Cancer Template draft #1 - Wales



CERVICAL CARCINOMA

Index

1. Screening

2. Referral pathway

2.1 For GP

2.2 For non-oncological consultants/ firms

2.3 For referral from unit to centre

3. Diagnosis

3.1 Early invasion

3.2 Clinical invasive disease

4. Investigations

4.1 Examination under anaesthesia

4.2 MR and CT imaging

4.3 Other investigations

4.4 Relative benefit over other management options and resource implications

5. Gynaecological cancer multidisciplinary team

5.1 Information

6. Pathology

6.1 Modified WHO histological classification

7. Staging

8. Histopathology minimum dataset

9. Treatment

9.1 Surgery

9.1.1 Loop/ cone

9.1.2 Radical trachelectomy

9.1.3 Wertheim hysterectomy

9.1.4 Shauta hysterectomy

9.1.5 Laparoscopic node dissection

9.1.6 Cancer complicating pregnancy

9.1.7 Cervical stump carcinoma/ management of unsuspected carcinoma after simple hysterectomy

9.1.8 Management of stage Ib2 carcinoma

9.2 Radiotherapy and chemoradiation

9.2.1 Radical treatment

9.2.2 Adjuvant treatment

9.3 Chemotherapy

9.4 Management of advanced disease

10. Dealing with recurrent disease

10.1 Imaging

10.2 Chemotherapy

10.3 Pelvic exenteration

10.4 Palliative care

10.5 Obstructive uropathy

11. Survival

11.1 Cancer dataset/ inventory of active trials

12. Follow up

12.1 Identification and management of late effects of treatment

13. Contact names/ numbers

14. Algorithm

15. Summary

16. References

Appendix 1: Relative benefit over other management options and resource implications for imaging

Introduction

Cervical carcinoma is the second commonest cause of female cancer worldwide but accounts for about 2% of all cancers in women in the UK. 3400 new cases are diagnosed each year in England and Wales of which about 1200 women die of their disease (NHS Executive, 1999).

The incidence and death rate for cervical carcinoma has been declining since records began in the early part of this century. However, the incidence of adenocarcinoma in 2001 had increased by 45% from 1971 (1.6/100,000 in 2001). The incidence of squamous carcinoma declined by 54% since 1971 (8.6/100,000 in 2001). Indeed the incidence has fallen by 42% between 1988 and 1997 in England and Wales. Incidence is declining in all age groups but over 25% of women are diagnosed over 65 years of age.

Mortality for all cases has declined by 67% from 1971-2001 (2.7/100,000 in 2001; Quinn et al, 2001).

This appears to be despite the increasing incidence of CIN and may reflect the apparent success of the national cervical screening programme which has been estimated to save 4500 lives/ year in England. Carcinoma of the cervix is most prevalent in Wales and the North of England and in the unskilled.

The patient may be asymptomatic and detected up by cervical cytology. Fifty percent of women present at an early stage appropriate for a surgical cure.

1. Screening

Following the introduction of computerised recall in 1988 the incidence of cervical cancer has declined by 7% per annum and has been the major contribution to the decline in mortality from this disease. Presently 3 yearly screening is from 20–65 years of age in Wales. There are slight variations throughout the rest of the UK. HPV testing and HPV vaccination are currently undergoing evaluation.

2. Referral pathway (see 13. Contact names/ numbers)

2.1 For GP

If cervical cancer is suspected then referral should be to a general gynaecologist, the lead in the cancer unit or gynaecological oncologist in the cancer centre.

2.2 For non-oncological consultants/ firms

If the diagnosis is suspected or confirmed referral to the local unit lead or gynaecological cancer centre should be made.

3. For referral from unit to centre

This is appropriate for all cancer cases FIGO substage Ia2 or greater.

3. Diagnosis

This usually depends upon colposcopic examination where features of high grade CIN (large lesion, mosaic, punctation) or invasion (abnormal vasculature, ulceration) may be present. Diagnosis depends on a suitable sized biopsy (loop or cone). Punch biopsy may not be satisfactory as a means of colposcopic diagnosis (ie for lesions that are not macroscopically visible).

3.1 Early invasion (see 9.1. Surgery)

The diagnosis of Ia disease requires a loop or cone biopsy.

The term microinvasive is used in different senses by different authors and is probably best dropped from common usage. Stage Ia1 and Ia2 squamous carcinoma is defined by the FIGO staging system (see 7). Debate surrounds the prognostic value of lymphovascular space involvement in stage Ia tumours. In the United States prevailing opinion is that if a tumour shows lymphovascular space invasion it cannot be included in the stage Ia category but others feel that evidence of the value of lymphovascular space invasion prognostically is still unclear or that it is probably only of value in the 3-5mm deep early invasive group. A diagnosis of stage Ia disease cannot be made in a biopsy where excision of tumour is incomplete.

Whilst the FIGO classification does not specifically exclude the application of stage Ia1 and 2 categories to invasive adenocarcinoma it has in the past been felt that there is insufficient data to define stage Ia1 and Ia2 adenocarcinoma in prognostic terms. What data is accumulating suggests that for tumours less than 2-3mm deep outcome in invasive adenocarcinomas is probably very good and similar to that for stage Ia squamous carcinoma.

Management of multifocal < 3mm depth of penetration disease must be discussed with the cancer centre MDT team.

3.2 Clinical invasive disease

More advanced lesions may present with a mass detectable at digital examination and diagnosed with a wedge, loop biopsy or punch biopsy.

4. Investigations

The patient with a bulky stage Ib or more advanced tumour may require an examination under anaesthesia to determine suitability for operative treatment.

4.1 Examination under anaesthesia

Examination under anaesthesia requires a vaginal examination to determine the degree of encroachment of tumour into the vagina, to the pelvic side wall and the mobility of any mass. A biopsy is then taken. Cystoscopy and sigmoidoscopy may be helpful but cystoscopy and sigmoidoscopy should not be routinely performed for staging purposes for all cancers (grade B recommendation).

Rectal examination allows assessment of parametrial involvement and spread of tumour toward the pelvic sidewall. Simultaneous rectal and vaginal examination may provide improved assessment of the uterosacral ligaments and pelvic sidewall compared to rectal examination. Clinical staging may underestimate the extent of tumour due to difficulties in assessing parametrial, pelvic sidewall, rectal and bladder invasion as well the presence or absence of metastatic disease.

4.2 MR and CT imaging

Primary tumour size (>1cm diameter; Fujiwara et al, 2000), vaginal invasion, presence of lymphadenopathy (>1cm diameter) and ureteric involvement are ideally assessed with an MR scan of the pelvis and abdomen (NHS Executive, 1999; grade B recommendation). MR imaging is therefore appropriate for all patients with biopsy proven invasive cervical cancer that is colposcopically visible

ie. > 7mm diameter or > stage Ia2. Exceptions are those patients with clinically advanced stage IV disease or contraindications to MR scanning when post contrast CT scanning will suffice.

MR technique is identified as being important in correct staging. Thin section T2 sequences including those perpendicular to the long axis of the cervix, are of most value in primary tumour assessment (Sironi et al, 2002; Shiraiwa et al, 1999) Intravenous contrast in MR is non contributory in primary tumour staging (Sheu et al, 2001; Choi et al, 2004; Sironi et al, 2002).

There are variable results of accuracy of parametrial staging of MR and CT (Bipat et al 2003; MSAC 2001, Hricak et al. 2005a), but MR is generally superior, with specificity of approximately 85% and sensitivity of approximately 55-70%. The greatest value of MR in influencing correct management options lies in the high negative predictive value (85%) for parametrial invasion (Hricak et al, 2005b), thus conferring operable versus inoperable status.

Absence of bladder and rectal invasion can be assessed reliably by MR (Rockall et al, 2006; evidence level IIb, grade B recommendation) and if combined by vaginal examination in clinic can accurately stage cervical cancer in the majority of cases. Sensitivities to bladder (75%) and rectal involvement (71%) are better with MR than CT (60% and 42% respectively), but MR has a considerably higher specificity than CT in determining bladder invasion (91% versus 71%). Specificities are similar (80%) for determining rectal involvement (Bipat et al, 2003). MR therefore provides a high negative predictive value for bladder or rectal invasion.

Post contrast spiral CT is a good alternative in patients who may not be MR compatible (good practice point). CT imaging of the abdomen and pelvis is a useful alternative for advanced (stage IV) disease, assessing lymph nodes, mapping for radiotherapy and guidance for directed biopsies.

4.3 Other investigations

Limited recent data is available on the use of chest X rays in staging, but as the yield of metastases in patients with clinical stage IIb or greater is reported as 4%, this is likely to be an accepted, widely available, non controversial and inexpensive imaging addition to determining FIGO stage in these patients.

CT scans are more accurate in identifying pleural effusions, thoracic nodal status and parenchymal metastases (ACR Appropriateness Criteria, 2005).

Intravenous urography has been superceded as a stand alone investigation, as CT or MR (or ultrasound) are as accurate in determining ureteric obstruction secondary to parametrial invasion and give additional information.

Barium enemas are not routinely indicated (ACR appropriateness criteria, 2005). Ultrasound is not reliable in either assessment of primary tumour size or nodal status (Hricak and Yu, 1996).

Despite lack of inclusion in FIGO staging criteria, it is generally agreed that the involvement of pelvic or para-aortic lymph nodes in most histological types of cervical cancer, is the greatest single predictor of long term survival. Lymphangiography is an invasive test, not now routinely available in many radiology departments and positive predictive values in cervical carcinoma values are variable, but probably comparable to MR and CT for the detection of involved pelvic and para-aortic nodes. There is consistent evidence that both CT and MR have poor sensitivity for detection of nodal metastases, based on size criteria.

PET/CT is likely to become a standard investigation tool over the next 5 years. In particular PET may provide precise restaging information for patients with recurrent or locally advanced cervical cancer being evaluated for salvage therapy (Nakamoto et al, 2005). Patient numbers in PET studies tend to be small, (due to the more recent introduction of this imaging technique) but results appear consistent that PET is superior to MR and CT in the detection of metastatic pelvic and para-aortic nodes, with higher sensitivities and specificities (Rose et al, 1999a). However, sensitivities remain suboptimal, and perhaps technique dependent, in 3mm or admixture with any other tumour type, then prognosis worsens considerably and so local excision is not always appropriate.

There has been considerable debate as to whether adenosquamous carcinomas have a poorer prognosis than other types but at the moment there is no clear evidence of this. Some evidence exists that its incidence is higher in younger women and that metastases to pelvic lymph nodes may be more frequent than in squamous carcinoma or adenocarcinoma but there is no clear evidence that prognosis differs. So-called glassy carcinomas are best considered a variant of adenosquamous carcinoma and these have been reported to have an aggressive clinical course. Adenoid cystic carcinomas account for less than 1% of adenocarcinomas. It is debatable whether they exist as a true entity in the cervix comparable to those seen, for example, in salivary glands. These tumours commonly show lymphatic involvement, have an aggressive local course but may also metastasise. They should be differentiated from adenoid basal carcinomas which are commonly a coincidental finding in the elderly or found in older women being investigated for CIN. These tumours are much less aggressive than adenoid cystic carcinomas and because

they have a very indolent course it has recently been suggested they are reclassified as adenoid basal epitheliomas.

Neuroendocrine tumours of the cervix include classical carcinoid tumours which are very rare, small cell and large cell neuroendocrine carcinoma. Some also recognise an atypical carcinoid tumour in the cervix. It is important to identify small and large cell neuroendocrine carcinomas as these appear to be aggressive tumours and in the literature some series have shown a median survival of only twelve months. Only around 40% of small cell carcinomas of neuroendocrine type are actually positive with neuroendocrine markers and differentiation of small cell squamous and small cell neuroendocrine carcinoma can be difficult.

Spread of cervical carcinoma is by direct extension of the primary tumour into adjacent structures, permeating lymphatics and at a late stage to blood vessels. Direct is spread to the vaginal, cardinal ligaments and to the pelvic sidewall, involving the ureters, bladder or rectum at a late stage. Lymph nodes are initially involved close to the parametrium, then to pelvic nodes around the obturator, internal iliac, external iliac and common iliac vessels. Para-aortic lymphadenopathy and blood borne distant metastases are generally believed to be late developments.

7. Staging

Stage I Carcinoma confined to the cervix.

Ia Invasive carcinoma diagnosed only by microscopy; all macroscopically

visible lesions, even with superficial invasion, are stage Ib.

