Cancer Care

FOREWORD
Sri. Rajeev Sadanandan IAS,

Additional Chief Secretary,
Health & Family Welfare
Government of Kerala
With the aging of the population, change in lifestyles and degradation of the environment
the incidence of Cancers in Kerala can be expected to increase substantially. In order to address
this, the Government of Kerala developed the Kerala Cancer Control Strategy (2018-2030). Major
components of this strategy were to improve outcomes by down staging cancers, which are being
diagnosed at an advance stage and to create a network of institutions from Levels I to IV covering
different levels of health care provision. Both would require broad basing the diagnosis and
treatment of cancer. In order to ensure that the quality of care is not compromised when services
are broad-based it is important to standardize the protocols for diagnosis and treatment of common
cancers. This is also necessary to facilitate collaboration between different branches of medicine
in preparation and execution of treatment plans. With the advent of Karunya Arogya Suraksha
Padhati (KASP), being implemented in partnership with Ayushman Bharat of Central
Government, the mode of financing of cancer care will shift from being tax funded and out of
pocket to insurance. Standardisation is also required to ensure that there are no disputes regarding
treatment provided and expenses reimbursed.
Cancers are a group of diseases that lend themselves readily to standardization. Many such
protocols have been developed in the west and are followed in Kerala. The National Cancer Grid,
an initiative of the Government of India, of which Kerala is a member, developed treatment
guidelines for treatment of common cancers. Since such guidelines have to locally owned if they
are to be observed in practice, Government of Kerala decided to adapt them to the state in
partnership with oncologists in the state in government and private sector. The directors of the
cancers centres of Malabar, Kochi and Trivandrum cancer centres were requested to lead on the
process. They adopted a consultative process. More than 200 oncologists from 30 institutions
actively participated in the process, which lasted for more than 4 months. These documents are the
result of their collaborative effort. The Government of Kerala wishes to thank all the participants
in the process who contributed their expertise, time and effort in producing this. The authors, their
institutions and the state can be proud of the product.
A document of this nature has to remain a live one. Knowledge in the etiology, diagnosis
and treatment of cancers is one of the fastest growing areas in medicine. When these guidelines
are followed there would be valuable lessons learnt which have to feed into the protocols. This can
be achieved if the community of oncologists gathers feedback, meet periodically to evaluate them
and make the needed modifications in the guidelines. The Kerala Cancer Grid established to
implement the Kerala Cancer Strategy could serve as the platform for future collaboration.
I wish that this document became the foundation for quality and accessible cancer care in
Kerala.
Rajeev Sadanandan IAS

STANDARD TREATMENT GUIDELINES- KERALA CANCER GRID
Process Description:
Health and Family welfare department, Government of Kerala released the Cancer control
strategy in 2018 in collaboration with WHO. The process involved all major cancer centers,
oncology wings of medical colleges and private cancer centers. The vision document was released
by Hon‘ble Chief Minister of Kerala Shri. Pinarayi Vijayan on 20th May 2018 at Cochin Cancer
and Research Centre. In order to attain the targets envisaged in the document, the need for
standard treatment guidelines was found essential. Although the state of Kerala has enviable
general health indices, which is on par with developed nations, there is very little impact in cancer
control. Kerala has one of the highest incidences of cancer in the country (135:100,000 in Kerala
vs 81:100, 000 for rest of India). In addition, over 60% of patients are diagnosed at advanced stage
precluding the possibility of cure and long term control of disease. This is despite the fact that
Kerala has over 23 cancer treatment centers to cater for its 33 million population which is one of
the highest in the country. In addition, the treatment provided across the state is found to be
variable. Multidisciplinary approach is the cornerstone of cancer care, which is not readily adopted
through out the state.
If cancer patients in Kerala need to get uniform standard of treatment closer to their home,
there should be a standard treatment guidelines (STG) for common cancers. This may reduce the
out of pocket expenditure. The process is expected to minimize variations in treatment, bring
accountability and improve treatment standard . It may also help to distribute cancer care through
out various cancer treatment facilities and facilitate optimal usage of resources and minimize
redundancies in infrastructure. The health care insurance could be linked to the guidelines and the
compliance can be periodically assessed. Annual review meetings on Standard Treatment
Guidelines shall encourage oncologists to update their knowledge and discuss various issues in
adopting international guidelines. In addition, the government may be able to prioritize the fund
allocations based on the gaps in resource availability. To implement the strategy of cancer control,
the concept of Kerala Cancer Grid was put forward. This included both public and private
hospitals and institutions involved in cancer care and control activities. As per the instruction of
Government of Kerala, three regional cancer centers of the state initiated the process of
developing the guidelines.
The National Cancer Grid (NCG) is a network of major cancer centers, research institutes,
patient advocacy groups and charitable institutions across India with the mandate of establishing
uniform standards of patient care for prevention, diagnosis, and treatment of cancer, providing
specialized training and education in oncology and facilitating collaborative basic, translational
and clinical research in cancer. With this goal, the NCG, which was launched in 2012.It now has
membership of 155 cancer centers and research institutes of the country. The NCG is an initiative
of the Department of Atomic Energy, Government of India through the Tata Memorial Centre.
Kerala state chapter of National Cancer Grid was formed in the month of November 2018 in
Kozhikode.
National Cancer Grid developed treatment guidelines with inputs from experts across the
country. Cancer treatment guidelines formulated by National Cancer Grid are adopted in States of
Telangana and Assam. In the inaugural meeting of the Kerala state chapter, all participating
centers agreed on the importance of having consensus treatment guidelines for common cancers. It
was decided to adapt the NCG guidelines after discussions among all members. Thirty oncologists
from 12 centers participated in the meeting.
In continuation to the instruction from the health department, a meeting of oncologists and
general surgeons and those involved in cancer management was organized at CCRC on 23 rd
February, 2019. Around 84 oncologists from various disciplines and different parts of Kerala
attended the meeting at Cochin. Prior to the meeting, all comprehensive cancer centers and
oncology departments of medical colleges were invited for the meeting. Soft copy of guidelines
for discussion was distributed to the participants. Based on the area of specialization and interest
all the delegates were divided into eight cancer sub-sites breakout sessions. One coordinator was
selected for each group to coordinate discussions. Each group prepared draft guidelines based on
NCG guidelines. The suggestions brought out at breakout sessions were presented in the afternoon
session to all delegates. The accepted suggestions were decided to be included in the guidelines.
Various internationally accepted guidelines like NCCN, ESMO, NICE etc were also referred. The
draft guidelines for each site was prepared by the coordinator and circulated to all participating
centers for discussion in their respective institutions. Many centers and oncologists provided their
inputs and suggestions. These were compiled by coordinators and made a draft document for final
discussion in RCC.
For finalizing the Standard Treatment Guidelines of common cancers, a meeting was
conducted at RCC on 30th & 31st March 2019. In this meeting to finalize the guidelines, all
participants participated in the discussion of all the guideline. This is because most oncologists in
Kerala treat all cancers except in a few dedicated cancer centers where site specific groups are
available. All coordinators made a detailed presentation on different types of cancer based on the
recommendations and suggestions. The meeting recommended few further modifications and
instructed the coordinator to incorporate the same and send to all other delegates those who
participated in the earlier meetings. The comments and suggestions if any were noted. A core
group was constituted that included the Directors of all three regional cancer centers, heads of
oncology wings of Govt. medical colleges and representatives of private cancer centers. The final
version was prepared in a format of symptoms, evaluation and treatment. Incorporation of site
specific AJCC staging to the guideline was approved. After receiving the comments, a final
version was prepared and the document was circulated to all participants for the approval.
The meeting at RCC also decided to conduct Core group meeting at Malabar Cancer
Centre on 4th April 2019 to approve the final draft of the STG. The intention of the MCC meeting
was to finalize the STG and recommendations on other related issues to be submitted to the
Government of Kerala to implement the same at earliest.
The highlights of the process were its democratic and inclusive approach. Majority of
oncologists of the state could contribute directly or indirectly in the development of the guideline.
The adaptation of NGC guidelines to a practical document for the state of Kerala, we envisaged,
will help to standardize care, improve the cancer outcome and contain cancer related expenses.
The cooperation and inputs from both public and private institutions were exemplary. The support,
guidance and encouragement from Hon‘ble minister for health and social justice, Smt.K.K
Shailaja Teacher and Shri.Rajeev Sadanandan, Additional Chief Secretary, Health and Family
welfare is extraordinary and contributed greatly to the success of bringing out the document.
The National Cancer Grid is duly thanked and acknowledged for the permission and
support to adapt the guidelines. Dr.C.S.Pramesh, Director of Tata Memorial Hospital and
coordinator of National Cancer Grid supported the process throughout the process and deserved
ample appreciation and gratitude.
KERALA CANCER GRID

STANDARD TREATMENT GUIDELINES-CAUTION STATEMENT
The guidelines presented is opinion of experts in the field in Kerala and India who
prepared based on current evidences available in medical literature and recent treatment
guidelines.Any oncologist or physician using the guidelines shall exercise his/her independent
clinical judgement in the context of clinical circumstances to determine patient care and treatment.
The use of guidelines should be judicious and the management of patient should be discussed in
multi-disciplinary tumor board. These are general guidelines aiming at assisting the
oncologist/physician in proper evaluation and management. This is not an exclusive document
incorporating every clinical scenario. It is necessary to formulate treatment plan for an individual
plan based on the general guideline. Hence the appropriate management of each patient shall be
based on the clinical judgement and various patient related factors. The treating
oncologist/physician has the liberty to deviate from the guidelines based on the clinical situation
and benefit of the patient. This decision ideally should be made in the Multi-disciplinary tumor
board.
The Standard Treatment Guidelines is not a medico-legal document and no claim on

management can be done based on the guidelines.It is subject to change based on emerging
evidences. It shall be reviewed periodically and updated. For each site, separate expert groups with
representatives from various major cancer treating facilities in the state shall be formed.The
deliberations of the expert panel will be presented in the periodic review meetings and
modifications in the document based on current evidences, evidences generated in each centre and
practical approaches shall be modified.
The various newer targeted therapy mentioned in the document does not indicate that such
drugs would be available through financial and social support schemes of Government.
SHORT FALLS
1) Some cancers are not included such as skin cancers. These will be included in the future
2) Principles of surgery, chemotherapy and radiotherapy requires should be considered as a
general document
3) Pathology standards are not included. This will be included in the future revisions
4) Radiology standard requirements and reporting format shall be discussed in next review
5) Palliative care will be included in subsequent reviews
CONTRIBUTORS
1 Dr. Abdul Malik Manzar
Junior consultant, Radiation Oncologist,
Aster MIMS, Calicut
2 Dr. Abhay Khattepure

Assistant Professor,
Dept. of Surgical Oncology,
Malabar Cancer Centre, Thalassery
3 Dr. Acka Priya Varghese

Additional Professor,
Dept. of Obstetrics and Gynaecology,
Govt. Medical College, Kottayam
4 Dr. Adarsh Anand

Consultant, Head and neck oncology,
Lakeshore Hospital, Ernakulam
5 Dr. Adarsh D
Dept.of Surgical Oncology,
6 Dr. Ajayakumar.T.K
Professor,
Dept. of Radiation oncology,
Govt. Medical Collge, Kozhikode
7 Dr. Aju Mathew

Medical oncologist,
I. Kerala Cancer Care, Kochi
II.University of Kentucky
8 Dr. Akhil P.Suresh

9 Dr. Amrutha Ramachandran

Associate Professor
Gynaec oncology division,
Dept.of Obstrectric and Gynaecology,
Govt. Medical College, Kozhikode
10 Dr. Anila K R
Associate Professor,
Dept. of Pathology
Regional Cancer Centre, Thiruvananthapuram
11 Dr. Anitha Gopal
Govt. Medical College , Kottayam
12 Dr. Anitha Mathews

Dept. of Pathology
Regional Cancer Centre, Thiruvanathapuram
13 Dr. Anoop TM
Dept. of Medical Oncology,
14 Dr. Ansar P P
Consultant surgical oncologist,
Sree Gokulam Medical college and research Foundation,
Venjaramoodu
15 Dr. Anupama Rajan Babu

Professor,
Gynaecologic oncology,
Amrita Institute of Medical Sciences, Kochi
16 Dr. Aravidh S Anand

Dept.of Radiation Oncology,
Govt.Medical College, Thiruvananthapuram
17 Dr. Arun Chandrasekharan T

Junior consultant-Medical Oncologist,
Aster MIMS, Calicut
18 Dr. Arun Peter Mathew

Dept. of Surgical Services,
19 Dr. Arun S
Assistant Professor-General Surgery,
Govt. Medical College, Manjeri
20 Dr. Arun Sankar S

Dept of Radiation Oncology
21 Dr. Arun P.Narendan
22 Dr. Aruna T.H

Senior Consultant-Obstetrics and Gynaecology,
Govt. Taluk Hospital, Chirayinkeezhu
23 Dr. Ashitha.G
Dept.of Surgical Oncology
24 Dr. Ashwathy Krishnan

Assistant professor,
Division of Onco-pathology
Dept.of Clinical Lab services and Translational Research
25 Dr. Aswathy P.Sivaram

Assistant professor, Dept.of Onco-pathology
Cochin Cancer & Research Centre, Kochi
26 Dr. Aswin Kumar

Dept .of Radiation Oncology,
27 Dr. Balagopal P G
Medical Superintendent
28 Dr. Balakrishanan
Professor, Dept.of Neuro-surgery,
Govt.Medical College, Kottayam
29 Dr. Balasubramonian.K.R
Dept. of Cardio-thoracic and Vascular Surgery
30 Dr.Basheer OT
Associate professor,
Dept.of Surgery Govt.Medical College, Kozhikode
31 Dr. Beela Sarah Mathew
Professor,
Division of Radiation oncology,
32 Dr. Beena K
Senior Consultant,
Department of Radiation oncology
33 Dr. Beenakumari R
Dept. of Obstetrics & Gynaecology,
34 Dr. Bindu K M
Dept. of Obstetrics and Gynaecology ,
35 Dr. Binesh P
Dept.of Radiation Oncology
Govt. Medical college, Kozhikode
36 Dr. Binitha T Thomas

Dept. of Radiotherapy and Oncology,
Govt. Medical college, Kottayam
37 Dr. Bipin T Varghese

Dept of Surgical Services
38 Dr. Boben Thomas

Medical Oncologist
G.G Hospital , Thiruvananthapuram and
Caritas Cancer Institute , Kottayam
39 Dr. Chandramohan.K
Dept of Surgical Services
40 Dr. Chandran K Nair

Professor,
Dept. of Clinical Hematology and Medical Oncology,
Malabar Cancer Centre,Thalassery
41 Dr. Chitrathara K
Senior Consultant-Surgical oncology,
Lakeshore Hospital Ernakulam
42 Dr. TB Culas
Professor of Surgery,
Dept. of Surgery,
Govt. Medical College, Palakkad
43 Dr. Deepa Susan Joy Philip

Division of Medical Oncology,
44 Dr. Dhanya Dinesh

Dept. of Surgical Services
45 Dr. Dileep Damodharan

Senior Consultatnt, Surgical oncology,
MVR Cancer Centre and Research Institute ,Kozhikode
46 Dr. Dileep Panicker

Consultant Neurosurgeon,
Aster Medicity, Ernakulam
47 Dr. Dinesan M
Assistant Professor, Radiation Oncology,
Govt Medical College, Kozhikode
48 Dr. Dinesh Makkuni

Senior Consultant and Head,
Dept. of Radiation Oncology
MVR Cancer Centre and Research Institute Kozhikode
49 Dr. Dineshan KM
Additional Professor ,
Department of Urology,
50 Dr. Divya G M
Dept.of ENT
51 Dr. Divya
Dept.of ENT,
Govt.Medical College, Manjeri
52 Dr. Divya R Prasad

Associate Professor, Dept. of Obstetrics and Gynaecology
Sree Gokulam Medical College, Thiruvananthapuram
53 Dr. Durga Prasanan

Medical oncologist,
Baby Memorial Hospital, Kozhikode
54 Dr. Elizhabeth Mathew Iype

Dept of Surgical Services,
55 Dr. Flowerlit Thomas

Radiotherapy and Oncology,
56 Dr. Francis V James

Professor,
Dept.of Radiation oncology
57 Dr. V.P. Gangadharan

Consultant, Medical and Pediatric Oncology,
Lakeshore Hospital, Ernakulam
58 Dr. K.V. Gangadharan

HOD, Medical Oncology,
Aster MIMS, Kozhikode
59 Dr. Geetha G Nair

Senior Consultant, Obstetrics and Gynaecology
W & C Hospital , Thycaud , TVM
60 Dr. Geetha M
Associate Professor and HOD,
Malabar Cancer Centre Thalassery
61 Dr. Geetha N
Additional Director and Professor,
Dept of Medical Oncology,
62 Dr. Geethi M.H

63 Dr.Gopi.E.V
Professor and HOD,
Dept.of Surgery,
Govt.Medical College, Kozhikode
64 Dr. Gopakumar
Division of Pediatric Oncology,
Dept.of Clinical Hematology and Medical Oncology
65 Dr. Greeshma K.E

Dept. of Radiation Oncology,
66 Dr. Guna Prasad C.S

67 Dr. Harish Sugathan

Govt Medical College, Thiruvananthapuram
68 Dr. Jacob K.J.

Professor & HOD,
Dept of Obstetrics & Gynaecology,
Govt. Medical College, Thrissur
69 Dr. K.K. Jayakumar

Professor and HoD, Dept.of Radiation Oncology
Govt Medical College, Thrissur
70 Dr. P.G. Jayaprakash

Senior Consultant –Radiation Oncology
(Retd. Professor & HOD Clinical Oncology & Radiation, RCC
Thiruvananthapuram)
71 Dr. Jayashree Vaman
Dept.of Obstetrics and Gynaecology
Govt. Medical College, Thiruvananthapuram
72 Dr. K. Jayasree
Professor and HOD ,
Department of Pathology
73 Dr. M. Jayasree
Senior Consultant,
Dept of Health Sciences
74 Dr. Jayasudha A V
75 Dr. Jem Prabhakar

Consultant Surgical oncologist,
Aster Medicity, Ernakulam
76 Dr. Jiji V
Dept. of Radio-diagnosis
77 Dr. Jithin T.K

Dept.of Clinical Hematology and Medical Oncology,
78 Dr. Jofin.K.Johny
Consultant Surgical Oncologist,
Govt. General Hospital, Ernakulam
79 Dr. John Joseph

80 Dr. Joneetha Jones

81 Dr. Joseph Francis
Professor and HOD,
Dept. of Surgery,
Govt. Medical College, Ernakulam
82 Dr. Jubie Roy

Dept.of Radio-diagnosis
83 Dr. Kainickal C T
84 Dr. Kandathil Joseph Philip

Dept.of Clinical Laboratory Services and Translational Research
85 Dr. Kiran.P
Radiotherapy and Oncology,
86 Dr. Krishnakumar T
Professor, Head and Neck Surgery and Oncology,
87 Dr.Kunjambu
Professor and HOD
Dept.of Surgery,
Govt.Medical College, Kannur
88 Dr. Kurien Cherian

89 Dr. Lakshmi Haridas K

Dept.of Medical oncology
90 Dr. Leelamoni S.Y

Senior Consultant,
W&C hospital, Trivandrum
91 Dr. Lijeesh AL
92 Dr. Lissiamma George

Professor and Unit Chief,
Govt. Medical College , Thrissur
93 Dr. Madhu Muralee

94 Dr. Mahadevan R
Professor & Head,
Govt.Medical College Thiruvananthapuram
95 Dr. Malu Rafi

96 Dr. Manjula M
Assistant Professor, Obstetrics and Gynaecology,
SAT Hospital, Govt. Medical CollegeThiruvananthapuram
97 Dr. Manoj Kumar R

Professor of Orthopaedics,
Dept. of Orthopedics,
98 Dr. Manu Prasad.A

Dept. of Clinical Hematology and Medical Oncology
99 Dr. Mathew Abraham

Professor and Head,
Dept.of Neurosurgery,
SCTIMST, Thiruvananthapuram
100 Dr. Megha Jayaprakash

Associate professor, Gynaec Oncologist ,
Dept. of Obstetrics and Gynaecology
Govt. Medical college, Thrissur
101 Dr. Michelle Aline Antony
Senior Consultant, Gynaecologic Oncology
Rajagiri Hospital, Aluva
102 Dr. Mini C. H.

