uterine

Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion NCCN.org Continue NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) Uterine Neoplasms Version 1.2011 Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion NCCN Guidelines™ Version 1.2011 Panel Members Uterine Neoplasms Continue NCCN Guidelines Panel Disclosures * * 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 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 � � � � � � § † Nadeem R. Abu-Rustum, MD Memorial Sloan-Kettering Cancer Center Sachin M. Apte, MD, MS H. Lee Moffitt Cancer Center & Research Institute Susana M. Campos, MD, MPh, MS Dana-Farber/Brigham and Women’s Cancer Center John Chan, MD UCSF Helen Diller Family Comprehensive Cancer Center Marta Ann Crispens, MD Vanderbilt-Ingram Cancer Center Nefertiti DuPont, MD, MPH Roswell Park Cancer Institute Patricia J. Eifel, MD The University of Texas MD Anderson Cancer Center Warner K. Huh, MD Lainie Martin, MD Fox Chase Cancer Center � � � § § § † David K. Gaffney, MD, PhD Huntsman Cancer Institute at the University of Utah Daniel S. Kapp, MD, PhD Stanford Comprehensive Cancer Center John R. Lurain, III, MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University � University of Alabama at Birmingham Comprehensive Cancer Center 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 Fidel A. Valea, MD Duke Comprehensive Cancer Center � † ‡ § David Mutch, MD Siteman Cancer Center at Barnes- Jewish Hospital and Washington University School of Medicine Steven W. Remmenga, MD UNMC Eppley Cancer Center at The Nebraska Medical Center R. Kevin Reynolds, MD University of Michigan Comprehensive Cancer Center William Small, Jr., MD Robert H. Lurie Comprehensive Cancer Center of Northwestern University � � � � � � � Gynecologic oncology † Medical oncology ‡ Hematology § Radiotherapy/Radiation oncology Pathology * Writing committee member NCCN Staff Miranda Hughes, PhD Nicole McMillian, MS Printed by wei ou on 10/10/2010 2:03:41 AM. For personal use only. Not approved for distribution. Copyright © 2010 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion NCCN Guidelines Name Panel Members Summary of the Guidelines Updates Uterine Neoplasms (UN-1) Disease limited to the uterus (ENDO-1) Suspected or gross cervical involvement (ENDO-2) Suspected extrauterine disease (ENDO-3) Surveillance (ENDO-8) Recurrence (ENDO-9) Papillary serous, Clear cell carcinoma, Carcinosarcoma (ENDO-10) Hysterectomy (ENDO-A) Systemic Therapy for Recurrent, Metastatic or High-risk Disease (ENDO-B) Disease limited to the uterus (UTSARC-1) Known or suspected extrauterine disease (UTSARC-1) Endometrial stromal sarcoma (ESS) (UTSARC-2) Undifferentiated sarcoma and Leiomyosarcoma (UTSARC-3) Surveillance Uterine Neoplasms Endometrial Carcinoma Uterine Sarcoma (UTSARC-4) Recurrence (UTSARC-4) Systemic Therapy for Uterine Sarcoma (UTSARC-A) Uterine Sarcoma Classification (UTSARC-B) Principles of Radiation Therapy (UN-A) Staging (ST-1) Clinical Trials: Categories of Evidence and Consensus: NCCN All recommendations are Category 2A unless otherwise specified. 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 See NCCN Categories of Evidence and Consensus The NCCN Guidelines™ are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN 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® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2010. NCCN Guidelines™ Version 1.2011 Table of Contents Uterine Neoplasms Printed by wei ou on 10/10/2010 2:03:41 AM. For personal use only. Not approved for distribution. Copyright © 2010 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion NCCN Guidelines™ Version 1.2011 Updates Uterine Neoplasms UPDATES (1 of 2) Global Changes young < 50 y and/or selected pathologic risk features ENDO-8 : The Staging tables were updated to reflect the 2009 FIGO Staging and . The Uterine Neoplasms algorithms were revised extensively (including deletion of pages) to reflect the 2009 FIGO staging. “Low-grade Endometrial stromal sarcoma” changed to “Endometrial stromal sarcoma”. “High-grade Undifferentiated sarcoma” changed to “Undifferentiated sarcoma”. Initial Evaluation: “Consider genetic counseling for patients...” changed to “Consider genetic counseling for patients ( ) with a significant family history (See HNPCC/Lynch syndrome in NCCN Colorectal Cancer Screening Guidelines)”. (Also for ) � � � � � ( ) ( )ST-1 ST-2 UN-1 Endometrial Carcinoma: ENDO-1 � � � � � � � � Footnote “d” regarding peritoneal cytology is new to the page. Footnote “f” regarding complete para-aortic lympadenectomy is new to the page. Additional Workup: “CA-125” is now listed as optional. Primary treatment for intra-abdominal disease: “TH/BSO + cytology ± maximal debulking ± pelvic and para-aortic lymph node dissection” changed to “TH/BSO + cytology debulking ± pelvic and para-aortic lymph node dissection”. Footnote “i” regarding the goal of surgical