婦癌

Taipei Veterans General Hospital 

Practice Guideline for GYN Cancer 

1 

2012 台北榮總婦癌診療指引 

初版 2007 年 10 月 17 日 

修正版 ( 七 ) 2012 年 04 月 25 日

1.前言 

2. Cervical Cancer 

目錄 

(1) Stage -------------------------------------------------------- 4 

(2) Treatment Strategy -------------------------------------- 5 

(3) Chemotherapeutic Regimens -------------------------- 9 

3. Endometrial Cancer 

2 


(1) Stage (uterine carcinoma & sarcoma) --------------- 14 



4. Epithelial Ovarian Cancer 

(1) Stage (ovary, PPSC , and tube cancer) ---------------- 25 



5. Borderline Ovarian Cancer 


6. 化療的毒性--------------------------------------------------- 37 

7. 參考資料-------------------------------------------------------42

前言 

3 


95 年癌症委員會與本院癌症治療專家共同參與討論制定癌症治療準 

則,於 95 年 5 月制定本院子宮頸癌治療準則,婦癌多專科醫療團隊以國家 

衛生研究院婦癌診療指引及 NCCN GUIDELINE 治療準則為基準,於 96 年 

10 月始召開本院第一次子宮頸癌團隊會議,腫瘤個案管理師並於 96 年 10 

月針對新診斷子宮頸癌個案開始收案,新診斷個案定義:含 class 1~3 病人, 

class 1 (本院診斷,於本院接受全部或部分首次治療療程,含拒絕治療決定 

不治療)、class 2 (外院診斷,於本院接受全部或部分首次治療療程,含拒絕 

治療決定不治療)、class 3 (外院診斷,於外院接受全部首次治療療程),為 

服務更多婦癌病患,於 98 年 1 月開始進行子宮內膜癌個案收案 (不含惡性 

肉瘤,99 年開始 MMMT 併入子宮內膜癌收案),99 年 1 月開始,針對卵巢 

癌個案收案(只收上皮性卵巢癌,於 100 年 1 月開始進行非上皮性卵巢癌收 

案) ,101 年 1 月開始將腹膜癌及輸卵管癌列入卵巢癌診療指引,團隊成員 

經多次會議修訂本院婦癌診療共識,並至少每年修訂診療指引一次,據以 

公告週知以供查閱。 

本共識與上一版差異 

1. 將三癌 (子宮頸癌、子宮體癌、卵巢癌) 分開版本彙整為一個版本 (婦癌) 

2. 加入子宮頸癌、子宮內膜癌、肉瘤 (未列入收案)、卵巢癌及輸卵管癌 

FIGO 及 TNM 期別參考 (2010 年第 7 版:The MX designation has been 

eliminated from the AJCC/UJCC TNM system)。 

3. 新增子宮體癌病理分化程度等級及第一型、第二型子宮體癌說明表格。 

4. 新增顏明賢主任編著之化療的毒性 

返回目錄

Cervical Cancer 

4 

2012 台北榮總婦癌診療指引-子宮頸癌 

Staging cervical cancer (FIGO stage, 2009 and TNM AJCC 7th ed, 2010) 

Primary tumor (T) 

TNM FIGO Definition 

T1 I Cervical carcinoma confined to uterus (extension to corpus should be disregarded) 

T1a IA 

T1a1 IA1 

T1a2 IA2 

Invasive carcinoma diagnosed only by microscopy. Stromal invasion with a maximum 

depth of 5.0 mm measured from the base of the epithelium and a horizontal spread of 

7.0 mm or less. Vascular space involvement, venous or lymphatic, does not affect 

classification. 

Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal 

spread 

Measured stromal invasion more than 3.0 mm and not more than 5.0 mm in depth with 

a horizontal spread 7.0 mm or less 

T1b IB Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 

T1b1 IB1 Clinically visible lesion 4.0 cm or less in greatest dimension 

T1b2 IB2 Clinically visible lesion more than 4.0 cm in greatest dimension 

T2 II 

Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of 

vagina 

T2a IIA Tumor without parametrial invasion or involvement of the lower one-third of the vagina 

T2a1 IIA1 

T2a2 IIA2 

Clinically visible lesion 4.0 cm or less in greatest dimension with involvement of less than 

the upper two-thirds of the vagina 

Clinically visible lesion more than 4.0 cm in greatest dimension with involvement of less 

than the upper two-thirds of the vagina 

T2b IIB Tumor with parametrial invasion 

T3 III 

Tumor extends to pelvic wall and/or involves lower third of vagina, and/or causes 

hydronephrosis or nonfunctioning kidney 

T3a IIIA Tumor involves lower third of vagina, no extension to pelvic wall 

T3b IIIB Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney 

T4 IVA 

Regional lymph nodes (N) 

Tumor invades mucosa of bladder or rectum, and/or extends beyond true pelvis (bullous 

edema is not sufficient to classify a tumor as T4) 


NX 

N0 

Regional lymph nodes cannot be assessed 

No regional lymph node metastasis 

N1 IIIB Regional lymph node metastasis 

Distant metastasis (M) 


M0 

M1 IVB 

No distant metastasis 

Distant metastasis (including peritoneal spread, involvement of supraclavicular, 

mediastinal, or paraaortic lymph nodes, lung, liver, or bone) 

*Note: All macroscopically visible lesion-even with superficial invasion are T1b/IB 

返回目錄

術前準備 

- Blood analysis 

- Pathology proved 

- Tumor marker 

子宮頸癌治療指引 

- CT scan / MRI / PET-CT (小心健保剔退) if clinically indicated 

- Cystoscopy / Colonoscopy if clinically indicated 

FIGO Early Stage (IA to IIA, selective IIB) 

Stage Treatment Plan 

IA1 

IA2 

IB1 

IIA1 

IB2 

IIA2 

Selective IIB 

50 y/o, adenocarcinoma, and poorly differentiated. 

● Treatment guideline for other cell types (adenosquamous、neuroendocrine、adenosarcoma、clear 

cell、MMMT、sarcoma ) will be discussed and planned after evaluation by the gynecology 

oncology committee. 

