Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer

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1 Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer Version

2 一本共識依下列參考資料修改版本 : NCCN Clinical Practice Guidelines in Oncology- Ovarian -Fallopian Tube -Primary Peritoneal Cancer V 年 Revised FIGO staging f carcinoma of the Ovarian -Fallopian Tube -Primary Peritoneum 二制訂人員 : 婦產科 : 魏銘洲醫師蕭聖謀醫師吳文毅醫師孫序東醫師放射腫瘤 : 熊佩韋醫師吳樂榮醫師謝忱希醫師組織病理 : 羅承裕醫師影像醫學 : 黃智旺醫師核子醫學科 : 吳彥雯醫師個管師 : 鄭玉琴護理師

3 CLINICAL PRESENTATION WORK-UP PRIMARY TREATMENT g,h,i,j Suspicious a /palpable pelvic mass detected on abdominal/ pelvic exam and/ ascites, abdominal distention, and/ Symptoms such as bloating, pelvic abdominal pain, difficulty eating feeling full quickly urinary symptoms (urgency frequency) b without other obvious source of malignancy Obtain family histy c and consider family histy evaluation c,d Abdominal/ pelvic exam GI evaluation as clinically indicated Ultrasound and/ abdominal/ pelvic CT as clinically indicated e Chest imaging CA-125, other tum markers as clinically indicated f Complete blood count (CBC), chemistry profile with liver function test (LFTs) Laparotomy/ Total abdominal hysterectomy (TAH) / Bilateral salpingo- oophectomy (BSO) with comprehensive staging j unilateral salpingo-oophectomy (USO) (Clinical Stage IA IC, all grades with comprehensive staging if patient desires fertility) Cyteductive surgery j if clinical stage II, III,Ⅳ Consider neoadjuvant chemotherapy k (categy 1)/primary interval cyteduction h (diagnosis by fine-needle aspiration [FNA],biopsy, paracentesis) f patients with bulky stage III/ Ⅳ who are po surgical candidates due to high-risk combidity conditions disease facts. See Pathologic Staging (OV-3) Diagnosis by previous surgery tissue biopsy (cytopathology) Obtain family histy and consider family histy evaluation Ultrasound and/ abdominal/pelvic CT/MRI as clinically indicated e Chest imaging CA-125 other tum markers as clinically indicated f CBC, chemistry profile with LFTs Institutional pathology review Refer f genetic risk evaluation c,d See Findings and Primary Treatment (OV-2) 第 OV-1 頁 a Im SS, Gdon AN, Buttin BM, et al. Obstet Gynecol 2005;105: See Discussion. b Goff BA, Mandel L,Drescher CW, et al. Cancer 2007;109: c See NCCN Guidelines f Genetic/Familial High-Risk Assessment: Breast and Ovarian and NCCN Guidelines f Genetic/Familial High-Risk Assessment: Colectal. d Primary treatment should not be delayed f a genetic counseling referral. e PET/CT scan MRI may be indicated f indeterminate lesions if results will alter management. f See Discussion f usefulness of diagnostic tests. h Standard recommendation includes a patient evaluation by a gynecologic oncologist pri to initiating chemotherapy. Published data demonstrate that primary assessment and debulking by a gynecologic oncologist result in a survival advantage. Patients being evaluated f neoadjuvant chemotherapy should be seen by a fellowship-trained gynecologic oncologist pri to being considered a po surgical candidate. A referral to a gynecologic oncologist is also recommended f management of occult serous tubal intraepithelial carcinomas. i All women undergoing surgery f ovarian cancer should be counseled about the clinical benefit associated with combined IV and IP chemotherapy administration pri to surgery. NCI Clinical Announcement. j See Principles of Surgery (OV-A). k See Principles of Chemotherapy (OV-B) and Management of Drug Reactions (OV-C).

