Updates in Version 2.2018 of the NCCN guidelines for small cell lung cancer from version 1.2018

The Discussion section has been updated to reflect the changes in the algorithm. (MS-1)

Updates in version 1.2018 of the NCCN guidelines for small cell lung cancer from version 3.2017

For consistency in imaging, statement was revised: “CT Chest / liver / adrenal” was replaced by “Chest / abdomen CT” with contrast.

Initial evaluation

Delete “Ca LDH”, add “BUN”; Add “(skull base to midthigh)” to PET/CT scan, (if limited stage is suspected).

团结乡乡村旅游发展以及“美丽家园”建设是一个长期而艰巨的任务，在其后期的发展、建设过程中，仍需要进一步研究和实践。将PPP模式运用到美丽乡村旅游发展建设中，及对乡村旅游相关从业人员进行培训等，对促进云南乡村旅游的发展有着积极的作用。

Footnote “b” for H & P was added: “See Signs and Symptoms of Small Cell Lung Cancer (SCL-A)” (Also for SCL-5).

Footnote “c” for pathology review was added: “See Principles of Pathologic Review (SCL-B)”.

1.3 调查方法 采用自行设计的调查表，由经过统一培训的调查员，对研究对象进行一对一的问卷调查。正式调查开始前，在南京进行了预调查，以完善调查问卷。调查过程中遵循知情同意原则，保证调查过程的真实可靠。

Additional workup

“During evaluation for surgery” was added to Pulmonary function tests (PFTs)

“(Consider biopsy if bone imaging is equivocal)” was added.

Adjuvant treatment

(SCL-F) principles of radiation therapy (1 of 3)

N1 adjuvant treatment option added: “Systemic therapy ± mediastinal RT (sequential or concurrent)”

N2 adjuvant treatment option added: “Systemic therapy + mediastinal RT (sequential or concurrent)”.

Footnote “o”

Footnote “o” was modified: “For patients receiving adjuvant therapy, response assessment should occur only after completion of adjuvant therapy (SCL-5); do not repeat scans to assess response during adjuvant treatment.”

Initial treatment of asymptomatic brain metastases

Statement was modified: “May administer the wholebrain RT after completion of systemic therapy”.

Updates in version 1.2018 of the NCCN guidelines for small cell lung cancer from version 3.2017

Response assessment following initial therapy

Bullet 5 was modified: “Electrolytes, LFTs, BUN,creatinine”. Deleted ”Ca”.

Adjuvant treatment; extensive disease

“PCI ± thoracic RT” revised to “Consider PCI ±thoracic RT”.

Surveillance

Footnote “s” was added to heading: “See NCCN Guidelines for Survivorship”.

Complete response or partial response

Limited stage

Statement was revised: “After completion of initial therapy” instaed of “After recovery from primary therapy”.

Bullet 1 was revised: “Oncology follow-up visits every 3–4 mo during y 1–2, every 6 mo during y 3–5, then annually”.

Bullet 1 revised: “At every visit: H&P, CT Chest/abdomen with contrast (delete liver/adrenal), bloodwork only as clinically indicated”.

Bullet 2 was added: “If PCI not given, then MRI(preferred) or CT brain with contrast every 3–4 mo during y 1–2”.

经过隋朝两代帝王的相继开凿,广通渠、永济渠、通济渠、邗沟、江南河等运河,形成了完备的沟通关中与魏、齐旧地和梁、陈旧地的水上交通体系。

Extensive stage

Statement was added: “After completion of initial or subsequent therapy”.

Bullet 1 was added: “Oncology follow-up visits every 2 mo during y 1, every 3–4 mo during y 2-3, then every 6 mo during years 4–5, then annually”.

在当今的高中数学课程中仍然存在着严重影响学生核心素养提高的问题，因此，必须要认真地进行分析并采取有针对性的应对措施.

Bullet 1 revised: “At every visit: H&P, CT Chest/abdomen with contrast (delete liver/adrenal), bloodwork only as clinically indicated”.

Bullet 2 was added: “If PCI not given, then MRI(preferred) or CT brain with contrast every 3–4 mo during y 1–2”.

Subsequent systemic therapy

Footnote “u” for thoracic RT was revised: “Sequential radiotherapy to thorax in selected patients, especially with residual thoracic disease and low-bulk extrathoracic metastatic disease that has responded to systemic therapy.” Deleted “complete response”.

Stable disease

Limited stage and Extensive stage

Statement was revised: “After completion of initial therapy” delete “recovery from primary therapy”.

Bullet 1 was revised: “Oncology follow-up visits every 3–4 mo during y 1–2, every 6 mo during y 3–5, then annually”.

Bullet 1 was added: “Oncology follow-up visits every 2 mo during y 1, every 3–4 mo during y 2–3, then every 6 mo during years 4–5, then annually”.

Statement was added: “After completion of initial or subsequent therapy”.