● Ovarian transposition during RH if adjuvant radiotherapy considered (No oophorectomy). 

●Laparotomy or Laparoscopic surgery is acceptable (stage IA1、IA2、IB1、IIA1,但 Radical 

trachelectomy 狀況除外) . 

返回目錄

手術後的輔助治療 (FIGO 早期) 

6 


LN Parametrium Bulky size Management 

(-) 

(-) 

(-) 

(+) 

(+) (-) or (+) 

(+) (-) or (+) (-) or (+) 

LVSI (-) 

DSI (-) 

LVSI (+) 

and / or 

DSI (+) 

LVSI (+) 

and / or 

DSI (+) 

LVSI (+) 

and / or 

DSI (+) 

LVSI (+) 

and / or 

DSI (+) 

If vaginal cut end (+) additional radiotherapy required 

Prognostic Risk Factors: 

High Risk: 

- LN (+) / Parametrial margin (+) / Vaginal cut end margin (+) 

Intermediate Risk: 

- Bulky tumor size ( ≥ 4 cm ) / LVSI (+) / DSI (+) 

Others 

- Age / Diploidy / Differentiation / Histological type 

Adenocarcinoma type 

- Adjuvant systemic treatment may be considered in the stage IB 

- IB2 with intermediate risk 

CCRT for primary treatment followed by systematic chemotherapy 

Observation 

Radiotherapy (C-1) 

or Observation 

Radiotherapy (C-1) 

or Obsertvation 

or CCRT (see below) 

CCRT (see below) 

or Radiotherapy 

CCRT (see below) ± vaginal 

brachytherapy (C-1) 

or Chemotherapy (see below) 

Or Radiotherapy 

返回目錄

FIGO 早期不能手術及晚期患者 

Step 1 

Lymph Node Assessment 

- Image study (CT scan, MRI or PET) ± FNA 

7 


- Surgical staging (laparotomy, extrafascial, or laparoscopic lymph node sampling) 

Step 2 

Lymph Node (-) 

- CCRT (platinum-based chemotherapy) ± Para-aortic boost (Point A ≧ 85Gy) 

Lymph Node(+) 

Step 3 

- CCRT (platinum-based chemotherapy) + Para-aortic boost (Point A ≧ 85Gy) 

Consolidation chemotherapy, if necessary 

- 5 year survival rate 

- Stage IIB-IVA: 20-60% 

- Stage IVB: < 20 % 

返回目錄

單純子宮切除後意外發現 

Stroma 

Invasion 

Depth < 3 mm 

Stroma 

Invasion 

Depth < 3 mm 

with LVSI (+) 

or 

Depth ≧ 3mm 

Surgical 

Margin 

(-) 

(+) 

* Re-operate includes the following: 

8 


LVSI Management 

(-) Observation 

(+) See below 

LN status 

(Image 

study) 

(-) 

(+) 

(-) 

(+) 

Management 

Re-operation* 

or 

brachytherapy ± 

Pelvic R/T 

LND + CCRT 

or 

Re-operation* 

or 


Radiotherapy 

or 


or 

Re-operation* 

LND + CCRT 

or 

Re-operation* 

or 


- Radical parametrectomy + Upper vaginectomy + PLND ± PALNS 

- Image study consistent with the following: 

- No parametrial invasion 

- No pelvic side-wall invasion 

- No rectal or bladder invasion 

Adjuvant 

Therapy 

According to 

pathological 

risk factors 

(see above) 

返回目錄

化療處方建議 

子宮頸癌化療處方適應症- 

- Adjuvant chemotherapy for postoperative lymph node metastasis 

- Neoadjuvant chemotherapy for bulky tumor 

- Followed by surgery 

- Followed by radiotherapy 

- Concurrent chemoradiotherapy 

- Early bulky tumor followed by surgery 

9 


- Postoperative with parametrial involvement and lymph node metastasis 

- Local advanced cancer 

- Consolidation chemotherapy after concurrent chemoradiotherapy for advanced cancer 

- Palliative chemotherapy for distant, recurrent, or metastatic cancer 

- If distant metastasis or recurrence Systemic Chemotherapy ± Palliative Radiotherapy 

Neoadjuvant Chemotherapy: (新輔助化療) 

1. Cisplatin Only (q w x 3 cycle) 

Cisplatin 40 mg/m 2 (at least > 25 mg/m 2 ) IVD 1hr 

- RH performed on 3 rd day after completing chemotherapy 

2. Palcitaxel + Cisplatin Regimen (q 10 d x 3 cycle) 

Palcitaxel 60 mg/m 2 IVD 1.5 hrs 

Cisplatin 60 mg/m 2 IVD 1 hr 

- RH performed within 3 weeks after completing chemotherapy 

CCRT regimen: (同步化學放射治療) 

1. Cisplatin Only (q w) 


2. POB Regimen (q 3 w) 

Cisplatin 50 mg/m 2 1 hr 

Vincristine 1 mg/m 2 IVD 15-30 mins 

Bleomycin 15 mg (D1~3) IVD 15 mins(累積劑量不可>150mg ) 

Consolidation Chemotherapy Regimen: (鞏固化療) 

1. I+P regimen (q 3 w x 6 cycle) 

(1) Ifosfamide (24 hrs) + Cisplatin 

Ifosfamide 5 gm/m 2 IVD 24 hrs 


返回目錄

(2) Ifosfamide (3 days) +Cisplatin 

Ifosfamide 1 gm/m 2 IVD 24 hrs 


2. Paclitaxel + Cisplatin Regimen (q 3 w x 6 cycle) 

Paclitaxel 135 mg/m 2 IVD 3 hrs 


3. Topotecan (D1~3) + Platinum Regimen (q 3 w x 6 cycle) 

Topotecan 0.75 mg/m 2 (D1~D3) IVD 30 mins 

10 


Cisplatin 50 mg/m 2 (D1) or Carboplatin AUC5 (D3) if Ccr

Cisplatin 50 mg/m 2 

7. Irinotecan + Cisplatin Regimen(x 6 cycle) 

Irinotecan 60mg/m 2 (D1 / D8 / D15) 