4 DIAGNOSIS BY PREVIOUS SURGERY FINDINGS PRIMARY TREATMENT c Adequate previous surgery and staging Suspected stage IA IB, Grade 1 g (suspect no residual disease) Surgical staging j Incomplete previous surgery e and/ staging: 1.Uterus intact 2.Adnexa intact 3.Omentum not removed 4.Documentation of staging incomplete 5.Residual disease disease, potentially resectable Suspected stage IA IB, Grade 2 g Suspected Stage IA IB, Grade 3 clear cell Or Stage IC If observation considered Suspect residual disease Suspect no residual disease Suspect residual disease Suspect no residual disease Completion Surgery/Surgical staging j Completion surgery/surgical staging j Chemotherapy f 6 cycles Completion Surgery/Surgical staging j Completion surgery/surgical staging j Chemotherapy f 6 cycles See Pathologic staging (OV-3) 第 OV-2 頁 Stage II, III, IV Suspect potentially resectable residual disease Suspect unresectable residual disease Tum reductive surgery j Chemotherapy k f a total of 6-8 cycles Consider completion surgery after 3-6 cycles l followed by postoperative chemotherapy h Standard recommendation includes a patient evaluation by a gynecologic oncologist. Published data demonstrate that primary assessment and debulking by a gynecologic oncologist result in a survival advantage. Patients being evaluated f neoadjuvant chemotherapy should be seen by a fellowship-trained gynecologic oncologist pri to being consider a po nonsurgical candidate. j See Principles of primary Surgery (OV-A). k See Principles of Chemotherapy (OV-B) and Management of Drug Reactions (OV-C). l Based on clinical judgement of gynecologic oncologist, surgery may be perfmed after considered a po nonsurgical candidate. m Completion surgery after 3 cycles is preferred; however, surgery may be perfmed after 4 6 cycles based on the clinical judgment of the gynecologic oncologist.

5 PATHOLOGIC STAGING l Grade 1 PRIMARY CHEMOTHERAPY/ PRIMARY ADJUVANT i Observe o Stage IA IB Stage IC Grade 1,2, 3 Grade 2 Grade 3 clear cell Observe Intravenous (IV) taxane/carboplatink k f 3-6 cycles( 本院 ) Chemotherapy f 3-6 cycles Chemotherapy f 3-6 cycles See Moniting/Follow- UP (OV-5) Stage II Stage III Stage Ⅳ Chemotherapy( 本院 ) p Intraperitoneal (IP) chemotherapy I,k in <1 cm optimally debulked stage II and stage III patients (categy 1 f stage III) IV taxane/carboplatink f a total of 6 8 cycles(categy 1) Completion surgery as indicated by tum response and potential resectability in selected patients j See Secondary Adjuvant (OV-4) i All women undergoing surgery f ovarian cancer should be counseled about the clinical benefit associated with combined IV and IP chemotherapy administration pri to surgery. j See Principles of primary Surgery (OV-A). k See Principles of Chemotherapy (OV-B) and Management of Drug Reactions (OV-C). l Some pathologists recommend that ovarian cancer be graded either low-grade (most grade 1 serous tums) high-grade (most grade 2 3 serous tums). See FIGO Guidelines (ST-5). n Patients receiving primary chemotherapy will be monited as follows: 1.Pelvic exams at least every 2 cycles 2.Interim CBC with platelets as indicated 3.Chemistry profiles if indicated 4.CA-125 levels other tum markers as clinically indicated pri to each cycle of chemotherapy 5.Radiographic imaging if indicated. o See Discussion f me details about treatment of low-grade tums. p See specific regimens on Primary Chemotherapy/Primary Adjuvant Therapy Regimens f Stage II-IV (OV-B 3 of 3). 第 OV-3 頁 Note:All recommendations are categy 2A unless otherwise indicated.

6 STAGE II, III, Ⅳ POST PRIMARY TREATMENT SECONDARY ADJUVANT Stage II, III, Ⅳ Post primary treatment Complete remission q Clinical trial Observe Postremission pazopanib m (categy 2B) Postremission paclitaxel r (categy 3) See Moniting/ Follow-Up (OV-5) Partial remission progression See Persistent Disease Recurrence Therapy (OV-6) 第 OV- 4 頁 q No objective evidence of disease (ie, negative physical exam, negative CA-125, negative CT with < 1 cm lymph nodes). r See Discussion f doing.

