骨癌2022.v2（英文）-NCCN肿瘤临床实践指南

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines®)BoneCancerrsionOctoberNCCNGuidelinesforPatients®availableat/patientsVersion2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.*J.SybilBiermann,MD/Chair¶τUniversityofMichiganRogelCancerCenter*AngelaHirbe,MD,PhD/Vice-Chair†SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineWarrenChow,MD†‡CityofHopeNationalMedicalCenterlasMBernthalMDSarahBoles,MD†‡cerCenterBrianBrigman,MD,PhD¶τAlexandraK.Callan,MDτ¶CenterLeeD.Cranmer,MD,PhD†ÞSeattleCancerCareAllianceSaeedDianat,MDфnterEricDonnelly,MD§NicolaFabbri,MD¶τesPanelDisclosuresJohnGroundland,MD¶SusanM.Hiniker,MD§MargoL.Hoover-Regan,MD€UniversityofWisconsinLisaKafchinski,MDτ¶O'NealComprehensiveCancerCenteratUABJosephB.Kuechle,MD,PhD¶τlParkComprehensiveCancerCenterDieterLindskog,MDτYaleCancerCenter/SmilowCancerHospitalDavidR.Lucas,MD≠UniversityofMichiganRogelCancerCenterJoelL.Mayerson,MD¶τeCancerCenterJamesCancerHospitalSeanV.McGarry,MDτ¶Fred&PamelaBuffettCancerCenterCarolD.Morris,MD,MS¶τkinsR.LorRandall,MD,FACS¶τUCDavisComprehensiveCancerCenterDamonR.Reed,MD€PeterS.Rose,MDτ¶VictorM.Santana,MD€St.JudeChildren’sResearchHospital/TheUniversityofTennesseeHealthScienceCenterRobertL.Satcher,MD,PhD¶τTheUniversityofTexasJosephSchwab,MD,MSτHerbertSchwartz,MD¶τVanderbilt-IngramCancerCenterBreelynA.Wilky,MD†UniversityofColoradoCancerCenterRosannaL.Wustrack,MD¶τUCSFHelenDillerFamilyCenterangPhDsticInterventional‡Hematology/HematologiconcologyÞInternalmedicine†MedicaloncologyτOrthopedics€§¶*athologyPediatriconcologyRadiotherapy/RadiationoncologySurgery/SurgicaloncologyDiscussionWritingaryoftheGuidelinesUpdatesupBONEPrintedbyMinTangon12/20/202111:24:30AM.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)ofBoneCancerManagementBONEABONEBlesofRadiationTherapyBONEClievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualclinicalcircumstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetwork®(NCCN®)makesnorepresentationsorwarrantiesofanykindregardingtheircontent,useorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinghtsreservedTheNCCNGuidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.©2021.Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.•Thefollowingreferenceupdated:CampbellKM,etal.PediatrBloodCancer;68:e28807.CHONcorrespondingto"dedifferentiated."•"SeeOSTEO-1"deleted.Modifiedfootnotek":Considertestingfortumormutationalburden(TMB)andMMRMSI•Thefollowingreferenceupdated:CampbellKM,etal.PediatrBloodCancer;68:e28807.CHONcorrespondingto"dedifferentiated."•"SeeOSTEO-1"deleted.Modifiedfootnotek":Considertestingfortumormutationalburden(TMB)andMMRMSIasdeterminedbyavalidatedand/orFDA-approvedassayastatictumorswhohaveprogressedfollowingpriortreatmentandwhotoryalternativetreatmentoptionsNotforGiantCellTumortoinformtheuseofpembrolizumab.(AlsoforCHOR-3,EW-3,OSTEO-3).Mayconsidertreatingasosteosarcoma(category2B)"textmovedfromforupto10yofBone.critical.DeletedthefollowingfootnoteForlaterelapse,considerre-treatmentwithivosidenib.dexVersionoftheNCCNGuidelinesforBoneCancerfromVersionincludeBONE-B(1of5)•Footnote"a"modified:removed"orChordoma"fromthelastsentence.MS-1•TheDiscussionhasbeenupdatedtoreflectthechangestothealgorithm.VersionoftheNCCNGuidelinesforBoneCancerfromVersionincludeTEAM-1•Palliativecarephysicianhasbeenaddedto"SpecialistsCriticalinCertainCases"BONE-1•"•"Age"addedto˂40and≥40.ChondrosarcomaaddedalinktoCHON-4.•Deleteddedifferentiatedarm"(TreatasosteosarcomaaddedalinktoCHON-4.MetastaticChondrosarcoma•Addedthefollowingfootnotetothetitle:ConsidercomprehensivegenomictargetedtherapyopportunitiesAlsoforCHOR-3,EW-3,OSTEO-3,).profiling(CGP)withtargetedtherapyopportunitiesAlsoforCHOR-3,EW-3,OSTEO-3,).ChordomaMRI±CT)andscreeningMRIofspinalaxis(CT/MRIMRI/CTwithcontrast).•Bullet3,modified:MRI±CT)andscreeningMRIofspinalaxis(CT/MRIMRI/CTwithcontrast).CHOR-3callyindicatedegxrayMRICTwithcontrastMRICTwithcontrastcallyindicatedegxrayMRICTwithcontrastMRICTwithcontrastEwingSarcoma•ConsiderCGPorotherfusionpanelforEwingsarcomatoidentifyisnegative,isanewfootnotecorrespondingtoEwingsarcoma.translocationsisnegative,isanewfootnotecorrespondingtoEwingsarcoma.ProgressiveDisease/RelapseRTsurgery"•Relapseinplaceof"Earlyrelapse"andRTsurgery"eviouslyeffectiveregimeneviouslyeffectiveregimenupGiantCellTumorofupBullet2,modified:ImagingofprimarysiteasclinicallyindicatedBullet2,modified:Imagingofprimarysiteasclinicallyindicated(eg,x-rayGCTB-2correspondingtodenosumab.•Considerconsultationwithdentistpriortoinitialtherapy,iscorrespondingtodenosumab.Surveillancethereafter•Bullet3,modified:Chestimagingevery6–12mofor24ythenthereafterBONE-APrinciplesofBoneCancerManagement•Biopsymusculoskeletalorinterventionalradiologist,andbonepathologistispBullet8,musculoskeletalorinterventionalradiologist,andbonepathologistisBONE-B(1of5)BONE-B(1of5)NGSortargetedexonsequencingisanewfootnotecorrespondingto•NGSortargetedexonsequencingisanewfootnotecorrespondingtoargetedtherapyopportunitiesTMBHforpatientswithunresectableorargetedtherapyopportunitiesTMBHforpatientswithunresectableorPrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,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-1Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexWORKUPgegeRefertoorthopediconcologist•Biopsy,ifindicated,tinginstitutiontinginstitutionborkupforbonesasyindicated•Historyandphysical•BonescanorPET/CT(category2B)labsc•labsc•Chest/abdominal/pelvicCTwithcontrast•PSAmogramnsleboneOtherlesions(Non-boneprimarysuspected)oneCancerorspecificbonecomasRefertoorthopediconcologist•BiopsyshouldbeperformedattreatinginstitutionRefertoappropriateNCCNGuidelinesforTreatmentbyCancerTypeaSeeMultidisciplinaryTeam(TEAM-1).bSeePrinciplesofBoneCancerManagement(BONE-A).cLabsincludeCBCandcomprehensivemetabolicpanel(CMP)withcalciumtoassessforhypercalcemia.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.BONE-1PrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexPRESENTATIONa,b,ctalNNN(gradell,gradelll)orClearcellorExtracompartmentalMetastaticdiseaseatpresentationSeeCHON-4 SeeCHON-4 TreatasEwingsarcoma(category2B)MesenchymalSee TreatasEwingsarcoma(category2B)aSeeMultidisciplinaryTeam(TEAM-1).bSeePrinciplesofBoneCancerManagement(BONE-A).cThereisconsiderablecontroversyregardingthegradingofchondrosarcoma.Inadditiontohistology,radiologicfeatures,size,andlocationoftumorsshouldalsobeconsideredindecidinglocaltreatment.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.CHON-1PrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dextalPRIMARYTREATMENTIntralesionalideexcisioneexcisionideexcisioneConsiderRT,fifunresectable(category2B)SURVEILLANCE•Physicalexam•Radiographsofprimarysiteand/orcross-sectionalimagingMRIorCT(bothwithcontrast)asclinicallyindicatedevery6–12mofor2y,thenyearlyasappropriate•Chestimagingasclinicallyindicatedevery6–12mofor2y,thenyearlyasappropriateRECURRENCE dedeBConsiderRTf(category2B)Considerre-resectiontoachievenegativesurgicalmarginsdThismanagementshouldberestrictedtoextremitytumors(notpelvictumors).eWideexcisionshouldprovidehistologicallynegativesurgicalmargins.Thismaybeachievedbyeitherlimb-sparingresectionorlimbamputation.fSeePrinciplesofRadiationTherapy(BONE-C).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHON-2Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.mayincludeCThatleastevery6mofor5y,thenyearlyforaminimumof10y•Reassessfunctionateveryfollow-upvisitysicalexamadiographsofprimaryteandorcrosssectionalmayincludeCThatleastevery6mofor5y,thenyearlyforaminimumof10y•Reassessfunctionateveryfollow-upvisitysicalexamadiographsofprimaryteandorcrosssectionalRIorCTbothwithcontrast)asclinicallydexPRIMARYSURVEILLANCERECURRENCETREATMENTHighgrade(gradell,gradelll)orClearcellorExtracompartmentaldeedeeleorBLocalLocalBdedeConsiderRT(category2B)Considerre-resectiontoachievenegativesurgicalmargins•Chestimaginggevery•Chestimaginggevery3–6morecurrence(CHON-4)Systemicrecurrence(CHON-4)eWideexcisionshouldprovidehistologicallynegativesurgicalmargins.Thismaybeachievedbyeitherlimb-sparingresectionorlimbamputation.fSeePrinciplesofRadiationTherapy(BONE-C).gBasedonphysician'sconcernforriskofrecurrence.hChestCTwithorwithoutcontrastasclinicallyindicated.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHON-3Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexMETASTATICCHONDROSARCOMAirosarcomastaticWidespreaddiseaseSurgicalexcisionofallsitesifpossibleerradiationforunresectablesitesclinicaltrialrablativetherapiesforsymptomaticsitesersystemictherapykSeeSystemicTherapyAgents(BONE-B)clinicaltrialiConsidercomprehensivegenomicprofiling(CGP)withavalidatedand/orFDA-approvedassaytodeterminetargetedtherapyopportunities.jMayconsidertreatingasosteosarcoma(category2B).kConsidertestingfortumormutationalburden(TMB)andMMR/MSIasdeterminedbyavalidatedand/orFDA-approvedassaytoinformtheuseofpembrolizumab.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHON-4Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.storyandphysicalPrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,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.Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.CHOR-1ancectionPrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.ancectiondexPRESENTATIONPRIMARYTREATMENTADJUVANTTREATMENTSacrococcygealandMobilespineSkullbase/ClivalTcdforpositivesurgicalmarginsorforartmentaltumorsConsiderRTddbSeePrinciplesofBoneCancerManagement(BONE-A).cRadiationtherapymaybegivenpreoperatively,intraoperatively,and/orpostoperatively.dSeePrinciplesofRadiationTherapy(BONE-C).eMaximalsaferesection.Maximaltumorremovalisrecommendedwhenappropriate.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHOR-2Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexSURVEILLANCERECURRENCEfTREATMENT•Physicalexam•Chestimaginggevery6moannuallyforythenannuallythereafter•Imagingofsurgicalsite,timing,andmodality,asclinicallyindicated(•Chestimaginggevery6moannuallyforythenannuallythereafterrrrctherapyhlexcisionbrlexcisionbrrand/orBestsupportivecarebSeePrinciplesofBoneCancerManagement(BONE-A).dSeePrinciplesofRadiationTherapy(BONE-C).fConsiderCGPwithavalidatedand/orFDA-approvedassaytodeterminetargetedtherapyopportunities.gChestCTwithorwithoutcontrastasclinicallyindicated.hSeeBoneCancerSystemicTherapyAgents(BONE-B).iConsidertestingforTMBandMMR/MSIasdeterminedbyavalidatedand/orFDA-approvedassaytoinformtheuseofpembrolizumab.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.CHOR-3Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexPRESENTATIONa,b,cWORKUP•HistoryandphysicalCTe•MRI±CT(bothwithcontrast)CTe•PET/CT(head-to-toe)and/orbonescan•Considerbonemarrowbiopsyand/ordpelvisfscreeningMRIdpelvisfCytogeneticsandCytogeneticsandor(mayrequirere-biopsy)•LDHilityconsultationuldbeconsideredRESTAGEPRESTAGETREATMENTapyjchemotherapyhchemotherapyh(category1)foratleast9weekspriortolocalCTe•CTe•MRI±CT(bothwithcontrast)ofprimarysite•Radiographsofprimarysite•ConsiderPET/CTadtotoeoronescanipeatotherlstudieszedResponse,metastaticdisease(EW-3)Progressivedisease(EW-2)aSeeMultidisciplinaryTeam(TEAM-1).bSeePrinciplesofBoneCancerManagement(BONE-A).cEwingsarcomacanbetreatedusingthisalgorithm,includingprimitiveneuroectodermaltumorofbone,Askintumor,andextraosseousEwingsarcoma.dConsiderCGPorotherfusionpanelforEwingsarcomatoidentifytranslocationsifpathologicworkupoftargetedPCR,FISH,orcytogeneticsisnegative.eChestCTwithorwithoutcontrastasclinicallyindicated.fCampbellKM,etal.PediatrBloodCancer2021;68:e28807.gNinetypercentofEwingsarcomawillhaveoneoffourspecificcytogenetictranslocations.ForpatientswithEwing-likesarcoma(eg,CIC-DUX4)analternatetreatmentparadigmcanbeconsidered.Forthosewhoarenegative,additionalmoleculartestingisrecommended.hSeeBoneCancerSystemicTherapyAgents(BONE-B).iUsethesameimagingtechniquethatwasperformedintheinitialworkup.jLongertreatmentpriortolocalcontroltherapycanbeconsideredinpatientswithmetastaticdiseasebasedonresponse.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version2.2022,10/08/21©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.arginslyh Relapse±mprovedollowingeatmentPrintedbyMinTangon12/20/202111:24:30AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2021National