Cisplatin 60 mg/m 2 (D1) IVD 1 hr 

Common used Regimen for Non-squamous Cell Carcinoma 

1. Paclitaxel + Cisplatin Regimen (q 3 w) 



2. Paclitaxel Only (q3w) 


11 


Paclitaxel 135 mg/m 2 IVD 3 hrs (if prior radiotherapy) 

- Dose escalation to 200 mg/m 2 or de-escalation to 110 mg/m 2 depending on toxicity 

3. Etoposide Only (every 28 days) 

- Oral Etoposide 50 mg/m 2 /day for 21 days 

- Oral Etoposide 40 mg/m 2 /day (if prior radiotherapy) for 21 days 

- Dose escalation to 60mg/m 2 /day depending on toxicity 

4. VIP Regimem (for neuroendocrine cell type) (q 3~4 w x 6 courses) 

- Etoposide 100mg/m 2 IVD 1 hr (D1~3) 

- Ifosfamide 1500 mg/m 2 IVD 1 hr (D1~3) 

- Cisplatin 50 mg/m 2 IVD 2 hr (D1) 

備註:Cisplatin 為子宮頸癌治療化學治療首選藥物,若 (CCr < 60),Carboplatin 可做 

為替代藥物取代 (婦癌個案注射 Cisplatin 若因 CCR ≤ 60,weekly Cisplatin 40 

mg/m 2 ,可改為 Carboplatin AUC 2;若非 weekly 用法,如 Cisplatin Q 3 W 使用,則 

為 75 mg/m 2 改為 Carboplatin AUC 5。) 

疾病持續/復發治療策略 

考慮因素: 

- Site of recurrence or metastases 

Pelvic Extra-pelvic 

- Central - Intra-abdominal organs 

- Side wall - Distant lymph nodes 

- Combined - Distant disseminated metastases 

- Prior therapy 

- Surgery Radiotherapy 

- Radiotherapy Surgery 

返回目錄

- Possible routes or mechanisms of spread 

- Status of patient's performance 

- Palliative or Curative treatment 

Cervical Cancer with Central Recurrence (中央復發) 

Prior Surgery 

- Surgical intervention if no contraindication 

- Radiotherapy if surgical intervention not possible 

Prior Radiotherapy 


- Radiotherapy indicated if recurrence outside of previously treated field 

- Palliative radiotherapy 

- Palliative chemotherapy (see above) 

Surgical Intervention 

- If previous surgery is only total abdominal hysterectomy 

- Radical parametrectomy + PLND + PALNS 

- If previous surgery is radical hysterectomy + PLND + PALNS 

- Exenteration can be considered (Total / Anterior / Posterior) 

12 


- Exenterative surgery should NOT be used as a palliative treatment, except in the 

presence of malignant fistulas in the pelvis. 

- Final intraoperative assessment: 

- The final decision to proceed with exenteration will not be made until the 

abdomen has been opened and assessment of the pelvic side-wall and posterior 

abdominal wall has been made, utilizing frozen section where necessary. 

- Contraindication of exenterative surgery 

Absolute Contraindication Relative Contraindication 

- Metastases to extrapelvic LN - Obesity 

- Metastases to abdominal viscera 

- Metastases to lung or bones - Triad * 

* TRIAD: 

- Pelvic side-wall spread: 

direct extension or nodal metastases 

1. Unilateral uropathy, non-functional kidney, or ureteric obstruction 

2. Unilateral leg edema 

3. Sciatic leg pain 

返回目錄

13 


Cervical Cancer with Pelvic Side Wall Recurrence (側壁復發) 

Prior Surgery 

- Radiotherapy recommended 



- LEER procedure: laterally extended endopelvic resection 

- CORT procedure: combined operative and radio-therapeutic treatment for close or 

positive margins 

- Indication: 

- Histological confirmed, unifocal pelvic side-wall recurrence 

- Free from tumor dissemination 

- Tumor limited to a maximal diameter of < 5 cm 

- Medical condition compatible with major surgery. 

- Willingness to accept urinary or fecal diversion 

- Radiotherapy ± chemotherapy indicated if recurrence outside of previously treated field 



Cervical Cancer with Central and Pelvic Side Wall Recurrence 

(中央及側壁復發) 

Prior Surgery 



- Radiotherapy indicated if recurrence outside of previously treated field 



Only Distant LN Metastasis (including para-aortic LN) 

(只有遠處淋巴結轉移(包括腹主動脈旁淋巴結)) 


- Chemotherapy recommended (see above) 

- CCRT recommended (see above) 

Intra-abdominal Organ Metastasis (腹內臟器轉移) 

- Chemotherapy recommended (see above) 

- Palliative surgery only for intestinal obstruction 

Dissemination(遠處轉移) 

- Multiple sites or unresectable → Chemotherapy recommended (see above) 

- Resectable →Surgery → R/T ± chemotherapy 

→ Chemotherapy ± R/T 

返回目錄

Uterine Cancer 

14 

2012 台北榮總婦癌診療指引-子宮內膜癌 

Staging uterine carcinoma (FIGO stage, 2009 and TNM AJCC 7th ed,2010) 

Primary tumor (T) (surgical-pathologic findings) 

TNM 

categories 

TX 

T0 

Tis* 

FIGO 

stages 

Definition 

Primary tumor cannot be assessed 

No evidence of primary tumor 

Carcinoma in situ (preinvasive carcinoma) 

T1 I Tumor confined to corpus uteri 

T1a IA 

Tumor limited to endometrium or invades less than one-half of the 

myometrium 

T1b IB Tumor invades one-half or more of the myometrium 

T2 II 

T3a IIIA 

T3b IIIB 

T4 IVA 


TNM 

categories 

NX 

N0 

FIGO 

stages 

Tumor invades stromal connective tissue of the cervix but does not 

extend beyond uterus 

Tumor involves serosa and/or adnexa (direct extension or 

metastasis) 

Vaginal involvement (direct extension or metastasis) or parametrial 

involvement 

Tumor invades bladder mucosa and/or bowel mucosa (bullous 

edema is not sufficient to classify a tumor as T4) 

Definition 



N1 IIIC1 Regional lymph node metastasis to pelvic lymph nodes 

N2 IIIC2 


TNM 

categories 

M0 

FIGO 

stages 

M1 IVB 

Regional lymph node metastasis to para-aortic lymph nodes, with 

or without positive pelvic lymph nodes 


Definition 

Distant metastasis (includes metastasis to inguinal lymph nodes 

intraperitoneal disease, or lung, liver, or bone. It excludes 

metastasis to para-aortic lymph nodes, vagina, pelvic serosa, or 

adnexa.) 

*Note: endocervical glandular involvement only should be considered as Stage I and no 

longer as Stage II 

返回目錄

15 


Staging uterine sarcoma (TNM and FIGO Study)參考用,個管未列入收案 

Primary tumor (T)* 


Leiomyosarcoma and endometrial stromal 

sarcoma 

Adenosarcoma 

T1 I Tumor limited to the uterus Tumor limited to the uterus 

T1a IA 

Tumor 5 cm or less in greatest 

dimension 

T1b IB Tumor more than 5 cm 

T1c IC X 

Tumor limited to the 

endometrium / endocervix 

Tumor invades to less than 

half of the myometrium 

Tumor invades more than 

half of the myometrium 

T2 II Tumor extends beyond the uterus, within the pelvis 

T2a IIA Tumor involves adnexa 

T2b IIB Tumor involves other pelvic tissues 

T3 III Tumor infiltrates abdominal tissues 

T3a IIIA One site 

T3b IIIB More than one site 

T4 IVA Tumor invades bladder or rectum 


TNM 

categories 

FIGO 

stages 

Definition 

Leiomyosarcoma, endometrial stromal sarcoma and Adenosarcoma 

NX 

N0 



N1 IIIC Regional lymph node metastasis 


TNM 

categories 

FIGO 

stages 

Definition 

Leiomyosarcoma, endometrial stromal sarcoma and Adenosarcoma 

M0 No distant metastasis 

M1 IVB 

Distant metastasis (excluding adnexa, pelvic and abdominal 

tissues) 

Carcinosarcomas should be staged as carcinomas of the endometrium 

返回目錄

子宮癌等級:病理分化程度 

16 


Cases of carcinoma of the corpus should be grouped with regard to the degree 

of differentiation of the adenocarcinoma as follows: 

G1 5 percent or less of a non-squamous or non-morular solid growth pattern 

G2 

6 percent to 50 percent of a non-squamous or non-morular solid growth 

pattern 

G3 More than 50 percent of a non-squamous or non-morular solid growth pattern 

Endometrial carcinoma, types 1 vs. type 2 

Histology endometrioid carcinoma 

typical patient 

Estrogen 

receptor 

MIB1 

proliferation 

index 

Molecular 

genetic 

changes 

perimenopausal or 

Type 1 Type 2 

early postmenopausal women 

background of endometrial 

hyperplasia 

serous carcinoma, 

clear cell carcinoma 

elderly women 

low-grade high-grade 

atrophic endometrium 

estrogen-dependent not estrogen-dependent 

may show a focal or diffuse 

papillary pattern 

usually positive; 

high-grade cases may be 

negative 

a glandular variant shows little or 

no papillary formation but has 

high-grade cytology 

negative 

low high 

PTEN or 

KRAS gene mutation; 

microsatellite instability 

P53 or 

HER2 or 

E-cadherin mutation 

返回目錄

術前準備 

- Blood analysis 

- Tumor marker 

- Ultrasound / Doppler / CT / MRI 

- Pathology proved 

主要治療 

- Staging surgery (分期手術) 

- Stage I 

子宮內膜癌治療指引 

17 


Peritoneal cytology + Hysterectomy (Level 1) + BSO ± (BPLND + PALNS) 

- Stage II 

Peritoneal cytology + Hysterectomy (Level 1 or 2) / Radical Hysterectomy 

(Level 3) + BSO + BPLND + PALND 

- Stage III/IV or type II histology (as ovarian cancer staging surgery) 

Peritoneal cytology + Hysterectomy (Level 1) + BSO + BPLND + PALNS + 

omentectomy + debulking surgery 

- Type II histology: papillary serous, clear cell or carcinosarcoma 

- Ovarian preservation: dependent on patient age, condition, and willingness 

- Inoperable condition (不能手術情況) 

- Radiotherapy 

返回目錄

輔助治療(According to FIGO stage 2009) 

Stage I (post complete surgical staging) 

Stage 1A 

MI + (-) 

Stage 1A 

MI + (+) 

Stage 1B 

Adverse 

risk 

factors 

(-) 

(+) 

18 


G1 G2 G3 

Observation Observation 

(-) Observation Observation 

(+) 

Vaginal 

brachytherapy 

(-) Observation 

(+) 

Vaginal 

brachytherapy 

or 

Pelvic RT ± Vaginal 

brachytherapy* 

Vaginal 

brachytherapy 

or 



Observation 

or 

Vaginal 

brachytherapy 

Vaginal 

brachytherapy 

or 



± Chemotherapy* 

Observation 

or 

Vaginal 

brachytherapy 

or 



Observation 

or 

Vaginal 

brachytherapy 

or 







Type II histology: Stage IA, MI (-): Observation or Chemotherapy or vaginal brachytherapy 

MI + : myometrial invasion 

Stage IA, MI (+), IB: Chemotherapy ± tumor-directed RT or Whole 

Adverse risk factors include the following: 

- > 60 y/o 

- positive lymphovascular invasion 

- tumor size ≧ 2cm 

- lower uterine involvement 

* 仍未定論 

abdominopelvic RT 

± Vaginal brachytherapy* 

返回目錄

Stage II (post complete surgical staging) 

MI < 50% 

MI > 50% 

Type II histology: 

19 


G1 G2 G3 

Observation 

or 

Vaginal brachytherapy 

Pelvic radiotherapy 

± Vaginal brachytherapy 


Observation 

or 


or 






Stage II: Chemotherapy ± tumor-directed RT or Whole abdominopelvic RT 

± vaginal brachytherapy* 

MI: myometrial invasion 

If stage II patient received radical hysterectomy, they can be treated as stage I 

Adjuvant pelvic radiotherapy (RT): 40 ~ 50 Gy to CTV 





+ Vaginal brachytherapy 


- Upper vaginal tumor bed as vaginal cut end + parametrium + pelvic lymph nodes. 


