2024年V2版《美国国家综合癌症网络结肠癌临床实践指南》更新解读

Interpretation of the updated NCCN clinical practice guidelines in oncology:colon cancer(version 2.2024)

2024年V2版《美国国家综合癌症网络结肠癌临床实践指南》的更新涵盖了诊断和治疗的多个领域,特别注重分子诊断技术的进步、免疫治疗的最新进展以及综合治疗方案的调整。在分子检测方面,指南推荐对疑似或已确诊的转移性腺癌病人进行更全面的基因分析,包括罕见基因突变/融合如POLE/POLD1、RET和NTRK的检测,并继续关注HER2、RAS、BRAF等基因突变。对于循环肿瘤DNA(ctDNA)的应用,指南持保守态度,建议仅在临床试验中使用,并在Ⅱ、Ⅲ期及接受辅助治疗的病人中谨慎使用ctDNA监测。治疗更新方面,推荐携带POLE/POLD1突变及错配修复功能缺陷(dMMR)/微卫星高度不稳定(MSI-H)的病人接受免疫治疗,尤其适用于存在不可切除转移的情况。同时,取消了抗表皮生长因子受体治疗对左半结肠肿瘤的限制,拓宽至所有适合的KRAS/NRAS/BRAF野生型病人,并将曲妥珠单抗的使用从RAS和BRAF野生型病人中解除限制,扩展到所有HER2扩增的结肠癌病人。此外,针对dMMR/MSI-H型病人的术后辅助化疗也进行了重组和更新建议,明确了辅助化疗在提升生存率方面的潜在限制。

The 2024 V2 guideline update encompasses multiple fields of diagnosis and treatment,with a particular focus on advancements in molecular diagnostic techniques,the latest developments in immunotherapy,and adjustments to comprehensive treatment regimens.In molecular testing,the guideline recommends a more comprehensive genetic analysis for patients with suspected or confirmed metastatic adenocarcinoma,including rare gene mutations/fusions such as POLE/POLD1,RET,and NTRK,and keep monitoring gene mutations like HER2,RAS,and BRAF.Regarding the application of circulating tumor DNA(ctDNA),the guideline adopts a conservative stance and suggests its usage in clinical trials,with special caution in stageⅡorⅢpatients and those undergoing adjuvant therapy.In treatment updates,patients with POLE/POLD1 mutations and dMMR/MSI-H are recommended to receive immunotherapy,particularly in cases of unresectable metastases.The restriction of anti-EGFR therapy on left-sided colon tumors has been deleted,broadening its application to all eligible KRAS/NRAS/BRAF wild-type patients.Meanwhile,the use of trastuzumab has also been expanded for all HER2-amplified colon cancer patients.Additionally,the guideline has restructured and updated recommendations for adjuvant chemotherapy in dMMR/MSI-H patients,clarifying the potential limitations of adjuvant chemotherapy in improving survival rates.