Ia1 Invasion < 3mm depth of invasion from parent epithelial base, horizontal

spread < 7mm

Ia2 Invasion > 3mm depth of invasion not greater than 5mm from parent epithelial

base, the horizontal spread < 7mm

Ib1 Carcinoma confined to cervix > 7mm wide or 5mm deep but < 4cm in size

Ib2 Carcinoma > 4cm diameter

Stage II Carcinoma extending beyond the cervix but not extending to the pelvic

sidewall or involving the lower third of vagina.

a No parametrial involvement

b Parametrial involvement

Stage III Tumour extends to the pelvic sidewall, or involves the lower third of vagina.

On rectal examination there is no tumour free space between the tumour

and pelvic sidewall. All cases of hydronephrosis with non functioning

kidney should be included unless it is known to be from another cause.

a No extension to pelvic sidewall

b Extension to sidewall or non functioning kidney

Stage IV Extension beyond the true pelvis or to mucosa of the bladder or rectum.

a Adjacent organ involvement*

b Distant organ involvement

* the presence of bullous oedema is not sufficient to classify tumour as stage IV.

FIGO, 1995

8. Histopathology minimum dataset

National Minimum Dataset – Cervical Cancer Histopathology Report

Gross description

Dimensions of uterus: Length ..........mm Transverse .......mm Antero-posterior........mm

Vaginal cuff: Present ( Absent ( Length .......mm

Maximum dimensions of tumour: .…......mm

Histology

Type: squamous carcinoma ( adenocarcinoma ( adenosquamous (

other (please specify) …………………………………………………………….

Histological differentiation: Well ( Moderate ( Poor (

Tumour size: maximum horizontal dimension .......mm depth of invasion .......mm

distance from closest resection margin (minimum tumour-free rim) .......mm position of this ……………………….

Paracervical involvement: Yes ( No (

Parametrical involvement: Yes ( No (

Vaginal involvement: Yes ( Distance from vaginal margin .......mm No (

Lymphovascular invasion: Present ( Absent (

CIN: Present ( Grade (please circle) 1 2 3 Absent (

CGIN: Present ( Grade (please circle) High Low Absent (

|Pelvic nodes |Right left |Common iliac nodes |right left |

|(including obturator, internal | | | |

|and external iliac) | | | |

|Total number of nodes retrieved| |total number of nodes retrieved| |

| |…….. …….. | |…….. …….. |

|lymph nodes with tumour | |lymph nodes with tumour | |

|deposits |…….. …….. |deposits |…….. …….. |

|Extranodal spread |Yes ( No ( | |Yes ( No ( |

Para-aortic nodes: not sampled ( positive ( negative (

Extranodal spread: Yes ( No (

Endometrium: Normal ( Abnormal (please state) ……………………….

Myometrium: Normal ( Abnormal (please state) ……………………….

Right ovary/tube: Normal ( Abnormal (please state) ……………………….

Left ovary/tube: Normal ( Abnormal (please state) ……………………….

Comments

SNOMED codes

T83000 (Cervix) M80703 (Squamous cell carcinoma) M81403 (Adenocarcinoma) T08000 (Lymph node) M85603 (Adenosquamous carcinoma)

M80706 (Metastatic squamous carcinoma) M81406 (Metastatic Adenocarcinoma)

9. Treatment

9.1 Surgery (see 14. Algorithm and 15. Summary)

Generally less than 1% of patients with Ia1 disease has pelvic lymph node involvement and do not need nodal assessment. 6% of patients have pelvic lymph node metastases in lesions extending deeper than 3mm (Duncan, 1986) and for these tumours radical surgery/ radiotherapy or chemoradiation is usually required (Robertson and Grant, 1998; grade C recommendation). With a Ia2 lesion, a 2cm deep loop or cone may be suitable if the invasive component or any CIN is completely excised. However, it will be necessary to examine the lymph nodes and this can be performed laparoscopically. Retrospective case series suggest that a simple hysterectomy and pelvic lymphadenectomy is adequate for Ia2 disease (Selman et al, 2005; Steed et al, 2006). An alternative would be to offer a radical hysterectomy and pelvic lymphadenectomy. Lymphovascular space involvement may be a marker for more aggressive disease (Van Nagell et al, 1983). Incompletely excised early invasive disease at loop excision or cone biopsy requires radical treatment.

Stage for stage survival for adenocarcinoma of the cervix appears similar to squamous cell carcinoma and it is treated in a similar manner.

