2. OVARIAN CANCER
ďŹ Leading cause of death from gynecologic cancer
ďŹ 75% present in advanced stage
ďŹ Improvement in 5yr survival â
ďŹ 36% in 1977
ďŹ 39% in 1986
ďŹ 45% in 2002
ďŹ More effective chemotherapy options
ďŹ Surgical techniques
3. OVARIAN CANCER â CLINICAL
FINDINGS
ďŹ Usual features :
ďŹ Abdomino âpelvic mass, ascites, left supraclavicular
lymph node
ďŹ Unusual presentations:
ďŹ Right supraclavicular or axillary lymph nodes with
abdominal mass
ďŹ Isolated pleural effusion
ďŹ Isolated ascites without any ovarian mass
4. OVARIAN CANCER - EVALUATION
ďŹ Detailed history and clinical exam
ďŹ Pelvic exam including per rectal exam to assess POD
- EUA
ďŹ Endometrial biopsy in selected cases
ďŹ Complete blood counts
ďŹ Renal function tests
ďŹ Liver function tests
ďŹ Tumor markers
ďŹ Chest x ray & other imaging studies
ďŹ Genetic counseling
5. OVARIAN CANCER - EVALUATION
Tumor markers:
ďŹ CA 125 âmost commonly elevated in 80% of serous tumors
ďŹ not elevated in 50% of early stage tumors, mucinous and clear
cell carcinomas
ďŹ Not a reliable diagnostic test
ďŹ Post operatively ca125 levels âsensitive âto monitor response
to chemo
ďŹ Normalization after 3 cycles âfavorable outcome
ďŹ Nadir <10u/ml â favorable
ďŹ Useful in follow up for detecting recurrence
ďŹ CEA , CA 19-9 - mucinous tumors & in krukenbergs tumor
6. OVARIAN CANCER â TUMOR
MARKERS
ďŹ Sr.VEGF levels
ďŹ HE4 (human epididymis 4)-WFDC gene product
ďŹ MCS-F in serum & ascitic fluid
ďŹ Proteomic spectral analysis of serum
ďŹ SELDI-TOF âMS : Surface enhanced laser desorption
and ionization time of flight MS
7. OVARIAN CANCER - IMAGING
ďŹ USG abdomen with colour doppler study â
transvaginal sonography
ďŹ Complex mass with increased vascularity
ďŹ Ascites
ďŹ Enlarged para aortic nodal masses
ďŹ Omental and peritoneal deposits larger than 1cm
ďŹ Matted bowel loops
9. OVARIAN CANCER - IMAGING
CT SCAN abdomen & pelvis:
ďŹ Extent of disease in upper abdomen
ďŹ Helps to decide on primary surgery or neoadjuvant chemotherapy
ďŹ Attachment of omentum to splenic hilum
ďŹ Disease/tumor nodules >2cm in mesentery, liver surface or parenchyma,
diaphragm, gall bladder fossa, suprarenal para aortic nodes
ďŹ Pulmonary or pleural nodules
18. OVARIAN CANCER - IMAGING
ďŹ MRI abdomen â not superior to CTscan except in pregnant
women where USG is inconclusive
ďŹ PET-CT scan : not for diagnosis
ďŹ Useful in rec.disease with isolated CA125 elevation
19. OVARIAN CANCER - INVESTIGATIONS
ďŹ UPPER GI SCOPY& COLONOSCOPY â NOT
INDICATED ROUTINELY
ďŹ Symptoms s/o gastric disease or lower GI symptoms or fecal
occult blood positive
ďŹ 4% have associated GI malignancy
ďŹ Mammography
ďŹ Genetic counseling in pts with positive family history
21. OVARIAN CANCER STAGING
Stage I - Limited to ovaries
A. Unilateral ovary
B. Bilateral ovaries
C. Positive cytology
Stage II - Limited to pelvis
A. Extends to uterus or tubes
B. other pelvic organs
C. Positive cytology
Stage III â Spread to upper abdomen or regional lymph nodes
A. Microscopic spread
B. Macroscopic < 2 cm
C. Macroscopic > 2 cm
Stage IV - Spread outside peritoneum, pleura or parenchymalliver metastases
22. OVARIAN CANCER
FIGO STAGING SYSTEM
Stage Description Incidence Survival
I Confined to ovaries 20% 73%
II Confined to pelvis 5% 45%
III Confined to abdomen/ 58% 21%
lymph nodes
IV Distant metastases 17% <5%
Jelic S, et al. Program and abstracts of the 27th Congress of the European
Society for Medical Oncology; 2002; Nice, France.