7 STAGE I-Ⅳ COMPLETE RESPONSE RECURRENT DISEASE t MONITORING/FOLLOW-UP Stage I, II, III, Ⅳ complete response Visits every 2-4 mo f 2y, then 3-6 mo f 3y, then annually after 5y Physical exam including pelvic exam CA-125 m other tum markers ever visit if initially elevated. CBC and chemistry profile as indicated Chest/abdominal/ pelvic CT MRI; PET-CT ( 自費 ) as clinically indicated. Chest x-ray as indicated Consider family histy evaluation, if not previously done Rising CA-125, no previous chemotherapy Clinical relapse, no previous chemotherapy Clinical relapse, previous chemotherapy ± Serially rising CA- 125, previous chemotherapy Imaging studies as clinically indicated : Chest/abdominal/ pelvic CT, MRI,PET-CT ( 自費 ) PET ( 自費 ) (categy 2B f PET) Imaging studies as clinically indicated : Chest/abdominal/ pelvic CT, MRI,PET-CT ( 自費 ) PET ( 自費 ) (categy 2B f PET) Imaging studies as clinically indicated : Chest/abdominal/ pelvic CT, MRI,PET-CT ( 自費 ) PET ( 自費 ) (categy 2B f PET) See Primary Treatment (OV-1) See Therapy f Persistent Disease Recurrence (OV-6) Delay treatment until clinical relapse Immediate treatment f recurrent disease (categy 2B) Clinical Trial 第 OV-5 頁 c See NCCN Guidelines f Genetic/Familial High-Risk Assessment: Breast and Ovarian and NCCN Guidelines f Genetic/Familial High-Risk Assessment: Colectal. s There are data regarding the utility of CA-125 f moniting of ovarian cancer after completion of primary therapy. See The Society of Gynecologic Oncology (SGO) position statement and Discussion. t Consider symptom management and best supptive care. See NCCN Guidelines f Palliative Care. Refer f palliative care assessement, if appropriate.

8 DISEASE STATUS c THERAPY FOR PERSISTENT DISEASE OR RECURRENCE u,v,w Progression, stable, persistent disease on primary chemotherapy Complete remission and relapse < 6 mo after stopping chemotherapy Stage II, III, and IV with partial response Complete remission and relapse 6 mo after stopping chemotherapy Radiographic and/ clinical relapse Clinical trial x Supptive only(see NCCN Guidelines f Palliative Care) Recurrence therapy u,w Clinical trial x Recurrence therapy u,w ± Best supptive care (See NCCN Guidelines f Palliative Care) Consider secondary cyteductive surgery j Clinical trial x Combination platinum-based chemotherapy u,w preferred f first recurrence (categy 1) Recurrence therapy u,w Biochemical relapse (rising CA-125 and no radiographic evidence of disease) Clinical trialx Delay treatment until clinical relapse Immediate treatment f recurrent disease (recurrence therapy w ) (categy 2B) 第 OV-6 頁 csee NCCN Guidelines f Genetic/Familial High-Risk Assessment: Breast and Ovarian and NCCN Guidelines f Genetic/Familial High-Risk Assessment: Colectal. jsee Principles of Surgery (OV-A). upatients who progress on 2 consecutive therapy regimens without evidence of clinical benefits have diminished likelihood of benefitting from additional therapy. Decisions to offer clinical trials, supptive care only, additional therapy should be made on a highly individual basis. vsee Ancillary Palliative Surgical Procedures in Principles of Surgery (OV-A 3 of 3). wsee Acceptable Recurrence Therapies (OV-D). xclinical trials with newer agents should be strongly considered.

9 CLINICAL PRESENTATION PRIMARY THERAPY k Diagnosis of low malignant potential (LMP) tum with institutional pathology review Previous surgical staging was comprehensive h No invasive implants Invasive implants Observe Observe Consider treatment as epithelial ovaian cancer l (categy 2B)(See OV-2) See Moniting/Follow- UP (LCOH-8) Incomplete surgical staging h See LCOH-7 h See Principles of Surgery (OV-A). 第 LCOH-6 頁 k Standard recommendation includes a patient evaluation by a gynecologic oncologist. l Chemotherapy (IV IP) has not been shown to be beneficial in ovarian low malignant potential tums (bderline epithelial ovarian tums).

10 CLINICAL PRESENTATION PRIMARY THERAPY k Diagnosis of low malignant potential (LMP) tum with institutional pathology review Residual disease remaining after first procedure No residual disease remaining after first procedure Fertility desire If no desire f fertility Observe No invasion implants Unknown Invasion implants at previous surgery No invasion implants Unknown Invasion implants at previous surgery Observe m Fertility-sparing surgery h and comprehensive surgical staging,(categy 2B f staging) n if not previously done Fertility-sparing surgery h and comprehensive surgical staging,(categy 2B f staging) n if not previously done Observe (categy 2B) Consider treatment as epithelial ovarian cancer (categy 2B) (See OV-2) Observe m Completion surgery h,n Completion surgery h Observe (categy 2B) Consider treatment as epithelial ovarian cancer (categy 2B) (See OV-2) See Moniting/ Follow-UP (LCOH-8) h See Principles of Surgery (OV-A). k Standard recommendation includes a patient evaluation by a gynecologic oncologist. l Chemotherapy (IV IP) has not been shown to be beneficial in ovarian low malignant potential tums bderline epithelial ovarian tums). m Observation is a reasonable option regardless of whether fertility is desired. n F pathologically proven LMP, lymph node evaluation may be considered on a case-by-case basis. 第 LCOH-7 頁

