2020 version of NCCN ovarian cancer guide important update points of comprehensive interpretation!

What are the important updates in ovarian cancer surgery, chemotherapy and maintenance therapy? It's all here! At the boa / BOC online conference, Professor Yang Hongying, the Third Affiliated Hospital of Kunming Medical University (Yunnan Cancer Hospital), explained in detail the update points of the 2020 V1 version of the NCCN ovarian cancer clinical diagnosis and treatment guidelines.before interpreting the current situation and management strategy of ovarian cancer, Professor Yang Hongying first summarized the current situation of ovarian cancer.worldwide, ovarian cancer accounts for about 4% of female cancers, with 2.954 million new cases and 1.848 million deaths each year.ovarian cancer is one of the most lethal tumors in the female reproductive system, known as "silent killer".the incidence of ovarian cancer worldwide. Therefore, the whole process management of ovarian cancer is very important.there are three key strategies for the whole process management of ovarian cancer: surgery as far as possible to achieve R0; chemotherapy with platinum in the course of foot therapy; and pay attention to maintenance treatment.ovarian cancer 2020 v1 In most cases, open surgery is the first choice for ovarian cancer surgery, with a long enough vertical median incision. Patients with small tumor volume or newly diagnosed late stage or recurrence can achieve the optimal cytoreductive surgery, experienced gynecologists can perform minimally invasive surgery, and those with unsatisfactory surgery should be treated The surgeon should describe the following contents in the operation record: the range of pelvic and abdominal tumors before operation, and the location, number, size and number of residual lesions after tumor reduction.for invasive epithelial ovarian cancer with initial treatment limited to ovary or pelvic cavity, all lesions in pelvic, abdominal or retroperitoneal should be removed as much as possible: ascites or peritoneal lavage fluid should be taken for cytological examination, the peritoneal surface should be inspected comprehensively, and the omentum should be removed; the uterus and double appendages should be removed completely to avoid tumor rupture; and fertility preservation should be expected and met For patients with functional indications, unilateral adnexectomy or bilateral adnexectomy should be considered, and retroperitoneal lymph nodes should be resected at least to the level of inferior mesenteric artery and preferably to the level of renal vessels.the lymph node must be resected in early stage! Surgical procedures of invasive epithelial ovarian cancer involving the pelvis and upper abdomen: try our best to remove all pelvic, abdominal and retroperitoneal tumor lesions. The standard of satisfactory tumor reduction is that the diameter of residual tumor is less than 1cm, and there is no residual lesion (R0) with naked eye as far as possible; to remove the enlarged or suspicious lymph nodes that can be resected, and the clinically negative lymph nodes do not need to be removed (based on lion) Results: bilateral pelvic and paraaortic lymphadenectomy must be performed in patients with extrapelvic tumor lesions ≤ 2cm (i.e. stage IIIB). In order to achieve satisfactory tumor reduction, the bowel, appendix, spleen, gallbladder, liver, stomach, bladder, bladder, pancreatic tail, ureter, diaphragm and other peritoneum can be removed according to the needs; epithelial ovarian cancer with small residual lesions after tumor reduction can be achieved Or peritoneal cancer patients, is the indication of intraperitoneal chemotherapy, can be considered in the initial operation of intraperitoneal chemotherapy catheter.lymphadenectomy: for ovarian cancer confined to the pelvic cavity and preservation of reproductive function, a comprehensive staged operation is required to exclude the occult lesions; for ovarian cancer involving the pelvis and upper abdomen, suspicious metastasis or enlarged lymph nodes must be removed, and clinically negative lymph nodes can not be removed; if the tumor exceeds the pelvic cavity but the metastasis is less than 2cm, pelvic and abdominal paraaortic lymph nodes should be performed Lymph node resection, intermediate tumor reduction (IDS) after neoadjuvant chemotherapy (NACT) should also reach the level of R0 as far as possible. Enlarged or suspicious lymph nodes must be removed, and lymph nodes with potential metastasis at the initial diagnosis should be removed.cases without lymph node resection: borderline tumor; clinically confirmed early childhood / adolescent germ cell tumor; sex cord stromal tumor.incomplete staged surgical treatment: for IA or IB stage without residual lesions, if observation is considered, comprehensive staged surgery is required; for IC-IV stage without residual lesions, adjuvant treatment is required; if residual lesions are suspected to be resectable, tumor reduction surgery is required; if residual lesions are suspected and cannot be removed, NACT + IDS is required.