Professor & HOD,
Dept of Obstetrics and Gynaecology,
103 Dr. Mira S Wagh

Dept.of Surgical Services
104 Dr. Mithun Chacko John

Dept.of Medical Oncology,
Jubilee Mission Medical College, Thrissur
105 Dr. Mobin Paul

Consultant Hematologist,
106 Dr. Moni Kuriakose

Director,
107 Dr. Muhammed Basheer OT

Additional Professor of Surgery,
108 Dr. Muhammed Rifayi

Dept.of Radiation oncology,
109 Dr. Murali T V

110 Dr. Nabeel Yahiya

Department of Radiation Oncology,
111 Dr. Narayanan Kutty Warrier
Managing Director and Consultant Medical Oncologist,
MVR Cancer Centre and Research Institute, Kozhikode
112 Dr. Nebu Abraham George

Division of Surgical Services,
113 Dr. Neelima Radhkrishnan

Dept. of Pathology,
114 Dr. Neelima V Nair

Professor,
Sree Gokulam Medical college, Trivandrum
115 Dr. Neetha Sreedharan

116 Dr. Nileena Nayak

Additional Professor ,
117 Dr. Nirmala C

Professor and Head , Dept. of Obstetrics and Gynaecolgy ,
SAT Hospital, Govt. Medical College , Thiruvananthapuram
118 Dr. Nizamudheen M.P

Dept. of Surgical Oncology
119 Dr. Noori Khalid

Dept. of Gynaecology,
DMWIMS Medical College, Wyanad
120 Dr. Noushad

Dept.of Clinical lab services and Translational Research
121 Dr. V.P. Paily
Retd. Prof and Head , Govt. Medical College , Thrissur
Sr. Consultant,,
Rajagiri Hospital, Ernakulam
122 Dr. Paul Augustine

Additional Professor and Head,
123 Dr. Paul George

Radiation oncologist,
124 Dr. V.M. Pradeep

Professor and HOD
Dept of Nuclear Medicine
125 Dr. Prakash N.P

126 Dr. Pranab K.Prabhakarn

127 Dr. Prasanth CC

Department of Radiation Oncology,
128 Dr. Pratheep Mohanan

Pathologist, SMIMS
129 Dr. Praveen Kumar Shenoy

Department of Medical Oncology,
130 Dr. Preethi T R

Division of Pathology,
131 Dr. Preeya.V
Associate Professor,Radiotherapy and Oncology,
132 Dr. Prem Ravivarma

Medical Oncologist,
133 Dr. Presannakumari B

Retd. Professor , Govt. Medical College , Thiruvananthapuram
Sr. Consultant, Obst.&Gynaecology,
Lifeline Hospital, Adoor
134 Dr. Priya B

135 Dr. Priya Kumari T

Professor,
Dept of Pediatric Oncology
136 Dr. Priya Mery Jacob

Division of Pathology,
137 Dr. Priya Radhakrishnan

Assistant Professor of Surgery,
138 Dr. Radha K R

Professor and HOD,
Govt. Medical College, Ernakulam
139 Dr. Rajeev K R

140 Dr. Rajesh P

Department of Orthopedics,
141 Dr. Rajitha L
Dept. of Medical Oncology
142 Dr. Ramaswamy N.V

Senior Consultant-Hematology,
Aster Medicity, Kochi
143 Dr. K. Ramadas

Professor and HOD,
144 Dr. Ramesh

Professor & HOD,
Govt. Medical College, Thiruvananthapuram
145 Dr. H. Ramesh

Director, Surgical Gastro-enterology,
Lakeshore Hospital Ernakulam
146 Dr. Rari P Mony

Assistant Professor, Dept of Pathology,
147 Dr. Ravindran

Dept. of Surgery, Govt.Medical College ,Thrissur
148 Dr. Rejnish Kumar R

149 Dr. Rekha Nair

Director,
150 Dr. Rema P.L

Professor and HOD
Dept of Radiotherapy and Oncology
151 Dr. Rema P
Additional Professor and Head of Gynae Oncology Division
152 Dr. Remya.A

Consultant, Gynaec- oncology,
Aster MIMS, Kottakkal
153 Dr. Renu Sukumaran

Dept of Pathology
154 Dr. Renuka

Division of Radio-diagnosis,
155 Dr. Rexeena Barghavan

156 Dr. Rona Joseph P

157 Dr. Roshni S

Dept.of Radiation oncology,
158 Dr. Saheer

Lecturer,
Govt. Medical College, Thrissur
159 Dr. Sajeed A

Medical Superintendent and Associate Professor
160 Dr. Sajeev George

Govt. Medical College, Allapuzha
161 Dr. Sajith Babu T P
Associate Professor and HOD,
162 Dr. Salim V P

163 Dr. Sanam P

Consultant Gynaecologic Oncologist,
Lakeshore Hospital,Ernakulam
164 Dr. Sandhya K Prathapan

Associate Professor (CAP ),
Govt. Medical College Hospital Alappuzha
165 Dr. Sangeetha K Nayanar

Professor and Head,
Division of Onco-pathology,
Dept.of Clinical lab services and Translational Research,
166 Dr. Sanju Cyriac

Consultant, Medical Oncology,
Rajagiri Hospital, Alwaye
167 Dr. Santhosh John Abraham

Senior Consultant, General and Laparoscopic surgery,
Lisie Hospital, Ernakulam
168 Dr. Santhosh Kuriakose

Associate Professor, Division Of Gynae Oncology
Dept. of Obstetrics and Gynaecology
Govt Medical College, Kozhikode
169 Dr. Satheesan B

Director,
170 Dr. Satheesh Babu.T.V

Department of Imageology,
171 Dr. Sathish Padmanabhan
Senior Consultant, Radiation Oncology,
172 Dr. Sathi M S

Dept. Of Obstetrics and Gynaecology ,
Govt. Medical College , Kottayam
173 Dr. Sekharan P.K

Retd. Professor of Obstestrics and Gynaecology.
Senior Consultant and HOD , PVS Hospital , Kozhikode
174 Dr. Shaji Thomas

Additional Professor and Head,
Dept.of Surgical Services,
175 Dr. Shamna Muhammad

Dept.of Surgical Oncology,
176 Dr. Sharath Krishnan

Assistant Professor,Surgical Oncology,
Govt. Medical college , Thrissur
177 Dr. Shibu George

Professor,
Dept. of ENT,
178 Dr. Shoba Kumari

Consultant, Obstetrics and Gynaecology
DMH, Peroorkada
179 Dr. Shwan.T.Joseph

Senior consultant, Head and Neck Oncology,
Lakeshore hospital, Ernakulam
180 Dr. Simi C M

Dept. of Pathology
181 Dr. Simi Raj
Consultant Gynaecologic Oncologist,
Lissie Hospital , Ernakulam
182 Dr. Sindhu Nair P

Dept. of Pathology
183 Dr. Sindhu V

Govt.Medical College , Thiruvananthapuram
184 Dr. Sisha Liz Abraham

185 Dr. Sithara Aravind

Associate professor,
Division of Onco-pathology,
Dept.of Clinical lab services and Translational Research
186 Dr. Siva Ranjith

187 Dr. Sivanandan CD

188 Dr. Sivaramakrishnan

Professor,
Govt. T.D.Medical College, Alappuzha
189 Dr. K.C Soman

Professor of Surgery,
Dept. of Surgery,
190 Dr. N.S. Sreedevi

Retd. Professor and Head , Govt, Medical College Kozhikode
Professor and Head,
Pushpagiri Medical College, Thiruvalla
191 Dr. P S Sreedharan
Consultant and Head,
Dept. of Medical Oncology,
MVR Cancer Centre and Research Institute, Kozhikode
192 Dr. Sreejith G Nair

Dept. of Medical Oncology
193 Dr. Sreekanth.S.Kumar

Department of Surgical Oncology,
194 Dr. Sreekumar Pillai

Professor,
Jubilee Mission Medical College, Thrissur
195 Dr. Sreelesh. K. P

Consultant Medical Oncologist,
Aster MIMS, Calicut
196 Dr. Subi.T.S

197 Dr. Subin Sugath

Senior Consultant, Dept. of Orthopedics,
Aster Medicity, Kochi
198 Dr. Subramania Iyer,

Professor,
Department of Head and Neck ,
199 Dr. Suchetha S

Additional Professor, Gynae Oncology Division
Dept.of Surgical Services,
200 Dr. Sugeed M.T

201 Dr. Suma R
Additional Professor of Surgery,
Department of Surgery,
202 Dr. Suresh Bhatt

Professor,
Dept. of Urology,
203 Dr. Suresh Kumar K

Department of Radiotherapy and Oncology,
204 Dr. Surij Salih

Senior Consultant-surgical Oncology,
Prathyasa (MJKMCRC) Cancer Centre, Cherthala
205 Dr. P.K.Syamala Devi

Retd. Professor and Head , Govt. Medical College , Thiruvananthapuram
Senior consultant, Obstetrics and Gynaecology
KIMS Hospital, Thiruvananthapuram
206 Dr. Syam Vikram

Consultant, Surgical Oncology,
MVR Cancer Centre and Research Institute Kozhikode
207 Dr. V.U. Thankamma

Professor,
Pushpagiri Medical College
208 Dr. Thara Somanathan

Additional Professo ,
Dept. of Pathology
209 Dr. Tobin George

Dept. of Neurosurgery,
SCTIMST, Thiruvananthapuram
210 Dr. Ushashree Warriar

Cochin Cancer and Research Centre, Kochi
211 Dr. Venugopal M
Professor and HOD,
Division of Radio-diagnosis,
212 Dr. Vidhyadharan Sivakumar

Assistant Professor ,
Department of Head and Neck,
213 Dr. Vijayakumar D.K

Professor,
214 Dr. Vineetha Raghavan

Dept. of Clinical Hematology & Medical Oncology,
215 Dr. Vinin N.V

Department of Radiation oncology,
216 Dr. Vishnu Rajan Nambiar

Consultant Radiation Oncologist,
Baby Memorial Hospital, Kozhikode
CORE GROUP
1. Director of Regional Cancer Centre

2. Director of Malabar Cancer Centre
3. Director of Cochin Cancer and Research Centre
4. Heads of Oncology wings in Government Medical Colleges
5. Senior Consultatnts in Oncology/CEO of Private Comprehensive Cancer Centres
The following members were presented in the core group meeting;

1. Dr.Ajayakumar.T.K
Professor and HOD
Dept.of Radiation oncology
Govt.MedicalCollge, Kozhikode
2. Dr.Anto Babu
Head of Oncology
St.Gregoricous Medical Mission Hospital
3. Dr.Moni Kuriakose
Director
Cochin Cancer & Research Centre, Cochin
4. Dr.Naryankutty Warrier
Medical Director
MVR CCRI, Calicut
5. Dr.Paul Gopu
Radiation Oncologist
Amala Institute of Medical Centre ,Thrissur
6. Dr. K. Ramadas
Professor
Division of Radiation Oncology,
7. Prof(Dr.) P R Sasindran,
Senior consultant,
Baby Memorial Hospital, calicut
8. Dr.Rema P.L
Professor
Govt.Medical College, Kottayam
9. Dr.Satheesan.B
Director,
10. Dr.Sathish P
Consultant Radiation Oncologist
Aster MIMS
11. Dr.Sivaramkrishnan
Professor, Radiation Oncology,
Govt. T.D.Medical College, Alapuzha
12. Dr.Suresh Kumar.K
Addl. Professor
Department of Radiothrapy and oncology,
Govt.Medical college, Kottayam
ACKNOWLDGEMENT
1. National Cancer Grid
2. Dr C S Pramesh, MS, FRCS, Director, Tata Memorial Hospital, Mumbai
(Co-ordinator, National Cancer Grid.)
3. Technical team for document preparation
a) Ms.Maya Padmanabhan
(Lecturer, Division of Clinical Research and Biostatistics, Malabar Cancer
Centre,Thalassery)
b) Mr.Riyaz M
(Lecturer, Division of Clinical Research and Biostatitsics, Malabar Cancer
Centre,Thalassery)
c) Mr.Ranjith M.K
(System Manager, Division of health Information Technology, Malabar Cancer
Centre,Thalassery)
d) Ms. Bhavina C
(Jr. System Analyst, Division of health Information Technology, Malabar Cancer
Centre,Thalassery)
e) Mr.Muhammed Sabique
(Technical Support Staff, Division of health Information Technology, Malabar Cancer
Centre,Thalassery)
f) Ms.Ayana K.V
(Trainee, Division of health Information Technology, Malabar Cancer
Centre,Thalassery)
4. All Post graduate students, Senior residents and Fellowship trainees of Government
Medical colleges, Regional Cancer Centre and Malabar Cancer Centre.
MAJOR REFERENCES FOR PREPARATION OF GUIDELINES

1. Standard Treatment Guidelines of common cancers – National Cancer Grid ,India
2. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in
Oncology 2018 and 2019
3. European Society of Medical Oncology Guidelines for management of various cancers
4. Euopean Urological Association Guidelines on Urological cancers
5. American Thyroid Association Guidelines on Management of thyroid malignancies
6. AJCC staging manual 8th Edition
7. CAP/ASCO Guidelines on surgical pathology]
8. NICE guidelines on cancer treatment
9. The International Federation of Gynecology and Obstetrics Stagimg system for
gynaecologic cancers (FIGO)
Kerala Cancer Grid acknowledges the above references.

INDEX
Topic Page
BREAST CANCER 47
HAEMATOLOGICAL MALIGNANCIES 65
 APML 67
 HODGKIN LYMPHOMA 68
 NON HODGKIN LYMPHOMA 70
 ACUTE MYELOID LEUKEMIA 75
 ACUTE LYMPHOBLASTIC LEUKEMIA 77
 CHRONIC MYELOID LEUKEMIA (CML) 80
 MULTIPLE MYELOMA 84
GASTRO-INTESTINAL CANCER 87
 CARCINOMA ANAL CANAL 89
 CANCER OF THE RECTUM 93
 CARCINOMA COLON 98
 INTRAHEPATIC CHOLANGIOCARCINOMA 102
 EXTRAHEPATIC CHOLANGIOCARCINOMA 104
 RETROPERITONEAL SARCOMA 108
 HEPATOCELLULAR CARCINOMA 109
 PANCREATIC / PERI-AMPULLARY CANCER 113
 STOMACH CANCER 116
 GIST (GASTROINTESTINAL STROMAL TUMOR) 119
GYNECOLOGICAL CANCER 135
 CERVICAL CANCER 142
 ENDOMETRIAL CANCER 150
 GESTATIONAL TROPHOBLASTIC NEOPLASIA (GTN) 161
 OVARIAN CANCERS 169
 RELAPSED OVERIAN CANCER 174
 BORDERLINE EPITHELIAL OVARIAN TUMOURS 177
 GERM CELL TUMOURS OF OVARY 180
HEAD & NECK CANCER 191
 ORAL CAVITY CANCERS-GENERAL 206
 ORAL CAVITY- LIP 209
 OROPHARYNX 210
 LARYNX 211
 HYPOPHARYNX 212
 NASOPHARYNX 213
 PARANASAL SINUSES (MAXILLO-ETHMOID) 214
 DIFFERENTIATED THYROID CANCERS 216
 MEDULLARY THYROID CANCERS 220
 ANAPLASTIC THYROID CANCERS 221
 MALIGNANT MAJOR SALIVARY 222
 UNKNOWN PRIMARY WITH NECK NODE 224
Topic Page
SARCOMA 231
 EWINGS SARCOMA 233
 CHONTROSARCOMA 237
 SOFT TISSUE SARCOMA 239
 OSTEOSARCOMA 246
THORACIC CANCER 251
 ESOPHAGEAL CANCER 253
 LUNG CANCER 259
UROLOGICAL CANCER 277
 BLADDER CANCER 279
 PROSTATE CANCER 285
 RENAL CELL CARCINOMA 289
 TESTICULAR TUMOUR 296
NEUROLOGICAL CANCER 313
 BRAIN TUMOUR 315
 NON-INFILTRATIVE LOW GRADE GLIOM A (LGG)/ 317
GLIONEURONAL TUMOURS
 INFILTRATING LOW GRADE GLIOMAS INCLUDING 319
OLIGODENDROGLIOMAS (ODG)
 ANAPLASTIC ASTRO/ ANAPLASTIC ODG 320
 GLIOBLASTOMA (GBM ) 321
 EPENDYMOMA 322
 BRAIN STEM GLIOMA 323
 PRIMITIVE / EMBRYONAL CNS TUMOURS 324
 CRANIOPHARYNGIOMA 325
 PITUITARY ADENOMA 326
 MENINGIOMA 327
 VESTIBULAR SCHWANNOMA 328
 PRIMARY CNS GERM CELL TUMORS / PINEAL TUMORS 329
 PRIMARY CNS LYMPHOMA 330
APPENDIX 337
 GUIDELINES ON MULTIDISCIPLINARY TUMOR BOARD 339
 FREQUENTLY ASKED QUESTIONS 344
Standard Treatment Guidelines for Common Cancers
Kerala Cancer Grid Page 46 of 346

BREAST CANCER


Breast Cancer Staging- AJCC 8th edition

Clinical classification of tumor
Tx Unable to assess primary tumor
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tis (DCIS) DCIS Ductal carcinoma in situ
Paget disease of the nipple not associated with invasive

carcinoma and / or DCIS in the underlying breast
parenchyma.
Tis (Paget ) Paget
Carcinoma in the breast parenchyma associated with
Paget disease is characterised based on the size and
characteristics of the parenchymal disease, although the
presence of Paget disease should still be noted
T1 T1 </= 20mm in greatest dimension
T1mi < /= 1mm in greatest dimension
>1mm but </=5mm in greatest dimension

T1a (round any measurement from 1.0mm to 1.9mm to
2mm)
T1b >5mm but </=10mm in greatest dimension
T1c >10mm but </=20mm in greatest dimension
T2 T2 >20mm but </=50mm in greatest dimension
T3 T3 >50mm in greatest dimension
Tumor of any size with direct extension to the chest wall

T4 T4 and/or the skin (ulceration or macroscopic skin nodules
)*
Extension to chest wall, not including only pectoralis

T4a
muscle adherence / invasion
Ulceration and/ or ipsilateral satellite nodule and / or

T4b edema (including peau d‘orange )of the skin, which do
not meet the criteria for inflammatory carcinoma

T4c Both (T4a+T4b)
T4d Inflammatory carcinoma**
*Invasion of the dermis alone does not qualify as T4.
**Inflammatory carcinoma is restricted to cases with typical skin changes involving one-third or
greater of the skin of the breast. While the histologic presence of invasive carcinoma invading
dermal lymphatics is supportive of the diagnosis, it is not required, nor is dermal lymphatic
invasion without typical clinical findings sufficient for a diagnosis of inflammatory breast
cancer.
Clinical classification of Regional lymph nodes
cNx* Regional lymph nodes cannot be assessed (eg, previously removed).
cN0 No regional lymph node metastases (neither by imaging nor clinical

exam).
cN1mi** Micrometastases (approximately 200 cells, larger than 0.2 mm, but
none larger than 2.0 mm).
N2 cN2 Metastasis to ipsilateral level I, II axillary lymph nodes that are

clinically fixed or matted; or in ipsilateral internal mammary nodes
in the absence of clinically evident axillary node metastases.
cN2a. Metastasis to ipsilateral level I, II axillary lymph nodes fixed to one

another (matted) or to other structures
cN2b Metastasis only in ipsilateral internal mammary nodes, and in the

absence of clinically evident axillary node metastases.
cN3 cN3 Metastases in ipsilateral infraclavicular (level III axillary) lymph

node(s) with or without level I, II axillary lymph node involvement;
or in ipsilateral internal mammary lymph node(s) with clinically
evident level I, II axillary lymph node metastases; or metastases in
ipsilateral supraclavicular lymph node(s) with or without axillary or
internal mammary lymph node involvement.
cN3a Metastasis to ipsilateral infraclavicular lymph node(s).
cN3b Metastasis to ipsilateral internal mammary lymph node(s) and

axillary lymph nodes.
cN3c Metastasis in ipsilateral supraclavicular lymph node(s).

*The cNX category is used sparingly in cases where regional lymph nodes have previously been
surgically removed or where there is no documentation of physical examination of the axilla.
**cN1mi is rarely used but may be appropriate in cases where sentinel node biopsy is performed
before tumor resection (such as in certain cases treated neoadjuvantly).
Pathological nodal staging
pNx pNx Regional lymph nodes cannot be assessed (eg, previously removed,
or not removed for pathologic study).
pN0 No regional lymph node metastases.
pN0 No regional lymph node metastasis identified or isolated tumor cells

(ITCs) only.
pN0(i+) Malignant cells in regional lymph node(s) no greater than 0.2 mm

(detected by hematoxylin and eosin stain [H&E] or
immunohistochemistry [IHC] including ITCs).
pN0(mol+) Positive molecular findings (reverse transcription polymerase chain

reaction [RT-PCR]), but no regional lymph node metastases detected
by histology or IHC.
pN1 Micrometastases, or metastases in one to three axillary lymph

pN1 nodes, and/or clinically negative internal mammary nodes with
micro- or macrometastases detected by sentinel lymph node biopsy.
pN1mi Micrometastases (approximately 200 cells, greater than 0.2 mm, but
none greater than 2.0 mm).
pN1a Metastases in one to three axillary lymph nodes, with at least one
metastasis greater than 2.0 mm
pN1b Metastases in ipsilateral internal mammary sentinel nodes, excluding

ITCs.
pN1c pN1a and pN1b combined
pN2 pN2 Metastases in four to nine axillary lymph nodes, or positive ipsilateral
internal mammary lymph nodes by imaging in the absence of axillary
lymph node metastases.
N2a N2a Metastases in four to nine axillary lymph nodes (at least one tumor
deposit greater than 2.0 mm).
pN2b pN2b Metastasis only in clinically detected internal mammary nodes with

or without microscopic confirmation; with pathologically negative

axillary nodes.
pN3 pN3 Metastases in 10 or more axillary lymph nodes; or in infraclavicular

(level III axillary) lymph nodes; or in ipsilateral internal mammary
lymph nodes by imaging in the presence of one or more positive level
I, II axillary lymph nodes; or in more than three axillary lymph nodes
and in internal mammary lymph nodes with micrometastases or
macrometastases detected by sentinel lymph node biopsy but not
clinically detected; or in ipsilateral supraclavicular lymph nodes.
pN3a pN3a Metastases in 10 or more axillary lymph nodes (at least one tumor
deposit greater than 2.0 mm); or metastases to the infraclavicular
(level III axillary lymph) nodes.
pN3b pN3b pN1a or pN2a in the presence of cN2b (positive internal mammary
nodes by imaging); or pN2a in the presence of pN1b.
pN3c pN3c Metastases in ipsilateral supraclavicular lymph nodes
Distant metastasis (M)
M0 M0 No clinical or radiographic evidence of distant metastases (no

pathologic M0; imaging studies are not required to assign the cM0
category).
cM0(i+) No clinical or radiographic evidence of distant metastases, but

deposits of molecularly or microscopically detected tumor cells that
are no larger than 0.2 mm are present in circulating blood, bone
marrow, or other nonregional nodal tissue in a patient without
symptoms or signs of metastases.
M1 Distant detectable metastases as determined by classic clinical and
radiographic means and/or histologically proven metastases larger
than 0.2 mm.
pM1 pM1 Any histologically proven metastases in distant organs; or if in non

regional nodes, metasyases greater than 0.2mm

Stage grouping
T N M Stage
Tis N0 M0 0
T1 N0 M0 IA
T0 N1mi M0 IB
T1 N1mi M0 IB
T0 N1 M0 IIA
T1 N1 M0 IIA
T2 N0 M0 IIA
T2 N1 M0 IIB
T3 N0 M0 IIB
T0 N2 M0 IIIA
T1 N2 M0 IIIA
T2 N2 M0 IIIA
T3 N1 M0 IIIA
T3 N2 M0 IIIA
T4 N0 M0 IIIB
T4 N1 M0 IIIB
T4 N2 M0 IIIB
Any T N3 M0 IIIC
Any T Any N M1 IV
Note:
1. Lobular carcinoma in situ (LCIS) is now considered a benign entity and is no longer classified as
Tis.
2. Tumors >1 mm and <2 mm should now be rounded to 2 mm, so as not to classify tumors
between 1 and 1.5 mm as microinvasive (T1mi) carcinomas.
3. The eighth edition confirmed that small, microscopic, satellite tumor foci around a primary
should not be added to the maximum tumor size.
4. It also clarified that the T size for multiple synchronous tumors is that of the largest tumor, but
the suffix "m" should be appended to the T score.
5. It defined T4b lesions as macroscopic satellite tumor nodules to the skin that are separate from
the primary tumor. Microscopic skin and dermal tumor satellite nodules do not qualify and
should be classified based on tumor size.

