CLINICAL PRESENTATION This practice algorithm has been specifically developed for M. D. Anderson using a multidisciplinary approach and taking into consideration circumstances particular to M. D. Anderson, including the INITIAL EVALUATION STAGING Yes PRIMARY TREATMENT Repeat Cone Reassign stage based on histologic margins Stage IA 1 2 ECC or Margins Positive? No Observation OR Simple Hysterectomy 5 Surveillance: See Page 4 Non-visible Lesion Cone Biopsy with ECC 1 Stage IA 2 Radical Hysterectomy and Pelvic Lymph Node Dissection OR Radical Trachelectomy and Pelvic Lymph Node Dissection OR Radiation Therapy High Risk Factors 3 Intermediate Risk Factors 4 Chemoradiotherapy 5 Radiotherapy or Chemoradiotherapy 5 1 ECC= Endocervical Cutterage 2 Consider radical hysterectomy for patients with Stage IA1 cancer with LVSI and/or grade 3 adenocarcinoma 3 High risk factors are positive nodes, positive margins, or parametrial involvement. 4 Intermediate risk factors (see Sedlis A. et al.) 5 Concurrent weekly Cisplatin Low Risk Factors
CLINICAL PRESENTATION STAGING Stage IB1 PRIMARY TREATMENT Radical Hysterectomy and Pelvic Node Dissection OR Radical Trachelectomy and Pelvic Lymph Node Dissection OR Radiation Therapy 1 High Risk Factors 3 Chemoradiation 5 Intermediate Risk Factors 4 5 Chemoradiation OR Radiation Therapy Low Risk Factors Surveillance Visible Lesion Chest X-ray Renal/Liver Function Testing Optional pelvic imaging Stage IB2 Stage IIA Stage IIB Stage IIIA/B Stage IVA Chemoradiation 2 Surveillance: See Page 4 Stage IVB Chemotherapy OR Palliative Treatment OR Supportive Care 1 Relative indications in favor of Primary Radiation Therapy are : + Nodes, extensive LVSI, deep stromal invasion. 2 Consider extraperitoneal surgical staging 3 High risk factors are positive nodes, positive margins, or parametrial involvement. 4 Intermediate risk factors (see Sedlis A. et al.) 5 Concurrent weekly Cisplatin
RECURRANCE TREATMENT No Prior Radiotherapy ChemoRadiation 1 Pelvic Recurrence Recurrence in Central Pelvis Pelvic Exenteration, OR Chemotherapy Prior Radiotherapy Isolated Extrapelvic Recurrence Surgical Resection, OR Radiotherapy, OR Chemotherapy OR Combined Modality Individualized follow-up based on clinical indications and treatment plan Multiple sites of metastatic disease Chemotherapy OR Supportive Care OR Palliative Treatment 1 Weekly Cisplatin
Surveillance: Interval H&P Cervical /vaginal cytology every 3-6 months for 2 years then, then very 6 months until 5 years then annually Chest X-ray annually (optional) CBC, BUN, Creatinine every 6 months (optional) Imaging as clinically indicated Recommended use of vaginal dilator after radiation treatment
SUGGESTED READINGS 1. National Comprehensive Cancer Network. (2010). Cervical Cancer Guidelines. Retrieved January 30, 2010,from http://www.nccn.org/professionals/physician_gls/ PDF/cervical.pdf 2. Hoskins, WJ, Perez, CA, Young, RC, Barakat, RR, Markman, M, Randall, ME. Principles and Practice of Gynecologic Oncology. 4th ed. Philadelphia, PA: Lippincott Willimas & Wilkins; 2004. 3. Sedlis A, et al. A Randomized Trial of Pelvic Radiation Therapy versus No Further Therapy in Selected Patients with Stage IB Carcinoma of the Cervix after Radical Hysterectomy and Pelvic Lymphadenectomy: A Gynecologic Oncology Group Study. Gynecologic Oncology. 1999;73(2):177-183.
DEVELOPMENT CREDITS This practice guideline is based on majority expert opinion of the Gynecologic Oncology Faculty at the University of Texas, M.D. Anderson Cancer Center. It was developed using a multidisciplinary approach that included input from the following medical oncologists, radiation oncologists, surgical oncologists, and interventional radiologists: Patricia Eifel, MD Ŧ Charles F. Levenback, MD Michael W. Bevers, MD Anuja Jhingran, MD Diane C. Bodrurka, MD Karen H. Lu, MD Thomas W. Burke, MD Pedro T. Ramirez, MD Robert L. Coleman, MD Lois M. Ramondetta, MD Ŧ Kathleen M. Schmeler, MD Anil K. Sood, MD, Ŧ Pamela T. Soliman, MD Judith K. Wolf, MD David M. Gershenson, MD Ann Klopp, MD Ŧ Michael Frumovitz, MD