adjuvanturveillance(COL-3)AppendicealadenocarcinomaesotheliomaorotherleuralmesotheliomasConsidersystemictherapy(AppendicealadenocarcinomaesotheliomaorotherleuralmesotheliomasNCCNGuidelinesforColonCancersidersystemictherapyaspertheNCCNGuidelinesforMalignantPleuralMesothelioma(MPM-A)anderitonealMesotheliomaMPMBaAllpatientswithcoloncancershouldbecounseledforfamilyhistoryandconsideredforriskassessment.ForpatientswithsuspectedLynchsyndrome,familialadenomatouspolyposis(FAP),andattenuatedFAP,seetheNCCNGuidelinesforGenetic/FamilialHigh-RiskAssessment:Colorectal.bPrinciplesofImaging(COL-A).cConfirmthepresenceofinvasivecancer(pT1).pTishasnobiologicalpotentialtometastasize.dIthasnotbeenestablishedifmolecularmarkersareusefulintreatmentdetermination(predictivemarkers)andprognosis.CollegeofAmericanPathologistsConsensusStatement1999.Prognosticfactorsincolorectalcancer.ArchPatholLabMed2000;124:979-994.ePrinciplesofPathologicReview(COL-B4of8)-MSIorMMRTesting.fPrinciplesofPathologicReview(COL-B)-Endoscopicallyremovedmalignantpolyp.gObservationmaybeconsidered,withtheunderstandingthatthereissignificantlygreaterincidenceofadverseoutcomes(residualdisease,recurrentdisease,mortality,hematogenousmetastasis,butnotlymphnodemetastasis)thanpolypoidmalignantpolyps.PrinciplesofPathologicReview(COL-B)-Endoscopicallyremovedmalignantpolyp.hPrinciplesofSurgery(COL-C1of3).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.COL-1Version1.2022,02/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.psyPathologyreviewflityriskoncounselingpriatepatientsPrintedbyMinTangon3/14/20227:29:16AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.psyPathologyreviewflityriskoncounselingpriatepatientsrdexCLINICALWORKUPFINDINGSPRIMARYCLINICALWORKUPPRESENTATIONaColectomyhColectomyhwithenblocremovalegionalegionallymphnodescolectomyhwithenblocremovalofregionallymphnodesorMSItestinge•Colonoscopy•Considerabdominal/chemistryprofile•Chest/abdominal/pelvicCTb•Enterostomaltherapistasindicatedforpreoperativemarkingofsite,teaching•PET/CTscanisnotobstructingResectable,obstructingResectionwithdiversionorDiversionntillanceResectable,obstructingResectionwithdiversionorDiversionatentinselectedcasesforresectionConsiderneoadjuvantatentinselectedcasesforresectionConsiderneoadjuvant(non-Xmetastaticineoadjuvanttherapy•FOLFOXorneoadjuvanttherapy•FOLFOXorCAPEOXor•([Nivolumab±ipilimumab]orIHonlySurgeryIHonlySurgeryAdjuvantblellyleonInfusional5-FU+RTk,lororesectablehrapycitabineoresectablehrapytedorprovennocarcinomatedorprovennocarcinomasynchronousadenocarcinomaCOL)aAllpatientswithcoloncancershouldbecounseledforfamilyhistoryandconsideredforriskassessment.ForpatientswithsuspectedLynchsyndrome,FAP,andattenuatedFAP,seetheNCCNGuidelinesforGenetic/FamilialHigh-RiskAssessment:Colorectal.bPrinciplesofImaging(COL-A).ePrinciplesofPathologicReview(COL-B4of8)-MSIorMMRTesting.fPrinciplesofPathologicReview(COL-B)-Coloncancerappropriateforresection,pathologicstage,andlymphnodeevaluation.hPrinciplesofSurgery(COL-C1of3).iFortoolstoaidoptimalassessmentandmanagementofolderadultswithcancer,seetheNCCNGuidelinesforOlderAdultOncology.jConsideranMRItoassistwiththediagnosisofrectalcancerversuscoloncancer(eg,low-lyingsigmoidtumor).TherectumliesbelowavirtuallinefromthesacralpromontorytotheupperedgeofthesymphysisasdeterminedbyMRI.kPrinciplesofRadiationandChemoradiationTherapy(COL-E).lBolus5-FU/leucovorin/RTisanoptionforpatientsnotabletotoleratecapecitabineorinfusional5-FU.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.COL-2Version1.2022,02/25/22©2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.•FOLFOX(6mo)q,r,tdetermineadjuvanttherapymoofCAPEOXisnon-inferiorto6mofordisease-freesurvival;non-inferiorityqPrinciplesofAdjuvantTherapyCOLGof3movs.6mo•FOLFOX(6mo)q,r,tdetermineadjuvanttherapymoofCAPEOXisnon-inferiorto6mofordisease-freesurvival;non-inferiorityqPrinciplesofAdjuvantTherapyCOLGof3movs.6moofFOLFOXhasnotbeenproven.InpatientswithcoloncancerrConsiderRTforTwithpenetrationtoafixedstructurestagedasT4,N1–2orTany,N2(high-riskstageIII),3moofFOLFOXisinferiorFUleucovorininstageIIcoloncancerTournigandCetalJClinOncolpatientswhoreceivemovsmooftreatment(3%vs.16%forFOLFOX;3%instability-high[MSI-H]):poorlydifferentiated/undifferentiatedhistology,lymphatic/uWhilenon-inferiorityof3movs.6moofCAPEOXhasnotbeenproven,3mordexPATHOLOGICSTAGEmADJUVANTTREATMENTbObservationObservationTN0,M0n(MSI-H/dMMR)MSSObservationObservationTN0,M0n(MSI-H/dMMR)MSSpMMRandaturesConsidercapecitabine(6mo)qor5-FU/leucovorin(6mo)qCapecitabine(6mo)q,ror5-FU/leucovorin(6mo)q,rtemicrecurrenceopTN0,M0attemicrecurrenceoporT4,N0,M0(MSS/pMMR)FOLFOX(6mo)q,r,s,torCAPEOXorT4,N0,M0(MSS/pMMR)orObservationPreferredFOLFOX6FOLFOX6mo)q,t(low-riskstageIII)uOtherOtheroptionsincludeCapecitabinemoqor5-FU(6mo)qT4,N1–2;TT4,N1–2;TAny,N2•CAPEOX(3–6mo)q,r,torfIiw(COL-B).Otheroptionsinclude:Capecitabine(6mo)q,ror5-FU(6mo)q,rofIiw(COL-B).Otheroptionsinclude:Capecitabine(6mo)q,ror5-FU(6mo)q,roHigh-riskfactorsforrecurrence(exclusiveofthosecancersthataremicrosatelliteyearsandolderhasnotbeenproven.vascularinvasion,bowelobstruction,<12lymphnodesexamined,perineuralofCAPEOXnumericallyappearedsimilarto6moofCAPEOXfor5-yearoverallinvasion,localizedperforation,orclose,indeterminate,positivemargins,orsurvival(82.1%vs.81.2%;HR,0.96),withconsiderablylesstoxicity.(AndreT,ettumorbudding.Inhigh-riskstageIIpatients,therearenodatathatcorrelateriskal.LancetOncol2020;21:1620-1629).Theseresultssupporttheuseof3moofpThereareinsufficientdatatorecommendtheuseofmul