Cervical Cancers Treatment Guideline KMHK

Transcription

1 Cervical Cancers Treatment Guideline KMHK

2 子宮頸癌修訂紀錄 修訂日期修訂內容摘要 修訂頁次 版本 97 年 98 年 99 年 100 年 101 年 102 年 103 年 104 年 子宮頸癌診療指引新制訂新增子宮頸篩檢凖則多科會議討論檢視後未修改多科會議討論檢視後未修改多科會議討論檢視後未修改多科會議討論檢視後未修改 ;stage Ia1 做 simple Hysterectomy 或 Conization;stage Ia2 以上評估是否可開刀做 radical hysterectomy 且要評估 lymph node 情形, 決定是否要做化療及放射線治療 多科會議討論檢視後未修改多科會議討論檢視後未修改 E3~

3 Cervical Cancer 子宮頸癌治療準則 E-1 STAGING TREATMENT Completed Simple Hysterectomy Stage IA Stage IA1 (Microinvasive) Childbearing t completed Conization + Surveillance Stage IA2 Operability RH + PLND Pelvic RT+Brachytherapy Stage IB Tumor size Histology (Biopsy) paraaortic nodes (MRI or CT or PET) Stage IB1 < 4 cm Squamous cell ca Adeno ca. Small cell ca. Stage IB2 > 4 cm enlarged paraaortic LN or pelvic LN Operability Operability Preop CCRT Cisplatin + 5 FU Good response Poor response Pelvic+RT +Brachytherapy RH + PLND CCRT(Cisplatincontaining RH + PLND Histology(surgical specimen) Tumor size > 4cm LVI (+) Deep stromal invasion Lymph node (+) Positive margin Parametrial invasion RH + PLND Completed RT + chemotherapy Surveillance Pelvic or paraaortic RT+chemotherapy

4 Cervical Cancer 子宮頸癌治療準則 E-2 STAGING Stage II A1, II A2 Operability TREATMENT RH + PLND Concurrent chemotherapy and radiation Histology(surgical specimen) Tumor size >4cm LVI(+) Deep stromal invasion Lymph node(+) Positive margin Parametrial invasion Surveillance Pelvic or Paraaortic RT + chemotherapy Stage IIB, III, IVA Concurrent chemotherapy and radiation (pelvic or paraaortic) Stage IVB Palliation (chemotherapy or / and radiation) Chemotherapy, palliation Recurrent Ca.. with Distant intra-abdominal or paraaortic metastases Prior treatment Pelvic RT Central Side wall Pelvic exenteration RT or Chemotherapy Completed RT ± Chemotherapy

5 Cervical Screening 子宮頸篩檢準則 FINDINGS ON COLPOSCOPY INITIAL FINDINGS SCREENING/ PAPTEST CERVICAL BIOPSY FINDINGS rmal Repeat Pap test at 6 mo Repeat Pap test every 6 mo E-3 FOLLOW-UP TREATMENT If LSIL persists for 24 mo,consider treatment If returns to normal, Pap test every 12 mo If Pap test indicates HSIL Colposcopy I CKC or LEEP or Cryotherapy or Laser Satisfactory colposcopy Cervical biopsy II Microinvasive CKC or LEEP or Cryotherapy or Laser or Total hysterectomy NCCN Cervical Cancer Treatment Guidelines Invasive NCCN Cervical Cancer Treatment Guidelines LSIL/ASCUS Cervical intraepithelial neoplasia (CIN) I ECC FINDINGS Positive Positive I or III I or III CKC or LEEP CKC or LEEP Unsatisfactory colposcopy Cervical biopsy +ECC I Positive I or III CKC or LEEP CKC or LEEP or Cryotherapy or Laser CKC=Cold-knife conization ECC=Endocervical curretage LEEP=Loop electrosurgical excision procedure II Cancer Positive I or III CKC or LEEP or Total hysterectomy after CKC or LEEP for definitive diagnosis CKC or LEEP or Cryotherapy or Laser or Total hysterectomy KMU Cervical Cancer Treatment Guidelines

6 Cervical Screening 子宮頸篩檢準則 E-4 FINDINGS ON INITIAL SCREENING/ PAPTEST COLPOSCOPY FINDINGS CERVICAL BIOPSY FINDINGS rmal Review screening Pap test FOLLOW-UP If high grade, consider LEEP for definitive TREATMENT If LSIL persists for 24 mo,consider treatment Repeat Pap test every 6 mo If returns to normal,pap test every 12 mo If Pap test indicates HSIL Colposcopy I CKC or LEEP or Cryotherapy or Laser Satisfactory colposcopy Cervical biopsy II CKC or LEEP or Cryotherapy or Laser or Consider Total hysterectomy Microinvasive NCCN Cervical Cancer Treatment Guidelines Invasive ECC FINDINGS NCCN Cervical Cancer Treatment Guidelines HSIL Positive for dysplasia CKC or LEEP Positive for dysplasia, II, III) CKC or LEEP Unsatisfactory colposcopy Cervical biopsy +ECC I Positive for dysplasia, II, III) CKC or LEEP CKC or LEEP or Cryotherapy or Laser CKC=Cold-knife conization ECC=Endocervical curretage LEEP=Loop electrosurgical excision procedure II Cancer Positive for dysplasia, II, III) CKC or LEEP or Total hysterectomy after CKC or LEEP for definitive diagnosis CKC or LEEP or Cryotherapy or Laser or Total hysterectomy KMU Cervical Cancer Treatment Guidelines

7 Cervical Screening 子宮頸篩檢準則 E-5 FINDINGS ATTREATMENT FOLLOW-UP POST-TREATMENT After CKC or LEEP for CIN margins or margin status unknown Cryotherapy Laser rmal (no dysplasia) I II Margin Pap test at 6 mo mo Pap test at 6 mo Pap test at 6 mo Pap test at 6 mo Pap test at 6 mo Consider ECC (category 2B) rmal ASCUS LSIL HSIL Resume annual PAP testing Repeat Pap test at 6 mo Repeat Pap test at 6 mo Repeat Pap test at 6 mo Consider colposcopy Colposcopy ASCUS LSIL HSIL Resume annual PAP testing Repeat Pap test at 6 mo Repeat Pap test at 6 mo Consider colposcopy Colposcopy Positive margins Margin I,III Pap test at 6 mo Consider ECC (category 2B) ASCUS HSIL LSIL Colposcopy or Total hysterectomy Resume annual PAP testing

8 Cervical Screening 子宮頸篩檢準則 E-6 FOLLOW-UP OF CERVICAL BIOPSY/ENDOMETRIAL BIOPSY FINDINGS FOLLOW-UP further evaluation of endometrium Endometrial biopsy Hyperplasia Atypical hyperplasia Consider dilatation and Curettage(D&C) D&C,II III See E7 for Follow-up of CKC AGCUS AGCUS with endometrial cells or Favor endometrial cells or Age > 40yr or Endometrial cancer risk factors f Colposcopy ECC and endometrial biopsy ECC Cancer ndiagnostic rmal, II, III KMU Endometrial Cancer Treatment Guidelines Consider repeat depending on ECC/ cervical biopsy findings or consider transvaginal ultrasound for metrial endo stripe thickness Individualized follow-up based on review of AGCUS smear CKC If CKC Adenocarcinoma in situ/ glandular intraepitheli al neoplasia Consider referral to gynecologic oncologist margins margins, fertility desired Hysterectomy (standard preferred) Pap test with ECC at 6 mo Requires consent / counseling Recommend hysterectomy when childbearing completed AGCUS favor cervical neoplasia Colposcopy ECC f Endometrial Cancer Risk Factors:Obesity,estrogen replacement therapy,polycystic ovarian disease, tamoxifen,anovulation Cervical biopsy Adenocarcinoma in situ Cancer rmal Adenocarcinoma in situ I, III (squamous) CKC KMU Endometrial/Cervical Cancer Treatment Guidelines Individualized follow-up based on review of AGCUS smear CKC Repeat Pap test at 6 mo if ECC negative CKC Cancer KMU Cervical Cancer Treatment Guidelines Positive margins Total hysterectomy or Repeat CKC at 3 mo If fertility desired, consent / counseling required Recommend hysterectomy when childbearing completed

