Pages from NCCN CA ENDOMETRIUM 2023.pdf.pptx

9
Pages from NCCN CA ENDOMETRIUM 2023.pdf.pptx


Pages from NCCN CA ENDOMETRIUM 2023.pdf.pptx

Pages from NCCN CA ENDOMETRIUM 2023.pdf.pptx

  • 1. NCCN Guidelines Version 1.2024
    Uterine Neoplasms
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    NCCN Guidelines Index
    Table of Contents
    Discussion
    UN-1
    a Initial preoperative evaluation for known or suspected malignancy.
    b Preoperative imaging and biopsy may help to identify uterine sarcomas, although biopsy sensitivity is less than for endometrial cancer. If there is suspicion of
    malignancy, fragmentation/morcellation should be avoided.
    c See Principles of Pathology for Endometrial Carcinoma (ENDO-A) and Principles of Pathology for Uterine Sarcoma (UTSARC-A).
    d See Principles of Imaging for Endometrial Carcinoma (ENDO-B) and Principles of Imaging for Uterine Sarcoma (UTSARC-B).
    e Consider referral to a center of expertise that specializes in the treatment of malignant mesenchymal tumors (sarcoma).
    f Should be treated as a high-grade endometrial cancer.
    g Also known as malignant mixed mesodermal tumor or malignant mixed Müllerian tumor, and including those with either homologous or heterologous stromalelements.
    INITIAL EVALUATIONa
    All staging in guideline is based on updated FIGO staging. (ST-1, ST-2, and ST-3)
    INITIAL CLINICAL FINDINGSc
    • History and physical (H&P)
    • Complete blood count
    (CBC) (including platelets),
    liver function test [LFT],
    renal function tests,
    chemistry profile; and
    consider CA-125
    • Expert pathology review
    with additional endometrial
    biopsy as clinically
    indicatedb,c
    • Imagingd
    • Recommend molecular
    evaluation of tumor and
    evaluation for inherited
    cancer risk (ENDO-Aand
    UTSARC-A)
    • For patients who are older
    with uterine cancer also
    see the NCCN Guidelines
    for Older Adult Oncology
    • Consider germline and/or
    multigene panel testing
    Malignant
    epithelial
    (carcinoma)
    Malignant mesenchymal (sarcoma)e
    • Low-grade endometrial stromal sarcoma (ESS) or adenosarcoma
    • High-grade ESS
    • Undifferentiated uterine sarcoma (UUS)
    • Leiomyosarcoma (LMS)
    • Other sarcomas (eg, perivascular epithelioid cell tumor [PEComa])
    Pure
    endometrioid
    carcinoma
    High-risk
    endometrial
    carcinoma
    histology
    Suspected or gross
    cervical involvement
    Suspected
    extrauterine disease
    Disease limited
    to uterus
    Primary Treatment
    (ENDO-1)
    Primary Treatment
    (ENDO-2)
    Primary Treatment
    (ENDO-3)
    Primary Treatment
    (UTSARC-1)
    Serous carcinoma
    Primary Treatment
    (ENDO-11)
    Primary Treatment
    (ENDO-12)
    Primary Treatment
    (ENDO-13)
    Primary Treatment
    (ENDO-14)
    Clear cellcarcinoma
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
    Undifferentiated/
    dedifferentiated
    carcinoma
    Carcinosarcomaf,g
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  • 2. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    ENDO-1
    a (UN-1) for classification of uterine neoplasms.
    b Disease is not amenable to resection or patient is not suitable for surgery based on comorbidities.
    c Principles of Pathology and Molecular Analysis (ENDO-A).
    d Minimally invasive surgery (MIS) is the preferred approach when technically feasible. See Principles of Evaluation and Surgical Staging (ENDO-C).
    e The degree of surgical staging to assess disease status depends on preoperative and intraoperative findings. Multidisciplinary expertise is recommended.
