中国实用外科杂志

中国实用外科杂志

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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

李心翔，张瑞嘉   

  1. 复旦大学附属肿瘤医院大肠外科，上海 200032
  • 出版日期:2024-07-01

  • Online:2024-07-01

摘要： 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。

关键词: 美国国家综合癌症网络, 结肠癌, 指南, 解读

Abstract: 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 stage Ⅱor Ⅲ patients 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.

Key words: National Comprehensive Cancer Network, colon cancer, guideline, interpretation