FLASCO / NCCN has published updates to the NCCN Guidelines and Chemo Order Templates

July 14, 2016
Clinical Practice Updates, News

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®) for Melanoma. These NCCN Guidelines^®are currently available as Version 3.2016.

Imaging recommendations were clarified, including the following:
- Addition of footnote “i”, specifying modalities wherever imaging is mentioned: “Chest/abdominal/pelvic CT with contrast, brain MRI with contrast, and/or FDG PET/CT. Neck CT with contrast if clinically indicated. Scans performed with contrast unless contraindicated. Contrast not necessary for CT chest screening for lung metastases.”
- Stage III in-transit: After primary treatment, “Imaging to assess treatment response” was added. (ME-5)
- Local, satellite and/or in-transit recurrence: After treatment for recurrence, “Imaging to assess treatment response” was added. (ME-9)
- Distant metastatic disease: For patients with limited (Resectable) disease, “Imaging to assess response or progression” was added after observation or systemic therapy. (ME-11)
The Discussion text has been updated to reflect the changes in the algorithm. (MS-1)

*For your reference, the previous update (Version 2.2016) to the NCCN Guidelines for Melanoma, published on November 25, 2015, is available at the following link: https://www.nccn.org/professionals/physician_gls/pdf/melanoma.pdf

NCCN has published updates to the NCCN Guidelines for Gastric Cancer. These NCCN Guidelines are currently available as Version 2.2016.

Imaging recommendations within the Guidelines were clarified.
The “Principles of Palliative/Best Supportive Care” section was revised extensively.

*For your reference, the previous update (Version 1.2016) to the NCCN Guidelines for Gastric Cancer, published on March 31, 2016, is available at the following link: https://www.nccn.org/professionals/physician_gls/pdf/gastric.pdf

NCCN has published updates to the NCCN Guidelines for Esophageal and Esophagogastric Cancer. These NCCN Guidelines are currently available as Version 2.2016.

Imaging recommendations within the Guidelines were clarified.
The “Principles of Palliative/Best Supportive Care” section was revised extensively.

*For your reference, the previous update (Version 1.2016) to the NCCN Guidelines for Esophageal and Esophagogastric Cancer, published on April 22, 2016, is available at the following link: https://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf

NCCN has published updates to the NCCN Guidelines and NCCN Drugs & Biologics Compendium (NCCN Compendium^®) for Thyroid Carcinoma. These NCCN Guidelines are currently available as Version 1.2016.

Global changes to NCCN Guidelines for Thyroid Carcinoma (including Papillary Carcinoma, Follicular Carcinoma, and Hürthle Cell Carcinoma)
- Postsurgical Evaluation (PAP-3, FOLL-2, HÜRT -2)
  - For “Unresectable” residual disease in the neck, a treatment option was revised: “Radioiodine treatment (preferred)”
- Clinicopathologic Factors (PAP-4, FOLL-3, HÜRT-3)
  - The recommendation, “Persistence of anti-Tg antibodies” was removed from the list of diagnostic procedures.
- RAI Not Typically Indicated Based On Clinicopathologic Features (PAP-5, FOLL-4, HÜRT-4)
  - A bullet was added: “No concerning findings on neck ultrasound”
  - A footnote was added to “Clinically significant, indeterminate or suspicious cervical nodes”: “For example, round morphology, microcalcifications, multiplicity, or growing enlarging nodes.”
  - A footnote was removed: “If structural disease is identified, additional evaluation and/or treatment may be clinically indicated.”
- RAI Being Considered Based On Clinicopathologic Features (PAP-6, FOLL-5, HÜRT-5)
  - For “Pretreatment ¹²³I diagnostic imaging with TSH stimulation (thyroid hormone withdrawal or rhTSH) (category 2B),” 3 statements were revised:
    - “No or minor thyroid bed uptake on scan, unstimulated Tg <1 ng/mL (with negative anti-Tg antibodies)”
    - “Suspected or proven thyroid bed uptake”
    - “Follow without RAI ablation or” was added
  - RAI doses were revised: “Selective use of RAI for remnant ablation (30–50 mCi) or adjuvant therapy (50–100 mCi); post-treatment imaging”
  - A footnote was revised: “While pre-ablation diagnostic scans in this setting are commonly done at NCCN Member Institutions, the panel recommends (category 2B) selective use of pre-ablation diagnostic scans based on pathology, postoperative Tg, intraoperative finds, and available imaging studies. Furthermore, dosimetry studies are considered in patients at high risk of having RAI-avid distant metastasis. Empiric RAI doses may exceed maximum tolerable activity levels in patients with decreased GFR. Dialysis patients require special handling.” (Also for PAP-7, FOLL-6, HÜRT-6)
  - A footnote was revised: “If RAI ablation is used in T1b/T2 (1–4 cm) clinical N0 disease, 30 mCi of ¹³¹I is recommended (category 1) following either recombinant human TSH stimulation or thyroid hormone withdrawal. This dose of 30 mCi may also be considered (category 2B) for patients with T1b/T2 (1–4 cm) with small-volume N1a disease (fewer than 3–5 metastatic lymph node metastases .5 cm in diameter) and for patients with primary tumors <4 cm, clinical M0 with minor extrathyroidal extension”
- Known Or Suspected Distant Metastatic Disease (PAP-7, FOLL-6, HÜRT 6)
  - A footnote was added: “rHTSH may be used for elderly patients for when prolonged hypothyroidism may be risky.”
  - A footnote was added to “Cervical uptake only”: “Clinically significant structural disease should be surgically resected if possible before radioiodine treatment.”
- Treatment of Metastatic Disease Not Amenable To RAI Therapy (PAP-10, PAP-11, FOLL-9, FOLL-10, HÜRT-9, HÜRT-10)
  - A footnote was revised: “ The decision of whether to use lenvatinib or sorafenib should be individualized for each patient based on likelihood of response and comorbidities.”
  - A footnote was revised to include “everolimus”: “While not FDA approved for treatment of differentiated thyroid cancer, commercially available small-molecule kinase inhibitors (such as axitinib, everolimus, pazopanib, sunitinib, or vandetanib [all are category 2A]) can be considered if clinical trials are not available or appropriate.”
- Follicular Carcinoma and Hürthle Cell Carcinoma
  - For footnote “a” for the diagnosis of follicular carcinoma, the last sentence has been added: “Use molecular markers with caution and caveat.” (FOLL-1)
  - For 6-12 weeks post-thyroidectomy, a bullet was added: “Lateral neck ultrasound if not done preoperatively” (FOLL-4, HÜRT-4)
  - For the “Pretreatment ¹²³I diagnostic imaging with TSH stimulation (thyroid hormone withdrawal or rhTSH),” a statement was revised: “ Central cervical (remnant) uptake only” (FOLL-6, HURT-6)
- Medullary Carcinoma
  - Diagnostic Procedures (MEDU-1)
    - A bullet was revised: “Consider contrast-enhanced CT of chest and Liver MRI if or 3-phase CT of liver”
    - A footnote was added: “Having distant metastases does not mean that surgery is contraindicated.”
    - A footnote was added: “Liver imaging is seldom needed if calcitonin <400 pg/mL.”
  - Anaplastic Carcinoma (ANAP-1)
    - Footnote “b”, “Preoperative evaluations need to be completed as quickly as possible and involve integrated decision making in a multidisciplinary team and with the patient. Consider referral to multidisciplinary high-volume center with expertise in treating ATC” was added to: “Stage IVC (metastatic disease).”