9.1.1 Loop/ cone (suitable for FIGO stage Ia1- Ia2)

For stage Ia1 disease, the pathology should be reviewed by the local cancer MDT and involve review by a pathologist with an interest in gynaecological oncology (good practice point). However assessment of the depth of infiltration is dependant on the quality of local preparation of the histological sections. Lymphovascular space involvement and multifocal disease may require lymph node dissection. Completely excised stage Ia1 disease can be treated in a cancer unit.

9.1.2 Radical trachelectomy (suitable for FIGO stage Ib1 - IIa)

Radical trachelectomy combined with pelvic lymphadenectomy appears a suitable alternative to Wertheim hysterectomy for women wishing to preserve their fertility with tumours under 2cm in size. Recurrence rates appear acceptable (Shepherd et al, 1998; grade B recommendation). Experience of this in the UK is limited and should still be considered as experimental with radical hysterectomy being the gold standard treatment. Completion treatment may be necessary in 10% of patients because of either positive pelvic lymph nodes or close/ incomplete excision margins.

9.1.3 Wertheim hysterectomy (suitable for FIGO stage Ib1 - IIa)

This procedure involves a radical hysterectomy, removing parametrium, the upper third of vagina and a formal bilateral lymphadenectomy, removing the common iliac, internal and external iliac and obturator lymph nodes. The para-aortic nodes may be selectively sampled at the start of the procedure and suspicious nodes sent for frozen section. If they are involved then surgery should be abandoned as disease will be widely disseminated. Para-aortic nodal involvement is seen in up to 6% of stage I disease and 11-29% of stage II disease. Para-aortic sampling appears difficult to justify in stage Ia2 disease in the absence of histologically involved pelvic nodes (Monaghan and Burghardt, 1993; grade C recommendation). The fallopian tubes should be removed and if the ovaries are conserved then they are lifted out of the pelvis away from any intended radiotherapy. The ovaries are only removed if there is coincident ovarian pathology or if the patient is approaching or beyond her menopause.

Patients wishing future fertility by surrogacy may wish cryopreservation of eggs and should contact the Hewitt Fertility Centre at Liverpool Womens Hospital.

9.1.4 Shauta hysterectomy

This is not part of the management algorithm for North Wales patients.

9.1.5 Laparoscopic node dissection

Patients are to be referred to the Liverpool Womens Hospital as part of management of FIGO stage Ia2 disease treated by cone biopsy and wishing preservation of fertility.

9.1.6 Cancer complicating pregnancy

Pregnancy itself does not appear to alter the biological behaviour of cervical carcinoma but a difficult decision is almost always encountered as to whether preterm delivery or termination of pregnancy is to be considered in a trade off between the survival of the fetus versus the mother. Vaginal delivery is

contraindicated as disease can disseminate through the large cervical venous sinuses and be implanted into the vagina or perineum during the course of delivery. These tumours should be managed as in the non-pregnant patient stage for stage.

9.1.7 Cervical stump carcinoma/ management of unsuspected carcinoma after simple hysterectomy

Stump carcinoma is a rare problem where cervical carcinoma occurs after a subtotal hysterectomy. A radical trachelectomy would be ideal and could be combined with post operative radiotherapy. Radical radiotherapy is an alternative but there can be difficulty with the intrauterine applicators.

Following simple hysterectomy after excision of an unsuspected stage Ib+ carcinoma a radical parametrectomy with excision of a cuff of vagina is possible but can be difficult. Again radical pelvic radiotherapy is an option.

Patients are to be referred to Liverpool Womens Hospital or to the Royal Marsden if radical Parametrectomy to be considered. Generally radiotherapy preferred but all cases must be discussed at the gynae cancer MDT to decide further treatment.

9.1.8 Management of stage Ib2 carcinoma (also see 9.2.1 Radical treatment)

To refer for radical radiotherapy or chemoradiotherapy at YGC.

9.2 Radiotherapy and chemoradiation

9.2.1 Radical treatment

Radiotherapy is preferred for more advanced disease (stage IIb and beyond) and for surgically unfit women with early stage disease. This can provide radical or palliative treatment. It is administered by external beam radiation to deal with the central tumour, pelvic sidewall extension and the pelvic lymph nodes. This is then supplemented by a remote after loading brachytherapy technique whereby intra-uterine and vaginal radioactive sources are inserted. After treatment, rectovaginal or vesicovaginal fistulae can rarely occur; more frequent are troublesome proctitis and cystitis.