    See Principles of Evaluation and Surgical Staging (ENDO-C).
    f Ovarian preservation may be safe in select patients who are premenopausal with early-stage endometrioid cancer, normal-appearing ovaries, and no family history of
    breast/ovarian cancer or Lynch syndrome. Salpingectomy is recommended.
    g Principles of Radiation Therapy for Uterine Neoplasms (UN-A).
    h Systemic Therapy for Endometrial Carcinoma (ENDO-D).
    INITIAL CLINICAL FINDINGS
    (Endometrioid Histology)a
    PRIMARY TREATMENT
    Disease limited
    to the uterus
    Suitable for
    primary surgery
    Not suitable for
    primary surgeryb
    Total hysterectomy and bilateral
    salpingo-oophorectomy
    (TH/BSO)c and surgical
    stagingd,e,f
    External beam RT (EBRT)g
    and/or brachytherapyg (preferred)
    or
    Consider hormone therapy (including
    levonorgestrel intrauterine device [IUD])
    in select patientsh
    Adjuvant treatment for
    surgically stagedd,e:
    • Stage I (ENDO-4)
    • Stage II (ENDO-5)
    • Stage III–IV (ENDO-6)
    Incompletely
    staged
    (ENDO-7)
    Surveillance
    (ENDO-9)
    Patient desires fertility-
    sparing options
    (ENDO-8)
    Printed by Alfarisi Sutrisno on 10/15/2023 9:59:56 AM. For personal use only. Not approved for distribution. Copyright © 2023 National Comprehensive Cancer Network, Inc., All Rights Reserved.
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
  • 3. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    INITIAL
    CLINICAL
    FINDINGS
    (Endometrioid
    Histology)a
    ADDITIONAL WORKUP PRIMARY TREATMENT
    Suspected or
    gross cervical
    involvement
    Cervicalbiopsy
    or pelvic MRIi
    (if not
    previously
    done)
    Negative
    result
    TH/BSOc and
    surgical staginge
    Incompletely
    staged
    (ENDO-7)
    Positive
    resultj
    Suitable
    for primary
    surgery
    Not suitable
    for primary
    surgeryb
    TH (preferred) or radical
    hysterectomy (RH) and
    BSOc and surgical staginge
    or
    Adjuvant treatment for
    surgically stagede:
    • Stage I (ENDO-4)
    • Stage II (ENDO-5)
    • Stage III–IV (ENDO-6)
    TH/BSOc and
    surgical staginge
    4–12 weeks post RT
    EBRTg ± brachytherapyg
    Surgical resection,
    if renderedoperable
    4–12 weeks post RT
    or
    Definitive RTg if
    inoperable
    Surveillance
    (ENDO-9)
    h Systemic Therapy for Endometrial Carcinoma (ENDO-D).
    i Principles of Imaging (ENDO-B).
    a (UN-1) for classification of uterine neoplasms.
    b Disease is not amenable to resection or patient is not suitable for surgery based on
    comorbidities.
    c Principles of Pathology and Molecular Analysis (ENDO-A).
    e The degree of surgical staging to assess disease status depends on preoperative
    and intraoperative findings. Multidisciplinary expertise is recommended.
    See Principles of Evaluation and Surgical Staging (ENDO-C).
    Systemic therapy
    (category 2B)h
    or
    Surgical resectionif
    rendered operable
    or
    EBRTg
    + brachytherapyg
    if inoperable
    g Principles of Radiation Therapy for Uterine Neoplasms(UN-A). j Clear demonstration of cervical stromalinvolvement.
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    ENDO-2
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
    EBRTg ± brachytherapyg:
    (category 2B)
    Printed by Alfarisi Sutrisno on 10/15/2023 9:59:56 AM. For personal use only. Not approved for distribution. Copyright © 2023 National Comprehensive Cancer Network, Inc., All Rights Reserved.
