2010NCCN宫颈癌治疗指南

Continue NCCN Clinical Practice Guidelines in Oncology™ Cervical Cancer V.1.2010 www.nccn.org Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. NCCN Cervical Cancer Panel Members � � Gynecology oncology Medical oncology Hematology Radiotherapy/Radiation oncology Pathology Writing committee member † ‡ § * Continue * * Benjamin E. Greer, MD/Co-Chair Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance Wui-Jin Koh, MD/Co-Chair Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance � � � � � § † † Nadeem R. Abu-Rustum, MD Memorial Sloan-Kettering Cancer Center Sachin M. Apte, MD, MS H. Lee Moffitt Cancer Center & Research Institute Michael A. Bookman, MD Fox Chase Cancer Center Robert E. Bristow, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Susana M. Campos, MD, MPh, MS Dana-Farber/Brigham and Women’s Cancer Center John Chan, MD UCSF Helen Diller Family Comprehensive Cancer Center Kathleen R. Cho, MD University of Michigan Comprehensive Cancer Center Larry Copeland, MD The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute Marta Ann Crispens, MD Vanderbilt-Ingram Cancer Center Nefertiti duPont, MD, MPH Roswell Park Cancer Institute Patricia J. Eifel, MD The University of Texas M. D. Anderson Cancer Center Warner K. Huh, MD � � � � � § § � University of Alabama at Birmingham Comprehensive Cancer Center Daniel S. Kapp, MD, PhD Stanford Comprehensive Cancer Center John R. Lurain, III, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Mark A. Morgan, MD Fox Chase Cancer Center Robert J. Morgan, Jr., MD City of Hope Comprehensive Cancer Center Nelson Teng, MD, PhD Stanford Comprehensive Cancer Center � � † ‡ § Steven W. Remmenga, MD UNMC Eppley Cancer Center at The Nebraska Medical Center R. Kevin Reynolds, MD University of Michigan Comprehensive Cancer Center Angeles Alvarez Secord, MD William Small, Jr., MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University � � � Duke Comprehensive Cancer Center NCCN Guidelines Panel Disclosures Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. These guidelines are a statement of evidence consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2009. Table of Contents NCCN Cervical Cancer Panel Members Clinical Stage (CERV-1) Stage IA1 (CERV-2) Stage IA2, IB1, and Stage IIA ( 4 cm) (CERV-2) Stage IB2 and Stage IIA (> 4 cm) (CERV-2) Selected bulky Stage IB2, IIA and Stages IIB, IIIA, IIIB, IVA (CERV-4) Incidental findings of invasive cancer at simple hysterectomy (CERV-7) Surveillance (CERV-8) Local/regional recurrence (CERV-9) Distant metastases (CERV-10) Chemotherapy Regimens for Cervical Cancer (CERV-A) Guidelines Index Print the Cervical Cancer Guideline Summary of Guidelines Updates � Clinical Trials: Categories of Evidence and Consensus: NCCN All recommendations are Category 2A unless otherwise specified. See The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. NCCN To find clinical trials online at NCCN member institutions, click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus For help using these documents, please click here Staging Discussion References The NCCN Cervical Cancer Guidelines include the management of squamous cell carcinoma, adenosquamous carcinoma, and adenocarcinoma of the cervix. Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Summary of the Guidelines updates ( ) ( ) Table of contents CERV-2 ( )CERV-A : The following statement was added, “The NCCN Cervical Cancer Guidelines include the management of squamous cell carcinoma, adenosquamous carcinoma, and adenocarcinoma of the cervix.” Footnote “c” that states, “ First-line combination therapy: “Cisplatin/paclitaxel” changed from category 2A to category 1. Possible first-line single agent therapy: After “Cisplatin”, the panel added “preferred as a single agent”. � � � � � Concurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil” was added for clarification. Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer Gemcitabine and Topotecan were removed from “Possible first-line single agent therapy” and placed under “Second-line therapy”. UPDATES Summary of changes in the 1.2010 version of the Cervical Cancer guidelines from the 1.2009 version include: Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. CERV-1 WORKUP Stage IA1 Stage IA2 Stage IB1 Stage IIA ( 4 cm)� Stage IB2 Stage IIA (> 4 cm) Incidental finding of invasive cancer at simple hysterectomy � � � � � � � � H&P CBC, platelets Cervical biopsy, pathologic review Cone biopsy as indicated LFT/renal function studies Imaging (optional for stage IB1) including chest x-ray, PET/CT scan, CT/MRI EUA cystoscopy/proctoscopy � Optional ( Stage IB2): a CLINICAL STAGE Selected bulky: Stage IB2, IIA Stage IIB Stage IIIA, IIIB Stage IVA See Primary Treatment (CERV- 2) See Primary Treatment (CERV-2) See Primary Treatment (CERV-2 ) See Primary Treatment (CERV-4) See Primary Treatment (CERV-7) aFor suspicion of bladder/bowel involvement, cystoscopy/proctoscopy with biopsy is required. Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. CERV-2 Stage IB1 and stage IIA ( 4 cm)� Stage IB2 and stage IIA (> 4 cm) ( )also see CERV-4 PRIMARY TREATMENT These doses are recommended for most patients based on summation of conventional external-beam fractionation and low-dose rate (40-70 cGy/h) brachytherapy equivalents. Modify treatment based on normal tissue tolerance. Concurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil. b c CLINICAL STAGE Stage IA2 Radical hysterectomy + pelvic lymph node dissection ± para-aortic lymph node sampling or Brachytherapy + pelvic RT (point A dose: 75-80 Gy) or Radical trachelectomy + pelvic lymph node dissection b for fertility preservation ± para-aortic lymph node sampling Radical hysterectomy + pelvic lymph node dissection (category 1) or Pelvic RT + brachytherapy (point A dose: 80-85 Gy) ± para-aortic lymph node sampling Radical trachelectomy for fertility preservation for lesions (Stage IB1) + pelvic lymph node dissection ± para-aortic lymph node sampling b or Radical hysterectomy + pelvic lymph node dissection + para-aortic lymph node sampling or Pelvic RT + concurrent cisplatin-containing chemotherapy + brachytherapy (point A dose 85 Gy) (category 1) or Pelvic RT + concurrent cisplatin-containing chemotherapy + brachytherapy (point A dose 75-80 Gy) + adjuvant hysterectomy (category 3) (category 2B) c � b b c See Surgical Findings (CERV-3) See Surgical Findings (CERV-3) See Surveillance (CERV-8) See Surveillance (CERV-8) See Surgical Findings (CERV-3) See Surveillance (CERV-8) Stage IA1 Extrafascial hysterectomy or Observe if patient desires fertility or if inoperable (only if cone biopsy has negative margins) or Modified radical hysterectomy + pelvic lymph node dissection if lymphovascular invasion (category 2B) See Surveillance (CERV-8) See Surgical Findings (CERV-3) Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. CERV-3 ADJUVANT TREATMENTSURGICAL FINDINGS Negative nodes Observe or Pelvic RT if combination of high-risk factors (category 1) (ie, large primary tumor, deep stromal invasion, and/or lymphovascular space invasion) ± concurrent cisplatin-based chemotherapy (category 2B for chemotherapy) c Positive pelvic nodes or Positive surgical margin or Positive parametrium Pelvic RT + concurrent cisplatin-containing chemotherapy (category 1) ± vaginal brachytherapy c See Surveillance (CERV-8) Para-aortic lymph node positive by surgical staging Negative for distant metastasis Chest CT/PET scan Consider biopsy of suspicious areas as indicated Positive for distant metastasis Para-aortic lymph node RT + concurrent cisplatin- containing chemotherapy + pelvic RT ± brachytherapy c cConcurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil. dSee Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer (CERV-A). Negative Positive Systemic therapy / Individualized RT d See Surveillance (CERV-8) Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. CERV-4 PRIMARY TREATMENT Selected bulky Stage IB2, Stage IIA (> 4 cm) Stage IIB, IIIA, IIIB, IVA Surgical staging: Extraperitoneal or laparoscopic lymph node dissection (category 2B) or Radiologic imaging only Negative Pelvic + concurrent cisplatin-containing chemotherapy (category 1) + brachytherapy RT c e Positive See Node Status (CERV-5) Pelvic RT + concurrent cisplatin-containing chemotherapy (category 1) + brachytherapy c e Negative adenopathy Positive adenopathy See Imaging Results (CERV-6) CLINICAL STAGE cConcurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil. ePelvic RT + brachytherapy total point A dose 85 Gy.� See Surveillance (CERV-8) FNA if clinically indicated Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. CERV-5 Pelvic lymph node positive/para-aortic lymph node negative by surgical staging Para-aortic lymph node positive by surgical staging Negative for distant metastasis Further radiologic workup as clinically indicated Pelvic RT + concurrent cisplatin-containing chemotherapy (category 1) + brachytherapy c e Consider biopsy of suspicious areas as indicated Positive for distant metastasis Pelvic RT + para-aortic lymph node RT + concurrent cisplatin-containing chemotherapy + brachytherapy f c e SELECTED BULKY Stage IB2, IIA (> 4 cm); Stage IIB, IIIA, IIIB, IVA NODE STATUS PRIMARY TREATMENT Negative Positive Systemic therapy / Individualized RT d c d Concurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil. clinical tumor volume e f Pelvic RT + brachytherapy total point A dose 85 Gy. RT dose is 45-50 Gy to (CTV). � See Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer (CERV-A). See Surveillance (CERV-8) Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. CERV-6 Pelvic node positive; Para-aortic lymph node negative Pelvic node positive; Para- aortic lymph node positive Pelvic RT + brachytherapy + concurrent cisplatin- containing chemotherapy ± para-aortic lymph node RT or Retroperitoneal lymph node dissection e c (category 1) f SELECTED BULKY Stage IB2, IIA Stage IIB, IIIA, IIIB, IVA IMAGING RESULTS (> 4 cm) PRIMARY TREATMENT Distant metastases; with biopsy confirmation as clinically indicated Consider retroperitoneal lymph node dissection Systemic therapy / Individualized RT d See Surveillance (CERV-8) c d Concurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil. RT dose is 45-50 Gy to clinical tumor volume (CTV). ePelvic RT + brachytherapy total point A dose 85 Gy.� f See Chemotherapy Regimens for Recurrent or Metastatic Cervical Cancer (CERV-A). Positive adenopathy by CT, MRI and/or PET Para-aortic negative Para-aortic positive Pelvic RT + brachytherapy + concurrent cisplatin-containing chemotherapy e c (category 1) Extended-field RT + brachytherapy + concurrent cisplatin-containing chemotherapy f e c See Surveillance (CERV-8) Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. CERV-7 INCIDENTAL FINDING OF INVASIVE CANCER AT SIMPLE HYSTERECTOMY Stage IA1 with lymphovascular space invasion or Stage IA2� Negative margins; negative imaging Positive marginsg, gross residual disease, or positive imaging Pelvic RT + brachytherapy ± concurrent cisplatin- containing chemotherapy or f c Complete parametrectomy + upper vaginectomy + pelvic lymph node dissection ± para-aortic lymph node sampling Negative nodes Observe or Optional pelvic RT ± vaginal brachytherapy if large primary tumor, deep stromal invasion and/or lymphovascular space invasion f Positive nodes or Positive surgical margin or Positive parametrium Pelvic RT (para-aortic lymph node RT if para-aortic lymph node positive) + concurrent cisplatin- containing chemotherapy ± individualized brachytherapy (if positive vaginal margin) f c PRIMARY TREATMENT � � � � � � H&P CBC, platelets Optional ( Stage IB2): EUA cystoscopy/proctoscopy LFT/renal function studies Imaging (optional for stage IB1) including chest x-ray, PET/CT scan, CT/MRI � a a f g For suspicion of bladder/bowel involvement, cystoscopy/proctoscopy with biopsy is required. RT dose is 45-50 Gy to clinical tumor volume (CTV). Invasive cancer at surgical margin. cConcurrent cisplatin-based chemotherapy with RT utilizes cisplatin as a single agent or cisplatin plus fluorouracil. Stage IA1 Pathologic review No lymphovascular space invasion See Surveillance CERV-8 Imaging negative for nodal disease Imaging positive for nodal disease Consider surgical debulking of grossly enlarged nodes See Surveillance (CERV-8) Guidelines Index Cervical Cancer TOC Staging, Discussion, References Practice Guidelines in Oncology – v.1.2010NCCN ® Cervical Cancer Version 1.2010, 10/20/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. CERV-8 SURVEILLANCE � � � � � � Interval H&P Cervical/vaginal cytology every 3-6 mo for 2 y, then every 6 mo for 3-5 , then annually Chest x-ray annually (optional) CBC, BUN, creatinine every 6 mo (optional) PET/CT scan as clinically indicated Recommend