Mocharnuk R. Medscape Web site.
http://www.medscape.com/viewarticle/444134. Accessed May 2, 2007.
FIGO = International
Federation of Gynecology
and Obstetrics
23. HOW TO PROCEED AFTER
INVESTIGATIONS ?
ďŹ Decision to proceed directly to surgery is a clinical one â in
advanced stage :
ďŹ based on extent of disease
ďŹ Performance status
ďŹ Nutritional status
ďŹ Comorbid illness
24. HOW TO PROCEED AFTER
INVESTIGATIONS?
ďŹ Operable tumors â laparotomy and proceed
ďŹ Avoid percutaneous FNA of localised masses
or complex cysts â upstage disease
25. WHO NEEDS NEOADJUVANT
CHEMOTHERAPY?
ďŹ Presence of gross ascites,
ďŹ huge fixed pelvi-abdominal mass,
ďŹ nodules in POD
ďŹ PS III-IV
ďŹ Supraclavicular nodes
ďŹ Pleural effusion â bilateral
27. CT SCAN FINDINGS
ďŹ Diffuse peritoneal thickening(DPT) >4mm â involving
atleast 2 of the 5 areas
ďŹ lateral colic gutters
ďŹ Lateral conal fascia
ďŹ Anterial abdominal wall
ďŹ Diaphragm and splenic peritoneal reflection
Sean C.Dowdy et al, CANCER - 2004
28. FOR NEOADJUVANT CHEMOTHERAPY
ďŹ Cytologic evidence of malignancy â ascitic fluid
ďŹ FNA of the mass ( transvaginal âpreferably)
ďŹ Laparoscopy before NACT:
- to assess disease extent and for biopsy in cases
where repeated cytology is negative for malignancy
29. OVARIAN CANCER SURGICAL
DEBULKING AND STAGING
Exploration
Washings/
Ascites
(Staging)
TAH/
BSO
Biopsies
(Staging)
Goals (Debulking)
â˘Assessment of extent of disease
â˘Optimal tumor reduction
TAH = total abdominal hysterectomy
BSO = bilateral salphingo-oophorectomy
30. Cytoreductive Surgery
ď§ Goal is elimination of all tumor
⢠No gross residual (microscopic)
⢠Optimal (<1 cm)
⢠Suboptimal (>1 cm)
ď§ Operative Technique
⢠Resection of urinary or intestinal tract
ď§ Surgical Outcomes
⢠Optimal in ~75% of cases
⢠Does it matter?
32. PROGNOSTIC FACTORS
ďŹ Volume of residual disease after surgery
ďŹ Stage
ďŹ Histologic subtype
ďŹ Histologic grade
ďŹ Performance status
ďŹ Age
ďŹ Ovarian cancer prognostic profile(OCPP)
ďŹ Chemotherapy response profile (CRP)
ďŹ Gene expression profiling
33. PRIMARY TREATMENT OF OVARIAN
CANCER
1995 1997 1999
Cyclophosphamide +
Cisplatin
STANDARD OF CARE
GOG 111 establishes Taxol-CDDP
as standard 1st line
2001
GOG 158 shows Taxol-carboplatin = Taxol-
CDDP, with improved toxicity and QoL
GOG 178 demonstrates improved DFS with
longer duration of maintenance Taxol â No
data on overall survival
GOG 172 confirms IP
therapy leads to a survival
advantage compared with IV
NEW STANDARD OF CARE?
