骨癌2023.v1（英文）-NCCN腫瘤臨床實(shí)踐指南

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)BoneCancerNCCNGuidelinesforPatients?availableat/patientsVersion1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.*J.SybilBiermann,MD/Chair?τUniversityofMichiganRogelCancerCenter*AngelaHirbe,MD,PhD/Vice-Chair??SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineMarkAgulnik,MD?CityofHopeNationalMedicalCenterlasMBernthalMDSarahBoles,MD??cerCenterBrianBrigman,MD,PhD?τAlexandraK.Callan,MDτ?CenterLeeD.Cranmer,MD,PhD?TSeattleCancerCareAllianceSaeedDianat,MDфnterEricDonnelly,MD§NicolaFabbri,MD?τangPhDJohnGroundland,MD?SusanM.Hiniker,MD§MargoL.Hoover-Regan,MD€UniversityofWisconsinLisaKafchinski,MDτ?O'NealComprehensiveCancerCenteratUABJosephB.Kuechle,MD,PhD?τlParkComprehensiveCancerCenterSameeraKumar,MD§FoxChaseCancerCenterDieterLindskog,MDτYaleCancerCenter/SmilowCancerHospitalDavidR.Lucas,MD≠UniversityofMichiganRogelCancerCenterJoelL.Mayerson,MD?τeCancerCenterJamesCancerHospitalSeanV.McGarry,MDτ?Fred&PamelaBuffettCancerCenterCarolD.Morris,MD,MS?τkinsDamonR.Reed,MD€PeterS.Rose,MDτ?VictorM.Santana,MD€St.JudeChildren’sResearchHospital/TheUniversityofTennesseeHealthScienceCenterRobertL.Satcher,MD,PhD?τTheUniversityofTexasJosephSchwab,MD,MSτHerbertSchwartz,MD?τVanderbilt-IngramCancerCenterStevenW.Thorpe,MDτ?UCDavisComprehensiveCancerCenterBreelynA.Wilky,MD?UniversityofColoradoCancerCenterRosannaL.Wustrack,MD?τUCSFHelenDillerFamilyCenteresPanelDisclosuressticInterventional?Hematology/HematologiconcologyTInternalmedicine?MedicaloncologyτOrthopedics€§?*athologyPediatriconcologyRadiotherapy/RadiationoncologySurgery/SurgicaloncologyDiscussionWritingaryoftheGuidelinesUpdatesupBONEPrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.NotapprovedforaryoftheGuidelinesUpdatesupBONEdexerPanelMemberscoma?Presentation(CHON-1)?PrimaryTreatment,LowGradeandIntracompartmental(CHON-2)?PrimaryTreatment,HighGrade,ClearCell,orExtracompartmental(CHON-3)?MetastaticChondrosarcoma(CHON-4)?WorkupandHistologicSubtype(CHOR-1)?PresentationandPrimary/AdjuvantTreatment(CHOR-2)?SurveillanceandRecurrence(CHOR-3)EwingSarcoma:?Workup,PrimaryTreatment,Restage(EW-1)?AdjuvantTreatment,Surveillance,andRelapse(EW-2)?MetastaticDisease(EW-3)GiantCellTumorofBone:?WorkupandPresentation(GCTB-1)?PrimaryTreatment(GCTB-2)?Surveillance,Recurrence(GCTB-3)oma?WorkupandPrimaryTreatment(OSTEO-1)?NeoadjuvantandAdjuvantTreatment(OSTEO-2)?MetastaticDisease(OSTEO-3)?SurveillanceandRelapse(OSTEO-4)ofBoneCancerManagementBONEABONEBlesofRadiationTherapyBONECAbbreviations(ABBR-1)lievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicalcircumstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetwork?(NCCN?)makesnorepresentationsorwarrantiesofanykindregardingtheircontent,useorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinghtsreservedTheNCCNGuidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexVersionoftheNCCNGuidelinesforBoneCancerfromVersionincludeGlobalchange:?Incorporatedasclinicallyindicatedforsurveillanceimagingonthefollowingpages:CHON-2,CHON-3,CHOR-3,EW-2,GCTB-3,andOSTEO-4.GCTB-2GiantCellTumorofBone?Removedinterferonalfa-2Bfromlocalizedandmetastaticdiseaseduetoformulationsbeingdiscontinued(AlsoforBONE-B3of6andBONE-C4of6).Footnotes?"c"modified:Intralesionalexcisionwithaneffectiveadjuvantismaybeadequate.?"d"modified:Denosumabshouldmaybecontinueduntildiseaseprogression,inrespondingdisease.Thisfootnotewasaddedtotheremainsunresectablenode.?"j"newfootnoteadded:Long-termdenosumabusemaybeassociatedwithincreasedriskoflocalrecurrence,correspondingtochangestoresectablenode.OSTEO-1oma?Category1addedtochemotherapyforhigh-gradeadjuvanttreatment.BONE-B(1of6)BoneCancerSystemicTherapyAgents?Nivolumabincombinationwithipilimumabisanewtreatmentoptionforpatientswithadvancedormetastaticsolidtumorsofhightumormutationalburden(TMB-H)withthefollowingreference.pSchenkerM,BurottoM,RichardetM,etal.CheckMate848:arandomized,open-label,phase2studyofnivolumabincombinationwithipilimumabornivolumabmonotherapyinpatientswithadvancedormetastaticsolidtumorsofhightumormutationalburden.OralPresentationpresentedattheAmericanAssociationforCancerResearch(AACR)2022AnnualMeeting;April8-13,2022;NewOrleans,LA.BMSplanstosubmitdataforpublicationinapeer-reviewedjournalin2022.BONE-B(2of6)?ClarificationofVAItoVAIA(vincristine,doxorubicin,ifosfamide,anddactinomycin)forEwingsarcoma,First-linetherapy(primary/neoadjuvant/adjuvanttherapy),Otherrecommendedregimens,andPrimarytherapyformetastaticdiseaseatinitialpresentation,preferredregimen.?Thefollowingreferenceisnew:pAlbergoJI,GastonCL,LaitinenM,etal.Ewing'ssarcoma:onlypatientswith100%ofnecrosisafterchemotherapyshouldbeclassifiedashavingagoodresponse.BoneJointJ2016;98-B:1138-1144.Correspondingtothefollowingregimens:?VAIA(vincristine,doxorubicin,ifosfamide,dactinomycin)?VIDE(vincristine,ifosfamide,doxorubicin,andetoposide)BONE-B(3of6)OsteosarcomaFootnote?"h"newfootnoteadded:MAPispreferredinpatients<40yearswithexcellentperformancestatuscorrespondingto(high-dosemethotrexate,cisplatin,anddoxorubicin).PrinciplesofRadiationTherapyBONE-C(3of6)?DefinitiveRT:VAC/IEtoVDC/IE.?Statementremoved:Considerincreasingboostdosetoatotalof59.4Gyforchemotherapyresponse<50%?ConsideruseofSRS/SBRT,especiallyforoligometastases,isnewundertreatmentofmetastaticdiseaseforEwingsarcoma.AlsoforOsteosarcomawiththefollowingreferences:pBrownLC,LesterRA,GramsMP,etal.StereotacticbodyradiotherapyformetastaticandrecurrentEwingsarcomaandosteosarcoma.Sarcoma2014;418270.pBaumannBC,NagdaSN,KolkerJD,etal.Efficacyandsafetyofstereotacticbodyradiationtherapyforthetreatmentofpulmonarymetastasesfromsarcoma:Apotentialalternativetoresection.JSurgOncol2016;114:65-69.pMehtaN,SelchM,WangPC,etal.SafetyandefficacyofstereotacticbodyradiationtherapyinthetreatmentofpulmonarymetastasesfromhighgradeUPDATESsarcoma.Sarcoma2013;360214UPDATESVersion1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexPrimarybonetumorsandselectedmetastatictumorsshouldbeevaluatedandtreatedbyamultidisciplinaryteamwithexpertiseinthemanagementofthesetumorsTheteamshouldmeetonaregularbasisandshouldinclude:CoreGroup?Orthopediconcologist?Bonepathologist?Medical/pediatriconcologist?Radiationoncologist?MusculoskeletalradiologistSpecialistsCriticalinCertainCases?Thoracicsurgeon?Plasticsurgeon?Interventionalradiologist?Physiatrist?Vascular/generalsurgeon?Neurosurgeon/orthopedicspinesurgeon?Palliativecarephysician?AdditionalsurgicalsubspecialtiesasclinicallyindicatedNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.TEAM-1Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexWORKUPgegeRefertoorthopediconcologist?Biopsy,ifindicated,tinginstitutiontinginstitutionborkupforbonesasyindicated???????HistoryandphysicalBonescanorPET/CT(category2B)ChestradiographSerumproteincominalpelvicCTwithcontrastProstate-specificantigen(PSA)MammogramnsleboneonsboneprimaryectedoneCancerorspecificbonecomasRefertoorthopediconcologist?BiopsyshouldbeperformedattreatinginstitutionRefertoappropriateNCCNGuidelinesforTreatmentbyCancerTypeaSeeMultidisciplinaryTeam(TEAM-1).bSeePrinciplesofBoneCancerManagement(BONE-A).cLabsincludecompletebloodcount(CBC)andcomprehensivemetabolicpanel(CMP)withcalciumtoassessforhypercalcemia.