6. The suffixes (sn) and (f) should be added to the N descriptor to note confirmation by sentinel
lymph node biopsy or fine needle aspiration /core needle biopsy, respectively
7. The eighth edition clarified that the largest contiguous tumor deposit should define pN.
Dimensions of satellite deposits are not added.
8. Furthermore, clarification was added that cNX should only be used when a nodal basin has been
removed and cannot be examined by imaging or clinical exam. cN0 is assigned to tumors in
which nodal exam and imaging, if obtained, are negative.
9. Imaging studies are not required to assign the M0 criteria

- Lump in the breast

- Nipple retraction Symptoms of Breast Cancer
- Suspecious Nipple discharge
(unilateral,spontaneous,blood Type of Lesion
stained or those that occur in
elderly)
Evaluation of a Breast Lump
-Clinical examination by Cystic lesion Benign solid Suspicious solid

an experienced clinician (Small multiple cysts can be observed
-Unilateral or Bilateral & do not need to be aspirated)
mammogram
Digital mammography
Excision biopsy/Observation
and Bilateral Core biopsy
with repeat USG in 6 months
mammography are
preferred
preferred
-Consider ultrasonogram Complex cyst or FNAC acceptable
of breast if dense breast Aspirate hemorrhagic
-MRI Breast to be contents/rapid
considered only if filling or
mammogram and refilling/residual
ultrasonography are solid component Benign Malignant
suboptimal
-If abnormal imaging
studies, follow radiology Biopsy
recommendation Observe/Excise
-Imaging should precede Serous
any procedure to obtain
pathology
-Core biopsy (trucut
biopsy) preferred Review and follow
Observe Benign Malignant
-FNAC is acceptable guidelines
-Avoid excision biopsy;
but if required,
specimens should be
properly marked with
sutures or ink so that
pathologist can report
on the margin

High Risk Lesions
Lobular Carcinoma Counseling

In Situ Bilateral Surgical Consider risk reduction strategies
Atypical Ductal mammogra excision (Tamoxifen for pre or
Hyperplasia m or postmenopausal women or AI for
Atypical Lobular Core biopsy Follow-up postmenopausal women) IF life
Hyperplasia (trucut expectancy >5-10 years
biopsy) Follow-up examination every 6-12
monthly and mammogram - 2-3
yearly
Non-invasive Breast Cancer
Ductal Bilateral Breast Conservation Surgery, BCS, If ER+ or PR+,

Carcinoma mammogram (2mm margin is adequate) +/-RT consider anti-
in Situ Core needle OR Mastectomy estrogen
(DCIS) biopsy (trucut) therapy(Tamoxif
Test Estrogen In high grade disease, axillary
en for pre or
and assessment by sentinel node postmenopausal
Progesterone (optimal) or low axillary sampling women or AI for
Receptor by IHC maybe done postmenopausal
RT +/- boost women)
Follow-up
RT may be omitted in elderly, mammogram
poor functional status, life every 2-3 yearly
expectancy <10 years, good risk is preferred (see
disease defined by size (≤2cm) page 5)
and grade and ER+ status

Stage I and II Breast Cancer
Stage I Bilateral mammogram Surgery (BCS or Mastectomy; BCS is optimal)

Breast Core biopsy (trucut) Sentinel node assessment is desirable. If SLN biopsyis not
Cancer preferred done, consider limited axillary dissection
T1N0M0,
Test ER and PR by IHC, RT for patients treated with BCS
T0/T1N1mi
M0 and HER2 Receptor by RT maybe omitted in age > 70 years, or life expectancy <5
CAP/ASCO guidelines years if Hormone receptor (HR) positive
(preferably on core
biopsy specimen) Adjuvant chemotherapyif indicated (T1b/c triple negative
disease, HER2+T1b/1c, high risk ‘luminal B’ type
Ki-67 disease).Anthracyclines maybe avoided
No other/additional Adjuvant Trastuzumab for HER2+ disease (T1b/T1c)
imaging studies
indicated if Adjuvant endocrine therapy for ER/PR + disease for
asymptomatic AND atleast 5 years (Tamoxifen for pre or postmenopausal
LFTis normal women or AI for postmenopausal women)
Stage II Bilateral mammogram Surgery (BCS or Mastectomy; BCS is optimal)

Breast Sentinel node assessment is desirable. If SLN biopsyis not
Core biopsy (trucut)
Cancer done, consider limited axillary dissection
preferred
T0/T1 N1
Test ER and PR by IHC, RT for patients treated with BCS or following Mastectomy (if
M0,
and HER2 Receptor by patient has node positive disease AND presence of adverse
T2N0M0,
CAP/ASCO guidelines factors such as high grade disease, ER negative disease, triple
T2N1M0,
(preferably on core negative disease, HER 2+, presence of LVSI, ECS)
T3N0M0
biopsy specimen) Adjuvant or neoadjuvant chemotherapy (+/- anti-HER2
therapy) if indicated
Ki-67 Avoid anthracyclines when possible
No imaging studies Adjuvant chemotherapy should be started preferably at the
indicated if earliest; (within 30 days for TNBC) or definitely within 12
asymptomatic AND weeks of surgery.
LFTis normal Adjuvant anti-estrogen therapy for ER/PR+ disease for at
least 5 years
(Tamoxifen for pre or postmenopausal women or AI for
postmenopausal women)
Consider Ovarian Function Suppression in young pre-
menopausal women with ER/PR+ disease at high risk for
distant recurrence (age <35)
Consider adjuvant zoledronate 4mg every 6 monthly for 2-3
years in postmenopausal women, if Bone Mineral Density
(BMD) study is abnormal
Neoadjuvant chemotherapy can be considered if down-

staging of disease is desired for operability or in patients with
unfavorable biology such as TNBC or HER2+ disease

Stage III Breast Cancer
Stage III Bilateral mammogram Surgery (BCS or total mastectomy)

Breast Axillary dissection
Cancer
Core biopsy (trucut)
preferred Neoadjuvant systemic therapy may be preferred for
T3N1M0, T4/N2/N3 disease for downstaging.
T0-3, N2 M0 Test ER and PR by IHC, Adjuvant RT
T0-3, N3 and HER2 Receptor by
M0, Adjuvant or neoadjuvant chemotherapy (+/- anti-HER2
CAP/ASCO guidelines
T4 N1-3 M0 therapy) as indicated
(on biopsy specimen)
Consider dose dense chemotherapy with growth factor
Chest XRay or CT support
Chest, USG abdomen Adjuvant chemotherapy should be started preferably at the
or CT abdomen, and earliest; (within 30 days for TNBC) or definitely within 12
Bone scan weeks of surgery.
PET/CT is indicated for
Adjuvant anti-estrogen therapy for ER/PR+ disease for at
equivocal results on
least 5 years
CT imaging
Recommend Ovarian Function Suppression in young pre-
MRI brain if menopausal women with ER/PR+ diseaseat high risk for
symptomatic for brain distant recurrence (age <35 or N2/3 disease)
metastases Consider adjuvant zoledronate 4mg every 6 monthly for 2-3
years in postmenopausal women regardless of BMD result
Neoadjuvant chemotherapy can be considered if down-
staging of disease is desired for operability or in patients
with unfavorable biology such as TNBC or HER2+ disease.
Neoadjuvant endocrine therapy could be considered in
elderly patients with ER+/PR+/HER2- disease, or in patients
with ER+/PR+/HER2- disease that is inoperable and
chemotherapy is contra-indicated.
Stage IV Breast Cancer

Stage IV Core biopsy Anti-estrogen therapy if ER/PR+ disease History
Breast (trucut) preferred Ovarian ablation in premenopausal women &Physical
Cancer Test ER and PR by with ER/PR+ disease (bilateral oophorectomy Examination
IHC, and HER2 preferred) every 3-4
Receptor by Chemotherapy for patients with ER+ disease months or as
CAP/ASCO but in visceral crises clinically
guidelines (on Chemotherapy for triple negative disease indicated.
biopsy specimen) Chemotherapy plus trastuzumab in HER2+ Imaging
Chest XRay or CT disease (desirable) studies when
Chest, USG Zoledronate 4mg every 3 months for 2 years indicated, for
abdomen or CT for patients with bone metastases treatment
abdomen, and Consider palliative RT in bone disease when response
Bone scan indicated (pain, impending fracture) assessment
PET/CT when Surgery (BCS or total mastectomy) or RT only
indicated for palliation
MRI brain when Oligometastatic low volume disease can be
indicated considered for intent-to-cure therapy, after
MDT discussion.

Optimal Axillary
Surgery
Histopathological Report(Minimum Requirments)
-Tumor size (all 3 dimensions)

-Tumor histology Sentinel node biopsy, by any
-Tumor grade method, is optimal in DCIS
-Presence of extensive intraductal carcinoma (EIC) requiring mastectomy or palpable
-Lymphovascular emboli DCIS and stage I, II invasive cancer.
-Margin status (Adequate margin for invasive disease is defined as no Axillary dissection up to Level II
tumour cells at resected inked margin. Margins should be assessed axillary lymph nodes (minimum of
by frozen section, if available. For DCIS, 2mm margin is adequate) 10 lymph nodes)
-No. of metastatic nodes and total axillary lymph node dissected
-Receptor status: ER, PR, HER2 (only for invasive disease, follow If significant nodes are seen in
CAP/ASCO guideline) level II / III, dissection of Level III
-Ki-67 preferred nodes is indicated.
Optimal Radiation Ovarian Function Suppression in

Therapy Pre-menopausal women
50Gy in 25 daily fractions over 5 weeks or its equivalent For adjuvant therapy in women deemed to
hypofractionated regimen of 40Gy/15 fractions over 3 weeks or be at high risk of recurrence, ovarian
42.5Gy/16# over 3 weeks. function suppression helps prevent
recurrences. Consider using GnRH agonist
Hypofractionated regimen is equivalent to the conventional regimen in
(preferred). Bilateral oophorectomy can
terms of disease control and survival. These hypofractionated
regimens results in significantly lower incidence of acute and late also be utilized.
breast toxicity and without excess cardiac morbidity at 15 years. Appropriate counseling regarding side
Appropriate planning should be done to minimize dose inhomogeneity effects and long term morbidity should be
and normal tissue morbidity especially cardiac dose. ensured.
Tumor bed boost after whole breast RT for BCS is given with If GnRH agonist is used, monitor estradiol &
appropriate energy electrons or 3DCRT photons or brachytherapy. FSH level every 3-6 monthly to ensure post-
menopausal hormonal levels.
Internal mammary nodeirradiation is indicated for Stage III patients
For metastatic disease, ovarian ablation by
with radiologically /histologically proven IMN positive disease. CT
based techniques are required for IMN irradiation. bilateral oophorectomy (preferred) or RT or
GnRH agonist
Definition of Optimal Follow-up for DCIS & invasive disease (stage

Menopause I, II, III)
Reasonable criteria for History &Physical Examination every 3-6 monthly for years 1-2, every 6 monthly for
determining menopause include years 3-5 and annually after year 5
any of the following: Bilateral mammogram every 2-3 yearlyor if clinically indicated
-Prior bilateral oophorectomy BMD assessment at baseline if on an AI
-Age >60 y Laboratory investigations, tumour markers and Imaging studies in asymptomatic
-Follicle-stimulating hormone individuals are not recommended
(FSH) and estradiol in the No indication for routine imaging gynecological evaluation in postmenopausal
postmenopausal range. patients on Tamoxifen

Paget’s disease
If breast imaging is positive, treat as per stage and histology.
If it is negative, obtain full thickness skin biopsy of affected area.
If positive, recommend wide local excision + RT Or Mastectomy followed by regular follow-up. If
negative skin biopsy, consider follow-up.
Male Breast Cancer

The surgical approach to treatment of breast cancer in men is similar to that of women and depends
on the extent of disease at presentation. Adjuvant and metastatic therapy guidelines are similar to
female patients with breast cancer. For adjuvant endocrine therapy, Tamoxifen is the preferred
option. For male patients who need to receive an AI, a concomitant LHRH agonist or orchiectomy
is preferred.
Genetic counseling and testing for detection of BRCA1/2 gene mutations maybe considered.
Breast Cancer during Pregnancy

If diagnosed in 1st trimester, discuss medical termination of pregnancy. If continuing with
pregnancy, recommend mastectomy/BCS + axillary assessment. Begin adjuvant chemotherapy in
2nd trimester. If indicated, adjuvant RT and/or adjuvant anti-estrogen and/or anti-HER2 therapy
post-partum.
If diagnosed in 2nd trimester, recommend mastectomy or BCS + axillary assessment. Consider

neoadjuvant or adjuvant chemotherapy if indicated. If indicated, adjuvant RT and/or adjuvant anti-
estrogen and/or anti-HER2 therapy post-partum. Alternatively, preoperative chemotherapy followed
by breast surgery (with axillary assessment) can be done post-partum.
If diagnosed in late 3rd trimester, recommend mastectomy or BCS + axillary assessment. Consider
neoadjuvant or adjuvant chemotherapy if indicated. If indicated, adjuvant RT and/or adjuvant anti-
estrogen and/or anti-HER2 therapy post-partum. No chemotherapy in 1st trimester. No RT during
pregnancy. No anti-HER2 therapy in pregnancy. No anti-estrogen therapy in pregnancy. Sentinel
node assessment can be done after MDT discussion. Although some consider the use of methylene
blue or radioactive colloid to be safe to the fetus in pregnant women with breast cancer, isosulfan
blue dye (Lymphazurin) is systemically absorbed after subcutaneous injection and therefore should
not be used during pregnancy.
Phyllodes Tumor
Suspect phyllodes tumor if palpable mass, rapid growth, large size (>3cm), imaging with ultrasound
suggestive of fibroadenoma except for size and/or history of growth. Recommend core biopsy. If it
is diagnosed as phyllodes tumor, including benign, borderline, and malignant, recommend wide
excision without axillary assessment or mastectomy as indicated. If recurrence of phyllodes tumor
occurs, recommend core biopsy, Chest XRay or CT Chest. If non-metastatic, re-excise the lesion
with wide margins without axillary assessment/mastectomy. Consider post-operative RT. If
metastatic, management follows principles of soft tissue sarcoma.

Surgical Principles
Tissue diagnosis
Trucut biopsy is the preferable method for tissue diagnosis. Biopsy has to be done after
mammogram, as the biopsy scar may make interpretation of mammogram difficult. Trucut biopsy
has to be done form the most prominent area of the tumour and it needs to be marked well for later
identification and excision with the final specimen. Unplanned incision biopsy and excision biopsy
should be avoided as this reduces possibility of breast conservation surgery and unnecessarily
increases cost of the treatment. Incision or excision biopsy can however be done whentrucut
biopsies fail to produce diagnosis twice or there is significant radio-pathological disparity after
trucut biopsy and mammogram or MR mammogram in selected cases.
Early breast cancer
Breast conserving surgery (BCS) is preferable, especially in young patients. Negative margin in the
final histopathology is the requirement. Multi-centricity, repeated margin positivity even after two
re-resections are contraindications for breast conservation. Active collagen vascular disease and
need of radiotherapy in pregnancy and unfavourable tumour-breast size ratio are general
contraindications for radiotherapy and hence for BCS. All patients planned for BCS must be seen
by radiation oncologists before procedure and should be discussed in MDT.
Axilla needs to be staged using sentinel node biopsy (SLNB) or axillary sampling (AS) in all
patients with clinically negative axilla. The retrieved nodes can be sent for frozen section and if
reported positive, axilla may be cleared upto level II. Alternatively, the nodes retrieved from the
axilla can be sent directly for histopathology and if final report is positive for nodal metastasis those
patients can be treated with axillary radiation therapy. This has to be discussed in MDT in every
case and institutional protocol may be followed. In clinically node negative axilla, axillary
dissection is not an acceptable method of axillary staging. Hence, if facility and expertise for SLNB
or axillary sampling are not available, patients should be referred to a centre with expertise.
In node positive axilla, after proving with FNAC, axillary dissection upto level II has to be done. If
there are significant nodes in level I and II, or enlarged nodes in level III, level III clearance has to
be done.
If patient is not willing for BCS, or BCS is contraindicated, modified radical mastectomy (MRM)
with appropriate management of the axilla as described above has to be done.
Breast reconstruction and oncoplasty
Oncoplasty may be considered for improving cosmesis of breast reconstruction after a BCS. If the
volume loss is higher than 20% of the total breast volume, a latissimusdorsi (LD) flap may be
considered to fill the volume loss. After MRM, in selected patients, breast reconstruction may be
achieved with LD flap, pedicled abdominal flap, breast implant or free flap.
Locally advanced breast cancer (LABC)
In T3/T4 disease, neo-adjuvant chemotherapy (NACT) is the preferred option. In early T3 disease
however, upfront mastectomy may be considered if the patient is not interested in BCS, after MDT
discussion. MRM is generally preferred in LABC over BCS. Those patients who respond to NACT,

may however be considered for BCS after explaining the slightly higher risk of local recurrence
compared to mastectomy.
In patients with T3 disease with clinically negative axilla, SLNB or axillary sampling is accepted
for staging. In T4 cancers and inflammatory breast cancer axillary dissection is done, SLNB/AS is
contraindicated.
In LABC with negative axillary nodes before NACT, SLNB/AS may be done for axillary staging.
However, if axillary examination before NACT showed pathologically proven nodes, axillary
dissection is done till evidence matures for safety of SLNB/AS is such clinical scenario.
In case of tumors infiltrating the pectoralis major or the chest wall, resection of the involved
structures may be considered after NACT if the patients is nonmetastatic.
Role of palliative mastectomy
Routine mastectomy is not recommended in metastatic patients. However, in patients with

fungating or bleeding tumours, a palliative mastectomy may be considered in order to reduce foul
smell and improve quality of life.
Role of surgical oophorectomy
In premenopausal patients with high risk disease, bilateral laparoscopic/open oophorectomy may be
considered.
Radiotherapy Doses
2D 40 Gy /15 #
IPSILATERAL 3DCRT 42.5 Gy in 16 #
BREAST IMRT/VMAT with Breath 50 Gy in 25 #
Hold or Gating
2D 10 -16 Gy in
3DCRT 5-8 #
TUMOUR BED IMRT/VMAT with Breath
BCS Hold or Gating
Electron beam therapy
ACCELERATED Brachytherapy 34 Gy in 10 #
PARTIAL BREAST
IRRADIATION Photon Therapy 38.5 Gy in 10 #
2D, 3DCRT, IMRT/VMAT 40 Gy in 15
with breathhold Technique or fractions
POST MRM Gating 42.5 Gy in 16
fractions
50 Gy in 25
fractions
+/- boost to the
scar 10 Gy in 5
fractions

Chemotherapy Regimens for Carcinoma Breast
Neoadjuvant / Adjuvant Chemotherapy Regimens for HER 2 Negative Cancer
1 Dose-dense AC x 4 followed by Paclitaxel x4*

2 Dose-dense AC x4* followed by weekly Paclitaxel x12
3 AC x4 followed by Docetaxelx4
4 AC x4 followed by weekly Paclitaxel x12
5 FECx3 followed by Docetaxelx3
6 TAC x6*
7 FEC x3 followed by weekly Paclitaxel x12
8 FAC x 6
9 TC x4*
10 AC x4
11 EC x 4
12 CMF x 6
13 Capecitabine x 6-8 (For TNBC with residual disease following
Neoadjuvant Anthracycline-Taxane chemotherapy)
*With Myeloid Growth Factor support for all cycles
Neoadjuvant / Adjuvant Chemotherapy + Anti-

HER 2 Regimens# for HER 2 Positive Cancer
1 Dose-dense AC x 4 followed by Paclitaxel x4* + Trastuzumab x 1 year/6
months
2 Dose-dense AC x4* followed by weekly Paclitaxel x12 + Trastuzumab x 1
year/6 months
3 AC x4 followed by Docetaxel x 4 + Trastuzumab x 1 year/6 months
4 AC x4 followed by weekly Paclitaxel x12 + Trastuzumab x 1 year/6
months
5 FECx3 followed by Docetaxel x 3 + Trastuzumab x 1 year/6 months
6 TCH : Docetaxel + Carboplatin x 6 + Trastuzumab x 1 year/6 months
7 TC x4* + Trastuzumab x 1 year/6 months
8 Docetaxel x 3 + Trastuzumab x 9 weeks followed by FEC

9 Paclitaxel x 12 + Trastuzumab X 1 year
10 Addition of Pertuzumab as neo-adjuvant for 4 cycles was associated
with improved pCR.
*With Myeloid Growth Factor support for all cycles
# Evaluate Left Ventricular Ejection Fraction prior to and 3 monthly during Trastuzumab therapy

For patients receiving neo-adjuvant systemic therapy, tumour response should be routinely
assessed by clinical examination during preoperative therapy. In presence of continuing response,
all cycles of neoadjuvant chemotherapy must be completed prior to surgery. Those experiencing
progression of disease on neoadjuvant therapy should either receive alternate chemotherapy or
undergo surgery.
Chemotherapy for Metastatic Disease

Single agents:
 Anthracyclines – Doxorubicin / Pegylated liposomal doxorubicin
 Taxanes – Paclitaxel/Docetaxel /Albumin-bound Paclitaxel
 Anti-metabolites – Capecitabine / Gemcitabine
 Other microtubule inhibitors – Vinorelbine / Eribulin
 Other single agents – Carboplatin / Cisplatin / Epirubicin / Ixabepilone
Chemotherapy combinations:
 FAC (cyclophosphamide/doxorubicin/fluorouracil)
 AC (doxorubicin/cyclophosphamide)
 EC (epirubicin/cyclophosphamide)
 CMF (cyclophosphamide/methotrexate/fluorouracil)
 Docetaxel + Capecitabine
 GT (Gemcitabine/Paclitaxel)
 Gemcitabine/Carboplatin
 Paclitaxel/Carboplatin
Agents for HER2-positive disease:
 Trastuzumab + Docetaxel +/- Pertuzumab
 Trastuzumab + Paclitaxel +/- Pertuzumab
 Trastuzumab + Paclitaxel ± Carboplatin
 Trastuzumab + vinorelbine
 Trastuzumab + capecitabine
 Ado-trastuzumab emtansine (T-DM1)
 Lapatinib + capecitabine
 Trastuzumab + Other agents
Sequential single agent chemotherapy is preferred over combination chemotherapy as there

is no evidence for superiority of combination regimens. Anti-HER 2 therapy is associated with
improved response rates, progression free survival and overall survival. Decisions may be based on
patient preferences.