  • 4. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    PRIMARY TREATMENT
    Primary Treatment
    (Disease limited to the
    uterus) (ENDO-1)
    No evidence
    of extrauterine
    disease
    Suspected
    extrauterine
    disease
    • Consider
    CA-125
    • Imaging as
    clinically
    indicatedi
    Abdominal/
    pelvic-confined
    disease
    TH/BSOc + surgical
    staginge/debulkingl
    (consider preoperative
    chemotherapyh)
    Systemic therapyh
    Adjuvant treatment for
    surgically stagede:
    • Stage III–IV (ENDO-6)
    Re-evaluate for
    surgical resection
    and/or RTg
    based on
    response
    Surveillance
    (ENDO-9)
    • Systemic therapyh
    ± EBRTg
    ± SBRTk
    ± TH/BSOc
    EBRTg
    ± brachytherapyg
    ± systemic therapyh
    or
    Re-evaluate for
    surgical resection
    4–12 weeks post RT
    ADDITIONAL
    WORKUP
    Suitable
    for primary
    surgery
    Not suitable
    for primary
    surgeryb
    Distant
    metastases
    INITIAL
    CLINICAL
    FINDINGS
    (Endometrioid
    Histology)a
    Locoregional
    disease
    Distant metastases Systemic therapyh
    a (UN-1) for classification of uterine neoplasms.
    b Disease is not amenable to resection or patient is not suitable for surgery based on comorbidities.
    c Principles of Pathology and Molecular Analysis (ENDO-A).
    e The degree of surgical staging to assess disease status depends on preoperative and intraoperative findings. Multidisciplinary expertise is recommended.
    See Principles of Evaluation and Surgical Staging (ENDO-C).
    g Principles of Radiation Therapy for Uterine Neoplasms (UN-A).
    h Systemic Therapy for Endometrial Carcinoma (ENDO-D).
    i Principles of Imaging (ENDO-B).
    k Consider ablative RT for 1–5 metastatic lesions if hysterectomy is performed (category 2B) (Palma DA, et al. Lancet 2019;393:2051-2058).
    Printed by Alfarisi Sutrisno on 10/15/2023 9:59:56 AM. For personal use only. Not approved for distribution. Copyright © 2023 National Comprehensive Cancer Network, Inc., All Rights Reserved.
    l The surgical goal is to have no measurable residual disease.
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    ENDO-3
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
  • 5. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    a (UN-1) for classification of uterine neoplasms.
    e The degree of surgical staging to assess disease status depends on preoperative and intraoperative findings. Multidisciplinary expertise is recommended.
    See Principles of Evaluation and Surgical Staging (ENDO-C).
    g Principles of Radiation Therapy for Uterine Neoplasms (UN-A).
    h Systemic Therapy for Endometrial Carcinoma (ENDO-D).
    m Initiate EBRT as soon as the vaginal cuff is healed, preferably no later than 12 weeks after surgery.
    Surgically staged:
    Stage Ie
    FIGO Stage Histologic Grade Adjuvant Treatment
    IA G1, G2 Observation preferred
    or
    Consider vaginal brachytherapy if lymphovascular space invasion (LVSI)
    and/or age ≥60 yn
    G3 Vaginal brachytherapy preferred
    or
    Consider observation if no myoinvasion
    or
    Consider EBRT if either age ≥70 y or LVSI (category 2B)
    IB G1 Vaginal brachytherapy preferred
    or
    Consider observation if age <60 y and no LVSI
    G2 Vaginal brachytherapy preferred
    or
    Consider EBRT if ≥60 y and/or LVSI
    or
    Consider observation if age <60 y and no LVSI
    G3 RT (EBRT and/or vaginal brachytherapy) ± systemic therapy
    (category 2B for systemic therapy)
    All staging in guideline is based on updated FIGO staging. (ST-1)
    CLINICAL FINDINGS
    (Endometrioid
    Histology)a
    HISTOLOGIC GRADE/ADJUVANT TREATMENTg,h,m
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    n Vaginal brachytherapy is strongly suggested if two risk factors are present.
