NCCN Guidelines® Updates

NCCN Guidelines® Updates

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Thymomas and Thymic Carcinomas and for Penile Cancer published in this issue (pages 562 and 594, respectively) include the latest updates. To assist readers interested in noting how the guidelines were updated, highlights of major changes pertaining to the abbreviated version published in this issue are printed below. To view the complete list of updates and full versions of these guidelines, visit the NCCN Web site at NCCN.org.

Thymomas and Thymic Carcinomas

Updates to Version 2.2013 of the NCCN Guidelines for Thymomas and Thymic Carcinomas from Version 2.2012 include:

THYM-2

  • The following node was added: “All patients should be managed by a multidisciplinary team with experience in the management of thymoma and thymic carcinoma.”

THYM-A

  • Bullet 8 was modified to read: “Minimally invasive procedures are not routinely recommended due to the lack of long-term data. However, minimally invasive procedures may be considered in select patients if done all oncologic goals can be met as in standard procedures, and if performed in specialized centers by surgeons with experience in these techniques.”

THYM-B 1 of 2

  • References 1 and 2 were added.

THYM-B 2 of 2

  • References 6 and 7 were added.

THYM-C 1 of 2

  • ADOC regimen was modified from “Administered every 4 weeks” to “Administered every 3 weeks.”

THYM-C 2 of 2

  • References 7-15 were added.

ST-1

  • Table 2 and Stage Grouping were added.

Penile Cancer

Updates to Version 1.2013 of the NCCN Guidelines for Penile Cancer from Version 1.2012 include:

PN-2

  • T1, Grade 3-4
    • The primary treatment “radiotherapy ± concurrent chemotherapy (category 2B)” was revised to read: “Radiotherapy (category 2B) or Radiotherapy with concurrent chemotherapy (category 3).”
  • T2 or greater
    • The primary treatment “Radiotherapy ± concurrent chemotherapy (category 2B)” was clarified as being for “T2 tumors only.”
  • Footnote “d” was added: “Moh’s surgery is an option.”
  • Footnote “g” was modified from “If positive or close margins and/or lymphovascular invasion (LVI), consider radiotherapy (category 2B)” to “Recommend intraoperative frozen sections to achieve negative margins.”
  • Footnote “h” was modified as: “Appropriate with proven negative margins for tumors involving the glans only.” glansectomy or radiotherapy (interstitial brachytherapy at experienced centers) with prior circumcision.
  • Footnote “i” was modified as: “...to achieve a negative margin, a partial or total penectomy is performed.” Total penectomy is required for lesions extending into the corpora cavernosum.

PN-3

  • Low risk
    • Ta was clarified by removing “G1-2” and footnote “k” was added: “Ta verrucous carcinoma is by definition a well-differentiated tumor and would require surveillance alone of inguinal lymph nodes.”
    • Footnote “n” was added: “A modified/superficial inguinal dissection with intraoperative frozen section is an acceptable alternative to stage the inguinal lymph nodes.”

PN-4

  • Heading was clarified as: “Risk Stratification Based on primary lesion Physical Examination Findings.
  • Footnote “q” was added: “Surveillance can be considered in patients with a negative FNA provided they are carefully surveyed. See Surveillance (PN-6).”

PN-5

  • Pelvic lymph nodes enlarged
    • “Radiotherapy with concurrent chemotherapy” was added as a treatment option.

PN-A

Principles of Surgery

  • 3rd bullet was modified by adding: “Standard or modified ILND or DSNB (category 2B)...”
  • 2nd sub-bullet was modified to read: “pT1G3 or greater ≥T2, any grade.”
  • 4th bullet was modified by adding: “...PLND should be considered at the time of ILND...or in a delayed procedure in patients with extranodal extension.”
  • Removed bullet: “Neoadjuvant chemotherapy should be considered the standard (prior to ILND) in patients with ≥4 cm inguinal lymph nodes, if FNA is positive for metastatic penile cancer.”

PN-B

Postoperative Adjuvant Radiotherapy

  • The “category 2B” designation was moved from the heading “Postoperative Adjuvant Radiotherapy” to the first bullet “Inguinal Lymph Node Positive (category 2B).”
  • 3rd sub-bullet was modified by removing: “Consider primary site irradiation if lymphovascular space invasion or close margin.”

PN-C

Principles of Chemotherapy

  • Neoadjuvant, 1st bullet was modified as: “Neoadjuvant, cisplatin-based chemotherapy should be considered the standard (prior to ILND) in patients with ≥4 cm or fixed inguinal lymph nodes (fixed or mobile), if FNA is positive for metastatic penile cancer.”
  • Neoadjuvant, 2nd bullet was modified as: “Patients with A Tx, N2-3, M0 penile cancer can receive 4 courses of preoperative neoadjuvant paclitaxel, ifosfamide, and cisplatin (TIP). Stable or responding patients should then undergo surgical resection consolidative surgery...”
  • For “Preferred radiosensitizing agents and combinations,” the heading was clarified to read: “For radiotherapy with concurrent chemotherapy” and the category 2B designation was removed. The category is noted on the algorithm pages and is variable depending on the clinical setting.

The goal of the NCCN Guidelines® Updates is to provide readers with important changes that the NCCN Guidelines Panels have incorporated into an algorithm since it was last published. For a more complete detailing of the updated guideline’s modifications, please access the NCCN Guidelines® in this issue or, for the complete and most up-to-date version, at NCCN.org.

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