HAEMATOLOGICAL
MALIGNANCIES


ACUTE PRO-MYELOCYTIC LEUKEMIA

Low and Intermediate risk disease ( TLC < 10,000)
ATO + ATRA induction. Once peripheral blood counts recover with no abnormal cells in
PS – proceed for BMA/BMT to document morphologic remission.
Followed by ATO + ATRA consolidation
Alternative protocols for low risk APML : APL protocol or AIDA protocol.
High Risk ( TLC >= 10,000)

ATO + ATRA + Anthracycline based induction . Once peripheral blood counts recover with
no abnormal cells in PS – proceed for BMA/BMT to document morphologic remission.
Followed by ATO + ATRA consolidation . Maintenance may be considered
Alternative protocols for high risk APML : APL protocol or AIDA protocol.
For elderly patients and patients with significant comorbidities ( especially cardiac) ATO + ATRA
may be used alone (avoiding anthracyclines) as used in a low risk APL
Notes:
 BMA PCR (qualitative) for PML RARA at the end of consolidation
 It is advised to stick to any of the published trials during the entire Rx (not to mix induction
from one trial with consolidation from an other)
 If TLC <5000 (Vellore low risk), option of single agent ATO induction and consolidation
may be considered after discussion in MDTB.
 CSF studies may be considered in high risk cases at the end of induction . So also CNS
prophylaxis.
Coagulopathy Mx
FFP/CPP to keep PT/ APTT within normal limits and to keep fibrinogen >=150. FFP at 15
ml/Kg OD /BD depending on PT/APTT values. CPP at 1-2 units /10 Kg body weight.
Platelet to be kept above 30,000/mm3, and if any bleeding manifestations to keep above 50,000.
This criteria to be followed till ccoagulopathy settles.
PCR monitoring : Qualitative PCR Q 3 months from Peripheral blood for 2 years. If positive at
any time then repeat at 4 weeks and if still positive treat as relapse.
Rx of differentiation syndrome : IV Dexa 10 mg BD . Severe differentiation syndrome may
mandate withdrawal of ATRA and ATO as per physician‘s discretion.
K, Mg and QTc have to be monitored while on ATO .

HODGKIN LYMPHOMA
Work up
Lymph node excision biopsy
CBC/ Differential
ESR
RFT/LFT/LDH/Uric acid
PET CT
HIV/HBsAg/Anti HCV
Consider PFT if Bleomycin based chemo planned
ECHO for cardiac assessment if Anthracycline based chemo planned.
BMA/BMT if cytopenias and PET marrow negative.
Lugano staging
Stage Involvement Extranodal (E) status

Limited
I One node or a group of adjacent nodes Single extranodal lesions without
nodal involvement
II Two or more nodal groups on the same Stage I or II by nodal extent with
side of the diaphragm limited contiguous extranodal
involvement
II bulky* II as above with ―bulky‖ disease Not applicable
Advanced
III Nodes in both side of the diaphragm; Not applicable
nodes above the diaphragm with spleen
involvement
IV Additional non-contiguous extralymphatic Not applicable
involvement
Early stage disease has a cure rate of 90% and hence risk adapted combined modality treatment is
the current standard of care. PET / PET-CT scans have an active role to play in reducing treatment
for early stage disease. Deauville score to be applied, timing of scan is after 2 (or 4) cycles.
Early Stage Favourable*: ABVD x 2 cycles + local RT (20 Gy)

PET CT after 2 cycles :
Deauville score 1-3 : complete 20 Gy RT
Deauville score 4 : 2 more cycles ABVD and then RT 30 Gy). End of Rx PET to be done
Deauville score 5 : biopsy to be done

Note: HDSG (HD 10 study criteria)

Risk Factors : Favourable*: no more than two sites of disease, no extranodal extension, no
mediastinal mass greater than or equal to one-third the maximum thoracic diameter, and ESR less
than 50 (less than 30 if B symptoms present).
Early Stage Unfavourable (bulky and non bulky): ABVD x 4 cycles + local RT PET CT after 4
cycles
If Deauville score 1-4 after Cycle 4- local RT ( 30 Gy)
If Deauville score 5 after Cycle 4, biopsy
Advanced Stage: ABVD x 2 cycles followed by PET CT
If Deauville score 1-3 , AVD for 4 more cycles.
If Deauville score 4-5 , complete ABVD for 4 more cycles. Repeat PET at the end of Rx.
ISRT may be considered at single residual disease site
For young fit patients , if Deauville score 4-5, consider Beacopp X 4
Notes:
 Some cases of limited stage unfavorable may be considered for 6 cycles ABVD on
individual basis. In such cases if PET neg after 4 cycles , then consider AVD for next 2
more cycles.
 For young females with early stage disease , 6 cycles of chemo alone may be considered to
avoid RT.
 Elderly patients above the age of 60 years may be treated with COPP or ABVD
 Advanced stage with bulky disease at baseline, Consider RT to the bulky site (PET neg at
end of Rx) after discussion in MDTB.

NON-HODGKIN’S LYMPHOMA
Work up
Lymph node /Lesion excision biopsy
CBC/ Differential
ESR
RFT/LFT/LDH/Uric acid
PET CT
HIV/HBsAg/Anti HCV
ECHO for cardiac assessment if Anthracycline based chemo planned
BMA/BMT
Lugano staging
Stage Involvement Extranodal (E) status
Limited
I One node or a group of adjacent nodes Single extranodal lesions without
nodal involvement
II Two or more nodal groups on the same side Stage I or II by nodal extent with
of the diaphragm limited contiguous extranodal
involvement
II bulky* II as above with ―bulky‖ disease Not applicable
Advanced
III Nodes in both side of the diaphragm; nodes Not applicable
above the diaphragm with spleen involvement
IV Additional non-contiguous extralymphatic Not applicable
involvement
Low grade lymphoma (FL/MZL)

Stage 1 & 2 Asymptomaticpatients can be observed or treated with local RT
OR Combined modality chemo-immunotherapy x 3 cycles + local RT
Stage 3 & 4- AsymptomaticObservation alone or Single agent Rituximab weekly x 4 followed by

Maintenance 2 to 3 monthly for 2 years.
Stage 3 & 4- SymptomaticChemo-immunotherapy x 6 cycles followed by Maintenance Rituximab for 2

years
Note: Symptomatic* disease is largely based on the BNLI Criteria which include the following: Subjective
symptoms, threatened end organ dysfunction, Bulky disease, Cytopenias, disease progressing steadily
(doubling time short). Grade 3B FL should be treated like DLBCL.

Choice of regimen should be based on patient age (≤ 65yr or ≥65yrs), co-morbidities. It should be
dictated by the local expertise. Common regimens include,
• CVP +R
• CHOP+R
• Bendamustine+ R
High grade Lymphoma (Common Adult Lymphoma)

LYMPHOBLASTIC LYMPHOMA (LBL):
Patients with LBL have typically been treated with regimens appropriate for acute
lymphoblastic leukaemia (ALL). Cytogenetics and risk stratification is applicable to these patients
also. Patients with systemic LBL can be treated with any one of the chemotherapy regimens. For
bcr-abl positive patients, a TKI containing protocol must be used.
Young Adults and Adolescent: Use Paediatric ALL Protocols likeBFM , MRC-UKALL or COG,etc
Older Adults (>40yrs): Use any of the following: GMALL, HyperCVAD, GRALL
Note:
1. Patients with CR to induction therapy should be continued with other components of the
treatment protocols. Itis important that patients be treated with a given treatment protocol in
its entirety and not be treated withdifferent components taken from different protocols.
2. Patients with high risk features (such as bcr-abl +) and a matched sibling donor should be
offered an allogeneic transplantation in first remission
Diffuse Large B Cell Lymphoma (DLBCL)

The treatment options vary between patients with localized (stage I-II) and advanced (stage III-IV)
disease. Prognosis is extremely good for patients with no adverse risk factors (Normal LDH, stage I
or II non-bulky disease, age less than 60 years or ECOG performance status less than 2).
Stage I-II :For patients with Non-bulky (<10 cm) stage I or II disease, CHOP +
Rituximab (R) for 3 cycles with IFRT or 6 cycles of CHOP + R alone is
recommended (Category 2A).
Patients with bulky disease (10 cm or more) should be treated with 6 cycles of
CHOP+R with or without IFRT (Category 1).
Stage III-IV: For patients with advanced stage disease, treatment with 6 cycles of
CHOP+Rrepeated every 21 days is recommended (Category 1).
In selected cases, RT to bulky sites may be beneficial (Category 2B).
Patients at increased risk of CNS relapse (those with involvement of the
paranasal sinuses, testes,kidney,adrenal breast, bone-marrow involvement with large cells orhaving
two or more extra-nodal sites with elevated LDH,double hit lymphoma, HIV associated

lymphoma,High grade lymphoma NOS should receive CNS prophylaxis with 4 doses of Intrathecal
methotrexate or 2 doses of 3-3.5 Gm/M2 of systemic methotrexate.
Note:
1) Patients with bulky disease or impaired renal function should be monitored for tumor lysis
syndrome.
2) Hepatitis B reactivation in patients on Rituximab should be discussed and appropriate
prophylaxis started
3) Doxorubicin in CHOP regimen can be replaced with etoposide(CEOP), liposomal
doxorubicin or mitoxantrone in patients with poor left ventricular function (Category 2B).
4) Elderly ‘frail’ patients may receive R-mini CHOP
5) Young patients with Burkitt like lymphomas may be treated with da EPOCH-R
Mantle Cell Lymphoma (MCL)

Stage I-II: Very few patients present with localized low grade MCL. Local RT (30- 36Gy) alone or
combination chemo-immunotherapy with CHOP-R is recommended (Category 2A).
Stage II (bulky) and stage III-IV: In highly selected patients (low Ki 67) with
asymptomatic disease, close observation without any therapy is a reasonable option, especially for
those with good performance status and lower IPI.
Aggressive therapies commonly used are CHOP+R alternating with high dose Ara- C based
regimens (CHOP-R alternating with DHAP-R x 6 cycles). Other regimens include R-
HyperCVAD, R-CHOP , R-ICE, Nordic regimen, CALGB, etc. Choice of the regimen should be
based on local expertise and support
Note:
1. For young patients with CR to first line therapy, consolidation with HDT/ASCR is recommended.
2. For patients with PR to first line therapy, second line therapy may be considered in an effort to
improve the quality of a response before they are taken for consolidation with HDT/ASCR
Less aggressive therapies or Bendamustine and Rituximab (B-R x 6 cycles) are recommended for
elderly patients, cardiac compromise and patients unfit to tolerate aggressive regimens.
Maintenance rituximabis recommended for patients who are not candidates for HDT/ASCR and
are in remission after first line therapy with R-CHOP. Post transplant maintenance also
recommended
Burkitts Lymphoma (BL)

There is a high incidence of tumour-lysis syndrome and measures should be taken to prevent
and treat this complication. Patients with bulky disease and organ dysfunction may be treated with
modified dose therapy (e.g. ‗prephase-CVP‘), in an attempt to modify the effects of tumor lysis.
Then proceed to more intensive therapy as outlined below based on local expertise and supportive
care,

R CODOX-M alternating with IVAC (MaGrath regimen)

R Hyper CVAD
daEPOCH +R
The BFM protocol (B-NHL 2002)
CALGB
T Cell Lymphoma
Peripheral T - Cell (PTCL) and Anaplastic large cell lymphoma (ALCL):
Aggressive T cell lymphoma is divided into two groups:
a. ALK positive ALCL, and
b. PTCL-NoS& others (including ALK negative ALCL).
Treatment with an anthracycline-based chemotherapy regimen – CHOP±E is
recommended.
Limited stage: ALCL and no adverse prognostic features by IPI should be treated
with 3-4 cycles of CHOP chemotherapy and involved field radiotherapy/ 6 cycles of CHOP ± E alone.
Advanced Stage: patients should receive 6-8 cycles of CHOP ± E chemotherapy.
Consideration should be given to consolidation with auto-HSCT in the PTCL-NoS group and ALK negative
ALCL
Note: All other subtypes of lymphoma are rare and need to be managed individually as per prevailing
guidelines
Follow Up
Patients should be followed up every 3 to 4 monthly for the first 2 years, followed by 6 monthly for
the next 3 year and then annually. The following format shall be followed:
1) Accurate history,
2) Careful physical examination,
3) Hematological investigation- CBC, ESR, LDH
4) Documentation of side effects: late effects of treatment,
5) Documentation of 2nd primary,
Surveillence PET scan has no role in the patient follow up as of date and must be used
judiciously
Relapsed Lymphoma
Histopathological examination is mandatory in the evaluation of relapsed disease.
Management Strategy:
Salvage chemotherapy with platinum based chemotherapy (DHAP,ESHAP,GDP,ICE) or
MINE or daREPOCH. After 2 to 3 cycles response assessment by PETCT imaging .If achieved
50% and above response patient is proceeded with auto transplant. In non-responders alternative
chemotherapy is considered. Patient who can not go for transplant will be given salvage
chemotherapy depending on performance status,comorbidity and tolerance.

Note:
1. Additional anthracyclines must be used after careful monitoring of the cardiac status.
2. Disease status should be evaluated with imaging studies and clinical assessment after two tothree
cycles, following which autologous HSCT should be carried out
Conditioning regimen will be BEAM or BEAM like chemotherapy (Ex: LACE)
Allogenic Stem Cell Transplantation

Allogeneic HSCT may be considered in younger patients with stem cell mobilisation failure or
relapse after autologous HSCT that are able to tolerate high dose chemotherapy a second time.
Chemotherapy regimens in patients who are not candidates for stem cell therapy
CEPP/PEP C (cyclophosphamide, etoposide, prednisone, procarbazine) ± rituximab
da-EPOCH ± rituximab
GDP ± rituximab
Lenalidomide± rituximab
Newer Molecules (compassionate access or if affordable)

ACUTE MYELOID LEUKEMIA
Work up
 History: Fever/ bleeding/Co-morbidity

 Examination: ECOG PS /Pallor/LNE/HSM/Gum hypertrophy/bleeds
 CBC/ Differential/MPO/Peripheral Smear
 RFT/LFT/LDH/Uric acid/Na/K/PO4/Ca
 PT/APTT/Fibrinogen
 Blood Gp
 HIV/HBsAg/Anti HCV
 ECHO for cardiac assessment if Anthracycline based chemo planned.
 BMA/BMT (Cytochemistry/Cytogenetics/Flow cytometry/Molecular studies )
 CXR may be considered at baseline for all patients. CT chest may be performed at baseline
if clinically indicated.
 HLA typing (for potential transplant candidates)
 Counselling/TLS management/Blood & Platelet transfusion/Management of infections with
antibiotics according to focus of infection
 PICC/Central line counselling and insertion
Risk stratification:
Favorable risk Intermediate risk Poor risk
Inv 16 Normal Complex(>3 abnormalities)
t(8;21) +8 only -5,-7,5q-,7q-
t(16;16) t(9;11) Inversion 3
Normal cytogenetics Other abnormalities not listed Abnormalities 11q23 except
with isolated NPM1 with better or poor risk t(9;11)
mutation/ biallelic
CEBPA
c-KIT mutation in patients with t(3;3),t(6;9),t(9;22)
t(8;21)and inv 16
Normal cytogenetics with
isolated FLT3 mutations
Age < 60, Good PS /No Co-morbidity

3+7 Induction
Day 21-28 BMA/BMT

If in CR
 Good Risk: 3 X HIDAC
 Intermediate Risk: If willing and HLA matched sibling available, allo BMT. If not
- 3 X HIDAC
 Poor Risk : Counsel for allo BMT. If not willing or no matched donor- 3 X HIDAC
If not in CR
Re-induction (HIDAC based)- If CR achieved counsel for allo BMT as in poor risk. If CR
not achieved, then ,BSC/Clinical trial
Age >60, Good PS/No Co-morbidity: If eligible for 3+7 – follow the above algorithm.
Patients not fit for 3+7 due to age/poor PS/Co-morbidity: The following options may be considered.
 Azacytidine/Decitabine/Lenalidomide/Low dose Cytarabine/Mitoxantrone/oral
chemotherapy/BSC
Notes:
 In view of importance in risk stratification ,FISH/PCR t 8:21, t16:16, inv 16 , FLT3,NPM1
should be considered at baseline in addition to karyotyping.
 3+7 : Dauno 60-90 mg/m2 for day1-3 IV bolus. Cytarabine 100-200 mg/m2 CIVI for days
1-7.
 BMA/BMT post induction : Cytomorphology/Flow for MRD. Also consider
cytogenetics/molecular if abnormal at baseline.
 HIDAC: Cytarabine 1.5-3 g/m2 BD on days 1,3,5 X 3 cycles.
 Azaytidine : 75 mg/m2/day SC/IV on days 1-7 Q 28 days. Decitabine : 20 mg/m2/day IV on
days 1-5 Q 28 days. If response achieved within 4-6 cycles, continue till progression
/toxicity
 Lenalidomide: Consider dose from 10 mg OD day 1-21 Q 28 days.
 Oral chemo : 6 TG 40 mg/m2/day for day 1-21 + Etoposide 50 mg/m2/day day 1-21 only for
first cycle.
 Platelet transfusion: If < 10,000 . or if < 20,000 with fever or bleed.
 PRC ; If Hb < 7 . Higher threshold for symptomatic /cardiac patients.
 FN protocol as per hospital antibiotic policy.
 Antifungal prophylaxis with Voriconazole/Posaconazole.

ACUTE LYMPHO BLASTIC LEUKEMIA
Work up
 History: Fever/ bleeding/Co-morbidity

 Examination: ECOG PS/Pallor/LNE/HSM/bleeds/Testes/CNS
 CBC/ Differential/MPO/Peripheral Smear
 PT/APTT/Fibrinogen
 Blood Gp
 BMA/BMT (Cytochemistry/Cytogenetics/Flow cytometry/Molecular studies )
 CSF cytology (with IT MTX)
 CXR may be considered at baseline for all patients. CT chest may be performed at baseline
if clinically indicated (suspected mediastinal mass).
 HLA typing (for potential transplant candidates)
 Counselling/TLS management(IVF at 3 L/m2/day, Allopurinol, Rasburicase sos)/Blood &
Platelet transfusion/Management of infections with antibiotics according to focus of
infection
 PICC/Central line counselling and insertion

• CT Thorax if clinically indicated
Standard Induction Repeat BM

CR Continue post
Risk Aspiration
remission therapy
at end of
(consolidation and
induction maintenance for a
total of 2 years)
Counsel If unwilling BSC

Not in CR
for allo
SCT Reinduction
&
If willing HLAtyping
Bone marrow aspiration

at end of induction
Not in CR
Inductio Repeat
Age <60 High n and BM
Matched Consolidation
years risk counsel aspiratio CR
n HLA sibling and also SCT
for BMT available
typing
Search For unrelated

donor .continue
No chemotherapy till
matched then (with imatinib If
sibling BCR/ABL positive )
Continue
BCR/ABL Induction plus
BM Transplant Chemotherapy
Positive imatinib
aspiration not feasible with imatinib
counsel for allo
as for good
SCT risk
Not in BSC
CR

BM Continue
Induction imatinib till
BCR/ABL aspiration
with steroids disease
positive and imatinib
at end of CR
induction progression
Not in CR BSC
Best
BCR/ABL
Age >60 years supportive
negative care
IRMA
2nd Line TKI may be considered
VCR +Steroid
based on IRMA results.

