1. ROLE OF CHEMOTHERAPY IN
GYNAEC MALIGNANCIES
DR. R. RAJKUMAR M.D., D.M.

2. OVARIAN CANCER
 Leading cause of death from gynecologic cancer
 75% present in advanced stage
 Improvement in 5yr survival –
 36% in 1977
 39% in 1986
 45% in 2002
 More effective chemotherapy options
 Surgical techniques

3. OVARIAN CANCER – CLINICAL
FINDINGS
 Usual features :
 Abdomino –pelvic mass, ascites, left supraclavicular
lymph node
 Unusual presentations:
 Right supraclavicular or axillary lymph nodes with
abdominal mass
 Isolated pleural effusion
 Isolated ascites without any ovarian mass

4. OVARIAN CANCER - EVALUATION
 Detailed history and clinical exam
 Pelvic exam including per rectal exam to assess POD
- EUA
 Endometrial biopsy in selected cases
 Complete blood counts
 Renal function tests
 Liver function tests
 Tumor markers
 Chest x ray & other imaging studies
 Genetic counseling

5. OVARIAN CANCER - EVALUATION
Tumor markers:
 CA 125 –most commonly elevated in 80% of serous tumors
 not elevated in 50% of early stage tumors, mucinous and clear
cell carcinomas
 Not a reliable diagnostic test
 Post operatively ca125 levels –sensitive –to monitor response
to chemo
 Normalization after 3 cycles –favorable outcome
 Nadir <10u/ml – favorable
 Useful in follow up for detecting recurrence
 CEA , CA 19-9 - mucinous tumors & in krukenbergs tumor

6. OVARIAN CANCER – TUMOR
MARKERS
 Sr.VEGF levels
 HE4 (human epididymis 4)-WFDC gene product
 MCS-F in serum & ascitic fluid
 Proteomic spectral analysis of serum
 SELDI-TOF –MS : Surface enhanced laser desorption
and ionization time of flight MS

7. OVARIAN CANCER - IMAGING
 USG abdomen with colour doppler study –
transvaginal sonography
 Complex mass with increased vascularity
 Ascites
 Enlarged para aortic nodal masses
 Omental and peritoneal deposits larger than 1cm
 Matted bowel loops

8. Ultrasonography &
Colour Doppler

9. OVARIAN CANCER - IMAGING
CT SCAN abdomen & pelvis:
 Extent of disease in upper abdomen
 Helps to decide on primary surgery or neoadjuvant chemotherapy
 Attachment of omentum to splenic hilum
 Disease/tumor nodules >2cm in mesentery, liver surface or parenchyma,
diaphragm, gall bladder fossa, suprarenal para aortic nodes
 Pulmonary or pleural nodules

17. CT Scan

18. OVARIAN CANCER - IMAGING
 MRI abdomen – not superior to CTscan except in pregnant
women where USG is inconclusive
 PET-CT scan : not for diagnosis
 Useful in rec.disease with isolated CA125 elevation

19. OVARIAN CANCER - INVESTIGATIONS
 UPPER GI SCOPY& COLONOSCOPY – NOT
INDICATED ROUTINELY
 Symptoms s/o gastric disease or lower GI symptoms or fecal
occult blood positive
 4% have associated GI malignancy
 Mammography
 Genetic counseling in pts with positive family history

20. EPITHELIAL OVARIAN
CANCER
DIAGNOSISSymptoms
Clinical Examination
Investigations
Ca125 Imaging
USG Colour Doppler CT/MRI
FNAC contraindicated

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 – 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 ?
 Decision to proceed directly to surgery is a clinical one – in
advanced stage :
 based on extent of disease
 Performance status
 Nutritional status
 Comorbid illness

24. HOW TO PROCEED AFTER
INVESTIGATIONS?
 Operable tumors – laparotomy and proceed
 Avoid percutaneous FNA of localised masses
or complex cysts – upstage disease

25. WHO NEEDS NEOADJUVANT
CHEMOTHERAPY?
 Presence of gross ascites,
 huge fixed pelvi-abdominal mass,
 nodules in POD
 PS III-IV
 Supraclavicular nodes
 Pleural effusion – bilateral

26.  USG abdomen showing
 extensive peritoneal,omental deposits and liver
sec, bilateral pleural effusion

27. CT SCAN FINDINGS
 Diffuse peritoneal thickening(DPT) >4mm – involving
atleast 2 of the 5 areas
 lateral colic gutters
 Lateral conal fascia
 Anterial abdominal wall
 Diaphragm and splenic peritoneal reflection
Sean C.Dowdy et al, CANCER - 2004

28. FOR NEOADJUVANT CHEMOTHERAPY
 Cytologic evidence of malignancy – ascitic fluid
 FNA of the mass ( transvaginal –preferably)
 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)
•Assessment of extent of disease
•Optimal tumor reduction
TAH = total abdominal hysterectomy
BSO = bilateral salphingo-oophorectomy

30. Cytoreductive Surgery
 Goal is elimination of all tumor
• No gross residual (microscopic)
• Optimal (<1 cm)
• Suboptimal (>1 cm)
 Operative Technique
• Resection of urinary or intestinal tract
 Surgical Outcomes
• Optimal in ~75% of cases
• Does it matter?

