Transcript of Taipei Veterans General Hospital Practice Guideline for Cervical Cancer (2008) 吳 華 席 Huahsi Wu...
- Slide 1
- Taipei Veterans General Hospital Practice Guideline for
Cervical Cancer (2008) Huahsi Wu
- Slide 2
- Clinical practice guidelines (CPG) CPG are systematically
developed statements to assist practitioners and consumer decisions
about appropriate health care for specific clinical circumstances .
They are tools used by healthcare professionals to assist in
clinical decision making and to improve healthcare for consumers.
[Ref:New Zealand Guidelines Group (NZGG). Handbook for the
preparation of explicit evidence-based clinical practice
guidelines, 2001.p4 ]
- Slide 3
- (guideline) (To make evidence based standards explicit and
accessible) (To make decision making easier and more objective) (To
educate patients and professionals about current best practice) (To
improve the cost effectiveness of health services) (To serve as a
tool for external control)
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- Clinical Practical Guidelines Development Process
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- Taipei Veterans General Hospital Practice Guideline for
Cervical Cancer (I) FIGO early stage (IA to IIA, selected IIB) (II)
FIGO easrly stage inoperable patients (III) and advanced stage (IV)
Incidental cervical cancer (post simple hysterectomy) (V)
Persistent/Recurrent cervical cancer (VI) Chemotherapy
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- ( I ) FIGO early stage ( IA to IIA, selective IIB)
StageTreatment Plan 5 year Survival Rate IA1 4cm) Radical
hysterectomy + PLND + PALNS CCRT (Point A 75-85 Gy) Neoadjuvant
Chemotherapy + Radical hysterectomy + PLND + PALNS 40-60% BSO
considered if age > 50 y/o, adenocarcinoma, and poorly
differentiated Ovarian transposition during RAH if adjuvant
radiotherapy considered (age < 40 y/o)
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- Post-operative Adjuvant Therapy (FIGO early stage) LN
ParametriumBulky size ( - ) LVSI ( - ) / DSI ( - )Observation LVSI
( + ) and / or DSI ( + ) Observation R/T ( + ) Obsertvation R/T ( +
)( - ) or ( + ) CCRT (see below) R/T ( + )( - ) or ( + ) CCRT (see
below) Chemotherapy (see below) R/T If vaginal cut end ( + )
additional radiotherapy required Prognostic Risk Factors: - High
Risk: LN (+) / Parametrial margin (+) / Vaginal cut end margin (+).
- Intermediate Risk: Bulky tumor size ( > 4 cm ) / LVSI (+) /
DSI (+) - Others Age / Diploidy / Differentiation / Histological
Type
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- ( II ) FIGO early stage inoperable patients and advanced stage
( 5 year survival rate: IIB-IVA: 20-60%, IVB: < 20 % ) Step 1
Lymph Node Assessment - Image study (CT scan, MRI or PET ) +/- FNA
- Surgical staging (laparotomic, extra-peritoneal, or laparoscopic
lymph node sampling ) Step 2 Lymph Node ( - ) - CCRT
(platinum-based chemotherapy) Para-aortic boost (Point A 85Gy)
Lymph Node ( + ) - CCRT (platinum-based chemotherapy) + Para-aortic
boost (Point A 85Gy) Step 3 Consolidation chemotherapy, if
necessary
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- (III) Incidental Cervical Cancer ( Post Simple Hysterectomy )
Stroma Invasion LVSIManagement Depth < 3 mm ( - ) Observation (
+ ) See below Stroma Invasion Surgical Margin LN status (Image
study) ManagementAdjuvant Tx Depth < 3 mm with LVSI (+) or Depth
3mm ( - ) Re-op* R/T According to pathological risk factors ( see
above ) ( + ) LND + CCRT Re-op* CCRT (see below) ( + ) ( - ) R/T
CCRT (see below) Re-op* ( + ) LND + CCRT Re-op* CCRT (see
below)