CHRONIC MYELOID LEUKEMIA (CML)
Management and monitoring of CML Chronic phase
History
Examination-Spleen size by palpation (cm below costal margin)
Investigations:
 Complete blood Count
 Peripheral smear
 Bone marrow studies:
o Bone marrow aspirate for cytomorphology
o Flow cytometry in blast phase
o Cytogenetics-FISH and Conventional
o Molecular Studies-Real Time PCR
Bone marrow biopsy
 Imatinib Resistance mutation analysis peripheral blood
[Accelerated phase/Blast phase/First line failure]
 HLA typing[ Accelerated phase/Blast phase ]
Calculate the Sokal and Eutos score.
Phpositive Chronic Myeloid Leukemia in Phpositive Chronic Myeloid Leukemia

chronic phase in Accelerated phase/blast crisis 1
First line Treatment Options:
 Imatinib 400mg OD
 Dasatinib 100mg OD
 Nilotinib 300mg BD
Monitor response as per the recommendation of the European leukemia net recommendation
(Indicated in table below) and categorize response.

European Leukemia net Recommendations for response assessment for previously untreated
patients with early chronic phase CML, treated with first line TKI.
TIME OPTIMAL RESPONSE FAILURE WARNINGS

Diagnosis ____ ____
High risk CCA/Ph+
3months
CHR,BCR ABL<=10% Less than CHR BCR ABL >10%
P CyR Ph>95% Ph36-95%
6months
BCR ABL<=1% C CyR BCR ABL 1-10% BCR ABL>10%
PH 1-35% Ph35%
12months
BCR ABL<=0.1% BCR ABL 1% BCR ABL 0.1-1%
Ph>0%
Any time Increase in transcript
(during MMR OR BETTER Loss of CHR ,Loss of levels/CCA/Ph+(-7/7q-)
treatment) CCgR,Mutations,CCA/Ph+
CCA –Clonal Chromosomal Abnormalities;CCA/Ph+ is a ―Warning― factor at diagonosis,although

its occurrence during treatment (I,e., clonal progression) is a marker of treatment failure, Two
consecutive cytogenetic tests are required and must show the same CCA in atleast two ph+ cells.
Optimal response means that there is no indication that a change of therapy may improve a
survival that is correctly projected as close to 100% After 60 to 7 years,
Failure means that a favorable characteristics outcome is unlikely, and that the patient should
receive a different treatment, whenever available and applicable.
Warning means that the characteristics of the disease may adversely affect the response to that
therapy and may require a more stringent and careful monitoring.
Note:
 FIRST line TKI option is Imatinib. Others (Nilotinib /Dasatnib) may be offered as
alternatives.
 Accelerated phase and blast crisis – Consider allogeneic stem cell transplantation
 In chronic phase – consider 2nd line if 1st line TKI fails, and in case of second line failure
proceed with allogeneic stem cell transplantation

Practical Management Algorithum for CML
Molecular monitoring of CML –Quantitative Real Time PCR for BCR –ABL transcripts
1. Molecular monitoring should be done ideally at 3 month intervals if facilities are available.
If not consider the same at 6month intervals.
2. Consider repeating tests at 3monthly intervals if there is a small increase in transcripts.
3. The frequency should be shorter (one month)if the level in increase is larger.
4. Patients should ideally achieve a major molecular response by 12 months and certainly by
18 months.
5. If major molecular response is not achieved by 18months consider for dose escalation of
imatinib or consider for a 2nd generation TKI after mutation analysis.
6. If there is loss of molecular response reflected \by a 3 log increase on two consecutive
reading 1month apart ,consider mutation analysis and shift to a 2nd generation TKI and even
consider for possible transplant if a appropriate matched donor is available.
Management of Advanced Phase (accelerated/blastic) CML
To consider HLA typing with siblings/ Parents
A. Denovo Accelerated Phase
Consider high dose Imatinib/ Second line TKI

Monitor as per ELN guidelines
a. If attains molecular response – Continue the same

b. If progress –
Consider IRMA
Switch to second line / another TKI – if attains response – continue same or if progress –
consider Allogeneic stem cell transplantation/ Best supportive care
Intolerance to TKI – change is acceptable
B.Treatment failure
Consider IRMA
Switch to second line / another TKI
Allogeneic stem cell transplantation/ best supportive care
Blast Crisis
To consider HLA typing with siblings/ Parents

A.Known CML – progressed into blast crisis

Consider IRMA
Switch to second line TKI+- Indction chemo / another TKI – if attains response - consider
Allogeneic stem cell transplantation
If progress – consider allogeneic stem cell transplantation/ best supportive care
B.Initial presentation – clinical and pathological profile favors primary presentation as CML in
Blast crisis
Consider TKI +/- remission induction chemotherapy followed by allogeneic stem cell
transplantation/ best supportive care
Intolerance to TKI – change is acceptab

MULTIPLE MYELOMA
Multiple Myeloma workup:

Indications for testing:
Bone pain, recurrent infections, anemia, unexplained renal dysfunction, lytic lesions or
reversal of A/G ratio
Work up
 History/ Physical examination
 CBC/ Differential/Peripheral Smear
 Blood Gp
 BMA/BMT (Molecular studies by FISH if available and affordable )
 Serum protein electrophoresis with IF
 Serum free light chain assay
 S Immunoglobulin assay
 S Beta 2 Microglobulin
 24 hr UPEP with IF
 24 Hr urine protein
 Skeletal survey by X ray (consider PET CT if indicated)
ISS staging for Myeloma
Myeloma – Diagnosis based on CRAB + additional myeloma defining events recommended by

IMWG 2014.
Categorize into
1. MGUS – keep in follow up – once in 3-6 months
2. SMM - keep in follow up – once in 3 months
3. Myeloma – Treatment as follows

Treatment for newly diagnosed Multiple Myeloma
Transplant Eligible Transplant ineligible
1. Transplant eligible
 3 drug induction is preferred – combinations based on proteosome inhibitor + /- steroids +/-
IMID‘s+/-Alkylators
 Proceed with autologous stem cell transplant after 4-6 cycles based on the response followed
by either 2 more consolidation / straight into maintenance with single agent based on pre-
transplant disease assessment.
Adjunct therapy
1. Bisphosphonates – based on renal function
2. Radiotherapy – painful bony lesions / cord compression.
2. Transplant ineligible
 3 drug induction is preferred – combinations based on proteosome inhibitor + /- steroids +/-
IMID‘s+/-Alkylators
 Usually treated with 12-18cycles followed by maintenance except for Len- Dex, where it is
recommended to continue till progression or intolerance.
Adjunct therapy
1. Bisphosphonates – based on renal function
2. Radiotherapy – painful bony lesions / cord compression.


GASTRO-INTESTINAL CANCERS


CARCINOMA ANAL CANAL

Carcinoma anal canal TNM staging
T staging
TX Primary tumor not assessed
TO No evidence of primary tumor
Tis High-grade squamous intraepithelial lesion

(previously termed carcinoma in situ, Bowen disease,
anal intraepithelial neoplasia II—III, high-grade anal
intraepithelialneoplasia)
TI Tumor<2 cm
T2 Tumor>2 cm but <5 cm
T3 Tumor>5 cm
T4 Tumor of any size invading adjacent organ, such as the vagina, urethra, or bladder
N staging
NX Regional lymph nodes cannot be assessed
NO No regional lymph node metastasis
NI Metastasis in inguinal, mesorectal, internal iliac, orexternal iliac nodes
N 1a Metastasis in inguinal, mesorectal, or internal iliaclymph nodes
N lb Metastasis in external iliac lymph nodes
N lc Metastasis in external iliac with any N 1a nodes
M Criteria
M0 Distant metastasis

Stage grouping
T N M Stage
Tis NO MO 0
TI NO MO I
TI NI MO IIIA
T2 NO MO IIA
T2 NI MO IIIA
T3 NO MO IIB
T3 NI MO IIIC
T4 NO MO IIIB
T4 NI MO IIIC
Any T Any N MI IV

Management
Clinical Symptoms and Evaluation
Digital rectal examination /

Proctoscopy/biopsy in case of
T1 / T2 N0# T3/ T4 N+ M+
anal growth or mass / bleeding
(Chemo-RT (Chemo-RT) (CHEMO+
PR /- RT
)
Chemothera
py
Squamous SBRT in
carcinoma of select mets)
anal canal / Reassess after 8-12 weeks
margin
USG / CECT abdomen / MRI pelvis

with contrast (preferable)
CT thorax
Local Persistent Complete
FNAC from clinically palpable inguinal progressio response*
disease
nodes *
HIV testing n
# Patients with T1 seen after local

excision and negative margins maybe
observed. Those with close or
involved margins need full Abdominoperine Observe for 3 months
chemoradiation al resection
** APR maybe needed in all patients
with poor sphincter function causing
fecal incontinence.
Local Regression
MRI pelvis progression
Observe. Examine every 3 months.

Consider APR if local progression,
Groin node dissection if inguinal
recurrence
*Surgery may be open/minimal access (laparoscopic/robotic) depending on

availability of facilities

Radiotherapy principles Anal Canal Cancer
3DCRT=/-ELECTRON 45GyIN 25#

RADICAL CTRT IMRT/VMAT FOLLOWED BY 9-14Gy
2D PLAN BOOST

CANCER OF THE RECTUM
AJCC Staging 8th Edition

Primary tumor (pT)
 TX: primary tumor cannot be assessed
 T0: no evidence of primary tumor
 Tis: carcinoma in situ, intramucosal carcinoma (involvement of lamina propria with no

extension through muscularis mucosae)
 T1: tumor invades submucosa (through the muscularis mucosa but not into the muscularis
propria)
 T2: tumor invades muscularis propria
 T3: tumor invades through the muscularis propria into the pericolorectal tissues
 T4:
o T4a: tumor invades through the visceral peritoneum (including gross perforation of
the bowel through tumor and continuous invasion of tumor through areas of
inflammation to the surface of the visceral peritoneum)
o T4b: tumor directly invades or adheres to other adjacent organs or structures
Regional lymph nodes (pN)

 NX: regional lymph nodes cannot be assessed
 N0: no regional lymph node metastasis
 N1: metastasis in 1 - 3 regional lymph nodes
o N1a: metastasis in 1 regional lymph node
o N1b: metastasis in 2 - 3 regional lymph nodes
o N1c: no regional lymph nodes are positive but there are tumor deposits in the
subserosa, mesentery or nonperitonealized pericolic or perirectal / mesorectal tissues
 N2: metastasis in 4 or more regional lymph nodes
o N2a: metastasis in 4 - 6 regional lymph nodes
o N2b: metastasis in 7 or more regional lymph nodes

Distant metastasis (pM)

 M0: no distant metastasis by imaging; no evidence of tumor in other sites or organs (this
category is NOT assigned by pathologists)
 M1: distant metastasis
o M1a: metastasis confined to 1 organ or site without peritoneal metastasis
o M1b: metastasis to 2 or more sites or organs is identified without peritoneal

metastasis
o M1c: metastasis to the peritoneal surface is identified alone or with other site or
organ metastases
AJCC Prognostic stage Groups
T N M Stage
T 1a NO MO IA
T 1b NO MO IB
T2 NO MO II
T3 NO MO IIIA
T4 NO MO IIIB
Any T NI MO IVA
Any T Any N M1 IVB

Symptom and Evaluation

Bleeding PR, Altered bowel habits, constipation
Lower GI scopy with multiple (6-8) biopsies
AdenoCa rectum
CECT scan thorax,abdomen,pelvis;MRI pelvis(preferred if localized)

Optimal-PET CT if pelvic exenteration considered
Management
T1-2, N0 M0 T3-4, N1, M0 Metastatic disease
CRM not involved

LAR/APR+TM
E
Unfit for surgery/ Neoadjuvant therapy followed by surgery
Refusing surgery -CTRT- > MRI for re evaluation - > surgery
-SCRT - > immediate surgery
pT1-2, N0-no adjuvant
treatment
pT3//T4/N+ - adjuvant
CRM threatened
CTRT& chemotherapy
Neoadjuvant therapy followed by surgery

-CTRT- > MRI for re evaluation - > surgery
SCRT/CTRT
-SCRT - >chemotherapy - > delayed surgery
CT sos
Adjuvant chemotherapy
If progression /unresectable
–chemotherapy & reassess
*surgery may be open/minimal access (laparoscopic
/robotic depending on availability of facilities)

Metastatic disease
T any, N any, M1
Resectable primary + Surgery followed by perioperative

Potentially resectable liver / lung chemotherapy for 6 months
metastases +/- pelvic RT
Table A
Locally advanced primary with SCRT to rectum x 5 days then start

potentially resectable liver / lung chemotherapy within 1 week
Table A metastases
Reassess – synchronous / staged

resection of primary with / without
metastectomy / SBRT / RFA
followed by chemotherapy
Unresectable metastatic disease
( total 6 months)
Chemotherapy
Palliative RT if symptomatic for
Table A primary
Synchronous / staged AR / APR with lung / liver RFA for liver / lung mets
resection: Perioperative chemotherapy SRS / SBRT for solitary brain mets
Chemotherapy +/- Biologicals followed by Palliative treatments
synchronous / staged AR / APR and resection of Colostomy / endoscopic stenting
metastatic disease Pain management
Surgery ( AR / APR) followed by chemotherapy +/- Clinical trials
biological and staged resection of metastatic
disease

Radiotherapy doses in Rectal Cancer
3DCRT
NEOADJUVANT CTRT 2D PLAN 45-50.4Gy in 25-28#
IMRT
NEOADJUVANT SHORT 3DCRT
25Gy in 5#
COURSE 2D PLAN
3DCRT
ADJUVANT CTRT 45-50.4Gy IN 25-28#
2D PLAN
3DCRT
RADICAL CTRT 2DPLAN 50.4Gy-54Gy IN 28-30#
IMRT
Refrences
1) ICMR Consensus document for management of colorectal cancer
2) https://www.icmr.nic.in/sites/default/files/guidelines/Colorectal%20Cancer_0.pdf
3) National Comprehensive Cancer Network. Rectal Cancer (Version 3.2018)
4) https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf

CARCINOMA COLON
AJCC Staging-8th Edition
T staging
TX Primary tumor cannot be assessed
Tis Carcinoma insitu, intramucosal carcinoma (involvement of lamina propria with no

extensionthrough muscularis mucosae)
TI Tumor invades the submucosa (through the muscularismucosa but not into the muscularis
propria)
T2 Tumor invades the muscularis propria
T3 Tumor invades through the muscularis propria intopericolorectal tissues
T4 Tumor invades the visceral peritoneum or invades oradheres to adjacent organ or structure
T4a Tumor invades through the visceral peritoneum(including gross perforation o f the bowel
throughtumor and continuous invasion of tumor through areasof inflammation to the
surface of the visceral peritoneum)
T4b Tumor directly invades or adheres to adjacent organsor structures
N staging
No regional lymph node metastasis
N1 One to three regional lymph nodes are positive (tumorin lymph nodes measuring >0.2 mm),
or any number of tumor deposits are present and all identifiablelymph nodes are negative
N 1a One regional lymph node is positive
N 1 b Two or three regional lymph nodes are positive
N lc No regional lymph nodes are positive, but there aretumor deposits in the
• subserosa
• mesentery
• or nonperitonealized pericolic, or perirectal/
mesorectal tissues.
N2 Four or more regional nodes are positive

N2a Four to six regional lymph nodes are positive
N2b Seven or more regional lymph nodes are positive
M staging
MO No distant metastasis by imaging, etc.; no evidence oftumor in distant sites or organs

(This category is notassigned by pathologists.)
M1 Metastasis to one or more distant sites or organs or peritoneal metastasis is identified

M1a Metastasis to one site or organ is identified without peritoneal metastastis
M1b Metastasis to two or more sites or organs is identified without peritoneal metastasis
M lc Metastasis to the peritoneal surface is identified alone or with other site or organ metastases
Stage grouping
T N M Stage
Tis NO MO 0
T1.T2 NO MO 1
T3 NO MO IIA
T4a NO MO IIB
T4b NO MO IIC
T1-T2 N l/N lc MO IIIA
TI N2a MO IIIA
T3-T4a N l/N lc MO IIIB
T2-T3 N2a MO IIIB
T1-T2 N2b MO IIIB
T4a N2a MO IIIC
T3-T4a N2b MO IIIC
T4b N1-N2 MO IIIC
Any T Any N M1a IVA
Any T Any N M lb IVB
Any T Any N M lc IVC

Symptoms and Evaluation

Bleeding PR, Altered bowel habits, constipation
Lower GI scopy with multiple (6-8) biopsies
Adenocarcinoma
CECT thorax, abdomen pelvis; S.CEA

Pre anesthetic evaluation
Nutritional support for severely malnourished
Management
Any T,any N,M0 M+
Surgery-colectomy with en bloc LN Unfit surgery

Clearance
pT1/T2, N0 pT3, N0 with pT4, N0 PT1-3, N1 pT4 N +,any

pT3 N0 with No high high p TN2
risk features # riskfeatures
N o adjuvant MSI MSI stable MSI

Adjuvant chemotherapy
treatment -high high
To start preferably
within 6 weeks of
surgery
No adjuvant
treatment/
Observation
Palliative chemo
Adjuvant chemotherapy Stoma/stending
#-High risk factors:

Poorly differentiated histology
Lymphatic/vascular/perineural invasion
Bowel obstruction, localized perforation
Close/inderminate/positive margins
Less than 12 LN analaysed

M+
Limited metastatic disease Extensive metastatic disease

Having potential for cure No potential for cure
Palliative chemotherapy
Those suited for surgery get synchronous or staged First line
resection of primary &resection/ local ablation of Second line
metastases (if mets are not resectable or patient is not fit Third line
to undergo resection of primary as well as metastasis Endoscopic stenting
Pain management
together or in staged manner)
systemic chemotherapy & Nutritional support
periodicre evaluation.
To consider surgery for primary with SBRT for metastases
HIPEC may be considered in suitable patients if facilities
and expertise are available
Those unsuited for R0 resection receive systemic

chemotherapy, periodicre-evaluation in MDCT , second
line chemo if progression
Patients with major bleeding or obstruction to be

considered for upfront surgery

INTRAHEPATIC CHOLANGIO CARCINOMA
AJCC TNM 8th Edition Staging

Definition of Primary Tumor (T)
T Category T Criteria
T0 No evidence o f primary tumor
Tis Carcinoma in silu (intraductal tumor)
TI Solitary tumor without vascular invasión, <5 cm or >5 cm
T 1a Solitary tumor <5 cm without vascular invasion
T lb Solitary tumor >5 cm without vascular invasion
Solitary tumor with intrahepatic vascular invasión or múltiple tumors, with or
T2
without vascular invasion
T3 Tumor perforating the visceral peritoneum
T4 Tumor involving local extrahepatic structures by direct invasion
Definition of Regional Lymph Node (N)
N Category N Criteria
N1 Regional lymph node metástasis present
Definition of Distant Metástasis (M)
M M Criteria
Category
M0 No distant metastasis
MI Distant metástasis present
AJCC Prognostic Stage Groups

T N M STAGE
Tis NO MO 0
T 1a NO M0 IA
T lb NO M0 IB
T2 NO M0 II
T3 NO M0 IIIA
T4 NO M0 IIIB
Any T N1 M0 IIIB
Any T Any N MI IV

Isolated intrahepatic mass on imaging (not consistent with HCC), jaundice, anorexia
 Multiphase CECT abdomen, pelvis and / or

 contrast MRI
 CT Thorax
 CEA, CA19-9, AFP, Hepatitis viral panel, LFT
 OGD, Colonoscopy ( if indicated )
 Biopsy ( if feasible and needed)
MANAGEMENT
Resectable Unresectable Metastatic
Consider MSI, MMR, molecular testing

 Surgery * Options:
 Consider staging -Chemotherapy (Gem/Cis or 5-FU
laparoscopy before based)
definitive surgery -Radiotherapy + / - chemo
-TACE / TARE
-SBRT if feasible
-Pembrolizumab (only for MSI-
R0, N0 R1 / N+ R2
H/dMMR tumors)
-Best supportive care
Options: -Clinical trial
-Chemotherapy
Observation -Chemo-radiation (5-
Or FU+RT) followed by Surveillance
Adjuvant chemo  Multiphase CECT Surgery may be
chemo -Chemotherapy followed abdomen, pelvis open or
(weak data) by chemo-radiation (5- and / or contrast laparoscopic or
FU+RT) MRI +/-CT Thorax robotic as
-Clinical trial every 6 months for feasible
2 yrs then annually
upto 5 yrs