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    ENDO-4
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
  • 6. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    Surveillance (ENDO-9)
    a (UN-1) for classification of uterine neoplasms.
    e The degree of surgical staging to assess disease status depends on preoperative and intraoperative findings. Multidisciplinary expertise is recommended.
    See Principles of Evaluation and Surgical Staging (ENDO-C).
    g Principles of Radiation Therapy for Uterine Neoplasms (UN-A).
    h Systemic Therapy for Endometrial Carcinoma (ENDO-D).
    m Initiate EBRT as soon as the vaginal cuff is healed, preferably no later than 12 weeks after surgery.
    o Consider additional imaging if not previously done. See Principles of Imaging (ENDO-B).
    p Adverse cervical risk factors including depth of stromal invasion, grade, LVSI, and adverse fundal risk factors influencing therapy decisions for stage I disease
    (ENDO-4), such as depth of myometrial invasion and LVSI, may also impact the choice of adjuvant therapy for stage II disease.
    q Vaginal brachytherapy is also an option for grade 1 or 2, ≤50% myometrial invasion, no LVSI, and microscopic cervical invasion (Harkenrider MM, et al. Int J Radiat
    All staging in guideline is based on updated FIGO staging. (ST-1)
    HISTOLOGIC GRADE/ADJUVANT TREATMENTg,h,m
    Surgically stagede:
    Stage IIo,p
    FIGO Stage Histologic Grade Adjuvant Treatment
    II G1–G3 EBRT (preferred)
    and/or vaginal brachytherapyq
    ± systemic therapy
    (category 2B for systemic therapy)
    Oncol Biol Phys 2018;101:1069-1077).
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    ENDO-5
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
    CLINICAL FINDINGS
    (Endometrioid
    Histology)a
    Printed by Alfarisi Sutrisno on 10/15/2023 9:59:56 AM. For personal use only. Not approved for distribution. Copyright © 2023 National Comprehensive Cancer Network, Inc., All Rights Reserved.
  • 7. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    a (UN-1) for classification of uterine neoplasms.
    e The degree of surgical staging to assess disease status depends on preoperative and intraoperative findings. Multidisciplinary expertise is recommended.
    See Principles of Evaluation and Surgical Staging (ENDO-C).
    g Principles of Radiation Therapy for Uterine Neoplasms (UN-A).
    h Systemic Therapy for Endometrial Carcinoma (ENDO-D).
    r Additional imaging if not previously done. See Principles of Imaging(ENDO-B).
    All staging in guideline is based on updated FIGO staging. (ST-1)
    ADJUVANT TREATMENTg,h
    Surgically stagede:
    Stage III, IVr
    CLINICAL FINDINGS
    (Endometrioid Histology)a
    s Combination therapy depends on assessment of both locoregional and distant metastatic risk. Consider combination therapy for stage IIIB and IIIC disease.
    Surveillance
    (ENDO-9)
    ENDO-6
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
    Systemic therapy
    ± EBRTs
    ± vaginal brachytherapys
    Printed by Alfarisi Sutrisno on 10/15/2023 9:59:56 AM. For personal use only. Not approved for distribution. Copyright © 2023 National Comprehensive Cancer Network, Inc., All Rights Reserved.