31. Does Cytoreduction Matter?
Optimal Suboptimal
Response Rate
Clinical CR 95% 75%
Pathologic CR 50% 25%
Progression free interval (mo) 34 13
Survival (mo) 50 36
10-yr survival 35% 15%

32. PROGNOSTIC FACTORS
 Volume of residual disease after surgery
 Stage
 Histologic subtype
 Histologic grade
 Performance status
 Age
 Ovarian cancer prognostic profile(OCPP)
 Chemotherapy response profile (CRP)
 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 – 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 –
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
– GOG 1111 and OV 102 - paclitaxel/cisplatin
vs cyclophosphamide/cisplatin
– 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

37. OVARIAN CARCINOMA:
CLINICAL COURSE
Symptoms
Diagnosis
Chemotherapy #1
Staging
Primary cytoreduction
Interval
Cytoreduction
Progression
Chemo #2 Chemo #3+
Supportive
Care
Death
Consolidation/
Maintenance
Cure
Secondary
CytoreductionSecond-Look

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 – EARLY STAGE
DISEASE
 High risk early stage:
 stage I, gr III, Ic,any stage II
 Stage Ia,Ib –gr I & II can be observed
 ICON I(International Collborative Ovarian Neoplasm Trial I) &
 ACTION (Adjuvant Chemotherapy in Ovarian Neoplasm Trial) –chemo
improves progression free & OS in high risk early stage disease(925 pts – os
– superior for platinum based chemo
 GOG study -3 vs 6 cycles – 33% reduction in risk of rec in high risk disease
who received 6cycles of chemo
 Patients with suboptimal surgery benefit from platinum based chemo

40. Chemotherapy in advanced stage
 GOG 111: paclitaxel+cisplatin superior to cisplatin +
cyclophosphamide
 RR 73% vs 60%
 Median PFS 18 vs 13mo
 Median os 38mo vs 24mo p<001
 60mo of follow up – 20% reduct. In risk of progression & 34%
reduction in risk of death
 OV10,ICON 3
 GOG 132 –sequential administration of pacli or cisplatin is
therapeutically equivalent

41. Chemotherapy in advanced stage
 GOG 158,AGO,NETHERLANDS-DENMARK:
 Carboplatin+paclitaxel vs cisplatin +paclitaxel is equivalent – PFS &OS
 Carbo+paclitaxel – preferred – favorable toxicity profile
 Reduced emesis,neutropenia,nephrotoxicity
 Short infusion time
 Marginal PS,Comorbid medical condition – start with single agent carboplatin – add
paclitaxel later
 No benefit for 12 vs 6 cycles
 No benefit for addition of 3rd cytotoxic agent – PLD,EPI,TOPO,GEM
 Addition of bevacizumab

42. Interventions to  Mortality?
Time
DiseaseVolume
Prevention
Screening
Current point of diagnosis
and initiation of treatment

43.  Prevention
– Pedigree Analysis
– Medical: Oral Contraceptives
– Surgical: Risk-Reducing Oophorectomy
 Screening
– Pelvic Examination
– Ultrasonography
– CA125 and other (OvaSure) Serum Testing
– Proteomics (OvaCheckTM)
Interventions to  Mortality?

44. NIH Consensus Development Panel
“…there 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 cancer…”
Screening – 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
– Include pelvic examination
• CA-125
• Imaging
– CT scan
– MRI?
– 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.

49. Refractory
P
R
I
M
A
R
Y
T
R
E
A
T
M
E
N
T
Resistant
Sensitive
0 3 6 12 18 24
Months
“Very Sensitive”
Ovarian Cancer at First Relapse
Definition of Sensitivity
Defined as measurable recurrence, not biochemical (CA-125) recurrence

50. Active Agents in Ovarian Cancer
FDA approved
Altretamine Carboplatin Cisplatin
Gemcitabine/
Carboplatin
Paclitaxel Pegylated liposomal
doxorubicin
Topotecan
Not FDA approved, compendium listed
Chlorambucil Cyclophosphamide Docetaxel
Doxorubicin Epirubicin Etoposide
5-FU/LV Gemcitabine Ifosfamide
Irinotecan Melphalan Methotrexate
Thiotepa Vinorelbine
Not FDA approved, not compendium listed
Aromatase inhibitors Bevacizumab Pemetrexed
Tamoxifen

51. Secondary
Cytoreduction
• Controversial
• Inconsistent definitions
• Benefit appears confined
to patients likely to
respond to additional
chemo:
• >12 month PFI
• Isolated site of
recurrence
• Disease
completely
resectable Kidney
Resected Liver
Diaphragm
Kidney
Vena Cava
Tumor Mass
Renal Vein
PFI = progression-free interval

52. Advanced Ovarian Cancer
cisplatin paclitaxelmulti-drugAlkeran
Median Survival: 1975 - 2005
IP therapy
(optimal)
(optimal)
months
12 14
24
37
52
57
66
0
20
40
60
80
1975 1983 1986 1996 1998 2003 2005

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 ≤5 mm and largest extension ≤7 mm
Stage IA1: Measured stromal invasion of ≤3.0 mm in depth and extension of ≤7.0 mm.
Stage IA2: Measured stromal invasion of >3.0 mm and ≤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 ≤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 ≤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 lesions—even with superficial invasion—are 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 tissue—superficial or glandular. The depth of invasion should always be reported
in mm, even in those cases with “early (minimal) stromal invasion” (~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
•Stage Ia1 with extensive LVSI
Stage Ia2
• Repeated conisation
• Modified radical hysterectomy (type B6) if re-conisation is not possible
± 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
± Chemotherapy
Radiation
± 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 ≥2 cm))
Pelvic (± 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
± 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
•• 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 ± Chemotherapy)
FIGO Ia1, LVSI
positive
or
Cervical cancer
Squamocellular, Adenocarcinoma,
Adenosquamous

60. Why are YOU here ???

61. Why am I here ???

62. Why are WE here ???