EXTRAHEPATIC CHOLANGIO CARCINOMA
Carcinoma Distal Bile Duct
T staging
Tis Carcinoma insitu /high-grade dysplasia
TI Tumor invades the bile duct wall with a depth lessthan 5 mm
T2 Tumor invades the bile duct wall with a depth of5-12 mm
T3 Tumor invades the bile duct wall with a depthgreater than 12 mm
T4 Tumor involves the celiac axis, superior mesentericartery, and/or common hepatic artery
N staging
NI Metastasis in one to three regional lymph nodes
N2 Metastasis in four or more regional lymphnodes
M staging
MO No distant metastasis
MI Distant metastasis
Stage grouping
T N M Stage
Tis NO MO 0
TI NO MO I
TI NI MO IIA
TI N2 MO IIIA
T2 NO MO IIA
T2 NI MO IIB
T2 N2 MO IIIA
T3 NO MO IIB

T3 NI MO IIB
T3 N2 MO IIIA
T4 NO MO IIIB
T4 NI MO IIIB
T4 N2 MO IIIB
Any T Any N MI IV
Carcinoma Perihilar Bile Duct
T staging
TO No evidence o f primary tumor
Tis Carcinoma insitu /high-grade dysplasia
TI Tumor confined to the bile duct, with extension up tothe muscle layer or fibrous tissue
T2 Tumor invades beyond the wall of the bile duct to surrounding adipose tissue or tumor
invades adjacenthepatic parenchyma
T2a Tumor invades beyond the wall of the bile duct tosurrounding adipose tissue
T2b Tumor invades adjacent hepatic parenchyma
T3 Tumor invades unilateral branches o f the portal vein orhepatic artery
T4 Tumor invades the main portal vein or its branches bilaterally, or the common hepatic artery;
or unilateralsecond-order biliary radicals with contralateral portal vein or hepatic artery
involvement
N staging
N1 One to three positive lymph nodes typically involvingthe hilar, cystic duct, common bile
duct, hepaticartery, posterior pancreatoduodenal, and portal vein lymph nodes
N2 Four o r more positive lymph nodes from the sites described for NI

M staging
Stage grouping
T N M Stage
Tis NO M0 0
TI NO M0 I
T2a-b NO M0 II
T3 NO M0 IIIA
T4 NO M0 IIIB
Any T NI M0 IIIC
Any T N2 M0 IVA
Any T Any N MI IVB

SYMPTOMS AND EVALUATION

Abdominal pain, jaundice, abnormal LFT, obstruction or abnormality on imaging
• Multiphase CECT abdomen Pelvic and/or

• Contrast MRI/MRCP
• CT Thorax
• CEA,CA19-9,AFP,HBV,HCV,LFT
• EUS-Optional
MANAGEMENT
Resectable Unresectable Metastatic
-Multi-disciplinary -Biliary drainage as -Biliary Drainage as

review indicated indicated
-Pre-op biliary drainage -Biopsy (after determining -Biopsy
as indicated transplant status) -MSI / MMR testing
-Consider staging -Consider molecular testing -Consider molecular
laparoscopy prior to -MSI/MMR testing testing
definitive surgery -Consider referral to
transplant centre if suitable
Options:
- Chemotherapy
Ro,No or Ca R1 R2 Options: (Gemcitabine+Cisplatin
In situ at and / -Chemotherapy or 5 –FU based or other
margins or N+ (Gemcitabine+Cisplati Gem-based regimen)
n or5 –FU based or -Palliative Radiotherapy
other Gem-based -SBRT if feasible
regimen) -Pembrolizumab (only for
Options: Options: -Radiotherapy+/- MSI-H/dMMR tumors)
-Observation -chemotherapy chemo -Best supportive care
-Chemotherapy (See table A). -SBRT if feasible -Clinical trail
(See table A) -Chemo-radiation -pembrolizumab(only
(5-FU+RT) for MSI-H/dMMR
-Chemo-
followed by tumors)
radiation (5- chemo. -Best supportive care
FU+RT) -Chemotherapy -Clinical trial
-Clinical trail followed by Table A
Chemo-radiation 5-FU based or
(5-FU+RT) Gemcitabine based
-Clinical trail chemotherapy
Surgery may be open or

Surveillance laparoscopic or robotic
• Multiphase CECT abdomen, pelvis and / or contrast MRI +/- as feasible
CT thorax every 6 months for 2 yrs then annually up to 5yrs

RETROPERITONEAL SARCOMA
Symptoms and evaluation
Abdominal mass, back pain,early satiety,weight loss

 Imaging:
o CECT of the Chest, Abdomen and Pelvis
 Functional assessment of the contra lateral kidney when
indicated.
 Biopsy(?)
Management
Localised disease: Surgery intact with adherent structures, when possible.
o Pre-operative Chemotherapy or RT to improve the quality of surgical resection.
o Adjuvant therapy after complete excision:NIL

HEPATOCELLULAR CARCINOMA
AJCC TNM Staging
T staging
TI Solitary tumor <2cm, or >2 cm without vascularinvasion
T 1a Solitary tumor <2 cm
T lb Solitary tumor >2 cm without vascular invasion
T2 Solitary tumor >2 cm with vascular invasion, or multiple tumors, none >5cm
T3 Multiple tumors, at least one of which is >5 cm
T4 Single tumor or multiple tumors of any size involving a major branch of the portal vein or
hepatic vein, or tumor with direct invasion of adjacent organsother than the gallbladder or
with perforation ofvisceral peritoneum
N staging
NI Regional lymph node metastasis
M staging

Incidentally diagnosed at screening / follow-up of chronic liver disease

Right upper quadrant pain / mass , jaundice, nausea, weight loss, symptoms related to metastasis
Triphasic CECT abdomen + pelvis or

Gadolinium-enhanced MRI abdomen (in cirrhotics and suspected cirrhosis )
Liver function tests, Child and BCLC scoring
Tumor markers : AFP, CEA, CA 19-9
Staging : Bone scan, CT Thorax, PET-CT ( optionalif SBRT is planned )
If surgery – measurement of FLR ( functional liver remnant ) for major resections
USG / CT guided biopsy in case of non-classical imaging
Nutritional evaluation
Quantitative assessment of Hepatitis viral panel

Management
Resectable tumor (
Larger tumors Extra-hepatic Poor liver
adequate FLR )
(inadequate FLR) disease function (
No main trunk venous
thrombosis No extra-hepatic Irrespective of Child score C )
No extra-hepatic disease portal vein Liver
disease Limited comorbidity thrombosis / transplant for
Limited comorbidity / Child score A/B number and small tumors
Good PS size of tumors Pain
Options: and good liver management
Curative treatment SBRT + / - TACE
options:
function ( Nutritional
TACE(Transarterial Child A or support
Liver resection if Child
chemo embolisation select B ) Liver failure
score –A,selectB /
) if no portal vein management
BCLC A-B and mild to
moderate portal HT thrombosis , SBRT Options :
( Stereotactic body Palliative
Liver transplantation if radiotherapy ) to be therapy with
Child score B,C or if added for patients targeted
moderate to severe with partial agents with
portal HT ( fitting LT response to TACE Sorafenib
criteria (MILAN criteria )
for HCC ) TARE ( Transarterial
radio-embolisation )
Microwave Ablation or
or SBRT if portal vein
RFA may be used as a
less curative alternative thrombosis
for tumors upto 3 cm in
patients unfit for Reassess for curative
surgery surgery + / -
augmentation of FLR
BCLC-B patients –
medically unfit for
surgery – for RFA

Sorafenib 400 mg BD is the standard dose. However many Indian patients are unable to
tolerate this dose, hence need dose reduction.
All patients with chronic HBV infection need prophylactic therapy to control viral replication
before and after interventions
Surveillance:
Patients must be followed up for liver failure and recurrence every 3 months with LFT,
relevant tumor markers and CECT thorax, abdomen and pelvis
Local recurrence with good liver function – needs complete work-up for potentially curable
treatment options.

PANCREATIC / PERI-AMPULLARY CANCER (ADENOCARCINOMA)
AJCC Staging Pancreatic Cancer
*Tis Carcinoma in situ
TI Tumor <2 cm in greatest dimensión
Tía Tumor <0.5 cm in greatest dimensión
T lb Tumor >0.5 cm and <1 cm in greatest dimension
T ic Tumor 1-2 cm in greatest dimensión
T2 Tumor >2 cm and <4 cm in greatest dimension
T3 Tumor >4 cm in greatest dimension
T4 Tumor involves celiac axis, superior m esenteric artery, and/or common
hepatic artery, regardless of size
*This includes high-grade pancreatic intraepithelialneoplasia (Panln-3), intraductal papillary

mucinous neoplasm with high-grade dysplasia, intraductal tubulopapillary neoplasm with high-
grade dysplasia, and mucinous cystic neoplasm with high-grade dysplasia.
NO No regional lymph node metastases
N1 Metástasis in one to three regional lymph nodes
N2 Metástasis in four or more regional lymph nodes
M Category M Criteria

AJCC Prognostic Stage Groups
T N M Stage group
Tis NO MO 0
TI NO MO IA
TI NI MO IIB
TI N2 MO III
T2 NO MO IB
T2 NI MO IIB
T2 N2 MO III
T3 NO MO IIA
T3 NI MO IIB
T3 N2 MO III
T4 Any N MO III
Any T Any N MI IV

Upper abdominal pain, anorexia, unexplained weight loss, obstructive jaundice
 Triphasic thin slice ( pancreas protocol ) CT abdomen + pelvis or contrast MRI

 CT Thorax
 LFT, Coagulation profile, pre-treatment CA 19-9 levels ( after liver function normalization )
When indicated :
 ERCP & Temporary stenting ( plastic/short metal ) (stenting as and when indicated)+ /- biopsy / Brush biopsy /
Bile cytology ( symptomatic jaundice,eg.: Cholangitis, fever. bilirubin > 15 mg/dlor patient considered for neo-
adjuvant therapy /optimization prior to surgery )
 SVE + EUS +/- FNAC ( borderline resectable tumors, no clear mass on imaging, pancreatitis, locally advanced +
M0 )
 CT/USG guided FNAC/biopsy if upfront surgery not planned / to prove metastatic disease
 Laparoscopy +/- biopsy / peritoneal washings ( borderline resectable/locally advanced bulky tumor, suspicious
LN, high CA19-9 in absence of obstructive jaundice, body and tail tumors ), Repeated EUS guided FNAC negative
in borderline or locally advanced or metastatic cases for planning non-surgical management
A – Resectable : B – Borderline resectable : C – Unresectable / No mets :

Periampullary/head mass Confirm tissue diagnosis Confirm tissue diagnosis
– Pancreatico- NACT +/- RT ( see table A ) foll. by Chemotherapy or chemo-RT
Duodenectomy restaging
D1 SBRT – in select cases
tumor/pyloroduodenal Resectable : Metastatic
involvement – Classical Pancreatico-duodenectomy / distal  Good PS :
Whipple pancreato-splenectomy First line palliative chemo ( table
Body & tail – Radical Unresectable : B)
distal pancreatectomy+/- Second line chemo ( table B ) Palliative RT – sos for pain
splenectomy, median Chemo-RT / SBRT – if feasible control
pancreatectomy Metastatic : see ‗C ‗ SBRT in select cases
Biliary/gastric bypass if indicated
Supportive and pain management
 Poor PS :
Nutritional support
Adjuvant therapy ( within 6-8 weeks ) Best supportive care
p T2 or less, R0 resection : Palliative RT for pain control
periampullary carcinoma
Observe Surveillance :
More than p T2 pancreatic cancer Every 3 mths for 2 yrs Recurrence :
Adjuvant chemo followed by every 6 mths Local :
If margin + ve : chemo or CT RT for 3 yrs then annually CT+RT ( if not received
If N+ : Adjuvant chemo-RT in select Each visit – CA19.9, earlier )
cases CBC, Biochemistry, Second line chemo ( table C )
USG A/P Surgery : in select cases
CECT A+P, Thorax – SBRT in select cases
annually for 3 yrs Metastatic :
Palliative chemo ( table C )

STOMACH CANCER
AJCC Staging Carcinoma Stomach
T staging

TO No evidence o f primary tumor
Tis Carcinoma in situ: intraepithelial tumor withoutinvasion of the lamina propria, high-grade
dysplasia
TI Tumor invades the lamina propria, muscularismucosae, or submucosa
T1a Tumor invades the lamina propria or muscularismucosae
T lb Tumor invades the submucosa
T3 Tumor penetrates the subserosal connective tissue without invasion of the visceral
peritoneum or adjacent structures
T4 Tumor invades the serosa (visceral peritoneum) or adjacent structures
T4a Tumor invades the serosa (visceral peritoneum)
T4b Tumor invades adjacent structures/organs
N staging
N1 Metastasis in one or two regional lymph nodes
N2 Metastasis in three to six regional lymph nodes
N3 Metastasis in seven or more regional lymph nodes
N3a Metastasis in seven to 15 regional lymph nodes
N3b Metastasis in 16 or more regional lymph nodes
M Staging
Stage grouping
T N M Stage
Tis N0 M0 0
T1 N0 M0 I
T2 N0 M0 I
T1 N1,N2, or N3 M0 IIA
T2 N I,N2, or N3 M0 IIA
T3 N0 M0 IIB
T4a N0 M0 IIB
T3 N1,N2, or N3 M0 III
T4a N1,N2, or N3 M0 III
T4b Any N M0 IVA
Any T Any N M1 IVB

Dyspepsia, pain, Bleeding, Vomiting, Lumps, Unexplained weight loss
Upper GI endoscopy with multiple (6-8) biopsies
Adenocarcinoma
CECT thorax, Abdomen and pelvis

Pre-anesthetic evaluation
Nutritional support-oral or tube feeding
PET-CT-Optional (Optional in OGJ Ca)
Staging Laparoscopy if CT s/o NO Mets (Optional)
Optional procedures
EUS (borderline cases)
Management
Early, localised Loco-regionally advance Metastatic disease

T1-2 N0 T3-4+ Any T any N M1 or T4 stuck tumors
Poor PS/ASA 4
Consider Her 2, EBV, MSI testing
Unfit for surgery
Refusing surgery
Surgery (if good PS) Options -Palliative

(D2 NACT treatment
Palliative NACT+RT9 (for Ca OGJ)
gastrectomy/endos -Chemotherapy
chemo +/- Followed by re-evaluation
copic resection in +/- Biologicals
RT with MDCT
select T1N0 cases) -Endoscopic
Suited by for R-0 surgery: D2 stenting if needed
gastrectomy followed by (GEJ pylorus)
adjuvant chemotherapy -Pain
nd
-Not suited for nR-0:2 line
-If p T1-2 N0: No adjuvant treatment management
chemo or CT+RT
-If p T3 and /or N+: -Nutritional
-Select few-palliative surgery
Adjuvant chemo support
-Major bleeding/obstruction-
-Adjuvant chemo –RT if R1 resection or may be considered for
less than D2 resection upfront surgery (adjuvant
-Even if D2 surgery –consider therapy based on post-op
adjuvant RT if multiple adverse risk HRR)
features on pathology (after MDTB
discussion)
-Palliative chemo if R+resection or
metastatic tumor
*surgery may be open/minimal access
(Laparoscopic /robotic) depending on availability of
facilities

RADIOTHERPY DOSES IN STOMACH CANCER
3DCRT
ADJUVANT CTRT IMRT 45-50.4Gy IN 25-28#
2D PLAN

GIST (GASTROINTESTINAL STROMAL TUMOR)

AJCC TNM Staging 8th Edition
T0 No evidence o f primary tumor
T1 Tumor 2 cm or less
T2 Tumor more than 2 cm but not more than 5 cm
T3 Tumor more than 5 cm but not more than 10 cm
T4 Tumor more than 10 cm in greatest dimensión
NO No regional lymph n ode metástasis or unknown lymph node status
N1 Regional lymph node metástasis
M0 No distant metástasis
MI Distant metástasis
Definition of Mitotic Rate
Mitotic rate Definition

Low 5 or fewer mito ses p e r 5 mm2, or per 50 HPF
High over 5 mitoses p e r 5 m m 2, o r per 50 HPF
Gastric and Omental GIST
T N M Mitotic rate Stage

TIorT2 NO MO Low IA
T3 NO MO Low IB
TI NO MO High II
T2 NO M0 High II
T4 NO M0 Low II
T3 NO M0 High IIIA
T4 NO M0 High IIIB
Any T NI M0 Any rate IV
Any T Any N MI Any rate IV

Small Intestinal, Esophageal, Colorectal, Mesenteric, and Peritoneal GIST
T N M Mitotic rate is Stage

T I or T2 NO M0 Low I
T3 NO M0 Low II
TI NO M0 High IIIA
T4 NO M0 Low IIIA
T2 NO M0 High IIIB
T3 NO MO High IIIB
T4 NO MO High IIIB
Any T NI MO Any rate IV
Any T Any N MI Any rate IV

Abdominal lump, dyspepsia, pain, bleeding, unexplained weight loss
Upper GI endoscopy with multiple (6-8) biopsies (lesions often submucosal)
GIST (look for C-kit positivity on IHC) **
CECT thorax, abdomen and pelvis

Pre-anesthetic evaluation
Optional Procedures
PET-CT (suspected mets) Desirable

Management
Localized, resectable Localized, borderline resectable Metastatic disease
Unfit for surgery OR Having major Palliative

refusing surgery bleeding or gastric treatment
outlet obstruction
(Uncommon) Imatinib
Palliative (Imatinib
Imatinib resistance can be
overcome by
Sunitinib)
Surgery with disease-free Neo-adjuvant Imatinib (level 2) (consider mutation
margins (partial Followed by re-evaluation with analysis)
gastrectomy/wedge MDCT after 8 weeks of therapy
Pain management
resection/sleeve resection)
(Level1) Suited for R 0 surgery – proceed with
resection
Neo-adjuvant
Not suited for R 0 resection – Imatinib can be
Risk stratification on final continue further Imatinib
histopathology given for 6-10
Consider Sunitinib / dose escalation
Adjuvant Imatinib for 3 yrs months
if progressive disease
if intermediate and high Kit Mutation
risk GIST Select few – palliative surgery (R2 analysis
4 monthly follow-up resections)
(Level 1) Patients with major bleeding and
deep ulcers may be considered for
upfront surgery
Imatinib
If recurrence on / or post-adjuvant Rx, then repeat biopsy, Kit mutation analysis on
previous and present samples and then decide
PDGFR-alpha, DOG-1 optional: Mutation analysis desirable if c-kit,

PDGFR-alpha, DOG-1 negative

Surgical principles of GI Cancers

Esopahgeal cancer
1. Pre-therapy assessment should rule out distant metastasis with CECT thorax, abdomen and
pelvis. PET-CT is a preferable investigation.
2. Patients should be physiologically fit to undergo surgery and tumor should be located > 5
cm from cricopharyngeus
3. Surgery can be done by minimally invasive (laparoscopic or robotic – preferable if expertise
is available) or open technique.
4. T1a N0 tumors which are well differentiated and fulfil criteria for endoscopic resection may
be considered for endoscopic resection in centres where facilities is available , provided that
the stage has been confirmed by EUS and in centres with expertise in doing such procedures
5. Transthoracic esophagectomy is the preferred method for squamous cell carcinoma. A
minimum margin of 5 cm should be aimed at. For adenocarcinoma of the lower esophagus
or GE junction transthoracic esophagectomy, trans hiatal esopahagectomy or
esopahagogastrectomy via abdominothoracic approach or a proximal gastrectomy may be
chosen depending on institutional preference. Frozen section may be utilised to confirm
negative margin if available.
6. Lymphadenectomy can be standard or extended depending on the general condition of
patient, type of tumor, site and expertise.
Stomach cancer
1. Margin of resection:
For T1 tumors( if confirmed on EUS ) – gross resection margin of at-least 2cm is adequate
For T2 and deeper tumors:
a. If expansive growth pattern (type 1 or 2/) – proximal resection margin of atleast 3 cm
should be obtained
b. If infilterative growth pattern (types 3 and 4) – proximal resection margin of atleast 5 cm
should be obtained.
For tumors involving esophagus, 5 cm margin is not necessarily required and a
microscopically negative margin should be confirmed on frozen section if feasible.
Microscopically Negative distal margin on duodenal side is acceptable
2. Gastrectomy: Total or subtotal as required for obtaining appropriate margins

Proximal gasrectomy can be considered if atleast ½ of distal stomach can be retained
Pylorus preserving gastrectomy can be done if a distal clearance of atleast 4 cm can be
obtained.
Limited gastrectomies / esophago-gastrectomies to be considered for elderly patients with
prohibitive co-morbidites and poor general condition
Select patients with T1a tumors confirmed on EUS can be considered for endoscopic
resection, if they fulfil the criteria for the same

3. Lymphadenectomy:
A spleen preserving D2 lymphadenectomy is the standard surgical approach to gastric
cancer.
*For early tumors being considered for endoscopic resections, the stage should be
confirmed by EUS in centres with expertise in doing such procedures
4. Omentectomy: is an integral part of gastrectomy for stomach carcinoma. In T1/2 tumors

(preferably confirmed by EUS), omentum distal to 3 cm from the gastro-epiploicaracade can
be preserved
5. Bursectomy:
However it should be considered for tumors perforating posterior gastric wall serosa.
Routine bursectomy is not recommended.
6. En bloc excision of adjcanct organs along with gastrectomy should be considered if

adjacent organs are involved by tumor and performance status of patient is good enough to
withstand such a surgery. There is limited data to support pancreaticoduodenctomy along
with gastrectomy for gastric carcinoma.
7. Minimally access surgery can be done for T1/2 N0 gastric cancers at the discretion of the
surgeon. However oncological safety should not be compromised.
8. Staging laparoscopy prior to starting neo-adjuvant therapy can be considered as per

institutional protocol and MDT decision
Hepatocellular carcinoma
Surgery is potentially curative if:
1. Solitary liver lesion without vascular invasion
2. Adequate liver function (Child PUGHS A without portal hypertension. Small series show a
benefit in patients with mild portal hypertension)
3. Adequate future liver remnant
Role of surgery is controversial but may be considered :
1. Limited, resectable multifocal disease