SWOG 8501 demonstrates improved
survival with IP therapy
2003 2005 2008
GOG 182 demonstrates
no survival advantage
to triplet or sequential
doublet therapy
34. FIRST-LINE THERAPY â
Standard Treatment Options
Platinum + Taxane Chemotherapy
(Carboplatin + Paclitaxel)
Surgery with maximum
cytoreduction effort <1cm
residual disease
35. CHEMOTHERAPY
⢠Standard front-line chemotherapy today is
carboplatin, AUC 6 to 7.5, paclitaxel 175
mg/m2 every 21 days for
6 cycles
⢠Result of several studies over last decade
â GOG 1111 and OV 102 - paclitaxel/cisplatin
vs cyclophosphamide/cisplatin
â GOG 1583 and AGO OVAR-34 - carboplatin
instead of cisplatin
1. McGuire WP, et al. N Engl J Med. 1996;334(1):1-6.
2. Piccart MJ, et al. J Natl Cancer Inst. 2000;92(9):699-708.
3. Ozols RF, et al. J Clin Oncol. 2003;21(17):3194-3200.
4. du Bois AD, et al. J Natl Cancer Inst. 2003;95(17):1320-1329.
GOG = Gynecologic Oncology Group
AGO = Arbeitsgemeinschaft
Gynaekologische Onkologie
36. The Role of Paclitaxel in First-line
Therapy for Ovarian Carcinoma
Study # Pts Regimen
Median PFS
(mo)
Median OS
(mo)
GOG
1321
377
III suboptimal-IV
Cisplatin/
Paclitaxel (24 h) x 6
14.1 26.3
Cisplatin 100 mg/m2 x 6 16.4 30.2
Paclitaxel 200 mg/m2 (24 h)* 10.8 25.9
ICON
32
2074
I-IV
Carboplatin/
Paclitaxel (3 h)
17.3 36.1
Carboplatin or CAP 16.1 35.4
CAP = cyclophosphamide, doxorubicin, cisplatin
GOG = Gynecologic Oncology Group
ICON = International Collaborative Ovarian Neoplasm Group
OS = overall survival
PFS = progression-free survival
1. Muggia FM, et al. J Clin Oncol. 2000;18(1):106-115.
2. International Collaborative Ovarian Neoplasm Group. Lancet. 2002;360(9332):505-515.
*CR/PR rates on paclitaxel
monotherapy (42%) vs cisplatin
regimens (67%), P <.001
38. EPITHELIAL OVARIAN CANCER
PLAN OF MANAGEMENT
Resectable
Primary cytoreductive surgery (Max)
Chemo 6 cycles
Unresectable
Chemo 3 cycles
Interval cytoreductive Surgery (Max)
Chemo 3 cycles
Stage III/IV
39. CHEMOTHERAPY â EARLY STAGE
DISEASE
ďŹ High risk early stage:
ďŹ stage I, gr III, Ic,any stage II
ďŹ Stage Ia,Ib âgr I & II can be observed
ďŹ ICON I(International Collborative Ovarian Neoplasm Trial I) &
ďŹ ACTION (Adjuvant Chemotherapy in Ovarian Neoplasm Trial) âchemo
improves progression free & OS in high risk early stage disease(925 pts â os
â superior for platinum based chemo
ďŹ GOG study -3 vs 6 cycles â 33% reduction in risk of rec in high risk disease
who received 6cycles of chemo
ďŹ Patients with suboptimal surgery benefit from platinum based chemo
40. Chemotherapy in advanced stage
ďŹ GOG 111: paclitaxel+cisplatin superior to cisplatin +
cyclophosphamide
ďŹ RR 73% vs 60%
ďŹ Median PFS 18 vs 13mo
ďŹ Median os 38mo vs 24mo p<001
ďŹ 60mo of follow up â 20% reduct. In risk of progression & 34%
reduction in risk of death
ďŹ OV10,ICON 3
ďŹ GOG 132 âsequential administration of pacli or cisplatin is
therapeutically equivalent
41. Chemotherapy in advanced stage
ďŹ GOG 158,AGO,NETHERLANDS-DENMARK:
ďŹ Carboplatin+paclitaxel vs cisplatin +paclitaxel is equivalent â PFS &OS
ďŹ Carbo+paclitaxel â preferred â favorable toxicity profile
ďŹ Reduced emesis,neutropenia,nephrotoxicity
ďŹ Short infusion time
ďŹ Marginal PS,Comorbid medical condition â start with single agent carboplatin â add
paclitaxel later
ďŹ No benefit for 12 vs 6 cycles
ďŹ No benefit for addition of 3rd cytotoxic agent â PLD,EPI,TOPO,GEM
ďŹ Addition of bevacizumab
42. Interventions to ďŻ Mortality?
Time
DiseaseVolume
Prevention
Screening
Current point of diagnosis
and initiation of treatment
44. NIH Consensus Development Panel
ââŚthere is no evidence available yet
that the current screening modalities
of CA 125 and ultrasonography can
be effectively used for widespread
screening to reduce mortality from
ovarian cancerâŚâ
Screening â US and CA 125
45. Goals of Treatment:
Relapsed Ovarian Cancer
⢠Prolong Survival
⢠Delay Time to Progression
⢠Control Disease-Related Symptoms
⢠Minimize Treatment-Related Symptoms
⢠Maintain or Improve Quality of Life
46. Surveillance Options for Ovarian
Cancer Patients in Remission
⢠Second-look laparotomy
⢠Physical examination
â Include pelvic examination
⢠CA-125
⢠Imaging
â CT scan
â MRI?
â PET scan? CT = computed tomography
MRI = magnetic resonance imaging
PET = positron emission tomography
47. Ovarian Cancer:
How is Relapse Defined?
⢠Continuous rise in CA-125
⢠CA-125 above 100
⢠Radiographic recurrence
⢠Symptomatic recurrence
⢠Physical examination findings
⢠Combination of above
48. Effect of Platinum-Free Interval
on Response Rate
% Response to Second-line
Platinum Therapy
Platinum-Free
Interval (mos)
Markman Gore Blackledge
0-6
17%
10%
7-12 27% 29%
13-18
33% 27%
63%
19-24 94%
>24 59% 57%
Non-Platinum
Therapy
15%
20%
30%
30%
Markman M, et al. J Clin Oncol. 1991;9(3):389-393.
Gore ME, et al. Gynecol Oncol. 1990;36:207-211.
Blackledge G, et al. Br J Cancer. 1989;59:650-653.
54. The tumor extends to the pelvic wall and/or involves lower third of the vagina and or causes hydronephrosis or non-functioning kidney**
Stage IIIA: Tumor involves lower third of the vagina, with no extension to the pelvic wall
Stage IIIB: Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney
The carcinoma is strictly confined to the cervix
(extension to the corpus would be disregarded)
Stage IA: Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion â¤5 mm and largest extension â¤7 mm
Stage IA1: Measured stromal invasion of â¤3.0 mm in depth and extension of â¤7.0 mm.
Stage IA2: Measured stromal invasion of >3.0 mm and â¤5.0 mm with an extension of not >7.0 mm
Stage IB: Clinically visible lesions limited to the cervix uteri or pre-clinical cancers greater than stage IA*
Stage IB1: Clinically visible lesion â¤4.0 cm in greatest dimension
Stage IB2: Clinically visible lesion >4.0 cm in greatest dimension
The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the mucosa of the bladder or rectum.
A bullous edema, as such, does not permit a case to be allotted to Stage IV
Stage IVA: Spread of the growth to adjacent organs.