Current practice in UK would be to give external beam radiotherapy (EBRT) to a dose of between 45-50 Gy with daily fractions of 1.8-2 Gy with minimal interruptions or gaps in treatment. Some centres use a parametrial/ sidewall boost with EBRT. This would be followed by a brachytherapy boost with MDR intracavity doses of 24-28 Gy to the “A” point whereas for HDR the dose would be 28-30 Gy in 4 or 5 insertions. An interstitial boost sometimes may be delivered for bulky residual disease. Planning of the radiation therapy should optimally be performed using CT simulator (or MRI) to determine the fields and organs at risk.

Recent studies have shown statistically highly significant improved survival after chemoradiotherapy (relative risks between 0.61-0.52; Keys et al, 1999; Morris et al, 1999; Rose et al, 1999b) with low dose weekly cisplatin or combination cisplatin regimens given during radiotherapy. Newer schedules including cisplatin and gemcitabine, vinorelbine, paclitaxel are under investigation and induction therapy with carboplatin and paclitaxel is in trial. The Italian SNAP 01 study showed paclitaxel, ifosfamide and cisplatin to be significantly better than ifosfamide and cisplatin (Buda et al, 2005; evidence level Ib). Chemoradiation is now recommended as standard treatment for patients having primary non-surgical treatment (grade A recommendation; evidence level Ia) and are fit enough to tolerate the additional morbidity (particularly neutropaenia and emesis).

9.2.2 Adjuvant treatment

Radiotherapy is also offered to patients with histologically involved nodes after hysterectomy/ lymphadenectomy or for undifferentiated tumours as their chance of recurrent disease is increased (grade A

recommendation; evidence level Ib). A close vaginal surgical margin is an indication for radiotherapy but there is no agreed measurement (IIb / Ib2 and node negative on imaging).

Surgery

Cone biopsy/ loop excision (as above).

Simple hysterectomy - this is suitable for remaining Ia2 disease.

Wertheim hysterectomy - this is suitable for remaining Ia2 disease; 3-5mm depth of penetration, lymphovascular space involvement or incomplete excision of carcinoma; Ib and IIa disease. If following cone/ loop then should ideally be performed stage Ib1 tumour on clinical exam or imaging (Liang et al, 2000; Chung et al, 2001; Hricak and Yu, 1996).

Lymphangiography is unreliable for preoperative assessment and may interfere with the specificity and interpretation of PET scans (Reinhardt et al, 2001).

Assessment of pelvic and para-aortic nodal disease is most accurately determined by laparotomy or laparoscopic surgery. This is an invasive procedure not routinely practised as part of pre treatment staging and thus the contribution of pre operative or pre radiotherapy imaging determination of nodal status is still worthwhile, despite the limitations in sensitivity of current techniques of MR, CT and PET.

The use of accurate cross sectional imaging in staging cervical cancer is more cost effective and less invasive than routine use of FIGO recognised investigations of IVU, barium enema, cystoscopy and examination under anaesthesia, with cost savings estimated at approximately £1100/ patient (£2.76 million across the UK, based on UK wide incidence of 2990 cervical cancer patients annually and that some early stage cancers do not require staging investigations – Rockall et al, 2005; Hricak et al, 2005, Hricak et al, 1996).

It is also a more effective use of the pre treatment investigative period, without use of day or inpatient beds for anaesthetic/ investigative purposes. This strategy should also allow more compliance with government waiting time referral targets.

PET/CT scanning has very limited availability at present. It is likely that the greatest impact of PET in initial staging will be for inoperable patients with stage IIb and III disease, in the detection of possible para-aortic nodal metastases, and unexpected distant metastases, with subsequent change in planned radiotherapy fields.

Whilst reported sensitivities are variable for detection of metastatic para-aortic nodes with PET, the alternative gold standard of laparoscopic staging carries significant risk of morbidity and has estimated costs of £1,628 -£4,646 compared to NHS costs for PET of approximately £750. (ISD data 2004/5 and Scottish Executive Health Dept). The general reported sensitivity and specificity of PET/CT still make PET imaging a cost effective alternative to inadequate radiotherapy fields, or inappropriate treatment options.