  • 8. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    All staging in guideline is based on updated FIGO staging. (ST-1)
    CLINICAL INTRAUTERINE FINDINGS
    (Endometrioid Histology)a
    Stage IA, G1–2 and no LVSI and age <60 y
    Stage IA, G3 and age <60 y and no LVSI and no myometrial invasion
    ADJUVANT TREATMENT
    Observe
    Incompletely
    surgically
    staged
    Imagingi
    Negative
    Suspicious/Positive Adjuvant treatment for
    surgically stagede:
    • Stage I (ENDO-4)
    • Stage II (ENDO-5)
    • Stage III–IV (ENDO-6)
    Surgical restaginge
    Surgically
    restage or
    pathologic
    confirmation
    of metastatic
    disease in select
    patients
    • Stage I (ENDO-4)
    • Stage II (ENDO-5)
    • If not surgically restaged
    and substantial LVSI,
    consider EBRTg
    ± brachytherapyg
    Stage IA, G3 or
    Stage IB, G1–2
    and
    Age ≥60 y and no LVSI
    Imagingi
    Stage IA, G1–3 and LVSI
    Stage IB, G1–2 and LVSI
    Stage IB, G3 ± LVSI
    Stage II
    At least ≥ stage IIIA Adjuvant treatment
    (ENDO-6)
    Imaging performed
    and negative
    Imagingperformed
    and suspicious/
    positive
    Surgical
    restaginge
    or biopsy
    Vaginal
    brachytherapyg
    Adjuvant treatment for
    surgically stagede:
    • Stage I (ENDO-4)
    • Stage II (ENDO-5)
    • Stage III–IV (ENDO-6)
    a (UN-1) for classification of uterine neoplasms.
    e The degree of surgical staging to assess disease status depends on preoperative and intraoperative findings. Multidisciplinary expertise is recommended.
    See Principles of Evaluation and Surgical Staging (ENDO-C).
    g Principles of Radiation Therapy for Uterine Neoplasms (UN-A).
    i Principles of Imaging (ENDO-B).
    Surveillance
    (ENDO-9)
    ENDO-7
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
    Printed by Alfarisi Sutrisno on 10/15/2023 9:59:56 AM. For personal use only. Not approved for distribution. Copyright © 2023 National Comprehensive Cancer Network, Inc., All Rights Reserved.
  • 9. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    d MIS is the preferred approach when technically feasible. See Principles of Evaluation and Surgical Staging (ENDO-C).
    e The degree of surgical staging to assess disease status depends on intraoperative findings. Multidisciplinary expertise is recommended. See Principles of Evaluation
    and Surgical Staging (ENDO-C).
    i Principles of Imaging (ENDO-B).
    t See Healthy Lifestyles (HL-1) and Nutrition and Weight Management (SNWM-1) in the NCCN Guidelines for Survivorship.
    CRITERIA FOR CONSIDERING
    FERTILITY-SPARING OPTIONS
    FOR MANAGEMENT OF
    ENDOMETRIAL CARCINOMA
    (All criteria must be met)
    PRIMARY
    TREATMENT
    SURVEILLANCE
    • Well-differentiated
    (grade 1) endometrioid
    adenocarcinoma on
    dilation and curettage
    (D&C) confirmed by
    expert pathology review
    • Disease limited to the
    endometrium on MRI
    (preferred) or
    transvaginal ultrasoundi
    • Absence of suspicious
    or metastatic disease on
    imaging
    • No contraindications to
    medical therapy or
    pregnancy
    • Patients should undergo
    counseling that fertility-
    sparing option is NOT
    standard of care for the
    treatment of endometrial
    carcinoma
    • Consultation with
    a fertility expert
    prior to therapy
    • Recommend
    molecular
    evaluation of tumor
    and evaluation for
    inherited cancer
    risk (UN-1)
    • Ensure negative
    pregnancy test
    • Continuous progestin-
    based therapy:
    Megestrol
    Medroxyprogesterone
    Levonorgestrel IUD
    (preferred for fertility
    preservation)
    • Weight management/
    lifestyle modification
    counselingt
    Endometrial
    evaluation
    every 3–6 mo
    (either D&C or
    endometrial
    biopsy)
    Complete
    response
    by 6 mo
    Endometrial
    cancer present
    at 6–12 moi,u
    Encourage
    conception
    (with continued
    surveillance/
    endometrial
    sampling
    every 6–12 mo
    and consider
    maintenance
    progestin-
    based therapy
    if patient is not
    actively trying
    to conceive)
    TH/BSO with
    stagingd,e
    after
    childbearing
    complete or
    progression
    of disease on
    endometrial
    sampling
    (ENDO-1)
    • Ovarian
    preservation
    may be
    considered in
    select patients
    who are
    premenopausal
    TH/BSO with
    stagingd,e
    (ENDO-1)
    • Ovarian
    preservation
    may be
    considered in
    selectpatients
    Printed by Alfarisi Sutrisno on 10/15/2023 9:59:56 AM. For personal use only. Not approved for distribution. Copyright © 2023 National Comprehensive Cancer Network, Inc., All Rights Reserved.