Stage IVB: Spread to distant organs.
Stage II
Stage I
FIGO staging system, 2009
Cevical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower third of the vagina
Stage IIA: Without parametrial invasion
Stage IIA1: Clinically visible lesion â¤4.0 cm in greatest dimension
Stage IIA2: Clinically visible lesion >4 cm in greatest dimension
Stage IIB: With obvious parametrial invasion
Stage III
Stage IV
*All macroscopically visible lesionsâeven with superficial invasionâare allotted to stage IB carcinomas. Invasion is limited to a measured stromal invasion with a maximal depth of 5.00 mm and a horizontal
extension of not >7.00 mm. Depth of invasion should not be >5.00 mm taken from the base of the epithelium of the original tissueâsuperficial or glandular. The depth of invasion should always be reported
in mm, even in those cases with âearly (minimal) stromal invasionâ (~1 mm). The involvement of vascular/lymphatic spaces should not change the stage allotment.
** On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. All cases with hydronephrosis or non-functioning kidney are included, unless they are known to be due to
another cause.
55. Diagnosis is based on conization!
Recommended work-up
⢠Vaginal and rectal examination, exfoliative cytology (Papanicolaou smear), colposcopy, biopsy and/or endocervical curettage (ECC), conization or Loop electrosurgical procedure (LEEP)
⢠Histopathological finding with all standard tumor parameters
⢠Laboratory analyses: WBC, biochemical analyses
⢠Imaging: Chest X-ray, pelvic and abdominal ulstrasound
ConizationNecessary HP parameters:2
⢠Depth of invasion
⢠Width of the tumor
⢠Tumor differentiaion
⢠Lympho-vascular space invasion (LVSI)
⢠Resection margins
Margins and/or
ECC positive for dysplasia
Margins clear
ECC negative
Stage Ia1
LVSI negative
â˘Stage Ia1 with extensive LVSI
Stage Ia2
⢠Repeated conisation
⢠Modified radical hysterectomy (type B6) if re-conisation is not possible
Âą pelvic lymphadenectomy
Conization if preservation of fertility is desired
or
Simple (extrafascial, type A6) hysterectomy with or
without salpingoophorectomy
Conization or radical trachelectomy if preservation of fertility is desired
or
Modified radical hysterectomy (type B6)
and
Pelvic lymphadenectomy
Recommended follow-up
Every 3 months after completed therapy during the first year; every 6 months up to 5 years. Annually afterwards. Investigations in addition to gynaecological examination, including cytology
and colposcopy, should be performed depending on symptoms, local findings and general condition of the patient
Cervical cancer
FIGO Stage I a
Microinvasive carcinoma (invasion ⤠5 mm)
56. Recommended work-up
Neccessary investigations:
⢠Vaginal and rectal examination, colposcopy, biopsy and/or endocervical curettage (ECC); conization or loop electrosurgical procedure (LEEP) if needed for definitive diagnosis
⢠Histopathological finding with all standard tumor parameters
⢠Laboratory analyses: WBC, biochemical analyses including check for renal function and Hb
⢠Imaging: Chest X-ray, abdominal and pelvic ultrasound (size and position of the tumor and tumor volume/cervix ratio)
Optional investigations:
Pelvic NMR, CT of the abdomen (PET/CT if possible), cystoscopy, rectoscopy, IVU or sonographic renal examination. Involvement of the bladder or rectum should be confimed histologically
Radical surgery
⢠Uterus with paracervical tissues and upper part of vagina (radical, type C6 hysterectomy) + pelvic lymphadenectomy
or
⢠Entire cervix with paracervical tissues (radical trachelectomy) if fertility is desired + pelvic lymphadenectomy
or
⢠Upper part of vaginal cuf, paracervical tissues + pelvic lymphnodes in case of previous simple hysterectomy
* At least 2 cm distance from the resection margins is desirable
** In premenopausal women ovaries can be retained; if so tranposition is advised.
*** For the desision of further management, all neccesary histopathologic parameters4 should be requested
Chemo-radiation
Neoadjuvant chemotherapy followed by radiation or surgery is an option for locally advanced
tumors (Ib2 and IIa2) but awaits confirmatory evidence from controlled clinical trials.