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- (III) Incidental Cervical Cancer ( Post Simple Hysterectomy )
Re-op include the following: Radical parametrectomy + Upper
vaginectomy + PLND PALNS Image study consistent with the following:
No parametrium invasion No pelvic side wall invasion No rectal or
bladder invasion ----
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- (IV) Treatment Strategies for Persistent / Recurrent Cervical
Cancer Factors to Consider: Site of recurrence or metastases
Pelvic: central, side wall, combined Extra-pelvic: intra-abdominal
organs, Distant lymph nodes, Distant disseminated metastasis Prior
therapy Surgery Radiotherapy Radiotherapy Surgery Status of
patient's performance Palliative or Curative treatment
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- (IV-1) Cervical Cancer with Central Recurrence Prior Surgery
Surgical intervention if no contraindication Radiotherapy if
surgical intervention not possible Prior Radiotherapy Surgical
intervention if no contraindication Radiotherapy indicated if
recurrence outside of previously treated field Palliative
radiotherapy or palliative chemotherapy Surgical Intervention If
previous surgery is only total abdominal hysterectomy Radical
parametrectomy + PLND + PALNS If previous surgery is radical
hysterectomy + PLND + PALNS Exenteration can be considered ( Total
/ Anterior / Posterior ).
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- ** Pelvic Exenteration Exenterative surgery should NOT be used
as a palliative treatment, except in the presence of malignant
fistulas in the pelvis. Final intraoperative assessment: The final
decision to proceed with exenteration will not be made until the
abdomen has been opened and assessment of the pelvic side-wall and
posterior abdominal wall has been made, utilizing frozen section
where necessary Contra-indications: * TRIAD: 1. Unilateral
uropathy, non-functional kidney, or ureteric obstruction 2.
Unilateral leg edema 3. Sciatic leg pain Absolute
ContraindicationRelative Contraindication - Metastases to
extrapelvic LN - Obesity - Metastases to abdominal viscera - Pelvic
side-wall spread: direct extension or nodal metastases - Metastases
to lung or bones - Triad *
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- (IV-2) Cervical Cancer with Pelvic Side Wall Recurrence Prior
Surgery Radiotherapy recommended Prior Radiotherapy Surgical
intervention if no contraindication LEER procedure: laterally
extended endopelvic resection CORT procedure: combined operative
and radio-therapeutic treatment Indication: Histological confirmed,
unifocal pelvic side-wall recurrence Free from tumor dissemination
Tumor limited to a maximal diameter of < 5 cm Medical condition
compatible with major surgery. Willingness to accept urinary or
fecal diversion Palliative chemotherapy if surgical intervention
not possible Radiotherapy indicated if recurrence outside of
previously treated field Palliative radiotherapy or palliative
chemotherapy
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- (IV-3 ) Cervical Cancer with Central and Pelvic Side Wall
Recurrence Prior Surgery Radiotherapy recommended Prior
Radiotherapy Palliative chemotherapy Radiotherapy indicated if
recurrence outside of previously treated field Palliative
radiotherapy
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- (IV-4) Only Distant LN Metastasis ( Including para-aortic LN )
Radiotherapy recommended Chemotherapy recommended ( see above )
CCRT recommended ( see above )
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- (IV-5) Intra-abdominal Organ Metastasis Chemotherapy
recommended ( see above ) Palliative surgery only for intestinal