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Compendium^®, the NCCN Chemotherapy Order Templates (NCCN Templates^®), and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

To access the NCCN Biomarkers Compendium^®, please visit NCCN.org/biomarkers.

To view the NCCN Guidelines for Patients^®, please visit NCCN.org/patients.

Free NCCN Guidelines apps iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps.

NCCN has published updates to the NCCN Chemotherapy Order Templates (NCCN Templates^®).

The “Safety Parameters and Special Instructions” section for all vinCRIStine-containing templates has been updated to include the following information when applicable:
- For VinCRIStine:
  - VinCRIStine is a vesicant
  - VinCRIStine is for IV use only and should be administered via a minibag (e.g. 25 mL for pediatric patients and 50 mL for adults).
  - Intrathecal Injection must be avoided and usually results in death or serious neurological damage.
  - Central venous access is recommended for administration of this agent. (if NOT given via continuous infusion)
  - This agent requires a central venous access device for administration in this regimen. (If given via continuous infusion).
  - VinCRIStine can be safely administered in a minibag via a peripheral vein by allowing the infusion to flow via gravity. Use of infusion pumps are not recommended for peripheral administration. (if NOT given via continuous infusion)
- List of affected templates:
  - Bone Cancer – Ewing’s Sarcoma
    - BON1, BON2, BON10, BON12a, BON19
  - Central Nervous System Cancers – Adult Medulloblastoma and Supratentorial Primitive Neuroectodermal Tumors (PNET)
    - AMED1, AMED2, AMED3
  - Central Nervous System Cancers – Anaplastic Gliomas
    - ANGL2
  - Central Nervous System Cancers – Adult Low-Grade Infiltrative Supratentorial Astrocytoma/Oligodendroglioma
    - ASTR5
  - Central Nervous System Cancers – Glioblastoma
    - GBM9
  - Hodgkin Lymphoma
    - HDL4, HDL5, HDL6, HDL19, HDL22, HDL23, HDL25, HDL26, HDL28, HDL42, HDL43, HDL46
  - Multiple Myeloma
    - MUM1, MUM8
  - Neuroendocrine Tumors – Pheochromocytoma/Paraganglioma
    - PHEO9
  - Non-Hodgkin’s Lymphomas – Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)
    - CLL24
  - Non-Hodgkin’s Lymphomas – Diffuse Large B-Cell Lymphoma
    - DBL1, DBL2, DBL3, DBL22, DBL28, DBL29, DBL30, DBL40, DBL41, DBL42, DBL43, DBL44, DBL45, DBL48
  - Non-Hodgkin’s Lymphomas – Follicular Lymphoma
    - FOL1, FOL2
  - Non-Hodgkin’s Lymphomas – Mantle Cell Lymphoma
    - MCL3, MCL17a, MCL18a, MCL22a, MCL23a, MCL24a, MCL27
  - Non-Melanoma Skin Cancers – Merkel Cell Carcinoma
    - MCC1, MCC7
  - Ovarian Cancer – Malignant Germ Cell Tumor
    - OVMGCT11
  - Ovarian Cancer – Malignant Sex Cord-Stromal Tumor
    - OVSCST7
  - Small Cell Lung Cancer
    - SCL9
  - Soft Tissue Sarcoma – Rhabdomyosarcoma
    - RHAB1, RHAB2, RHAB3a, RHAB5, RHAB9, RHAB10, RHAB13
  - Thymomas and Thymic Carcinomas
    - THYM3
  - Waldenström’s Macroglobulinemia/Lymphoplasmacytic Lymphoma
    - WAL20

For the complete updated versions of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines^®), NCCN Guidelines^® with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium^®), the (NCCN Templates^®, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

To access the NCCN Biomarkers Compendium^®, please visit NCCN.org/biomarkers.

To view the NCCN Guidelines for Patients^®, please visit NCCN.org/patients.

Free NCCN Guidelines apps iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps.