NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Thymomas and Thymic Carcinomas Version 2.2018 — February 16, 2018 NCCN.org Continue Version 2.2018, 02/16/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index NCCN Guidelines Version 2.2018 Table of Contents Thymomas and Thymic Carcinomas Discussion *David S. Ettinger, MD/Chair † Ramaswamy Govindan, MD † Gregory A. Otterson, MD † The Sidney Kimmel Comprehensive Siteman Cancer Center at Barnes- The Ohio State University Comprehensive Cancer Center at Johns Hopkins Jewish Hospital and Washington Cancer Center - James Cancer Hospital University School of Medicine and Solove Research Institute *Douglas E. Wood, MD/Vice Chair ¶ Fred Hutchinson Cancer Research Matthew A. Gubens, MD, MS † Karen Reckamp, MD, MS † ‡ Center/Seattle Cancer Care Alliance UCSF Helen Diller Family City of Hope Comprehensive Cancer Center Comprehensive Cancer Center Dara L. Aisner, MD, PhD ≠ Gregory J. Riely, MD, PhD † Þ University of Colorado Cancer Center Mark Hennon, MD ¶ Memorial Sloan Kettering Cancer Center Roswell Park Cancer Institute Wallace Akerley, MD † Steven E. Schild, MD § Huntsman Cancer Institute at the Leora Horn, MD, MSc † Mayo Clinic Cancer Center University of Utah Vanderbilt-Ingram Cancer Center Theresa A. Shapiro, MD, PhD ¥ Jessica Bauman, MD ‡ † Rudy P. Lackner, MD ¶ The Sidney Kimmel Comprehensive Fox Chase Cancer Center Fred & Pamela Buffett Cancer Center Cancer Center at Johns Hopkins Joe Y. Chang, MD, PhD § Michael Lanuti, MD ¶ James Stevenson, MD † The University of Texas Massachusetts General Hospital Cancer Center Case Comprehensive Cancer Center/ MD Anderson Cancer Center University Hospitals Seidman Cancer Center Ticiana A. Leal, MD † and Cleveland Clinic Taussig Cancer Institute Lucian R. Chirieac, MD ≠ University of Wisconsin Carbone Cancer Center Dana-Farber/Brigham and Women’s Scott J. Swanson, MD ¶ Cancer Center Leah J. Leisch, MD Þ Dana-Farber/Brigham and Women’s University of Alabama at Birmingham Cancer Center Thomas A. D’Amico, MD ¶ Comprehensive Cancer Center Duke Cancer Institute Kurt Tauer, MD † Rogerio Lilenbaum, MD † St. Jude Children’s Research Hospital/ Malcolm M. DeCamp, MD ¶ Yale Cancer Center/Smilow Cancer Hospital University of Tennessee Health Science Center Robert H. Lurie Comprehensive Cancer Center of Northwestern University Jules Lin, MD ¶ Stephen C. Yang, MD ¶ University of Michigan The Sidney Kimmel Comprehensive Thomas J. Dilling, MD, MS § Comprehensive Cancer Center Cancer Center at Johns Hopkins Moffitt Cancer Center Billy W. Loo, Jr., MD, PhD § Michael Dobelbower, MD, PhD § Stanford Cancer Institute University of Alabama at Birmingham NCCN Comprehensive Cancer Center Renato Martins, MD, MPH † Kristina Gregory, RN, MSN, OCN Fred Hutchinson Cancer Research Center/ Miranda Hughes, PhD Seattle Cancer Care Alliance † Medical oncology ф Diagnostic/Interventional ¶ Surgery/Surgical oncology radiology NCCN Guidelines Panel Disclosures Continue § Radiation oncology/Radiotherapy ¥ Patient advocate ≠ Pathology Þ Internal medicine ‡ Hematology/Hematology *Discussion Section Writing oncology Committee Version 2.2018, 02/16/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index NCCN Guidelines Version 2.2018 Table of Contents Thymomas and Thymic Carcinomas Discussion NCCN Thymomas and Thymic Carcinomas Panel Members Clinical Trials: NCCN believes that Summary of Guidelines Updates the best management for any patient with cancer is in a clinical trial. Initial Evaluation (THYM-1) Participation in clinical trials is especially encouraged. Initial Management (THYM-2) To find clinical trials online at NCCN Postoperative Treatment and Management (THYM-3) Member Institutions, click here: Locally Advanced, Advanced, or Recurrent Disease (THYM-4) nccn.org/clinical_trials/clinicians.aspx. NCCN Categories of Evidence and Principles of Surgical Resection (THYM-A) Consensus: All recommendations Principles of Radiation Therapy (THYM-B) are category 2A unless otherwise Principles of Chemotherapy for Thymic Malignancies (THYM-C) indicated. World Health Organization Histologic Classification (THYM-D) See NCCN Categories of Evidence and Consensus. Staging (ST-1) The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2018. Version 2.2018, 02/16/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index NCCN Guidelines Version 2.2018 Table of Contents Thymomas and Thymic Carcinomas Discussion Updates in Version 2.2018 of the NCCN Guidelines for Thymomas and Thymic Carcinomas from Version 1.2018 include: MS-1 • The Discussion section has been updated to reflect the changes in the algorithm. Updates in Version 1.2018 of the NCCN Guidelines for Thymomas and Thymic Carcinomas from Version 1.2017 include: THYM-1 • Initial Evaluation, Thymic tumor unlikely: added “Consider tissue biopsy” prior to “See disease-specific guidelines as appropriate” THYM-A • Bullet 7 is new to the page: “Surgical clips should be placed at the time of resection to areas of close margins, residual disease, or tumor adhesion to unresected normal structures to help guide accurate radiation therapy when indicated.” THYM-B (1 of 3) • General Principles; bullet 4 modified: “The review of preoperative imaging and co-registration of preoperative imaging into the planning system may be are helpful in defining treatment volumes.” • Radiation Doses; last bullet added: Depending on the treatment objectives in the palliative setting, typical palliative doses (e.g., 8 Gy single fraction, 20 Gy in 5 fractions, 30 Gy in 10 fractions) up to definitive doses for more durable local control and highly conformal techniques for limited volume metastases may be appropriate, given the relatively long natural history of even metastatic thymoma. THYM-C (1 of 2) • VIP replaced with “Etoposide/Ifosfamide/Cisplatin.” THYM-D • WHO Classification information has been updated. ST-2 • AJCC Staging has been updated to reflect the changes in the AJCC Cancer Staging Manual, 8th Edition (2017). Version 2.2018, 02/16/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. UPDATES NCCN Guidelines Index NCCN Guidelines Version 2.2018 Table of Contents Thymomas and Thymic Carcinomas Discussion INITIAL EVALUATION • Chest CT with contrast See Initial Management Thymic tumor likelyb • Serum beta-HCG, AFP, if (THYM-2) appropriate Mediastinal • CBC, platelets mass • PET/CT scan as indicated • Pulmonary function tests, as clinically indicated Consider tissue See disease-specific • Chest MRI with contrast, Thymic tumor unlikely biopsy guidelines as appropriate as clinically indicateda (NCCN Table of Contents) aWhen assessing a mediastinal mass, detection of thymic malignancy versus thymic cyst can be better discriminated with chest MRI compared to chest CT, potentially avoiding an unneccessary thymectomy. bWell-defined anterior mediastinal mass in the thymic bed, tumor markers negative, absence of other adenopathy, and absence of continuity with the thyroid. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged. Version 2.2018, 02/16/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. THYM-1 NCCN Guidelines Index NCCN Guidelines Version 2.2018 Table of Contents Thymomas and Thymic Carcinomas Discussion INITIAL MANAGEMENT d Surgically Surgical resection (total See Postoperative resectablec thymectomy and complete Management (THYM-3) All patients should be excision of tumor) managed by a Thymic tumor multidisciplinary team likelyb with experience in the management of thymoma Tissue diagnosis with core and thymic carcinoma Locally advanced, See Treatment needle biopsy or open biopsy unresectablec (THYM-4) (Avoid transpleural approach) bWell-defined anterior mediastinal mass in the thymic bed, tumor markers negative, absence of other adenopathy, and absence of continuity with the thyroid. cDetermination of resectability should be made