2. Major vascular invasion
Patients with chronic liver disease being considered for resection, may be considered for portal
vein embolisation
Patients fulfilling Milans criteria should be considered for transplant.
Patients with Child PUghsA , who are resectable and who fulfil milans criteria can be
considered for resection or transplant. Multidisciplinary tumor board should decide which
modality to be offered first

Patients who are not candidate for curative surgery, as a bridging procedure for curative surgery
locoregional therapy should be considered (ablation, arterially directed therapy or
radiotherapy)s
Gall Bladder carcinoma
Patients who are highly suspected to have gall bladder cancer- defer laparoscopic approach for
cholecystectomy
T1 tumors (Stage Ia) : simple cholecystectomy. Any suspicious nodes should be taken for frozen
section analysis
Stage Ib , II and select stage III (T4 N0): enblock resection of gall bladder, segmentsIVb and V of
liver/ wedge resection of liver with negative margin and regional lymph node dissection.
Patients who have an incidental diagnosis of carcinoma gall bladder after simple cholecystectomy:
consider laparoscopic evaluation for presence of small volume peritoneal and liver disease.
Extent of lymphadenectomy: lymph nodes from behind the duodenum, pancreas, nodes along
hepatico duodenal ligament (by skeletonising potal vein and hepatic artery)upto liver hilum should
be resected.
Routine resection of bile duct is not mandatory for lymph node clearance. However if bile duct is
scarred or inflamed (due to previous surgery , procedures or tumor )making lympahdenectomy
unsafe or difficult, CBD can be resected.
Frozen section analysis of cystic duct margin should be highly considered.
For patients who are incidentally diagnosed to have carcinoma gall baldder after laparoscopic
cholecystectomy and warrant completion surgery due to stage- after ruling out distant disease
consider sending sending cystic duct margin for frozen, complete resection of gall bladder bed and
lymphadenectomy with or without bile duct resection.
Diagnostic laparoscopy may be considered for patients with any suspicion of metastasis.
Extrahepatic Bile Duct cancer

- Rule out distant metastasis and assess local resectability
- Diagnostic laparoscopy should be considered
- General principle: wide excision with negative margins and regional lymphadenectomy
a. For distal tumors- ofternpancreaticoduodenectomy
b. For proximal tumors- liver resection
- Incases where liver is resected – ensure portal and arterial inflow and biliary outflow to
remanant liver
- If required, pre-operative biliary drainage of future liver remnant and portal vein
embolisation in cases where FLR is less should be considered
Bile duct margins should preferably be assessed by frozen section during surgery

Intrahepatic cholangiocarcinoma
Pre-operative biopsy is not always mandatory.
-Diagnostic laproscopy should be considered to rule out unresectable disseminated disease
-Lymph node metastasis beyond the porta and distant metastasis contra-indicate resection
- Gross lymph nodes at porta indicate a poor prognosis. Surgery in such cases should be considered
in highly select situation
-Multifcal disease contra-indicate surgery. However surgery might be considered in highly selected
cases
- In resectable and operable cases appropriate hepatic resection with negative margins should be
done along with regional lymphadenectomy at portahepatis.
Pancreatic and peri-ampullary carcinoma

Careful intraopeartive evaluation for distant metastasis should be made. Definitive surgery should
be deferred in the presence of distant metastasis
Role of staging laparoscopy before surgery:

1. For pancreatic neck, body, tail tumors
2. For large pancreatic head cancers (>4cm)
3. High Ca 19.9 >200
4. Equivocal pre-operative findings like small ascitis, small hypodense lesions on liver surface
that could be metastasis and not amenable to percutaneous biopsy, suspected very limited
peritoneal disease.
5. Clinical findings suggestive of advanced disease but radiology picture of operable tumor (
sever pain, hypoalbunemia, significant weight loss, significantly high CA 19.9)
Pancreatic head, uncinate process tumorsandperiampullarytumors:

- Should undergo pancreaticoduodenectomy with negative margins with or without resection
and reconstruction of vein depending on pre-operative and intra-operative findings
- Minimally access surgery can be considered if expertise and facilities are available and the
procedure should be performed without compromising oncological safety and without
significant increase in morbidity
Tumors involving body and tail of pancreas:

To consider distal pancreatico splenectomy with or without vein resection depending upon
pre-operative and intra-operative findings
Pancreatic neck tumors:

- Careful pre and intra-operative assessment of extent of involvement is required
- Depending upon the site of tumor, pancreaticoduodenectomy extending to left of superior
mesenteric vein or distal pancreaticosplenectomy extending to right of superior mesenteric
vein might be required
- Venorapphy or venous resection and reconstruction may be required if vein is involved

Role of arterial resection and reconstructionfor tumor clearance is limited in pancreatic cancers
Role of total pancreatectomy:

-In highly select cases
-To be done in preferably in high volume centres
- Endocrinology support should be readily available for perioperative and lifelong
management of patient.
Colon cancer
1. Surgery can be done by open technique or using minimally invasive techniqueif expertise is
available (laparoscopic or robotic). Minimally invasive surgery may be avoided in cases
with perforation or acute intestinal obstruction. In curable cases presenting in emergency
radical surgery should be perceived whenever possible.
2. Appropriate colectomy with D3 lymphadnectomy (lymph node clearance upto origin of
feeding vessels) should be done
3. Suspicious lymph nodes outside the field of regional nodes should be biopsied or removed
for pathological examination
4. In patients with limited metastasis, surgery of metastasis may be considered along with
surgery for primary or in a staged fashion (depending upon general condition of patient and
extent of disease)
5. In patients with poor general condition to undergo metastatectomy and surgery for primary
both - SBRT can be considered for very limited metastasis.
6. More extensive colectomies should be considered in patients with strong family history of
colon cancers, known genetic syndrome which predisposes to colonic malignancy, multiple
polyps or young age (< 50 years) with possibility of genetic predisposition
7. Patients who undergo endoscopic poylpectomies for suspicious looking polyps and who
might require completion surgery should be considered for tattooing of the site during
polypectomy
8. Metastatic patients who are being considered for palliative treatment and who undergo
colectomy for bleeding, obstruction or perforation can undergo segmental colectomy
9. Adjacant organs, if infiltrated by tumor or densely adherent to tumor can be removed
preferably en-block with tumor(eg- small bowel, bladder or bladder cuff, etc)
10. Pre-operative chemotherapy can be considered in select patients with extensive local
disease.
11. Preoperative stenting of ureters to be considered in patients where tumor is abutting or
involving ureter, surgery for recurrences, etc at the discretion of operating surgeon
12. Peritonectomy for limited peritoneal disease and HIPEC can be considered if facilities and
expertise is available

Rectal cancer
1. Surgery can be done primary or after neo adjuvant therapy depending upon stage of tumor at
presentation and site of tumor (Primary surgery should be done for T1/2 N0 and early T3 N0
tumors where circumferential margin is not threatened after proper evaluation with pre-
operative MRI or EUS. Advanced T3 and T4 tumors N+ tumors should be subjected to
neoadjuvant radiation or chemradiation.
2. Surgery can be done by open technique or using minimally invasive technique (laparoscopic
or robotic- if expertise is available). Minimally invasive surgery may be avoided in cases
with perforation or acute intestinal obstruction. In curable cases presenting in emergency
radical surgery should be perceived whenever possible.
3. Total or partial Mesorectal excision should be done fortumors involving rectum or
rectosigmoid junction.
4. Every attempt should be made to preserve automomic nerves if not involved by tumor
5. Lymphadenectomy along the inferior mesenteric vessels should preferably include apical
nodes (nodes at the origin of inferior mesenteric artery) especially if the tumor involves
upper rectum and /or sigmoid. No positive looking regional node should be left behind.
6. Lateral pelvic lymphadenectomy should be done in patients with significant lateral pelvic
nodes on pre-operative imaging
7. a. Distal margin of atleast 5 cm should be prefered for tumors involving upper
rectum orrectosigmoid.
b. For mid or low rectal tumors distal margin of atleast 2 cm should be aimed at. Less than
2 cm margin is acceptable when there is no other option available for sphincter
preservation. However of lesser margins, an intra-operative frozen section analysis , if
available should be considered. Tumor involvement within 1 mm of cut margin should be
considered as a positive margin.
(In general, for T1/2 or ypT1/2 tumors which are not poorly differentiated, atleast 1 cm
distal clearance should be obtained ;
fortumors which are T3/4 or yT3/4 , and/or poorly differentiated, a distal clearance of
atleast 2 cm should be aimed at)
c. Involved distal margin, but distal doughnut free of tumor should not be considered as a
negative margin
8. Adjacant organs, if infiltrated by tumor or densely adherent to tumor can be removed
preferably en-bloc with tumor. If exentration is being considered for a patients- extent of
local, regional and distant disease, comorbidities and performance status of patient should
be considered. Sacral resection to be considered in select cases with frank sacral involvement
below S1, patients with good performance status and otherwise limited disease at distant site.
9. Extra-levator excision should be considred for tumors involving levatorani inorder to ensure
a circumferentially negative margin
10. Surgery for metastasis can be considered in staged fashion or along with the primary
depending of extent of local and distant disease and general condition of patient
11. In patients with poor general condition to undergo metastatectomy and surgery for primary
both - SBRT can be considered for very limited metastasis.

12. More extensive colectomies/ proctocolectomy should be considered in patients with strong
family history of colon cancers, known genetic syndrome which predisposes to colonic
malignancy, multiple polyps or young age (< 50 years) with possibility of genetic
predisposition
13. Patients who undergo endoscopic poylpectomies for suspicious looking polyps and who
might require completion surgery should be considered for tattooing of the site during
polypectomy
14. Trans anal excision procedure can be done if patient fulfils selection criteria for the same and
appropriatefacitlites are available for the same. If required and indicated patients should
undergo sompletion resection/ adjuvant therapy after such procedures.
15. Peritonectomy for limited peritoneal disease and HIPEC can be considered if facilities and
expertise is available
Anal canal squamous cell cancer

Local excision:
- For tumors removed completely during biopsy with < 3 mm basement membrane invasion and a
horizontal spread of < 7mm : local excision with negative margin may be adequate treatment
- For perianal cancers which are T1 N0 and well differentiated squamous cell carcinoma: wide local
excision with> 1 cm margin is adequate
Abdomino-perineal resection:
-For recurrent or persistent disease
- Should include total mesorectal excision
- Wider lateral per-anal margins might be required for anal canal tumors compared to distal rectal
cancers
- Patients are prone to wound break down and healing issues due to high dose of radiation. Use of
flaps should be considered at the time of surgery.
Groin dissection:
Groin dissection may be considered with or without surgery for primary depending on the site of
persistent or recurrent disease is located.
Principles of Systemic Therapy

Stomach
Neoadjuvant
1. EOX ( Epirubicin/Oxaliplatin/Capecitabine)Every 21 days ; 3 cycles preoperatively and 3
cycles postoperatively
2. FLOT- 5FU /Oxaliplatin/Leucovorin/Docetaxel) Every 2 weeks, 4 cycles preoperatively
and 4 cycles postoperatively
3. FOLFOX 5 FU/Leucovorin/Oxaliplatin

4. Cisplatin /5FU Repeat cycle every 28 days for 2–3 cycles preoperatively and 3–4 cycles
postoperatively for a total of 6 cycles.
Concurrent Chemotherapy regimes (Post operative)

1. Mc Donalds regimen- 5FU/LV based
(Less than D2 dissection or margin positivity)
2. Capecitabine
Adjuvant Chemotherapy regimens

CAPEOX - Capecitabine,Oxaliplatin ( Every 21 days for 6-8 cycles)
Metastatic Disease
Three drug regimens should be used only in medically fit patients with good PS and adequate
end organ function
Epirubicin,Oxaliplatin,Capecitabine (EOX)
Docetaxel ,Cisplatin,5 FU (DCF)
Capecitabine,Oxaliplatin(CAPEOX)
Epirubicin,Cisplatin,5 FU (ECF)
5FU,LV,Oxaliplatin (FOLFOX)
5 FU/Cisplatin
Paclitaxel- Second line
Docetaxel –Second line
Irinotecan- Second Line
Targeted Therapy
Trastuzumab may be considered along with chemotherapy in patients with HER2 positive
metastatic breast cancer
Ramucirumab in second line setting
Pembrolizumab ( Second line in case of MSI –H tumours and third line in case of high PD-L1
expression)

Gastrointestinal Stromal Tumour

Adjuvant /Neoadjuvant
Imatinib 400 mg OD
Metastatic/Recurrent/Inoperable
Imatinib Sunitinib Regorafenib
ESOPHAGUS AND ESOPHAGOGASTRIC JUNCTION
PREOP CHEMORADIATION
1. Paclitaxel /carboplatin AUC - Weekly

2) Cisplatin /5FU
PREOP CHEMOTHERAPY
Adenocarcinoma ( including OG junction)

1) FLOT
2) 5FU/Oxaliplatin
3) ECF/ECF modifications in ( mainly OG junction cancers )
DEFINITE CHEMORADIATION
Preferred regimens
1. Paclitaxel/carboplatin ( Weekly )
2. Cisplatin /5 FU
3. 5 FU/Oxaliplatin
ADJUVANT CHEMOTHERAPY (In OG junction)

CAPEOX (Capecitabine/oxaliplatin)
METASTATIC/UNRESECTABLE DISEASE
Cisplatin /5 FU
Paclitaxel/carboplatin
DCF
ECF/EOX
Paclitaxel /Docetaxel
Trastuzumab can be added to the chemotherapy regime in case of Her2 positive tumours.

Second line therapy

Paclitaxel
Docetaxel
Irinotecan
Paclitaxel + Ramucirumab
Pembrolizumab in patients with MSI-H tumours
Hepatocellular Carcinoma
First Line ( Child A/ Select patients with Child B)
Sorafenib 400 mg PO BD ( In case of tolerance issues 200 mg BD)
Alternative : Lenvatinib
Second Line
Nivolumab (Child A or B7)
Regorafenib (Child A)
Ramucirumab (AFP> 400 ng/ml)
Hepatobiliary Cancers
Adjuvant
Gemcitabine based chemotherapy is considered as a standard .Following are the regimens
which can be used
Single Agent Gemcitabine Single Agent Capecitabine
Gemcitabine / Cisplatin
Gemcitabine / Carboplatin
Metastatic Disease
Single Agent Gemcitabine Gemcitabine/ Oxaliplatin
Gemcitabine / Cisplatin Gemcitabine/ Capecitabine
5 FU/Cisplatin CAPEOX
Gemcitabine / Carboplatin Capecitabine
5 FU

Carcinoma Pancreas
Adjuvant
Gemcitabine /Capecitabine
Modified FOLFIRINOX ( only for PS 0-1)
Single Agent Gemcitabine
5 FU/Leucovorin
Metastatic
Gemcitabine/Nab Paclitaxel FOLFIRINOX/ Modified FOLFIRINOX
Single Agent Gemcitabine Capecitabine

Gemcitabine/Capecitabine
Neoadjuvant
FOLFIRINOX
Gemcitabine/Nab Paclitaxel
Chemoradiation
Capecitabine + RT 5 FU (Infusional ) +RT
Gemcitabine + RT
Colorectal Cancers
Adjuvant
Duration 3-6 months
Single agent Capecitabine
CAPEOX
FOLFOX
5FU/LV
Concurrent(In rectal cancers)

Capecitabine
5FU/LV
5 FU

Metastatic/advanced
Capecitabine CAPEOX
FOLFOX FOLFIRI
Irinotecan CAPEIRI
Tegafur/Uracil 5FU/LV
FOLFOXIRI
Targeted therapy ( Bevacizumab/Cetuximab/Panitumumab ) may be added based on RAS
testing.Immunotherapy can be considered for patients with dMMR/MSI-H status.
Carcinoma Anal Canal

Localised Cancer-Concurrent
Preferred
5 FU+ Mitomycin
Capecitabine+Mitomycin
Other-5FU + Cisplatin
Metastatic Disease
Paclitaxel/Carboplatin 5 FU+Cisplatin
FOLFCIS FOLFOX

GYNECOLOGICAL CANCERS


FIGO STAGING OF GYUNAECOLOGIC MALIGNANCIES
1. Carcinoma Vagina
International Federation of Gynecology and Obstetrics Clinical Staging of Carcinoma of the
Vagina
 Stage Description
 Carcinoma in situ, intraepithelial carcinoma.
 I The carcinoma is limited to the vaginal wall.
 II The carcinoma has involved the subvaginal tissues but has not extended onto the
pelvicwall
 III The carcinoma has extended onto the pelvic wall
 IV The carcinoma has extended beyond the true pelvis or has clinically involved the
mucosa of the bladder or rectum.Bullous edema as such does not permit a case to be
allotted to stage IV.
 IVA Spread of the growth to adjacent organs and/or direct extension beyond the true
pelvis.
 IVB Spread to distant organs.
2.International Federation of Gynecology and Obstetrics Staging of Carcinoma

of the Vulva (2009)
Stage Description
I Tumor confined to the vulva
 IA - Lesions ≤2 cm in size, confined to the vulva or perineum and with stromal invasion ≤1
mm,no nodal metastasis
 IB - Lesions >2 cm in size or with stromal invasion >1.0 mm,a confined to the vulva or
perineum, with negative nodes
 II- Tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3
lower vagina, anus) with negative
 nodes
 III - Tumor of any size with or without extension to adjacent perineal structures (1/3 lower
urethra, 1/3 lower vagina, anus)with positive inguinofemoral lymph nodes
 IIIA-
With 1 lymph node metastasis (≥5 mm)
(2) 1–2 lymph node metastasis(es) (<5 mm)
 IIIB
With 2 or more lymph node metastases (≥5 mm)
3 or more lymph node metastases (<5 mm)
 IIIC With positive nodes with extracapsular spread
 IV Tumor invades other regional (2/3 upper urethra, 2/3 upper vagina) or other distant
structures
 IVA
Tumor invades any of the following:
Upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic
bone
Fixed or ulcerated inguinofemoral nodes
 IVB- Any distant metastasis including pelvic lymph nodes

3. Revised International Federation of Gynecology and Obstetrics Staging for

Endometrial Cancer
 Stage I -Tumor confined to the corpus uteri
IA -No or less than half myometrial invasion
IB -Invasion equal to or more than half of the myometrium
 Stage II -Tumor invades cervical stroma but does not extend beyond the uterus
 Stage III-Local and/or regional spread of the tumor
IIIA-Tumor invades the serosa of the corpus uteri and/or adnexae
IIIB -Vaginal and/or parametrial involvement
IIIC-Metastases to pelvic and/or para-aortic lymph nodes
IIIC1- Positive pelvic nodes
IIIC2 -Positive para-aortic lymph nodes with or without positive pelvic nodes
 Stage IV-Tumor invades bladder and/or bowel mucosa, and/or distant metastases
IVA-Tumor invasion of bladder and/or bowel mucosa
IVB-Distant metastases, including intra-abdominal metastases and/or inguinal lymph nodes
4. Leiomyosarcoma
FIGO Staging forleio (2leio009)
Stage Definition
 Stage I -Tumor limited to uterus
IA- <5 cm
IB -->5 cm
 Stage II -Tumor extends to the pelvis
IIA -Adnexal involvement
IIB -Tumor extends to extrauterine pelvic tissue
 Stage III Tumor invades abdominal tissues (not just protruding into the abdomen)
IIIA One site
IIIB more than one site
IIIC Metastasis to pelvic and/or para-aortic lymph nodes
 Stage IV
IVA Tumor invades bladder and/or rectum
IVB Distant metastasis
5. Endometrial stromal sarcoma & adenosarcoma

FIGO Staging of Endometrial ll
Stage Definition
 Stage I- Tumor limited to uterus
IA- Tumor limited to endometrium/endocervix with no myometrial invasion
IB -Less than or equal to half myometrial invasion
IC -More than half myometrial invasion
 Stage II- Tumor extends to the pelvis
IIA -Adnexal involvement
IIB- Tumor extends to extrauterine pelvic tissue
 Stage III- Tumor invades abdominal tissues (not just protruding into the abdomen)
IIIA -One site
IIIB ->One site
IIIC -Metastasis to pelvic and/or para-aortic lymph nodes

 Stage IV
IVA- Tumor invades bladder and/or rectum
IVB Distant metastasis
6. International Federation of Gynecologists and Obstetricians Staging of Gestational

Trophoblastic Neoplasia and World Health Organization Scoring System Based on
Prognostic Factors
 Stage I -Disease confined to the uterus