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.BONE-1PrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexPRESENTATIONa,b,ctalNNN(gradell,gradelll)orClearcellorExtracompartmentalMetastaticdiseaseatpresentationSeeCHON-4 SeeCHON-4MesenchymalTreatasEwingsarcoma(categoryMesenchymalTreatasEwingsarcoma(category2B)aSeeMultidisciplinaryTeam(TEAM-1).bSeePrinciplesofBoneCancerManagement(BONE-A).cThereisconsiderablecontroversyregardingthegradingofchondrosarcoma.Inadditiontohistology,radiologicfeatures,size,andlocationoftumorsshouldalsobeconsideredindecidinglocaltreatment.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.CHON-1PrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dextalPRIMARYTREATMENTIntralesionalideexcisioneexcisionideexcisioneConsiderRT,fifunresectable(category2B)SURVEILLANCE?Physicalexam?Radiographsofprimarysiteand/orcross-sectionalimagingMRIorCT(bothwithcontrast)every6–12mofor2y,thenyearly,asclinicallyindicated?Chestimagingevery6–12mofor2y,thenyearly,asclinicallyindicatedRECURRENCE dedeBConsiderRTf(category2B)Considerre-resectiontoachievenegativesurgicalmarginsdThismanagementshouldberestrictedtoextremitytumors(notpelvictumors).eWideexcisionshouldprovidehistologicallynegativesurgicalmargins.Thismaybeachievedbyeitherlimb-sparingresectionorlimbamputation.fSeePrinciplesofRadiationTherapy(BONE-C).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHON-2Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.mayincludeCThatleasteveryyforaysicalexamadiographsofprimaryteandorcrosssectionalRIorCTmayincludeCThatleasteveryyforaysicalexamadiographsofprimaryteandorcrosssectionalRIorCTbothwithcontrast)asclinically?Chestimaginggevery3–6mossessfunctionateveryollowupvisitdexPRIMARYSURVEILLANCERECURRENCETREATMENTHighgrade(gradell,gradelll)orClearcellorExtracompartmentaldeedeeleorBLocalLocalBdedeConsiderRT(category2B)Considerre-resectiontoachievenegativesurgicalmarginsastaticrecurrence(CHON-4)Systemicrecurrence(CHON-4)eWideexcisionshouldprovidehistologicallynegativesurgicalmargins.Thismaybeachievedbyeitherlimb-sparingresectionorlimbamputation.fSeePrinciplesofRadiationTherapy(BONE-C).gBasedonphysician'sconcernforriskofrecurrence.hChestCTwithorwithoutcontrastasclinicallyindicated.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHON-3Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexMETASTATICCHONDROSARCOMAirosarcomastaticWidespreaddiseaseSurgicalexcisionofallsitesifpossibleerradiationforunresectablesitesclinicaltrialrablativetherapiesforsymptomaticsitesersystemictherapykSeeSystemicTherapyAgents(BONE-B)clinicaltrialiConsidercomprehensivegenomicprofiling(CGP)withavalidatedand/orFDA-approvedassaytodeterminetargetedtherapyopportunities.jMayconsidertreatingasosteosarcoma(category2B).kConsidertestingfortumormutationalburden(TMB)andmismatchrepair/microsatelliteinstability(MMR/MSI)asdeterminedbyavalidatedand/orFDA-approvedassaytoinformtheuseofpembrolizumab.