返回目錄

Stage III/ IV (post complete surgical staging) 

Stage III A 

20 


G1 G2 G3 

Tumor-directed radiotherapy ± chemotherapy 

or 

Pelvic radiotherapy ± Vaginal brachytherapy* 

or 

Whole abdominopelvic RT ± vaginal brachytherapy* 

or 

Chemotherapy ± radiotherapy** 

Stage IIIB Tumor-directed radiotherapy ± chemotherapy 

Stage IIIC1 

Stage IIIC2 

Stage IVA/B 

Type II histology 

Debulked and without 

gross residual disease 

or microscopic 

abdominal disease 

Chemotherapy ± Tumor-directed radiotherapy 

*Chemotherapy ± Tumor-directed radiotherapy 

Stage III/IV (adequately debulked): Chemotherapy ± tumor-directed RT or 

Stage III/IV (inadequately debulked): Chemotherapy 


** 尚有爭議 

Whole abdominopelvic RT ± vaginal brachytherapy* 

返回目錄


Single agent Regimen(單一藥劑處方) 

21 


Dose Schedule IVD Cycle 

Cisplatin 50 mg/m 2 Q 3 W 1 hr 6 

Carboplatin AUC 5 以上 Q 4 W 1 hr 6 

Doxorubicin 60 mg/m 2 Q 3 W 20 mins ~1 hr 6 

Ifosphamide 1500 mg/m 2 (3-5 days) Q 3 W 1~2 hrs 6 

Paclitaxel 175 mg/m 2 Q 3 W 3 hrs 6 

Combination Regimen (組合藥劑處方) 

Dose Schedule IVD Cycle 

Doxorubicin + Cisplatin 60 / 50 mg/m 2 Q 3 W 1 hr /1 hr 8 

Paclitaxel + Cisplatin 175 (3 hrs) / 50 mg/m 2 Q 3W 3 hrs /1 hr 6 

Paclitaxel + Carboplatin 175 (3 hrs) / AUC 5~7.5 Q 3 W 3 hrs /1 hr 6 

CAP 

Cyclophosphamide + 

Doxorubicin + Cisplatin 

TAP 

Paclitaxel + Doxorubicin 

+ Cisplatin+ GCSF 

600 / 45 / 50 mg/m 2 Q 4W 

160 / 45 / 50 mg/m 2 Q 3 W 

>30mins/ 

1~2 hrs/1 hr 

3 hrs / 

>30mins/1 hr 

6 

7 

返回目錄

不完整分期手術後意外發現 

Histologic 

findings 

Stage IA G1, 2 

without risk 

factors 

Stage IA G1, 2 

with adverse risk 

factors 

Stage IB 

Stage II All G3 

22 


Image studies Management 

(-) 

Observation 

Observation 

or 


or 


(+) Complete surgical staging 

(-) 

Adverse risk factors include the following: 

- > 60 y/o 

- positive lymphovascular invasion 

- tumor size ≧ 2cm 

- lower uterine involvement 



+ Vaginal brachytherapy 

± Radiotherapy to PALN 


(+) Complete surgical staging 

返回目錄

復發或復發性疾病 

Relapse or 

recurrence 

Vaginal 

recurrence 

Isolated 

metastasis 

Disseminated 

metastases 

Resectable 

lesion 

Unresectable 

lesion 

Asymptomatic 

or 

Grade 1 

Symptomatic 

or 

Grade 2.3 

or 

Large lesion 

23 


Salvage therapy 

Resection or Radiotherapy 

Surgery 

or 

± Radiotherapy 

Hormone treatment 

or 

Chemotherapy 

Hormone treatment 

or 

Chemotherapy 

or 

Clinical trials 

Chemotherapy or/± Tumor-directed radiotherapy 

or 

Chemotherapy ± palliative tumor directed radiotherapy 

or 

Clinical trials 

返回目錄

Conservative Treatment (Early Stage)早期保守治療 

Patient criteria 

- Type 1, Grade 1 tumor 

- No cervical or myometrial invasion (MRI) 

- Absence of suspicious of pelvic or para-aortic LN 

- Absence of synchronous ovarian tumor 

- No contraindication for medical treatment 

- Fertility preservation 

- Compliant and strict follow-up 

Medical treatment (high-dose progestin) 

- Medroxyprogesterone acetate: 200-600mg/day for 6 months 

- Megestrol acetate: 80-160mg/day 

Follow-up 

D&C every 3 months 

(maximum up to 6 

months) 

24 


Biopsy (-) Biopsy (+) 

Encourage pregnancy 

or 

Intermittent biopsy 

Surgical intervention 

返回目錄

Epithelial Ovarian Cancer 

25 

2012 台北榮總婦癌診療指引-卵巢癌 

Staging ovarian and primary peritoneal carcinoma (FIGO stage, 2009 and TNM AJCC 7th ed, 2010) 



T1 I Tumor limited to ovaries (one or both) 

T1a IA 

T1b IB 

T1c IC 

Tumor limited to one ovary; capsule intact, no tumor on ovarian surface. No 

malignant cells in ascites or peritoneal washings. 

Tumor limited to both ovaries; capsules intact, no tumor on ovarian 

surface. No malignant cells in ascites or peritoneal washings. 

Tumor limited to one or both ovaries with any of the following: 

capsule ruptured, tumor on ovarian surface, malignant cells in ascites or 

peritoneal washings 

T2 II Tumor involves one or both ovaries with pelvic extension 

T2a IIA 

T2b IIB 

T2c IIC 

T3 III 

Extension and/or implants on uterus and/or tube(s). 

No malignant cells in ascites or peritoneal washings. 

Extension to and/or implants on other pelvic tissues. 

No malignant cells in ascites or peritoneal washings. 