11 MONITORING/ FOLLOW-UP RECURRENT DISEASE RECURRENT THERAPY Visits exam every 3-6 mo f up to 5y, then annually Physical exam including pelvic exam Ultrasound as indicated f patients with fertility-sparing surgery CA-125 o other tum markers every visit if initially elevated CBC chemistry profile as indicated After completion of childbearing in patients who underwent unilateral salpingooophectomy,consider completion surgery (categy 2B) Clinical relapse Surgical evaluation + debulking if appropriate Non-invasive disease Invasive implants of low malignant potential Observe See Primary Treatment (LCOH-7) Invasive carcinoma ( low high grade) Threatment as epithelial ovarian cancer l (categy 2B f low grade) (See OV-3) 第 LCOH-8 頁 l Chemotherapy (IV IP) has not been shown to be beneficial in ovarian low malignant potential tums (bderline epithelial ovarian tums). o There are data regarding the utility of CA-125 f moniting of ovarian cancer after completion of primary therapy. See The Society of Gynecologic position statement and Discussion.

12 Staging in Oncology, FEMH v Table 1 American Joint Committee on Cancer (AJCC); TNM and FIGO Staging f Ovarian and Primary Peritoneal Cancer (7th ed.,2010) TNM FIGO Surgical-Pathologic Findings TNM FIGO TX Primary tum cannot be assessed T0 No evidence of primary tum T1 I Tum limited to ovaries (one both) T1a I A Tum limited to one ovary; capsule intact, no tum on ovarian surface. No malignant cells in ascites peritoneal washings. T1b I B Tum limited to both ovaries; capsule intact, no tum on ovarian surface. No malignant cells in ascites peritoneal washings. T1c I C Tum limited to one both ovaries with any of the following; capsule ruptured, tum on ovarian surface, malignant cells in ascites peritoneal washings. T2 II Tum involves one both ovaries with pelvic extension. T2a IIA Extension and/ implants on uterus and/ tube(s). No malignant cells in ascites peritoneal washings. T2b IIB Extension and/ implants on other pelvic tissues. No malignant cells in ascites peritoneal washings. T2c IIC Pelvic extension and/ implants (T2a T2b) with malignant cells in ascites peritoneal washings. T3 III Tum involves one both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis. T3a III A Microscopic peritoneal metastasis beyond pelvis (no maroscopic tum). T3b III B Microscopic peritoneal metastasis beyond pelvis 2 cm less in greatest dimension. T3c III C Peritoneal metastasis beyond pelvis me than 2 cm in greatest dimension and/ regional lymph node metastasis. Regional Lymph Nodes (N) Nx Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 III C Regional lymph node metastasis Distant metastasis (M) M0 No distant metastasis M1 IV Distant metastasis Note: Liver capsule metastasis is T3/Stage III; liver parenchymal metastasis, M1/Stage IV. Pleural effusion must have positive cytology f M1/Stage IV. 第 ST-1 頁 Continued

13 Staging in Oncology, FEMH v Table 1 (Continued) American Joint Committee on Cancer (AJCC); TNM and FIGO Staging f Ovarian and Primary Peritoneal Cancer (7th ed.,2010) Stage Groping Stage I T1 N0 M0 Stage IA T1a N0 M0 Stage IB T1b N0 M0 Stage IC T1c N0 M0 Stage II T2 N0 M0 Stage IIA T2a N0 M0 Stage IIB T2b N0 M0 Stage IIC T2c N0 M0 Stage III T3 N0 M0 Stage IIIA T3a N0 M0 Stage IIIB T3b N0 M0 Stage IIIC T3c N0 M0 Any T N1 M0 Stage IV Any T AnyN M1 The staging system f ovarian and primary peritoneal cancer is also used f malignant germ cell tums, malignant sex cd-stromal tums, and carcinosarcoma (malignant mixed Müllerian tums). Note: F histologic grade and histopathological type, see AJCC staging manual. 第 ST-2 頁 Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago IIIinois. The iginal and primary source f this infmation is the AJCC Center Staging Manual, Seventh Edition(2010) published by Springer Science and Business Media LLC (SBM). (F complete infmation and data suppting the staging tables, visit citation quotation of this material must be credited to the AJCC as its primary source. The inclusion of this infmation herein does not authize any reuse further distribution without the expressed, written permission of Spring SBM, on behalf of the AJCC.