■ NACT + IDS includes hysterectomy and bilateral oviduct oophorectomy (BSO) and staging. IDS should be implemented after 3-4 cycles of NACT.NACT: 2018 guidelines emphasize evaluation before the fourth course of treatment; 2019 guidelines: the best 3 courses, or 4-6 courses according to the doctor's experience; 2020 guidelines update: ① there must be histological evidence before chemotherapy, the best biopsy, also can be evaluated by laparoscopy; ② if biopsy can not be carried out, the ratio of ascites or pleural effusion cytology + CA125 / CEA > 25; ③ the operation time should be based on the patient's relevant conditions Adjustment: patients in remission after 3-4 courses of chemotherapy were treated with IDs and follow-up adjuvant therapy; those who were stable after 3-4 courses of chemotherapy were treated with IDS immediately or continued with chemotherapy for 6 courses before IDS + postoperative chemotherapy; those who progressed after 3-4 courses of chemotherapy were treated according to recurrence; ④ abdominal cavity hyperthermic perfusion chemotherapy with cisplatin (100mg / m2) after stage III IDs.both NACT and IDS aim to achieve R0.how to select NACT beneficiaries: through imaging or laparoscopic evaluation, the patients with extensive IIIc stage can not achieve satisfactory cytoreductive surgery; patients with stage IV (resection rate < 10%); patients with poor general condition and unable to tolerate surgery; lack of experienced women's tumor surgery team.■ PDS can be considered if initial tumor reduction surgery (PDS) or NACT + intermittent tumor reduction surgery can achieve satisfactory tumor reduction for advanced ovarian cancer; NACT is not always the alternative of PDS in the selection of first-line treatment options; chemotherapy can be considered if surgery is not feasible or the possibility of satisfactory tumor reduction is low; pathological type and gene mutation status may also affect the treatment of patients The choice of treatment plan. ■ secondary cytoreductive surgery: Although the gog213 study does not support secondary surgery, the European desktop III study shows that patients with platinum sensitive recurrent (PSR) ovarian cancer can benefit from progression free survival (PFS); the overall survival (OS) data is not yet mature. presented at ASCO 2020, desktop The conclusions published in Study III support the second operation: for patients with platinum free interval > 6 months and screened by ago score, tumor cytoreductive surgery can significantly prolong OS and PFS; only patients with complete resection have OS benefit, and the most benefit (if total resection is achieved, the median OS will be extended by more than 12 months); and the optimization of patients selection (e.g. through ago score) is emphasized ）And the importance of optimizing the selection of medical centers with professional knowledge and greater probability of complete resection. therefore, the 2020nccn guidelines indicate that secondary cytoreductive surgery can be performed under the following conditions: PSR (recurrence > 6-12 months after the end of primary chemotherapy); isolated (or localized) lesions are suitable for complete eradication; and no ascites. encourage patients to participate in clinical trials to evaluate whether secondary tumor reduction surgery can really benefit. ovarian cancer 2020 v1 NCCN guidelines update - chemotherapy chapter 2020 guidelines basically maintain the previous chemotherapy principles and chemotherapy indications, but specify the dose of chemotherapy drugs; according to the clinical pathological stages, chemotherapy regimens are classified according to the preferred recommendation, other recommendations and useful schemes under specific conditions, and tabulated, which is more conducive to the clinical application