Recommended follow-up
Every 3 months after completed therapy during the first year; every 6 months up to 5 years. Annually afterwards. Investigations in addition to gynaecological examination should be performed
depending on symptoms, local findings and general condition of the patient
⢠Positive resection margins
⢠Involvement of parametria
⢠Residual tumor
⢠Multiple positive nodes (>3)
⢠Positive nodes (1-3)
⢠Poorly differentiated or undifferentiated tumor (G3)
⢠LVSI present
⢠Primary tumor
(tumor-cervix volume) >3 cm
⢠Endocervical invasion
(barrel shaped cervix)
⢠Inadequate surgery
⢠Insufficient HP (if report of all necessary parts is missing)
⢠Medical contra-indications for surgery
⢠Ib2/IIa2 tumors in selected cases
⢠Anterior vaginal extension
⢠Invasive cancer after simple hysterectomy
⢠Choice of the patient
Concomitant
Chemo-radiation
Radiation
Âą Chemotherapy
Radiation
Âą Chemotherapy
Follow up
Negative nodes
GOG score*
*consider using GOG score as a guide for adjuvant treatment5
Low risk
(GOG score < 120)
Low risk
(GOG score < 120)
or
Cervical cancer
FIGO Stage Ib - IIa
Squamocellular, Adenocarcinoma, Adenosquamous
57. Recommended work-up
⢠Vaginal and rectal examination, biopsy or endocervical curettage (ECC)
⢠Histopathological finding with all standard tumor parameters
⢠Laboratory analyses: WBC, biochemical analyses including check for renal function and Hb
⢠Imaging: Chest X-ray, abdominal and pelvic ultrasound
⢠Pelvic NMR, CT of the abdomen (PET/CT if possible), cystoscopy, rectoscopy, IVU or sonographic renal examination. Involvement of the bladder or rectum should
be confimed histologically
Recommended follow-up
Every 3 months after completed therapy; every 6 months up to 5 years. Annually afterwards. Investigations in addition to gynaecological examination should be performed depending on
symptoms, local findings and general condition of the patient
Pelvic MRI and
Abdominal CT
Paraaortic nodes (PALN) negative
(=not enlarged)
Pelvic or paraaortic nodes (PALN)
positive (enlarged âĽ2 cm))
Pelvic (Âą paraaortic) radiation
+ brachytherapy
+ concomitant chemotherapy
CT of the lungs & mediastinum
CT negative CT positive
Pelvic radiation (with paraaortic if PALN are positive) + brachytherapy + concomitant chemotherapy
* Consider:
⢠resection of adnexal mass and/or extraperitoneal resection of enlarged nodes
⢠Sequential chemoth and Concomitant ChemoRadioTherapy /External Beam RadioTherapy (CCRT/EBRT)
Palliative pelvic RT
Âą Palliative chemotherapy
*Stage IVa
⢠with vesicovaginal fistula: if pelvic, abdominal and chest imaging exclude distant metastases primary pelvic exenteration can be considered
⢠NACT may be offered to large bulky tumors to downsize tumor prior to CCRT
Cervical cancer
FIGO stage IIb- IV
58. Recommended work-up
â˘â˘ Vaginal and rectal examination, biopsy - histopathological confirmation of recurrence
⢠Laboratory analyses: WBC, biochemical analyses including check for renal function and Hb
⢠Imaging: Chest X-ray, pelvic and abdominal ultrasound, pelvic NMR and CT of the lungs and abdomen; (PET/CT if possible)
⢠Cystoscopy, rectoscopy, IVU or sonographic renal examination
Recommended follow-up
Every 3 months for two years or more often if clinically indicated. Every 4-6 months thereafter. Annually afterwards. Investigations in addition to gynaecological examination should be