Pelvic extension and/or implants (T2a or T2b) with malignant cells in 

ascites or peritoneal washings 

Tumor involves one or both ovaries with microscopically confirmed 

peritoneal metastasis outside the pelvis 

T3a IIIA Microscopic peritoneal metastasis beyond pelvis (no macroscopic tumor) 

T3b IIIB 

T3c IIIC 


Macroscopic peritoneal metastasis beyond pelvis 2 cm or less in greatest 

dimension 

Peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension 

and/or regional lymph node metastasis 


NX 

N0 






M0 


M1 IV Distant metastasis (excludes peritoneal metastasis) 

Note: liver capsule metastasis is T3/Stage III; 

liver parenchymal metastasis,M1/ Stage IV. 

Pleural effusion must have positive cytology for M1/ Stage IV. 

返回目錄

26 


Staging fallopian tube cancer (FIGO stage, 2009 and TNM AJCC 7th ed, 2010) 



Tis• Carcinoma in situ (limited to tubal mucosa) 

T1 I Tumor limited to the fallopian tube(s) 

T1a IA 

T1b IB 

T1c IC 

Tumor limited to one tube, without penetrating the serosal surface; 

no ascites 

Tumor limited to both tubes, without penetrating the serosal surface; 

no ascites 

Tumor limited to one or both tubes with extension onto or through the 

tubal serosa, or with malignant cells in ascites or peritoneal washings 

T2 II Tumor involves one or both fallopian tubes with pelvic extension 

T2a IIA Extension and/or metastasis to the uterus and/or ovaries 

T2b IIB Extension to other pelvic structures 

T2c IIC Pelvic extension with malignant cells in ascites or peritoneal washings 

T3 III 

Tumor involves one or both fallopian tubes, with peritoneal implants 

outside the pelvis 

T3a IIIA Microscopic peritoneal metastasis outside the pelvis 

T3b IIIB 

T3c IIIC 

Macroscopic peritoneal metastasis outside the pelvis 2 cm or less in 

greatest dimension 

Peritoneal metastasis outside the pelvis and more than 2 cm in 

diameter 



NX 

N0 






M0 


M1 IV Distant metastasis (excludes metastasis within the peritoneal cavity) 

Note: liver capsule metastasis is T3/Stage III; 

liver parenchymal metastasis,M1/ Stage IV. 

Pleural effusion must have positive cytology for M1/ Stage IV. 

返回目錄

卵巢癌治療指引 

27 


(Include fallopian tube cancer and primary peritoneal cancer from 2012.01.01) 

I Primary Treatment 

- Standard treatment 

- Initial surgical cytoreduction followed by chemotherapy 

- Alternative treatment 

- Neodjuvant chemotherapy + interval cytoreductive surgery + adjuvant 

chemotherapy 

II Salvage Therapy 

- 2 nd look surgical reassessment 

- Extent of disease surgical reassessment 

- Secondary cytoreductive surgery 

- Intraperitoneal chemotherapy 

- Radiotherapy for local control 

III Palliative Therapy 

- Palliative chemotherapy 

- Palliative surgery 

- Hospice care 

術前準備 

* Stage IVb with malignant pleural effusion consider pleurodesis 

- Ultrasound and / or abdominal CT 

- Chest imaging 

- CBC/DC 

- Chemistry profile with liver and renal function tests 

- Institutional pathology review (if diagnosis by previous surgery or tissue biopsy) 

- CA-125 or other tumor markers as clinically indicated 

- Upper / Lower GI endoscopy if clinically indicated 

- Breast image survey if clinically indicated 

建議之減積手術 

- Debulking surgery 

- Complete staging surgery + dissection of all removable tumor 

- Complete staging surgery 

- Peritoneal cytology + Hysterectomy + BSO + BPLND + PALNS + 

返回目錄

28 


Appendectomy + Infracolic omentectomy + Subdiaphragm smear + Liver surface 

smear 

- Conservative staging surgery 

- Peritoneal cytology + Unilateral salpingo-oophorectomy + BPLND + PALNS + 


smear 

* Only for Early stage (Ia & Ib) and Grade I, II 

* 且強烈要求保留生育能力的患者 


epithelial ovarian cancer (including tubal cancer, peritoneal cancer、MMMT) for adjuvant 

chemotherapy: 

(一) Primary Chemotherapy/Primary adjuvant therapy regimens for stage II-IV 

(Paclitaxel 的健保局給付規定: 只給付在 Advanced stage 如:stage III or IV、recurrent disease) 

1. Paclitaxel + Carboplatin or Cisplatin (stage III, IV) (q 3 w × 6 cycles) 

Paclitaxel (175 mg/m 2 ) IVD 3 hrs 

Carboplatin (AUC 5 ~7.5) or Cisplatin (75 mg/m 2 ) IVD 1 hr 

2. Paclitaxel + Carboplatin or Cisplatin (q 3 w × 6 cycles) 

+ Maintenance Paclitaxel 自費 (for clinical complete responders Individualized q m x 12 courses) 

Paclitaxel (175 mg/m 2 ) IVD 3 hrs on D1 

Carboplatin (AUC 5 ~7.5) or Cisplatin 75 mg/m 2 IVD 1 hr on D1 

Paclitaxel (135 mg/m 2 ) IVD 3 hrs 

3. Paclitaxel + Carboplatin (q 3 w × 6 cycles) 

+ Maintenance Bevacizumab 自費 (cycles 2~22, q 3 w, 共 21 次) 


Carboplatin (AUC 6) IVD 1hr on D1 

Bevacizumab 15mg/kg 

4. Paclitaxel + Carboplatin (q 3 w × 6 cycles) 

+ Maintenance Bevacizumab 自費 (cycles 1 or 2~18, q 3 week,共 17~18 次) 


Carboplatin (AUC 5~ 6) IVD 1 hr on D1 

Bevacizumab 7.5 mg/kg 

返回目錄

5. Paclitaxel weekly + Carboplatin (q 3 w) 

Paclitaxel (80 mg/m 2 ) IVD 1 hr on D1, D8, D15 

Carboplatin (AUC 5~ 6) IVD 1~2 hrs on D1 

6. Cyclophosphamide + Cisplatin (stage I, II) (q 3 w × 6 courses) 

Cyclophosphamide (750 mg/m 2 ) IVD 2 hrs on D1 

Cisplatin (75 mg/m 2 ) IVD 1 hr on D1 

7. Cyclophosphamide + Carboplatin (q 3 w × 6courses) 

Cyclophosphamide (750 mg/m 2 ) IVD 2hrs on D1 

Carboplatin (AUC 5~7.5) IVD 1hr on D1 

8. Paclitaxel over 24 hrs+ Cisplatin 


Cisplatin (75 mg/m 2 ) 

(二) Acceptable Recurrence Therapies 

1. Combination if platinum sensitive 

(1) Paclitaxel + Carboplatin (q 3 w × 6 cycles) 


Carboplatin (AUC 5 ~7.5) IVD 1 hr on D1 

(2) Weekly paclitaxel /Carboplatin (6 cycles) 

Paclitaxel (80 mg/m 2 ) IVD 1 hr on D1 

Carboplatin (AUC 1.5) IVD 1 hr on D1 

(3) Docetaxel /Carboplatin 

Docetaxel (60 mg/m 2 ) IVD 1 hr 

Carboplatin (AUC 5 ~7.5) IVD 1 hr 

(4) Gemcitabine / Carboplatin (q 3 w × 6 cycles) 

Gemcitabine (1000 mg/m 2 ) IVD 30 mins on D1, D8 

29 


Carboplatin (AUC 4) IVD 1 hr on D1 (或 Cisplatin 30mg/m 2 IVD 1 hr on D1, D8) 

(5) Liposomal doxorubicin/ Carboplatin(q 4 w × 6 cycles) 

Pegylated Liposomal Doxorubicin (40 mg/m 2 ) IVD 90 mins on D1 

Carboplatin (AUC 5) IVD 1 hr on D1 (Cisplatin 建議可用 30-50 mg/m 2 ) 

2. Single-agent if platinum sensitive 

(1) Carboplatin 

Carboplatin (AUC 5 ~7.5) 

(2) Cisplatin 

Cisplatin (50~75 mg/m 2 ) 

返回目錄

3. Single-agent non-platinum based if platinum resistant 

(1) Docetaxel (q 3 w) 

Docetaxel 100 mg/m 2 IVD 1 hr 

(2) Melphalan, oral (q 4~6 w) 

Melphalan 0.2 mg/kg/day × 5 days 

(3) Gemcitabine weekly 

Gemcitabine 800 mg/m 2 IVD 1 hr 

(4) Liposomal doxorubicin (q 4 w × 6 cycles) 

Liposomal Doxorubicin (40~50 mg/m 2 ) IVD 90 mins on D1 

(5) Paclitaxel, weekly (6 cycles) 

Paclitaxel (60~80 mg/m 2 ) IVD 1 hr on D1 

(6) Paclitaxel 


(7) Topotecan 

Topotecan (q 1 w on D1, D8, D15,休一周-q 28 day× 6 cycles) 

Topotecan (4mg/m 2 ) IVD 90 mins on D1 

Topotecan (q 21 day × 6 cycles) 

Topotecan (1.25 mg/m 2 /day) IVD 30 mins on D1~D5 

(三) Intraperitoneal Chemotherapy 

(1) Paclitaxel + Cisplatin 


Cisplatin (100 mg/m 2 ) IP 1 hr on D1 

(2) Paclitaxel + Cisplatin + Paclitaxel 

Paclitaxel (135 mg/m 2 ) IVD 24 hrs D1 

Cisplatin (100 mg/m 2 ) IP 1 hr on D1 

Paclitaxel (60 mg/m 2 ) IP 1 hr on D8 

(四) Chemotherapy for non-epithelial ovarian cancer 

1. Germ cell tumor of the ovary 

(1) PE (q 3~4 w × 6 cycles) 

Etoposide (100 mg/m 2 ) IVD 1 hr on D1~D3 


30 


返回目錄

(2) PVB (q 3~4 w × 4~6 cycles) for immature teratoma 

Etoposide (100 mg/m 2 ) IVD 1 hr on D1~D3 (或 D1~D5) 

Cisplatin (100 mg/m 2 ) IVD 1 hr on D1 (或 20 mg/m 2 D1~D5) 

Bleomycin (25 mg) IVD 30 mins on D2 (或 300 mg/m 2 D2、9、16) 

2. Sex cord-stromal tumor of the ovary, advanced or recurrent: 

(1) PVB (q 3~4 w × 6 cycles) 

Etoposide (100 mg/m 2 ) IVD 1 hr on D1~D3 


Bleomycin (25 mg) IVD 30 mins on D2 

(2) Paclitaxel+ Cisplatin or Carboplatin (stage III, IV) 


Cisplatin (75 mg/m 2 ) or Carboplatin (AUC 5) IVD 1 hr on D1 

妊娠滋養層細胞腫瘤疾病抗癌藥物治療處方: 

(Chemotherapy Regimen for Gestational Trophoblastic Disease) 

1. MTX-single agent (low-risk GTT) 

Methotrexate (MTX) (1 mg/Kg) IM on D1, 3, 5, 7 

Folinic acid (0.1 mg/ Kg) IM on D2, 4, 6, 8 

2. MTX + Actinomycin-D (low-risk GTT) 

Methotrexate (MTX) (1 mg/Kg) IM on D1, 3, 5, 7 

Folinic acid (0.1 mg/ Kg) IM on D2, 4, 6, 8 

Actinomycin-D (1.25 mg/m 2 ) IVD 15 mins on D1 (q 2 w × 4 cycles) 

31 


3. EMA/CO (medium- & high-risk GTT) (q 2 w × 4~5 cycles) (medium-risk), (q 2 weeks × 

6~7 cycles) (high-risk) after undetectable hCG level 

Actinomycin-D (0.5 mg/m 2 ) IVD 15 mins on D1 

Etoposide (VP-16) (100 mg/m 2 ) IVD 1 hr on D1 

Methotrexate (MTX) (100 mg/m 2 IVD < 5 mins and then 200 mg/m 2 IVD 12 hr) on D1 

Actinomycin-D (0.5 mg/m 2 ) IVD 15 mins on D2 

Etoposide (VP-16) (100 mg/m 2 ) IVD 1 hr on D2 

Folinic acid 15mg PO q12h × 4 doses; beginning 24 hrs after start of MTX on D2 

Vincristine (Oncovin) (1 mg/m 2 ) IVD 10 mins on D8 

Cyclophosphamide (endoxan) (600 mg/m 2 ) IVD 10 mins on D8 

** Carboplatin 的健保局使用規定 : 限 Ccr < 60 cc/min 

返回目錄

完整或保守的分期手術後治療策略 

Stage Management 

Stage IA or IB 

Stage Ic 

Stage II, III, IV 

32 


Grade 1 Observation and follow-up. 