of gynecologists. according to the 2020 guidelines, TC regimen is recommended as the first choice for initial and post relapse chemotherapy of malignant cord stromal tumors (EP regimen is also listed as 2A evidence; while BEP regimen is useful in specific conditions). the first choice of chemotherapy for carcinosarcoma is TC paclitaxel 175mg / m2 carboplatin. chemotherapy regimens for different stages and types of ovarian cancer are shown in table 1-3: Table 1 initial systemic treatment plan for stage I epithelial ovarian cancer / fallopian tube cancer / primary peritoneal cancer: 6 cycles are recommended for stage I patients; 3-6 cycles are recommended for all other ovarian cancer types. Table 2 initial systemic treatment plan for stage II ~ IV epithelial ovarian cancer / fallopian tube cancer / primary peritoneal cancer Table 3 Chemotherapy regimens for epithelial ovarian cancer (including special cases) / fallopian tube cancer / primary peritoneal cancer are classified and selected based on platinum sensitivity for recurrent ovarian cancer, fallopian tube cancer or primary peritoneal cancer, as shown in table 4-6: platinum refractory: disease progression within 4 weeks after platinum treatment or at the end of platinum treatment; platinum resistant recurrence: disease after platinum treatment for 1-6 months Progression; platinum sensitive relapse: end of platinum therapy for 6-12 months of disease progression; PSR: end of platinum therapy for more than 12 months of disease progression. Table 4 The selection principles of platinum sensitive regimen for PSR epithelial ovarian cancer (including rare pathological types) / fallopian tube cancer / primary peritoneal cancer: all the initial first-line regimens can be selected; platinum containing combination regimen is preferred; carboplatin or cisplatin is still preferred for platinum; at least 6 courses of treatment; in vitro drug sensitivity test is not recommended; PLD and bevacizumab are the most commonly used regimens in the United States; the treatment goal is to delay as much as possible Long platinum free interval. Table 5 platinum resistant recurrent epithelial ovarian cancer (including rare pathological types) / fallopian tube cancer / primary peritoneal cancer table 6 Platinum resistant recurrent ovarian cancer / fallopian tube cancer / primary peritoneal cancer recommended drug non platinum single drug chemotherapy: no first choice of chemotherapy drugs; weigh the efficacy and toxicity of drugs; pay special attention to the quality of life of patients; encourage patients to participate in clinical trials. chemotherapy regimens for rare pathological types of ovarian malignant tumors are shown in table 7-10: Table 7 initial treatment plan for 2020nccn malignant germ cell tumor Table 8 treatment plan for recurrence of 2020nccn malignant germ cell tumor Table 9 initial treatment plan for 2020nccn malignant sex cord stromal tumor table 10 2020nccn malignant sex cord stromal tumor recurrence treatment plan for ovarian cancer 2020 v1 NCCN guideline update maintenance therapy chapter ■ first line maintenance therapy PARP inhibitors move from PSR to first-line: new nilapali, olapali + bevacizumab for first-line maintenance; first-line introduction of homologous recombination defect (HRD) detection; reduced recommendation of bevacizumab, single drug only for previous use of bevacil and BRCA wild type / unknown. first line maintenance therapy after initial treatment of ovarian cancer (Table 11): it is suitable for patients with stage II-IV complete remission / partial remission (CR / PR), but not for stage I, stable and progressive patients; the presence of germline and / or systemic BRCA1 / 2 mutation indicates the need for maintenance treatment; in the absence of BRCA1 / 2 mutation, HRD status may provide information about the benefit of PARP inhibitor treatment (2B Class of evidence). Table 11 maintenance treatment of Cr / PR after initial treatment of stage II ~ IV ovarian cancer ■ other targeted therapy anti angiogenesis drugs: bevacizumab, as a representative, is applicable to almost all solid tumors and does not need to rely on tumor gene test results. adding bevacizumab in the first-line chemotherapy of ovarian cancer can improve the remission rate and expand the applicable population of PARP inhibitors. After the remission of chemotherapy, olapali + bevacizumab or nilapali monotherapy can be selected for maintenance treatment.