14 Staging in Oncology, FEMH v Table 2 American Joint Committee on Cancer (AJCC); TNM and FIGO Staging f Fallopian Tube Cancer (7th ed.,2010) TNM FIGO Surgical-Pathologic Findings TNM FIGO TX Primary tum cannot be assessed T0 No evidence of primary tum Tis* Carcinoma in situ (limited to tube mucisa) T1 I Tum limited to the fallopian tube(s) T1a I A Tum limited to one tube, without penetration the serosal surface; no ascites. T1b I B Tum limited to both tubes, without penetration the serosal surface; no ascites. T1c I C Tum limited to one both tubes with extension onto through the tubal serosa, with malignant cells in ascites peritoneal washings. T2 II Tum involves one both fallopian tubes with pelvic extension. T2a IIA Extension and/ metastasis to the uterus and/ ovaries. T2b IIB Extension to other pelvic structures. T2c IIC Pelvic extension with malignant cells in ascites peritoneal washings. T3 III Tum involves one both fallopian tubes, with peritoneal implants outside the pelvis. T3a III A Microscopic peritoneal metastasis outside the pelvis. T3b III B Microscopic peritoneal metastasis outside the pelvis 2 cm less in greatest dimension. T3c III C Peritoneal metastasis outside the pelvis and me than 2 cm in greatest diameter. Regional Lymph Nodes (N) Nx Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 III C Regional lymph node metastasis Distant metastasis (M) M0 No distant metastasis M1 IV Distant metastasis (excludes metastssis within the peritoneal cavity) * Note: FIGO no longer includes Stage 0 (Tis) Note: Liver capsule metastasis is T3/Stage III; liver parenchymal metastasis, M1/Stage IV. Pleural effusion must have positive cytology f M1/Stage IV. 第 ST-3 頁 Continued

15 Staging Table 2 (Continued) American Joint Committee on Cancer (AJCC); TNM and FIGO Staging f Fallopian Tube Cancer (7th ed.,2010) Stage Groping Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IA T1a N0 M0 Stage IB T1b N0 M0 Stage IC T1c N0 M0 Stage II T2 N0 M0 Stage IIA T2a N0 M0 Stage IIB T2b N0 M0 Stage IIC T2c N0 M0 Stage III T3 N0 M0 Stage IIIA T3a N0 M0 Stage IIIB T3b N0 M0 Stage IIIC T3c N0 M0 Any T N1 M0 Stage IV Any T Any N M1 第 ST-4 頁 * Note: FIGO no longer includes Stage 0 (Tis) Note: F histologic grade and histopathological type, see AJCC staging manual. Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago IIIinois. The iginal and primary source f this infmation is the AJCC Center Staging Manual, Seventh Edition(2010) published by Springer Science and Business Media LLC (SBM). (F complete infmation and data suppting the staging tables, visit citation quotation of this material must be credited to the AJCC as its primary source. The inclusion of this infmation herein does not authize any reuse further distribution without the expressed, written permission of Spring SBM, on behalf of the AJCC.

16 六 Updated on 2015/08/27 內容 :

卵巢輸卵管腹膜癌臨床指引亞東紀念醫院. Ovarian -Fallopian Tube -Primary Peritoneal Cancer Clinical Guidelines in Oncology, FEMH v CLINICAL PRESENTATION

卵巢輸卵管腹膜癌臨床指引亞東紀念醫院. Ovarian -Fallopian Tube -Primary Peritoneal Cancer Clinical Guidelines in Oncology, FEMH v CLINICAL PRESENTATION CLINICAL PRESENTATION WORK-UP PRIMARY TREATMENT c,d Suspicious a /palpable pelvic mass detected on abdominal/ pelvic exam and/ ascites, abdominal distention, and/ Symptoms such as bloating, pelvic abdominal