obstruction
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- (IV-6) Dissemination Chemotherapy recommended ( see above
)
- Slide 19
- (V) Chemotherapy for Cx Ca Cisplatin is regarded as the most
active agent in treating patients with cervical cancer and is
recommended as first-linechemotherapy drug. In selective cases with
poor renal function ( CCr < 60 ) Carboplatin can be substituted
as an alternative drug
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- Indications for Chemotherapy in Cervical Cancer Adjuvant
chemotherapy for postoperative lymph node metastasis Neoadjuvant
chemotherapy for bulky tumor Followed by surgery Followed by
radiotherapy Concurrent chemoradiotherapy Early bulky tumor
followed by surgery Postoperative with parametrium involvement and
lymph node metastasis Local advanced cancer Consolidation
chemotherapy after concurrent chemoradiotherapy for advanced cancer
Palliative chemotherapy for distant, metastatic, or recurrent
cancer If distant metastasis or recurrence Systemic Chemotherapy
Palliative Radiotherapy
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- (V-1) Neoadjuvant Chemotherapy Regimen Cisplatin Only (qw x 3
course) Cisplatin 40 mg/m 2 RH performed on 3rd day after
completing chemotherapy POB Regimen (q3wk x 3 course) Cisplatin 50
mg/m 2 + Vincristine 1 mg/m 2 + Bleomycin 15 mg/m 2 (D1~3) RH
performed within 3 weeks after completing chemotherapy TP Regimen
(q10d x 3 course) Cisplatin 60 mg/m 2 + Palcitaxel 60 mg/m 2 (3hrs)
RH performed within 3 weeks after completing chemotherapy
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- (V-2) CCRT regimen Cisplatin Only (qw) Cisplatin 40 mg/m 2 POB
Regimen (q3wk ) Cisplatin 50 mg/m 2 + Vincristine 1 mg/m 2 +
Bleomycin 15 mg/m 2 (D1~3)
- Slide 23
- (V-3) Consolidation Chemotherapy Regimen I+P regimen ( q3w ) 1.
Cisplatin 50 mg/m 2 + Ifosfamide 1 gm/m 2 (3 days) 2. Cisplatin 50
mg/m 2 + Ifosfamide 5 gm/m 2 (24 hours)
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- (V-4) Chemotherapy Regimen for Disseminated or Recurrent
Disease 1. Squamous cell carcinomas 2. Non-squamous cell
carcinomas
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- Common used Regimen for Squamous Cell Carcinoma Cisplatin +
Ifosfamide ( q3w ) Cisplatin 50 mg/m 2 + Ifosfamide 5 gm/m 2 (24
hours) Cisplatin + Ifosfamide ( D1~3) + Epirubicin ( q3w )
Cisplatin 50 mg/m 2 + Ifosfamide 1 gm/m 2 + Epirubicin 50 mg/m 2
Cisplatin + Ifosfamide (D1~3) + Paclitaxel ( q3w ) Cisplatin 50
mg/m 2 + Ifosfamide 1 gm/m 2 + Paclitaxel 175 mg/m 2 Cisplatin +
Paclitaxel ( q3w ) Cisplatin 75 mg/m 2 + Paclitaxel 175 mg/m 2
Cisplatin + Topotecan (D1~3) ( q3w ) Cisplatin 50 mg/m 2 +
Topotecan 1 mg/m 2 Cisplatin + Vincristine + Bleomycin (D1~3) ( q3w
) Cisplatin 50 mg/m 2 + Vincristine 1 mg/m 2 + Bleomycin 15 mg/m 2
Cisplatin + Gemcitabine Cisplatin 50 mg/m 2 (D1) + Gemzar 1000 mg/m
2 (D1 / D8) Cisplatin + Camptothecin Cisplatin: 75 mg/m 2 (D1) +
CPT-11: 60mg/m 2 (D1 / D8 / D15)
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- Common used Regimen for Non-squamous Cell Carcinoma Cisplatin +
Paclitaxel ( q3w ) Cisplatin 75 mg/m 2 + Paclitaxel 175 mg/m 2
Paclitaxel ( q3w ) Paclitaxel 170 mg/m 2 ( 24 hrs ) Paclitaxel 135
mg/m 2 ( 24 hrs ) ( if prior radiotherapy ) Dose escalation to
200mg/m 2 or de-escalation to 110mg/m 2 depending on toxicity
Etoposide ( every 28 days ) Oral Etoposide 50mg/m 2 /day for 21
days Oral Etoposide 40mg/m 2 /day ( if prior radiotherapy ) for 21
days Dose escalation to 60mg/m 2 /day depending on toxicity
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