performed depending on symptoms, local findings and general condition of the patient
Lungs & abdominal CT
Pelvic recurrence Extrapelvic recurrence
Options include:
⢠Palliative radiotherapy or chemo-radiation
⢠Systemic therapy
⢠Supportive care
* Resection in selected cases
(in particular paraaortic nodes)
may be considered
Previous radiationNo previous radiation
Options include:
⢠Chemo-radiation
⢠Neoadjuvant chemotherapy (NACT)
⢠Supportive care
Central pelvic
recurrence
Sidewall pelvic
recurrence
Options include
⢠Radical hysterectomy in tumor <2 cm
⢠Pelvic exenteration
⢠Neoadjuvant chemotherapy (NACT) + surgery
Other options if surgery is not possible:
⢠Re-irradiation
⢠Neoadjuvant chemotherapy (NACT) + radiation
⢠Systemic therapy
⢠Supportive care
Options include:
⢠Resection of isolated disease
⢠Systemic therapy
⢠Supportive care
Cervical cancer
- recurrence -
59. Recommended work-up
Neccessary investigations:
⢠Vaginal and rectal examination, colposcopy, biopsy and/or endocervical curettage (ECC); conization or loop electrosurgical procedure (LEEP) if needed for definitive diagnosis
⢠Histopathological finding with all standard tumor parameters
⢠Laboratory analyses: WBC, biochemical analyses including including check for renal function and Hb
⢠Imaging: Chest X-ray, abdominal and pelvic ultrasound (size and position of the tumor and tumor volume/cervix ratio)
Optional investigations:
⢠Pelvic NMR, CT of the abdomen (PET/CT if possible), cystoscopy, rectoscopy, IVU or sonographic renal examination. Involvement of the bladder or rectum should be confirmed histologically
*Stage of the disease is determined using FIGO classification1
Recommended follow-up
Every 3 months after completed therapy during the first year; every 6 months up to 5 years. Annually afterwards. Investigations in addition to gynaecological examination
should be performed depending on symptoms, local findings and general condition of the patient
FIGO Ia FIGO Ib-IIa FIGO IIb-IV
⢠Diagnosis is based on conization;
resection margins should be clear
⢠Further decision depends on the
presence of poor histologic prognostic
factors2
Surgery Chemo-radiation Concomitant chemoradiation
or
Radical radiation only if unfit for
chemotherapy
* Stage IV1 with vesicovaginal fistula: if
pelvic, abdominal and chest CT exclude
distant metastases, primary pelvic
exenteration can be considered
⢠Medical contra-indications for surgery
⢠Ib2/IIa tumors
⢠Anterior vaginal extension
⢠Invasive cancer after simple hysterectomy
⢠Choice of the patient
⢠Radical hysterectomy (type C6)
or
⢠Radical trachelectomy
or
⢠Resection of the upper part of vagina and parametrectomy in case of previous
simple hysterectomy
and
⢠Pelvic lymphadenectomy
* Decision about further therapy is based on the presence of adverse histological
factors
Neoadjuvant chemotherapy followed by
radiation or surgery is an option for locally
advanced tumors, but awaits confirmatory
evidence from controlled clinical trials.
FIGO Ia1
LVSI negative
⢠Conization/radical
trachelectomy
or
⢠Modified radical
hysterectomy(type B6)
and
⢠Pelvic Lymphadenectomy
⢠Conization
or
⢠Simple hysterectomy
(type A6)
Follow-up No adverse prognostic factors Adverse prognostic factors4 present
Follow-up Adjuvant therapy
(Radiation Âą Chemotherapy)
FIGO Ia1, LVSI
positive
or
Cervical cancer
Squamocellular, Adenocarcinoma,
Adenosquamous