debulking is new to the page. Stage IA; Adverse risk factors present; G2: “category 2B for all options” changed to “category 2B for ”. IIIC2: Common iliac or para-aortic node positive” changed to “Para-aortic node positive ”. Surveillance: The recommendation “Vaginal cytology every 6 mo for 2y then annually” changed from category 2A to category 2B. Surveillance; Last bullet: Changed to “Consider genetic counseling for patients with a significant family history (See HNPCC/Lynch syndrome in NCCN Colorectal Cancer Screening Guidelines)”. + surgical pelvic RT ± pelvic node positive young (< 50 y) and/or selected pathologic risk features � ENDO-3 ENDO-4 ENDO-6 ENDO-8 ENDO-8 ENDO-9 ENDO-10 ENDO-A ENDO-B Management of Drug Reactions (OV-C NCCN Ovarian Cancer Guidelines ) --continued Disseminated metastases pathway; Therapy for relapse: “Chemotherapy and/or palliative RT” changed to “Chemotherapy ± palliative RT”. “Previous brachytherapy only” pathway; Therapy for relapse: “RT + brachytherapy or Surgical exploration...” changed to “RT + brachytherapy Surgical exploration...” Footnote “p” was revised. Uterus; Last arrow: Consider mismatch repair analysis to identify genetic problems” changed to “Consider mismatch repair analysis to identify e ”. Chemotherapy regimens: “Ixabepilone may be used as a single agent for second line treatment of patients (category 2B)” was removed. “Liposomal doxorubicin” was added as a chemotherapy regimen. Footnote that references the from the is new to the page. � � � � � � � and/or familial cancer syndromes, such as HNPCC/Lynch syndrom (See NCCN Colorectal Cancer Screening Guidelines) Continued Updates in Version 1.2011 of the NCCN Uterine Neoplasms Guidelines from Version 1.2010 include: Printed by wei ou on 10/10/2010 2:03:41 AM. For personal use only. Not approved for distribution. Copyright © 2010 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion NCCN Guidelines™ Version 1.2011 Updates Uterine Neoplasms Updates in Version 1.2011 of the NCCN Uterine Neoplasms Guidelines from Version 1.2010 include: UPDATES (2 of 2) Uterine Sarcoma tumor-directed or CT imaging every 6-12 mo : � � � � � � � � Primary treatment for operable disease: Under “TH/BSO,” bullets for “Cytology” and “Lymph node dissection” were removed. Footnote “c”: “Oophorectomy/LND individualized for reproductive age patients. Fertility consultation as appropriate” changed to “Oophorectomy individualized for reproductive age patients”. Footnote “d”: “For incidental finding of uterine sarcoma after TH/BSO: Recommend imaging and consider additional surgical resection on an individual basis” is new to the page. Stage I; Adjuvant treatment: “Hormone therapy (category 2B)” was added as an option. Stage II, III, IVA; Adjuvant treatment: “Hormone therapy ± pelvic RT” changed to “Hormone therapy ± RT”. Surveillance: “Chest x-ray annually” changed to “Chest x-ray ”. “Other imaging as clinically indicated” was added. Second bullet: “(high-grade undifferentiated sarcoma [HGUD]) or pure heterologous sarcoma” was removed after “Undifferentiated sarcoma”. Footnote regarding rare tumors was removed. � � UTSARC-1 UTSARC-2 UTSARC-4 UTSARC-B Printed by wei ou on 10/10/2010 2:03:41 AM. For personal use only. Not approved for distribution. Copyright © 2010 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion 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. UN-1 NCCN Guidelines™ Version 1.2011 Uterine Neoplasms INITIAL EVALUATION INITIAL CLINICAL FINDINGS � � � � � � � H&P CBC (including platelets) Endometrial biopsy Chest x-ray Current cervical cytology consistent with LFT/renal function tests/chemistry profile Consider genetic counseling for young patients (< 50 y) with a significant family history and/or selected pathologic risk features Optional: NCCN Cervical Screening Guidelines (See HNPCC/Lynch syndrome in NCCN Colorectal Cancer Screening Guidelines) Pathology review Disease limited to uterus Suspected or gross cervical involvement Papillary serous or clear cell carcinoma Suspected extrauterine disease See Treatment for Papillary Serous or Clear Cell Carcinomas of the Endometrium or Carcinosarcoma (ENDO-10) See Primary Treatment (ENDO-1) See Primary Treatment (ENDO-2) See Primary Treatment (ENDO-3) Pure endometrioid Epithelial carcinoma Stromal/mesenchymal tumors � � � Endometrial stromal sarcoma (ESS) Undifferentiated sarcoma Leiomyosarcoma (LMS) Carcinosarcomaa,b a b Staged as aggressive; should be treated as a high-grade endometrial cancer. Also known as malignant mixed mesodermal tumor or and including those with either homologous or heterologous stromal elements.malignant mixed Müllerian tumor All staging in guideline is based on updated 2009 FIGO staging. (See ST-1) Disease limited to uterus Known or suspected extrauterine disease See Primary Treatment (UTSARC-1) Printed by wei ou on 10/10/2010 2:03:41 AM. For personal use only. Not approved for