References:

Chung H, Ahn HS, Kim YS et al.(2001) The value of cystoscopy and intravenous urography after magnetic resonance imaging or computed tomography in the staging of cervical carcinoma. Yonsei Medical

Journal; 42: 527-31.

Hricak H, Yu KK. (1996) Radiology in invasive cervical cancer. Am J Roentgenol; 167: 1101-8.

Hricak H, Powell CB, Yu KK et al. (1996) Invasive cervical carcinoma: role of MR imaging in pretreatment work up – cost minimization and diagnostic efficiency analysis. Radiology; 198: 403-9.

Hricak H, Gatsonis C, Chi DS et al. (2005) Role of imaging in pretreatment evaluation of early invasive cervical cancer: results of the intergroup study American College of Radiology

Imaging Network 6651-Gynecologic Oncology Group 183. J Clin Oncol: 23: 9329-37.

Liang CC, Tseng CJ, Soong YK. (2000) The usefulness of cystoscopy in the staging of cervical cancer. Gynecol Oncol; 76:200-3.

Reinhardt MJ, Ehritt-Braun C, Vogelgesang D et al. (2001) Metastatic lymph nodes in patients with cervical cancer: detection with MR imaging and FDG PET. Radiology; 218: 776-82.

Rockall AG, Sohaib SA, Harisinghani MG, et al. (2005) Diagnostic performance of nanoparticle-enhanced magnetic resonance imaging in the diagnosis of lymph node metastases in patients with endometrial and cervical cancer. J Clin Oncol; 23: 2813-21.

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Exenteration for solitary central pelvic disease/ or chemotherapy/ palliative care

Chemotherapy/ palliative care for multiple metastases

Chemoradiotherapy/ ERT + Brachytherapy depending upon patients fitness

Radical trachelectomy (for Ib1 only) / radical hysterectomy and pelvic lymphadenectomy

Radical trachelectomy or @loop/ cone and pelvic lymphadenectomy

Radical hysterectomy (or simple hysterectomy) and

pelvic lymphadenectomy

This guideline has been developed from the Guideline Group of the British Gynaecological Cancer Society

Simon Leeson Obstetrician and Gynaecologist (chair)

Rachel Connor Consultant Radiologist

Richard Edmondson Gynaecological Oncologist

Mark Heatley Gynaecological Pathologist

Nick Johnson Gynaecological Oncologist

Sean Kehoe Gynaecological Oncologist

Tracy Miles Nurse Specialist Gynaecological Oncology

Alison Mitchell Palliative Care Specialist

Nick Reed Clinical Oncologist

Karina Reynolds Gynaecological Oncologist

Terry Rollason Gynaecological Pathologist

North Wales Cancer Centre Guideline Group

Simon Leeson Obstetrician and Gynaecologist (chair)

Philip Toon Obstetrician and Gynaecologist

Nigel Bickerton Obstetrician and Gynaecologist

ERT if node positive or ERT + Brachytherapy

Close margins, poor differentiation for surgically unfit

(consider adjuvant chemoradiation)

Further excision

Cytological/ colposcopic follow up

Core/ extended teams to include members from YGC/ NEWT

Standards

All patients must have access to a gynaecological oncology clinical nurse specialist within 24 hours of the patient being informed of her diagnosis (this should include a daytime contact telephone number for the clinical nurse specialist). Preferably the nurse specialist should be at the consultation when the patient is given her diagnosis.

All referring practitioners and/ or patients GP’s should be informed by letter or secure fax within 24 hours of the patient being informed of her diagnosis.

All patients must be given appropriate literature about the management, treatment and outcome for cervical cancer such as a Cancerbackup leaflet or equivalent.

All these activities must be documented in the patient’s case record.

Standards

Radiotherapy should start 14 days after referral for radical treatment (good practice) although 28 days is acceptable (minimum standard).

Radiotherapy should start 28 days after referral for adjuvant treatment (minimum standard).

JCCO/RCR guidance

Standards

Rapid access to the specialist should be available with the patient seen within 2 weeks of date of receipt of the referral letter/ fax.

Definitive treatment should be commenced no later than 62 days after receipt of the referral letter/ fax.

Definitive treatment should be commenced no later than 31 days after diagnosis for non urgent suspect cancer referrals.

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