Grade 2 

Grade 3 

* Treat clear cell type pathology as grade III 

Observation 

or 

Intravenous chemotherapy for 3-6 cycles and 

then close follow-up 

Intravenous chemotherapy for 6 cycles 

and then close follow-up. 

Intravenous chemotherapy for 6 cycles 

and then close follow-up. 

Intravenous Paclitaxel/Carboplatin for a total of 6-8 cycles 

or 

Intraperitoneal chemotherapy [Optimally debulked (< 1 cm)] 

返回目錄

不完整分期手術後意外發現 

Reassessment with appropriate evaluation: 

Suspicion Management 


Grade 1 


Grade 2 or 3 

Stage IC 

Stage II, III, IV 

Residual Tumor 

(-) 

Residual Tumor 

(+) 

Resectable 

residual tumor 

Unresectable 

residual tumor 

33 


Surgical staging procedure 

Chemotherapy for 6 cycles 

or 



Debulking surgery 

Chemotherapy for a total of 6-8 cycles. 

or 

Neoadjuvant chemotherapy for 3 cycles 

followed by surgical staging procedure 

and postoperative chemotherapy 

* Arrange treatment plan as recommended by guideline after complete staging surgery and 

determining final disease stage (see above) 

返回目錄

追蹤 

- 門診追蹤 

第一年每 2 個月 1 次 

第二年每 3 個月 1 次 

此後每 6 個月追蹤 1 次 

- 追蹤建議 

34 


若 CA-125 或其他腫瘤指數一開始即高於正常值,建議每次追蹤依個人狀況若有臨床 

需求可行抽血(CBC 或其他功能)、身體檢查如骨盆腔檢查,依臨床徵象需要可行影像 

檢查如:Chest / Abdominal / Pelvic CT, MRI, PET-CT, PET or Chest x-ray。 

臨床完全緩解 

- Observe 

- Maintenance chemotherapy with paclitaxel 135-175mg/m2 every 4 weeks for 12 cycles 

- Clinical trial 

持續性或復發疾病 

評估疾病的程度和進展 

- Clinical symptoms and signs 

- Imaging studies 

- Chest / Abdominal / Pelvic CT, MRI or PET as clinically indicated. 

- Tumor marker level 

停止化療後完全緩解,但 6 個月疑似復發情形。 

Consider secondary cytoreductive surgery / PET scan followed by chemotherapy (可同 

first line C/T regimen;或 platinum-based + 非 paclitaxel 類 agent;或 

non-platinum-based agent) 

Consider secondary cytoreductive surgery followed by clinical trial 

停止化療後完全緩解,但 >12 個月內復發 

Consider secondary cytoreductive surgery followed by platinum-based combination 

chemotherapy (同 first line C/T regimen) 

Consider secondary cytoreductive surgery followed by clinical trial 

無臨床復發,但 CA-125 上升 

Delay treatment until clinical relapse 

Immediate treatment as recurrent disease 

返回目錄

I Primary Treatment 

- Standard treatment 

II Chemotherapy 

- Surgical cytoreduction 

- No recommendations / Individualized 

III Salvage Therapy 

- 2 nd look surgical reassessment 

- Extent of disease surgical reassessment 

- Secondary cytoreductive surgery 

- Whole abdominal radiation (WAR) 

IV Palliative Therapy 

- Palliative chemotherapy 

- Palliative surgery 

- Hospice care 

術前準備 

- Ultrasound and /or abdominal CT 

- Chest imaging 

- CBC/DC 

低惡性度卵巢癌診療指引 

- Chemistry profile with liver and renal function tests 

35 

2012 台北榮總婦癌診療指引-低惡性度卵巢癌 

- Institutional pathology review (if diagnosis by previous surgery or tissue biopsy) 

- CA-125 or other tumor markers as clinically indicated 

- Upper/Lower GI endoscopy if clinically indicated 

建議之減積手術 

- Debulking surgery 

- Complete staging surgery + dissection of all removable tumor 

- Complete staging surgery 

- Peritoneal cytology + Hysterectomy +BSO+ BPLND + PALNS + Appendectomy + 

Infracolic omentectomy + Subdiaphragm smear + Liver surface smear 

返回目錄

- Conservative staging surgery 

36 

2012 台北榮總婦癌診療指引-低惡性度卵巢癌 

- Peritoneal cytology + Unilateral salpingo-oophorectomy + BPLND + PALNS + 


smear 

* Only for Early stage (Ia & Ib) 

* 且強烈要求保留生育能力的患者 

Stage I-IV 

- After completion of surgical staging, regular out-patient follow up is suggested 

- Chemotherapy is not recommended 

Recurrent Disease 

- Consider secondary cytoreductive surgery then arrange regular follow up. 

返回目錄

37 

2012 台北榮總婦癌診療指引-化療的毒性 

化療的毒性 (引用自中華民國婦癌醫學雜誌 – 顏明賢主任編著) 

化療藥物是醫師治病中最具毒性的處方,不管劑量、療程、給藥方式,都是相當 

重要。嚴重時,即使正確使用藥物、劑量、與適當的療程,仍有 1-3%的病人,因其 

藥物毒性或併發症造成病人死亡,不可不慎! 

返回目錄

38 


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39 


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40 


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41 


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42 

2012 台北榮總婦癌診療指引-參考資料 

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