distribution. Copyright © 2010 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion 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. ENDO-1 NCCN Guidelines™ Version 1.2011 Endometrial Carcinoma INITIAL CLINICAL FINDINGS Disease limited to the uterus (endometrioid histologies)a Medically inoperable Operable PRIMARY TREATMENT Tumor-directed RTb a for clarification of uterine neoplasms. Although peritoneal cytology by itself does not affect 2009 FIGO staging, cytology results should still be obtained and recorded. b e f c d American College of Obstetricians and Gynecologists practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005 Aug;106:413-425. A complete para-aortic lymphadenectomy would include nodes up to the renal vessel. See (UN-1 See Hysterectomy (ENDO-A) ) . See Principles of Radiation Therapy (UN-A). See Surveillance (ENDO-8) Total hysterectomy and bilateral salpingo- oophorectomy (TH/BSO)c � � Cytology Lymph node dissection (not random sampling) Pelvic lymphadenectomy Para-aortic lymphadenectomy d e f � � Adjuvant Treatment for completely surgically staged: � � � � Stage I (See ENDO-4) Stage II (See ENDO-5) Stage IIIA (See ENDO-5) Stage IIIB-IV (See ENDO-6) See (ENDO-7) Incompletely surgically staged Printed by wei ou on 10/10/2010 2:03:41 AM. For personal use only. Not approved for distribution. Copyright © 2010 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion 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. ENDO-2 NCCN Guidelines™ Version 1.2011 Endometrial Carcinoma Suspected or gross cervical involvement (endometrioid histologies)a Negative result ADDITIONAL WORKUP PRIMARY TREATMENT Consider cervical biopsy or MRI Positive result or gross involvement g Operable Radical hysterectomy and bilateral salpingo- oophorectomy (RH/BSO) or RT: 75-80 Gy to point A (category 2B) c e � � Cytology Lymph node dissection (not random sampling) Pelvic lymphadenectomy Para-aortic lymphadenectomy d f � � h Inoperable Tumor-directed RT b TH/BSO Para-aortic lymph node dissection c See Surveillance (ENDO-8) INITIAL CLINICAL FINDINGS TH/BSO Cytology Lymph node dissection (not random sampling) Pelvic lymphadenectomy Para-aortic c e � � d � � lymphadenectomyf Adjuvant treatment for completely surgically staged: � � � � Stage I (See ENDO-4) Stage II (See ENDO-5) Stage IIIA (See ENDO-5) Stage IIIB-IV (See ENDO-6) Clear demonstration of cervical stromal involvement. a for clarification of uterine neoplasms. Although peritoneal cytology by itself does not affect 2009 FIGO staging, cytology results should still be obtained and recorded. A complete para-aortic lymphadenectomy would include nodes up to the renal vessel. Based on summation of conventional external-beam fractionation and low-dose-rate brachytherapy equivalent. b c d e f h American College of Obstetricians and Gynecologists practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005 Aug;106:413-425. g See (UN-1) See Hysterectomy (ENDO-A) See Principles of Radiation Therapy (UN-A). . See (ENDO-7) Incompletely surgically staged Printed by wei ou on 10/10/2010 2:03:41 AM. For personal use only. Not approved for distribution. Copyright © 2010 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not be reproduced in any form without the express written permission of NCCN®. NCCN Guidelines Index Uterine Neoplasms TOC Discussion 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. ENDO-3 NCCN Guidelines™ Version 1.2011 Endometrial Carcinoma Suspected extrauterine disease (endometrioid histologies)a None Intra-abdominal: � � � � � Ascites Omentum Nodal Ovarian Peritoneal Extrauterine pelvis: � � � � Vaginal Bladder Bowel/rectum Parametrial Extra-abdominal/liver See Primary Treatment (disease limited to uterus) (ENDO-1) RT ± surgery + brachytherapy ± chemotherapy � � CA-125 (optional) MRI/CT, as clinically indicated TH/BSO + cytology + surgical debulking ± pelvic and para-aortic lymph node dissection c d e i Consider palliative TH/BSO ± RT ± hormonal therapy ± chemotherapy Adjuvant treatment for completely surgically staged: � � Stage IIIA (See ENDO-5) Stage IIIB-IV (See ENDO-6) See Surveillance (ENDO-8) ADDITIONAL WORKUP PRIMARY TREATMENTINITIAL CLINICAL FINDINGS a d for clarification of uterine neoplasms. Although peritoneal cytology by itself does not affect 2009 FIGO staging, cytology results should still be obtained and recorded. c e i American College of Obstetricians and Gynecologists practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005 Aug;106:413-425. The surgical goal is to have no measurable residual disease. See (UN-1) See Hysterectomy (ENDO-A). Printed by wei ou on 10/10/2010 2:03:41 AM. For personal use only. Not approved for distribution. Copyright © 2010 National Comprehensive Cancer Network, Inc., All Rights Reserved. Version 1.2011, 10/06/10 © National Comprehensive Cancer Network, Inc. 2010, All rights reserved. The NCCN Guidelines™ and this illustration may not b