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.CHON-4storyandphysicalPrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.storyandphysicaldexWORKUPaHISTOLOGICSUBTYPE?Allpatientsshouldbeevaluatedandtreatedbyamultidisciplinaryteamwithexpertiseinthemanagement?Adequateimagingofprimarysite(eg,x-ray,MRI±CT)andscreeningMRIofspinalaxis(MRI/CTwithcontrast)?Chest/abdominal/pelvicCTwithcontrast?ConsiderPET/CT(skullbasetomid-thigh)?ConsiderbonescanifPET/CTisnegativealorChondroidesentationandPrimaryRPoorlydifferentiatedorDedifferentiatedSeeNCCNGuidelinesforSoftTissueSarcomaultidisciplinaryTeamTEAMNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.CHOR-1ancectionPrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.ancectiondexPRESENTATIONPRIMARYTREATMENTADJUVANTTREATMENTSacrococcygealandMobilespineSkullbase/ClivalTcdforpositivesurgicalmarginsorforartmentaltumorsConsiderRTddbSeePrinciplesofBoneCancerManagement(BONE-A).cRadiationtherapymaybegivenpreoperatively,intraoperatively,and/orpostoperatively.dSeePrinciplesofRadiationTherapy(BONE-C).eMaximalsaferesection.Maximaltumorremovalisrecommendedwhenappropriate.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHOR-2Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexSURVEILLANCERECURRENCEfTREATMENT?Physicalexam?Chestimaginggevery6momayincludeCTannuallyfor5sclinicallyindicated?Imagingofprimarysite,timing,andmodality,as?Chestimaginggevery6momayincludeCTannuallyfor5sclinicallyindicatedrrrctherapyhlexcisionbrlexcisionbrrand/orBestsupportivecarebSeePrinciplesofBoneCancerManagement(BONE-A).dSeePrinciplesofRadiationTherapy(BONE-C).fConsidercomprehensivegenomicprofiling(CGP)withavalidatedand/orFDA-approvedassaytodeterminetargetedtherapyopportunities.gChestCTwithorwithoutcontrastasclinicallyindicated.hSeeBoneCancerSystemicTherapyAgents(BONE-B).iConsidertestingforTMBandMMR/MSIasdeterminedbyavalidatedand/orFDA-approvedassaytoinformtheuseofpembrolizumab.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHOR-3Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.uirerebiopsytedehydrogenasepeatotherlstudiesPrintedbyMinTangon8/6/20227:05:20AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationaluirerebiopsytedehydrogenasepeatotherlstudiesdexPRESENTATIONa,b,cWORKUPPRIMARYTREATMENTRESTAGE?HistoryandphysicalCTe?MRI±CT(bothwithcontrast)CTe?PET/CT(head-to-toe)and/orbonescan?Considerbonemarrowbiopsyand/ordpelvisfscreeningMRIdpelvisfiesgCytogeneticsiesg?Fertilityconsultationshouldbeconsideredchemotherapyh(category1)foratapyi9weekspriortoapyiCTe?MRI±CT(bothwithcontrast)ofprimarysite?Radiographsofprimarysite?ConsiderPET/CTadtotoezedResponse,metastaticdisease(EW-3)seaSeeMultidisciplinaryTeam(TEAM-1).bSeePrinciplesofBoneCancerManagement(BONE-A).cEwingsarcomacanbetreatedusingthisalgorithm,includingprimitiveneuroectodermaltumorofbone,Askintumor,andextraosseousEwingsarcoma.dConsidercomprehensivegenomicprofiling(CGP)orotherfusionpanelforEwingsarcomatoidentifytranslocationsifpathologicworkupoftargetedpolymerasechainreaction(PCR),fluorescenceinsituhybridization(FISH),orcytogeneticsisnegative.eChestCTwithorwithoutcontrastasclinicallyindicated.fCampbellKM,etal.PediatrBloodCancer2021;68:e28807.gNinetypercentofEwingsarcomawillhaveoneoffourspecificcytogenetictranslocations.ForpatientswithEwing-likesarcoma(eg,CIC::DUX4)analternatetreatmentparadigmcanbeconsidered.Forthosewhoarenegative,additionalmoleculartestingisrecommended.hSeeBoneCancerSystemicTherapyAgents(BONE-B).iLongertreatmentpriortolocalcontroltherapycanbeconsideredinpatientswithmetastaticdiseasebasedonresponse.jUsethesameimagingtechniquethatwasperformedintheinitialworkup.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,08/02/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserve