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Recently, the 2021 V1 version of the NCCN Guidelines for Gastric Cancer was released.
This article summarizes the updated points of the latest version of the guidelines for readers' reference.
GAST-1-Inspection, staging, and further evaluation The 9th point of the inspection is revised to: Recommend all newly diagnosed patients to detect microsatellite instability (MSI) through polymerase chain reaction (PCR)/through immunohistochemistry (IHC) Detection of mismatch repair (MMR).
The new point 11 of the inspection: If there is still enough tissue available after completing the above inspection, the second-generation sequencing (NGS) should be considered.
GAST-9-Palliative treatment for unresectable locally advanced, local recurrence or distant metastasis For patients with unresectable locally advanced, locally recurring or metastatic disease, Karnofsky score ≥ 60% or ECOG score ≤ 2 points: if suspected For metastatic adenocarcinoma, carry out HER2 and PD-L1 detection, detect MSI by PCR (if it has not been tested before), and IHC for MMR (if it has not been tested before); new addition: if there is still enough tissue available after completing the above inspection, it should be Consider second-generation sequencing (NGS).
GAST-B 1 of 6-Principles of Pathological Examination and Biomarker Detection Table 1 Update For biopsy tissue samples, endoscopic mucosal resection samples, gastrectomy samples, pathological examination analysis/reports are newly added: For all newly diagnosed patients , It is recommended to conduct a comprehensive test: MSI detection by PCR / MMR detection by IHC.
GAST-B 4 of 6-Principles of pathological examination and biomarker detection MSI or MMR detection: Modified to: For all newly diagnosed gastric cancer patients, MSI or IHC should be used to detect MMR by PCR.
The test specimen is formalin-fixed, paraffin-embedded (FFPE) tissue.
According to the "CAP DNA Mismatch Repair Biomarker Reporting Guide", the results can be interpreted as MSI-H or mismatch repair defect (dMMR).MMR or MSI testing can only be performed in laboratories certified under the Clinical Laboratory Improvement Act of the United States (CLIA).
Patients with MSI-H or dMMR tumors should be referred for genetic counseling for further evaluation.
Liquid biopsy: It is a form of "liquid biopsy" that can identify genetic mutations in solid tumors by assessing the circulating tumor DNA (ctDNA) in the blood.
Liquid biopsy is increasingly being used for advanced patients who cannot pass clinical biopsy to monitor and manage the disease.
Detection of DNA mutations shed by gastric cancer can find gene mutations that can be targeted for therapy or clones that change the response to treatment.
Therefore, for patients with metastatic or advanced gastric cancer (new) or patients who cannot undergo traditional biopsy, consider using a certified NGS-based comprehensive genomic analysis method for testing in a CLIA-certified laboratory.
Negative results should be interpreted with caution, as they cannot exclude the presence of tumor mutations or amplifications.
GAST-D 3 of 8-principles of genetic evaluation of gastric cancer.
Hereditary cancer susceptibility syndrome is associated with an increased risk of gastric cancer: New: This is an autosomal dominant genetic disease characterized by a diffuse disease that usually develops at a young age Sex (signet ring cell) gastric cancer.
CDH1 truncation mutations are found in 30%-50% of cases, and the CDH1 gene is responsible for encoding the cell adhesion molecule E-cadherin.
It is estimated that when a patient with hereditary cancer susceptibility syndrome is 80 years old, the risk of gastric cancer in men is 67%, and the risk of gastric cancer in women is 83%.
The median age at diagnosis of gastric cancer was 37 years.
Women with CDH1 mutations have a higher risk of breast lobular cancer.
Such patients should be transferred to a center with a multidisciplinary team for treatment.
The team should include professional surgeons, gastroenterologists, clinical geneticists, nutritionists, psychologists, or psychologists for upper gastrointestinal cancer surgery.
GAST-D 5 of 8-Principles of genetic evaluation of gastric cancer Screening recommendation: For the screening of the CDH1 gene of hereditary diffuse gastric cancer, gastric cancer screening recommendation New: For patients without a clear family history of diffuse gastric cancer (DGC) , Need genetic consultation and multidisciplinary expert team diagnosis and treatment.
GAST-F 1 of 15-Principles of Systemic Treatment Preoperative Radiotherapy and Chemotherapy: All preferred options are removed; other recommended options include: paclitaxel + carboplatin (from category 1 to category 2B); fluorouracil + oxaliplatin ( Change from category 1 to category 2B); fluorouracil + cisplatin (category 2B); fluoropyrimidine (fluorouracil or capecitabine) (category 2B); fluoropyrimidine (fluorouracil or capecitabine) + paclitaxel removed GAST- F 1 of 15——Systematic treatment principle Second-line and later-line treatment preferred plan: Pembrolizumab can be used for the third-line and above treatment of patients with PD-L1 CPS≥1 gastric cancer (from gastric adenocarcinoma to gastric cancer).
Other programs: New: irinotecan + ramucirumab (category 2A); fluorouracil + irinotecan + ramucirumab (changed from the "under specific circumstances" treatment program to other recommended programs).
Treatment options under specific circumstances: For patients with NTRK gene fusion positive, you can choose Entritinib or Lolatinib (Class 2A) (new); for patients with MSI-H/dMMR, you can choose Pembrolizumab ( Category 2A) (previously the preferred option); for patients with high TMB levels (TMB≥10mut/mb), pembrolizumab (category 2A) (new indication) can be selected.
Reference: NCCN clinical practice guideline in oncology.
Version 1.
2021.
Gastric Cancer.
NCCN.
org.
This article summarizes the updated points of the latest version of the guidelines for readers' reference.
GAST-1-Inspection, staging, and further evaluation The 9th point of the inspection is revised to: Recommend all newly diagnosed patients to detect microsatellite instability (MSI) through polymerase chain reaction (PCR)/through immunohistochemistry (IHC) Detection of mismatch repair (MMR).
The new point 11 of the inspection: If there is still enough tissue available after completing the above inspection, the second-generation sequencing (NGS) should be considered.
GAST-9-Palliative treatment for unresectable locally advanced, local recurrence or distant metastasis For patients with unresectable locally advanced, locally recurring or metastatic disease, Karnofsky score ≥ 60% or ECOG score ≤ 2 points: if suspected For metastatic adenocarcinoma, carry out HER2 and PD-L1 detection, detect MSI by PCR (if it has not been tested before), and IHC for MMR (if it has not been tested before); new addition: if there is still enough tissue available after completing the above inspection, it should be Consider second-generation sequencing (NGS).
GAST-B 1 of 6-Principles of Pathological Examination and Biomarker Detection Table 1 Update For biopsy tissue samples, endoscopic mucosal resection samples, gastrectomy samples, pathological examination analysis/reports are newly added: For all newly diagnosed patients , It is recommended to conduct a comprehensive test: MSI detection by PCR / MMR detection by IHC.
GAST-B 4 of 6-Principles of pathological examination and biomarker detection MSI or MMR detection: Modified to: For all newly diagnosed gastric cancer patients, MSI or IHC should be used to detect MMR by PCR.
The test specimen is formalin-fixed, paraffin-embedded (FFPE) tissue.
According to the "CAP DNA Mismatch Repair Biomarker Reporting Guide", the results can be interpreted as MSI-H or mismatch repair defect (dMMR).MMR or MSI testing can only be performed in laboratories certified under the Clinical Laboratory Improvement Act of the United States (CLIA).
Patients with MSI-H or dMMR tumors should be referred for genetic counseling for further evaluation.
Liquid biopsy: It is a form of "liquid biopsy" that can identify genetic mutations in solid tumors by assessing the circulating tumor DNA (ctDNA) in the blood.
Liquid biopsy is increasingly being used for advanced patients who cannot pass clinical biopsy to monitor and manage the disease.
Detection of DNA mutations shed by gastric cancer can find gene mutations that can be targeted for therapy or clones that change the response to treatment.
Therefore, for patients with metastatic or advanced gastric cancer (new) or patients who cannot undergo traditional biopsy, consider using a certified NGS-based comprehensive genomic analysis method for testing in a CLIA-certified laboratory.
Negative results should be interpreted with caution, as they cannot exclude the presence of tumor mutations or amplifications.
GAST-D 3 of 8-principles of genetic evaluation of gastric cancer.
Hereditary cancer susceptibility syndrome is associated with an increased risk of gastric cancer: New: This is an autosomal dominant genetic disease characterized by a diffuse disease that usually develops at a young age Sex (signet ring cell) gastric cancer.
CDH1 truncation mutations are found in 30%-50% of cases, and the CDH1 gene is responsible for encoding the cell adhesion molecule E-cadherin.
It is estimated that when a patient with hereditary cancer susceptibility syndrome is 80 years old, the risk of gastric cancer in men is 67%, and the risk of gastric cancer in women is 83%.
The median age at diagnosis of gastric cancer was 37 years.
Women with CDH1 mutations have a higher risk of breast lobular cancer.
Such patients should be transferred to a center with a multidisciplinary team for treatment.
The team should include professional surgeons, gastroenterologists, clinical geneticists, nutritionists, psychologists, or psychologists for upper gastrointestinal cancer surgery.
GAST-D 5 of 8-Principles of genetic evaluation of gastric cancer Screening recommendation: For the screening of the CDH1 gene of hereditary diffuse gastric cancer, gastric cancer screening recommendation New: For patients without a clear family history of diffuse gastric cancer (DGC) , Need genetic consultation and multidisciplinary expert team diagnosis and treatment.
GAST-F 1 of 15-Principles of Systemic Treatment Preoperative Radiotherapy and Chemotherapy: All preferred options are removed; other recommended options include: paclitaxel + carboplatin (from category 1 to category 2B); fluorouracil + oxaliplatin ( Change from category 1 to category 2B); fluorouracil + cisplatin (category 2B); fluoropyrimidine (fluorouracil or capecitabine) (category 2B); fluoropyrimidine (fluorouracil or capecitabine) + paclitaxel removed GAST- F 1 of 15——Systematic treatment principle Second-line and later-line treatment preferred plan: Pembrolizumab can be used for the third-line and above treatment of patients with PD-L1 CPS≥1 gastric cancer (from gastric adenocarcinoma to gastric cancer).
Other programs: New: irinotecan + ramucirumab (category 2A); fluorouracil + irinotecan + ramucirumab (changed from the "under specific circumstances" treatment program to other recommended programs).
Treatment options under specific circumstances: For patients with NTRK gene fusion positive, you can choose Entritinib or Lolatinib (Class 2A) (new); for patients with MSI-H/dMMR, you can choose Pembrolizumab ( Category 2A) (previously the preferred option); for patients with high TMB levels (TMB≥10mut/mb), pembrolizumab (category 2A) (new indication) can be selected.
Reference: NCCN clinical practice guideline in oncology.
Version 1.
2021.
Gastric Cancer.
NCCN.
org.