9 Endometrial cancer Treatment Guideline KMHK

10 子宮頸癌修訂紀錄修訂日期修訂內容摘要修訂頁次版本 104 年子宮內膜癌診療指引新制訂 E7~10 1.0

11 Endometrial cancer 子宮內膜癌治療準則 E7 Medically Primary (+)for Surgical radiation staging operable Primary surgery Endomctrial (+) for cancer (-) for Hysteroscopel (-) for cancer Follow-up G1 G2 G3 Completely surgical staging:.ath+bso Stage Adverse risk(-) Adverse risk(+) observe Brachytherapy and/or pelvic RT Brachytherapy and/or pelvic RT.Cytology.Pelvic lymphadenectomy.para-aortic lymphadenectomy(optional) Pontential adverse risk factor:.age.positive lymphovascular invasion.tumor size Stage IB Adverse risk(-) Adverse risk(+) Brachytherapy and/or pelvic RT Brachytherapy and/or pelvic RT Brachytherapy and/or pelvic RT pelvic RT and/or vaginal.lower +chemotherapy uterine(cervical/glandular)involvement

12 Endometrial cancer 子宮內膜癌治療準則 Stage II Stage IIIA Completely surgical staging:.ath+bso.cytology.pelvic lymphadenectomy.para-aortic lymphadenectomy Stage IIIB (optional) E8 G1 G2 G3 Pelvic RT+ Pelvic RT+ and/or pelvic RT +chemotherapy Chemotherapy+RT Chemotherapy+RT Chemotherapy+RT Or tumor-directed RT+ Or tumor-directed RT+ Or tumor-directed RT+ Chemotherapy Chemotherapy Chemotherapy Or Pelvic RT+ Or Pelvic RT+ Or Pelvic RT+ Chemotherapy and/or tumor-directed RT Stage IIIC1 Pelvic node:positive Chemotherapy and/or tumor-directed RT Stage IIIC2 Para-aortic nod positive+ Pelvic node positive Chemotherapy and/or tumor-directed RT Stage IVA and B Debulking and with no gross residual disease or microscopic abdominal disease Chemotherapy+RT Stage I with positive cytology Large tumor High grade Deep myometrium Invasion LVSI Adjuvant chemotherapy

13 Endometrial cancer 子宮內膜癌治療準則 E9 Stage IA G1-2 Observe Observation or vaginal +pelvic RT Radiologic image Incomplete surgical staged Stage IA G1-2 (myometrial invasion<50%) Positive Surgical restaging or pathologic Conirmation of metastaic disease Adjuvant treatment for complete surgically staged Positive Stage IA G3 Stage IB Stage II Radiologic image Pelvic RT+ vaginal +para-aortic RT(+chemotherapy for grade 3 tumors)

14 Endometrial cancer 子宮內膜癌治療準則 E10 Stage IA (no myometrial invasion) Chemotherapy or Tumor-directed radiotherapy Biopsy: Completely surgical staging as ovarian cancer:.ath+bso Stage IA (with myometrial invasion) Stage IB Stage II Chemotherapy+Tumor-directed RT Or whole abdomen pelvic RT +vaginal.papillary serous carcinoma.cytology.clear cell carcinoma.omentectomy.carcinosarcoma.peritoneal biospy.pelvic lymphadenectomy.para-aortic lymphadenectomy.maximal tumor debulking Stage II Stage IV (adwquately debulking) Chemotherapy+Tumor-directed RT Or whole abdomen pelvic RT +vaginal Stage III or IV Chemotherapy (inadwquately debulking)