5.6.2 术后3 d按摩 伤口水平以下肌肉进行按摩，每日3～5次，每次10 min，并适当活动未固定的关节，以改善静脉、淋巴回流，减少肿胀。术后1周开始肌肉舒缩运动，对未固定的关节进行主动或被动伸屈运动，每日3次，每次10 min。防止肌肉萎缩，预防关节僵直。训练时注意活动幅度由小到大，次数由少到多，被动与主动相结合，由健侧协助完成。

问卷星自2016年上线至今，运营时间虽不长，却已是目前国内最大的在线问卷调查、考试和投票平台。截至2018年4月10日，已有2 237万用户累计回收超过14.49亿份试卷。问卷星调查问卷被广泛用于德育课堂[1]、随堂测验[2]及信息化教学[3]，然而从笔者目前掌握的资料来看，尚未有过用于医学类课堂教学的系统报道。现将问卷星随堂“微测试”使用方法、注意事项、使用心得及需要改进的地方综述如下，供医学界同仁参考。问卷星平台分为免费版和企业版，对于高校课程日常教学中的“微测试”，免费版即可完全满足要求。

SCL-6

Footnote “k,” “See Principles of Supportive Care(SCL-D)” was added after all “Palliative symptom management” statements.

Footnote “v,” “See Principles of Palliative Care (PAL-1)” was added after all “Palliative symptom management”statements.

For “PS 0-2,” “or” was removed from between “Consider subsequent systemic therapy” and “Palliative symptom management, including localized RT to symptomatic sites”.

(SCL-A) signs and symptoms of small cell lung cancer

A new section was added: “Signs and Symptoms of Small Cell Lung Cancer”.

Bullet 4 was revised: “Use of more advanced technologies is appropriate when needed to deliver adequate tumor doses while respecting normal tissue dose constraints. Such technologies include (but are not limited to) 4D-CT and/or PET/CT simulation, IMRT/VMAT, IGRT, and motion management strategies.IMRT is preferred over 3D conformal external-beam RT (CRT) on the basis of reduced toxicity in the setting of concurrent chemotherapy/RT. Quality assurance measures are essential and are covered in the NSCLC guidelines (see NSCL-C).”

A new section was added: “Principles of Pathologic Review”.

(SCL-C) principles of surgical resection

A footnote was removed: “Slotman B, Faivre-Finn C, Kramer G, et al. Prophylactic cranial irradiation in extensive small-cell lung cancer. N Engl J Med 2007; 357:664-672.”

(SCL-D) principles of supportive care

Syndrome of inappropriate antidiuretic hormone

Sub-bullet 5 was revised: “Vasopressin receptor inhibitors (conivaptan, tolvaptan) for refractory hyponatremia”.

(SCL-E) principles of systemic therapy (1 of 3)

Extensive stage (maximum of 4–6 cycles)

(SCL-E) principles of systemic therapy (2 of 3)

Footnote “†” was added: “If not used as original regimen, may be used as therapy for primary progressive disease.”

（e）密码管理：由统一用户身份管理系统统一接管用户在其他应用系统中的账户和密码信息，密码策略按照企业保密规定统一执行。采用统一密码的方式，即企业门户密码与其他应用系统密码保持一致，在企业门户中集成用户的密码管理模块，用户将企业门户密码更改后，接口会把新密码同步到各应用系统中。

语言迁移研究的最佳解释推理视角 ………………………………………………………………… 杨 丽（1.46）

Footnote “‡” was added: “Subsequent systemic therapy refers to second-line and beyond therapy.”

Relapse ≤ 6 mo, PS 0-2: nivolumab ± ipilimumab

Reference “22” was added: “Hellmann MD, Ott PA, Zugazagoitia J, et al. First report of a randomized expansion cohort from CheckMate 032 [abstract]. J Clin Oncol 2017;35: Abstract 8503.”

Bullet 7 was revised: “Cisplatin 30 mg/m2 days 1, 8 and irinotecan 65 mg/m2 days 1, 8”.

大多数年轻人不会单纯为老字号而埋单，甚至认为老字号不够新鲜、不够有朝气。为了迎合主流消费者更追逐时尚和潮流的特性，青岛啤酒作出了变革。青岛啤酒公司相关负责人表示，青啤的年轻化首先是以“快时尚”品牌的速度打造新品。

Limited-stage

文中设计了一种基于振动传感的智能光纤安防系统，由信号传感、采集处理和显示三部分构成，系统能够实现光缆沿线的实时观测，并通过人机交互界对管理员发出实时预警。

Sub-bullet 1 was revised: “For patients receiving adjuvant therapy, response assessment should occur only after completion of adjuvant therapy; do not repeat scans to assess response during adjuvant treatment.”

Clinical stage N+ separated into N1 and N2.

General Principles

类比映射阶段是根据类比访问所搜寻到的结果，找出一个从始源S到目标T的类比映射函项fM，建立始源S和目标T中的组成元素间的全面对应。fM是一个有序对(s,t)的集合,其中，s∈S,t∈T。这种对应关系要能最大程度地保持源域的结构。结构保持映射最好是一一对应的，如果达不到，也可以是多对一的。

(SCL-B) principles of pathologic review

Reference “1” was added: “Chun SG, Hu C, Choy H,et al. Impact of intensity-modulated radiation therapy technique for locally advanced non-small-cell lung cancer: a secondary analysis of the NRG oncology RTOG 0617 randomized clinical trial. J Clin Oncol 2017; 35:56–62.”