    u Gunderson CC, et al. Gynecol Oncol 2012;125:477-482 and Hubbs JL, et al. Obstet Gynecol 2013;121:1172-1180.
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    ENDO-8
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
  • 10. NCCN Guidelines Version 1.2024
    Endometrial Carcinoma
    NCCN Guidelines Index
    Table of Contents
    Discussion
    g Principles of Radiation Therapy for Uterine Neoplasms(UN-A).
    h Systemic Therapy for Endometrial Carcinoma (ENDO-D).
    i Principles of Imaging (ENDO-B).
    v Principles of Gynecologic Survivorship (UN-B).
    SURVEILLANCE CLINICAL THERAPY FOR RELAPSE
    PRESENTATION
    • Physical exam (including pelvis)
    every 3–6 mo for 2–3 y,
    then every 6–12 mo for up t
    o
    year 5,
    then annually
    • CA-125 if initially elevated
    • Imaging as indicated based on
    symptoms or examination findings
    suspicious for recurrencei
    • Patient education regarding
    symptoms of potential recurrence,
    lifestyle, obesity, exercise, smoking
    cessation, sexual health (including
    vaginal dilator use and lubricants/
    moisturizers), nutrition counseling,
    and potential long-term and late
    effects of treatmentv
    (Also see NCCN Guidelines for
    Survivorship and NCCN Guidelines
    for Smoking Cessation)
    Locoregional
    recurrence
    • Negative for distant
    metastases on
    radiologic imagingi
    Isolated
    metastases
    Therapy for Relapse (ENDO-10)
    • Consider resection
    and/or EBRTg
    or
    Ablative therapyw
    • Consider systemic
    therapyh (category 2B)
    Not amenable to
    local treatment
    or
    Further recurrence
    Treat as
    disseminated
    metastases
    (See below)
    Disseminated Systemic therapyh
    metastases ± palliative EBRTg
    If progression,
    Best
    supportive
    care
    (NCCN
    Guidelines for
    Palliative Care)
    Printed by Alfarisi Sutrisno on 10/15/2023 9:59:56 AM. For personal use only. Not approved for distribution. Copyright © 2023 National Comprehensive Cancer Network, Inc., All Rights Reserved.
    w Consider ablative RT for 1–5 metastatic lesions if the primary cancer has been controlled (category 2B) (Palma DA, et al. Lancet 2019;393:2051-2058).
    Note: All recommendations are category 2A unless otherwise indicated.
    Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
    ENDO-9
    Version 1.2024, 09/20/23 © 2023 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.


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much more over just two days, you are guaranteed to gain an all-encompassing insight into
the industry to tackle the challenges of disasters.
By uniting global disaster risk management experts, well experienced emergency
responders and the leading innovators from the world, the event is the hub of the solutions
that provide attendees with tools that they can use to protect the communities and mitigate
the damage from disasters.
Tickets for the event are $119, but we have been given the promo code: HUGI100 that will
enable you to attend the event for FREE!

So don’t miss out and register today: https://shorturl.at/aikrW

And in case you missed it, here is our ultimate road trip playlist is the perfect mix of podcasts, and hidden gems that will keep you energized for the entire journey

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