Limited Stage

Bullet 5 was revised: “Dose and schedule: For limitedstage SCLC, the optimal dose and schedule of RT have not been established; 45 Gy in 3 weeks (1.5 Gy twice daily[BID]) is superior (category 1) to 45 Gy in 5 weeks (1.8 Gy daily). When BID fractionation is used, there should be at least a 6-hour inter-fraction interval to allow for repair of normal tissue. If using once-daily RT, higher doses of 60–70 Gy should be used. The current randomized trial CALGB 30610/RTOG 0538 is comparing the standard arm of 45 Gy (BID) in 3 weeks to 70 Gy in 7 weeks; accrual to an experimental concomitant boost arm has closed.The European CONVERT trial demonstrated comparable overall survival and toxicity between 45 Gy (BID) and 66 Gy (daily).”

Reference 20 was added: “Faivre-Finn C, Snee M,Ashcroft L, et al Concurrent once-daily versus twicedaily chemoradiotherapy in patients with limited-stage small-cell lung cancer (CONVERT): an open-label, phase 3, randomised, superiority trial. Lancet Oncol 2017; 18:1116-1125.”

Extensive stage

Bullet 1 modified: “Consolidative thoracic RT is beneficial for selected patients with extensive-stage SCLC with CR or good response to systemic therapy.Studies have demonstrated that consolidative thoracic RT up to definitive doses is well tolerated, results in fewer symptomatic chest recurrences, and improves long-term survival in some patients. The Dutch CREST randomized trial of modest-dose thoracic RT (30 Gy in 10 fractions),in patients with extensive stage SCLC that responded to systemic therapy demonstrated significantly improved 2-year overall survival and six-month PFS, although the protocol-defined primary endpoint of one-year overall survival was not significantly improved. Subsequent exploratory analysis found the benefit of consolidative thoracic RT is limited to the majority of patients who had residual thoracic disease after systemic therapy.”

Bullet 2 was added: “Dosing and fractionation of consolidative thoracic RT should be individualized within the range of 30 Gy in 10 daily fractions to 60 Gy in 30 daily fractions, or equivalent regimens in this range.”

Reference 24 was added: “Slotman BJ, van Tinteren H,Praag JO, et al. Radiotherapy for extensive stage smallcell lung cancer– Authors reply. Lancet 2015; 385: 1292–1293.”

Prophylactic Cranial Irradiation (PCI)

Bullet 1 modified: “In patients with limited-stage SCLC who have a good response to initial therapy, PCI decreases brain metastases and increases overall survival(category 1).

In patients with extensive-stage SCLC that has responded to systemic therapy, PCI decreases brain metastases. A randomized trial conducted by the EORTC found improved overall survival with PCI. However, a Japanese randomized trial found that in patients who had no brain metastases on baseline MRI, PCI did not improve overall survival compared with routine surveillance MRI and treatment of asymptomatic brain metastases upon detection. In patients not receiving PCI, surveillance for metastases by brain imaging should be considered performed.”

丁珰道：“你们两个长得一模一样，在我心里，实在也没什么分别，何况我和你相聚多日，你又一直待我这么好。‘日久情生’这四个字，你总听见过吧？”她抓住了石破天双手，说道：“天哥，你答允我，你无论如何，不能去死。”

Bullet 5 was added: “When administering PCI,consider adding memantine during and after RT, which has been shown to decrease neurocognitive impairment following whole brain radiation therapy (WBRT) for brain metastases.”

Reference 28 was updated: “Takahashi T, Yamanaka T,Takashi S et al. Prophylactic cranial irradiation versus observation in patients with extensive-disease small-cell lung cancer: a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol 2017; 18: 663–671.”

研究表明，使用麻育秧膜，秧苗根系盘结力强，不散秧、不散盘、不漏插，取秧、运秧、装秧的工效提高2至3倍，机插效率提高20%至30%；育成的秧苗根系发达、整齐健壮，可提早3至5天进入适插期；机插后返青快、分蘖早，有利高产，早稻平均增产12.6%，中稻平均增产9.0%，晚稻平均增产5.5%；每亩节本增效110元至160元。截至2017年，我国麻育秧膜应用面积超过6000万亩，直接增产增收达64亿元。

Reference 31 was added: “Brown PD, Pugh S,Laack NN, et al. Memantine for the prevention of cognitive dysfunction in patients receiving whole-brain radiotherapy: a randomized, double-blind, placebocontrolled trial. Neuro Oncol 2013; 10: 1429–1437.”

Brain Metastases

Bullet 1 modified: “Brain metastases should be treated with WBRT rather than stereotactic radiotherapy/radiosurgery (SRT/SRS) alone, because these patients tend to develop multiple CNS metastases. In patients who develop brain metastases after PCI, repeat WBRT may be considered in carefully selected patients. SRS, is preferred if feasible, especially if there has been a long-time interval from initial diagnosis to occurrence of brain metastases and there is no uncontrolled extracranial disease.”