 Stage II-GTN extends outside of the uterus but is limited to the genital structures
 Stage III -GTN extends to the lungs, with or without genital tract involvement
 Stage IV- All other metastatic sites
 Prognostic Factors
 Score 0 1 2 4
 Age in years <40 ≥40 — -
 Antecedent pregnancy Mole Abortion Term -
 Interval (months) <4 ≥4 but <7 ≥7 but <13 ≥13
 Pretreatment hCG (mIU/mL) <1,000 1,000 to <10,000 10,000 to <100,000 ≥100,000
 Largest tumor, — 3 to <5 cm ≥5 cm —
 Site of metastases Lung Spleen, kidney GI tract Brain, liver
 Number of metastases — 1–4 5–8 >8
 Prior failed chemotherapy — — Single drug 2 or more drugs
7. Carcinoma Cervix
FIGO staging of cancer of the cervix uteri (2018).
Stage Description
 I -The carcinoma is strictly confined to the cervix (extension to the uterine corpus should be
disregarded)
IA -Invasive carcinoma that can be diagnosed only by microscopy, with maximum depth of
invasion <5 mm
A1- Measured stromal invasion <3 mm in depth
IA2- Measured stromal invasion ≥3 mm and <5 mm in depth
IB- Invasive carcinoma with measured deepest invasion ≥5 mm (greater than Stage IA),
lesion limited to the cervix uteri
IB1- Invasive carcinoma ≥5 mm depth of stromal invasion, and <2 cm in greatest dimension
IB2- Invasive carcinoma ≥2 cm and <4 cm in greatest dimension
IB3- Invasive carcinoma ≥4 cm in greatest dimension
 II -The carcinoma invades beyond the uterus, but has not extended onto the lower third of
the vagina or to the pelvic wall
IIA- Involvement limited to the upper two-thirds of the vagina without parametrial
involvement
IIA1 -Invasive carcinoma <4 cm in greatest dimension
IIA2- Invasive carcinoma ≥4 cm in greatest dimension
IIB- With parametrial involvement but not up to the pelvic wall

 III -The carcinoma involves the lower third of the vagina and/or extends to the pelvic wall
and/or causes hydronephrosis or nonfunctioning kidney and/or involves pelvic and/or para-
aortic lymph nodesc
IIIA- The carcinoma involves the lower third of the vagina, with no extension to the pelvic
wall
IIIB- Extension to the pelvic wall and/or hydronephrosis or nonfunctioning kidney (unless
known to be due to another cause)
IIIC- Involvement of pelvic and/or para-aortic
lymph nodes, irrespective of tumor size and extent (with r and p notations)c
IIIC1- Pelvic lymph node metastasis only
IIIC2- Para-aortic lymph node metastasis
 IV The carcinoma has extended beyond the true pelvis or has involved (biopsy proven) the
mucosa of the bladder or rectum. (A bullous edema, as such, does not permit a case to be
allotted to Stage IV)
IVA Spread to adjacent pelvic organs
IVB Spread to distant organs
8. Carcinoma Ovary
I I Tumor confined to ovary

IA Tumor limited to one ovary, capsule intact, no tumor on
surface; negative washings
IB Tumor limited to both ovaries otherwise like IA
IC Tumor limited to one or both ovaries with any of the following:

IC1 Surgical spill
IC2 Capsule ruptured before surgery or tumor on ovarian surface
IC3 Malignant cells in ascites or peritoneal washings
II II Tumor involves one or both ovaries with pelvic extension

( below pelvic brim )or primary peritoneal cancer
IIA Extension and/or implants on the uterus and/or fallopian tube(s)
IIB Extension to other pelvic intraperitoneal tissues
III III Tumor involves 1 or both ovaries with cytologically or

histologically confirmed spread to the peritoneum outside the
pelvis and/or metastasis to the retroperitoneal lymph nodes

Positive retroperitoneal lymph nodes and /or microscopic

IIIA metastasis beyond the pelvis
A1 Positive retroperitoneal lymph nodes only
IIA1(i) Metastasis ≤ 10 mm
IIIA1(ii) Metastasis > 10 mm
Microscopic,extrapelvic(above brim)peritoneal involvement +

A2
/- positive retroperitoneal lymph nodes
Macroscopic ,extrapelvic, peritoneal metastasis </=2 cm

positive retroperitoneal lymp nodes.
IIIB
Includes extension to capsule of liver/spleen.
IIIC Macroscopic,extrapelvic, peritoneal metastasis >2 cm +/-

positive retroperitoneal lymph nodes.
Includes extension to capsule of liver/spleen.
Pleural effusion with positive cytology

IV IVA
Hepatic and/or splenic parenchymal metastases , metastases to

extra-abdominal organs (including inguinal lymph nodes and
IVB
lymph nodes outside of the abdominal cavity)

CERVICAL CANCER
Symptoms:
- Asymptomatic, in early stages
- Post-menopausal bleeding
- Post-coital bleeding
- Metrorrhagia (inter menstrual bleeding)
- Menorrhagia (heavy or prolonged menstrual bleeding)
- Vaginal discharge-prolonged blood stained or foul smelling
- Unexplained persistent Pelvic/back/loin pain or bladder/bowel symptoms in
advanced cases
Diagnostic/staging evaluation should include:
 Pelvic examination: Per speculum and bimanual pelvic and rectovaginal
examination
- Cervical Biopsy /Cone Biopsy if cervical biopsy is inadequate to define invasiveness or
for accurate diagnosis of microinvasion
 MRI Abdomen and Pelvis*
 Cystoscopy/proctoscopy as clinically indicated **
Treatment: Type I Extrafascial hysterectomy

Vaginal/open/minimally invasive
Stage 1 A1
Fertility Desired
Close observation if cone margins
negative
1A1 Preferably a non fragmented
specimen with 3mm margin , If +ve
Diagnosed on repeat cone trachelectomy
cone biopsy *
Modified Radical hysterectomy or
Trachelectomy + pelvic
lymphadenectomy if LVSI+ **
Brachytherapy alone
* If margins + for Ca/ dysplasia consider repeat cone biopsy to evaluate depth of invasion to rule
out stage IA2, IB1
OR trachelectomy
**Consider SLN ( only in centres where they have validated their clinical data )
# Imaging :MRI is the best method of radiologic assessment of primary tumors greater than
10 mm.MRI is the preferred investigation in cases planned for surgery and also when MR
brachytherapy is planned. If MRI is not available CT scan may be done. For suspected advanced
cases CECT may be considered as minimum. PET CT should be reserved for carefully
selected cases and is to be done after MDT discussions if clinically indicated.

Stage IA2:
Modified Radical Hysterectomy +

Pelvic lymphadenectomy*
Stage IA2
(diagnose
Radical Trachelectomy or Radical
d on cone
cone + Pelvic
biopsy)
lymphadenectomy**
1 (if fertility desired )
Brachytherapy ± External beam

Radiotherapy
**cervical conization with laparoscopic (or extraperitoneal) pelvic lymphadenectomy; or radical

abdominal, vaginal, or laparoscopic trachelectomy with pelvic lymphadenectomy.Consider SLN.
Follow Up
3- Monthly Pap smears for 2 years, then 6- monthly for the next 3 years is recommended after
treatment of microinvasive carcinoma. With normal follow- up at 5 years, the patient can return to
the routine screening schedule.
Stages IB1 Radical hysterectomy + pelvic

lymphadenectomy*
If fertility desired Radical

trachelectomy + pelvic
Stage IB1
lymphadenectomy **
Radical Radiotherapy
Brachytherapy + External
Radiotherapy***
* TypeC, (consider nerve sparing in 1B1) (open /minimally invasive – Lap/robotic),; +/- PAND
(considerSLN)
**+/- PAND, Consider SLN

Stages IB2 and IIA1 Radical Radiotherapy

(External Radiotherapy
+ Brachytherapy)***
*Stages IB2
andIIA1**
Radical hysterectomy +
pelvic
lymphadenectomy
* Primary chemo RT / Primary Surgery .Surgery ( type C +BPLND ) or radiotherapy can be

chosen as the primary treatment depending on other patient factors and local resources ; more
evidence needed for routine SLN ; Open /Minimally Invasive – Lap/robotic (more studies needed to
confirm LACC trial findings ;therefore MIS to be preferably done in centres who have validated
their data )
** Fertility sparing options for 2A1( < 2cm only ) Radical trachelectomy + pelvic
lymphadenectomy
***For decision regarding, choice of treatment between surgery and RT in early stages – patient‘s
preference to be considered.
• IMRT is not recommended as modality of Radiation in patients with intact cervix. However in
select cases IMRT may be used.
Stages IB3 andIIA2
Concurrent platinum- based

Stages IB3 and IIA2 chemoradiation (CCRT) is the
preferred treatment option

Adjuvant treatment after Radical surgery
High risk (any one) Adjuvant RT

with
 Node+ve
concomitant
 Parametrium+ve
CT
 Margin+ve
Assess
Risk Intermediate risk(any
based on two) Adjuvant Pelvic
detailed  T> 4cm RT
HPR  Deep
stromalinvasion
 LVSI +ve
Low risk (none of the

above mentioned risk Observation
factors)

Stage IIb and III

Stage II B –III (External +
C1 Brachytherapy) +
Concurrent weekly
Stage II B and
III cisplatin
Stage IIIC2 Extended field RT* +

Concurrent weekly
cisplatin

Stage IV
Palliative RT / CT
Stage IVA# Pelvic
Exenteration**
Concurrent CT +
Stage IV
Individualized Rx RT**
Palliative
Stage IV B Chemotherapy
Palliative
Radiotherapy
Palliative Care
** Select cases

# Procedures like Urinary diversion in case of fistula should be individualised and is to be

done after MDT decision only
Ca cervix detected post hysterectomy - Inadvertent Incomplete Surgery:

( Ref : FIGO Cancer Report 2018 )
 Inadvertent simple hysterectomy is inadequate for invasive cervical carcinoma and

subsequent therapy is always required.
 CCRT or postoperative radiation therapy has been recommended.
 In stages of suspected Stage IA2 and IB1 cervical cancer detected following hysterectomy,
Radical parametrectomy is an option in carefully selected cases after appropriate imaging if
expertise is available in select cases after appropriate imaging. The procedure is challenging
due to previous scarring , adhesions , distortion of anatomy , but does have the potential for
curative surgery as well as allow assessment of the need for adjuvant CCRT.
Radiotherapy doses in cervical cancer
RADICAL RADIOTHERAPY (EBRT+ Brachytherapy)

EBRT 3DCRT 40-50.4 Gy (1.8-2Gy/#)
IMRT(RA SIB)-Node positive PTV HR (GTV NODE+1CM)

disease 55Gy/25#
PTV LR (ITV+CTV LN)
50Gy/25#
BRACHYTHERAPY HDR BRACHYTHERAPY 30-40Gy LDR EQUIVALENT
SCHEDULES:
1. ICA:
a. 7 Gy point A X 3
#
b. 6Gy X 4#
c. 8-9 Gy X 2
2. Interstitial: 5 to 7Gy
toCTV x 3#
ADJUVANT RT
EBRT 3DCRT 45- 50.4 Gy /25 to 28#
1.8-2 Gy per fraction
BRACHYTHERAPY HDR BRACHYTHERAPY VAULT BRACHYTHERAPY:
6Gy TO 0.5 cm FROM THE
VAGINAL SURFACE

Follow-up Visits: Patient history, complete physical examination including pelvic-rectal

examination every 3-4 months in the first three years and every six months for the next two
years, and annually after that. A CT scan may be done only if clinically indicated. PET-CT is
only indicated in patients with recurrent cervical cancer being considered for pelvic exenteration.
References:
1. FIGO CANCER REPORT 2018 , Cancer of the cervix uteri , Neerja Bhatla, Daisuke Aoki,
Daya Nand Sharma, Rengaswamy Sankaranarayanan, International Journal of Gynecology &
ObstetricsVolume 143, Issue S2 , https://obgyn.onlinelibrary.wiley.com/
2. ICMR Consensus document for management of cancer cervix
,https://www.icmr.nic.in/sites/default/files/reports/Cervix%20Cancer.pdf
3. Cervical Cancer , Version 3.2019, NCCN Clinical Practice Guidelines in Oncology
https://jnccn.org/view/journals/jnccn/17/1/article-p64.xml
4. National Cancer Grid Guidelines https://obgyn.onlinelibrary.wiley.com/

ENDOMETRIAL CANCER
Mode of Presentation:
• Post Menopausal bleeding , Menorrhagia especially anovulatory AUB
(in all cases of postmenopausal bleeding, high index of suspicion about the possibility of
having Ca endometrium should be considered.)
• TAH +/- BSO done for some other benign condition, final HPR – Ca Endometrium
• AGUS on cervical smear
• Thickened Endometrium on USG done for other benign condition
History
o Presenting complaints
o Menopausal status/ parity
o H/o risk factors
o Family history ( Lynch Syndrome )
o Comorbidities ( PCOS , Obesity )
Physical Examination
• P/A: Abdominal examination unremarkable except in advanced cases
• Local examination
• Suburethral area, vagina & cervix
• Pelvic examination:
• Per speculum
( Cervical smear :AGUS, malignant cells )
• Size, mobility, adnexae, parametium, cul de sac
Diagnosis: EM biopsy *
Imaging: PreferablyContrast enhanced MRI of the whole abdomen ; USG Abdomen and pelvis
( TAS + TVS ) is the minimum requirement and sufficient if full lymphadenectomy is planned
Preop work up : CBC, LFT, RFT , Serum electrolytes, blood sugar and others as indicated
Discussion :
*Endometrial Biopsy
Office endometrial sampling procedures are the methods of choice as all of them have a
specificity of 98% with pipelle aspiration device being the best among them with a sensitivity of

about 99.6% especially in cases of postmenopausal bleeding. Office Endometrial sampling is

preferably the first method of evaluation. If negative a Dilatation and curettage to be done as a
second step. If lesion still persists a hysteroscopy directed biopsy may be considered Even
though not required many a time , office hysteroscopy in suspected / for ruling out focal lesions .
D and C may be also done if reports of office endometrial sampling procedures are
inconclusive. Slide Review to be done if D&C already done .
 The cutoff Endometrial thickness to sample endometrium in TVS >4mm in case of
postmenopausal bleeding
IHC may be done in an endometrial aspiration or endometrial curettage specimen in selected

cases to differentiate Type I and Type II cancers and to rule out cervical cancer.P 16, ER, PR,
p53 , vimentin and CEA may be undertaken if facilities exist .
Presentation and Initial Work Up

( Post Menopausal bleeding , Menorrhagia especially anovulatory AUB ,TAH +/- BSO done for
some other benign condition, final HPR – Ca Endometrium ,AGUS on cervical smear,
Thickened Endometrium on USG done for other benign condition )

Presentation
Endometrial Biopsy (Pipelle‘s sampling)
Endometrial Intraepithelial Inconclusive

neoplasia or Endometrial
Simple hyperplasia or non-
cancer
malignant pathology
D&CHysteroscopyDD or
Endom High Risk Hysteroscopy and guided
etroid endometrial biopsy
endome histology Then treat as per histology If repeat Manage
trial (carcinosarcoma episode of as per
carcino clear or serous abnormal endometri
ma cell uterine al
undifferentiated) bleeding hyperplasi
a
Inconclusive
Surgical management if family

completed
(TAH+BSO+Resection of
enlarged node)

Treatment: (FIGO 2009 staging):

Initial treatment: **
Stage I A: Total Hysterectomy+ Bilateral Salpingo-oophorectomy ± Lymphadenectomy
Stage I B: Total Hysterectomy+ Bilateral Salpingo-oophorectomy ± Lymphadenectomy
(pelvic and para-aortic)
Stage II:Total Hysterectomy+ Bilateral Salpingo-oophorectomy + Systematic Pelvic
Lymphnode dissection
Stage III/IV:Maximum de-bulking surgery possible
Maximal surgical debulking is indicated in patients with a good performance status and
resectable tumour . In distant metastatic disease, palliative surgery could be considered in
patients with a good performance status
Principles of Surgery:
 Primary Treatment Modality- SURGERY ie STAGING LAPAROTOMY. Surgical

staging
 Steps of Staging Laparotomy :
 Peritoneal fluid/wash cytology
 Hysterectomy + BSO + Bilateral Pelvic LND + PALND +/- Omentectomy +/- Peritoneal
biopsy
 In presumed low risk cases LND is not required.LN dissection can be omitted in
Endometroid Ca IA Grade 1 / Grade 2 less than 2 cm.However uncontrollable variables
such as change in grade, depth and histology makes this preoperative decision difficult
and lymphadenectomy may be undertaken on a selective basis.
 In presumed High intermediate and High risk cases LND will help tailor the selection of
appropriate adjuvant treatment
 In Type II and Stage II cancer LND should be undertaken as part of staging. Para-aortic
lymphadenenctomy may be done in selected cases.
 Ovarian preservation can be considered pts

o Can be considered in < 45 yrs + Stage IA Grade I Endometroid Ca with no
extrauterine disease
o Not recommended in Lynch and BRCA carriers

 Omentectomy if
o Clear cell carcinoma
o Serous carcinoma
o Upper abdomen disease/ omental deposit
 Peritoneal biopsy of any suspicious lesion
 Minimally invasive procedures are the method of choice in expert hands and is to be
done without compromising on oncological safety . What is more important is to adhere
to oncological principles ie to remove the tumour / uterus in toto without intraperitoneal
morcellation or tumour fragmentation .
 Radical hysterectomy is not often required unless there is gross cervical involvement and
a type B ( type 2 ) RH is often sufficient in these cases . In cases where suggestion of
cervical involvement is there only in MRI and if the cervix is grossly normal clinically , a
RH is not needed in order to avoid the complications of multi modal treatment as these
patients receive adjuvant RT
 SLN biopsy , even though category 2B as per NCCN guidelines , may be practiced and
strict adherence to SLN algorithm is a must in such cases. Eventhough the recommended
method is cervical injections both deep and superficial , combined fundal and cervical
injections may be given especially if the growth is limited to fundus .
 Not candidates of primary surgery if ,

o Stage III B disease ( parametrium involved)
o Stage IV requiring multi visceral resection
Histopathology : Determine the following

• Histological subtype
• Grade
• LVSI
• Tumor Size
• Depth of myometrial infiltration
• Cervix, vaginal, parametrium extension
• LN positive
Two main histological types of clinical significance are the type 1 tumours which are
estrogen-dependent endometrioid ( and mucinous ) and estrogen-independent non-
endometrioid carcinomas (Type 2). Type 1 tumours are with better prognosis compared to

type 2 ie clear cell and serous . Carcinosarcomas are also to be managed as type 2 tumours.
Carcinoma Endometrium – Initial Management
-MRI (Preferred)/USG
-Institutional Review of
slide and block +/- IHC
Not confined to the

Confined to the uterus
uterus
Surgical staging with * Total Operable Inoperable

Hysterectomy( RH if gross cervical
disease ) + BSO + **BPLND +
PALND (or ***SLN )+/-
Omentectomy +/- Peritoneal biopsy Consider Systemic
surgical therapy
debulking
*peritoneal fluid /wash for cytology to be taken and documented even though it does not alter
the stage
**Factors for Pre-operative Risk Stratification for Pelvic or para-aortic Lymph node assessment
>50% Invasion, Grade 3, Cervical extension, type 2 tumours - Clear cell or serous cell
pathology, >2cm tumour with Grade 2, Carcinosarcoma (Lymphadenectomy preferred)
***Sentinel Lymph node mapping is Category 2B as per NCCN Guidelines

Adjuvant Treatment***
Decision regarding Adjuvant treatment is to be done after Risk Stratification
Observation Alone :
o Low Risk - Stage 1 , Grade 1-2 , endometrioid , with less than 50% myometrial
invasion without LVSI
VBT Alone :
o Intermediate Risk : Stage 1 , Grade 1-2 , endometrioid , with more than 50%
myometrial invasion without LVSI . Observation alone is justifiable to this group in
less than 60 yrs old .
o High – Intermediate Risk and Node Negative : Grade 3 ,<50% MI or Grade 1-2 with
LVSI belong to the group .
o Type 2 Stage 1A without LVSI
EBRT alone :
o High risk and surgically staged
o No surgical staging with unequivocal positivity of LVSI , Grade 3 and 1 B
EBRT + Brachy :
o Stage 2
EBRT + Sequential Adj Chemo
o High Risk and no surgical staging
o Stage 3
o Type 2 node positive

***Adjuvant treatment:
Based on Risk stratification
Risk Treatment
Category
Low Stage 1 , grade 1-2 , endometrioid ,<50% Observation
myometrial invasion ,No LVSI
Intermediate Stage 1, grade 1-2 , endometrioid , > 50% Vaginal Brachytherapy
myometrial invasion ,No LVSI
Observation < 60 years
High Stage 1 , Grade 3 , <50% myometrial invasion Node negative
Intermediate VBRT
Stage 1 Grade 1-2 with LVSI No Surgical Staging
EBRT (LVSI unequivocally
positive )
High Stage 1 ,grade 3 endometrioid, Surgical Staging
>50% myometrial invasion EBRT
No Surgical Staging
EBRT,sequential adjuvant
Stage 2 chemo
Add vaginal brachytherapy
Stage 3 Chemotherapy and EBRT
III A/B III C
III C1 III C2
Chemotherapy 4cycles (paclitaxel 175/m2 Chemotherapy 4cycles (Paclitaxel

+ Carboplatin AUC 5-6) pelvic 175mg/m2 +Carboplantin AUC 5-6)
RT+vaginal BT Followed by pelvic +/-Para-aortic
RT +vaginal BT

Radiation Dose:
ADJUVANT RT (EBRT + BRACHYTHERAPY)

EBRT 3DCRT 45- 50.4 Gy /25 to 28#
1.8-2 Gy per fraction
BRACHYTHERAPY HDR BRACHYTHERAPY VAULT

BRACHYTHERAPY: 4- 6 Gy
TO 0.5 cm FROM THE
VAGINAL SURFACE X 2-3
SITTINGS
ADJUVANT BRACHYTHERAPY ALONE

HDR BRACHYTHERAPY VAULT
BRACHYTHERAPY: 6 Gy
TO 0.5 cm FROM THE
VAGINAL SURFACE X 5
SITTINGS
Unexpected HPR of Ca endometrium in Hysterectomy specimen
Type1 endometrioid ca
 CE CT at 4- 6 weeks
 If enlarged nodes: Restaging with lymphadenectomy
 CT normal: follwup
Restaging:
• In Type I or Low risk cases if imaging shows a enlarged pelvic or para-aortic node then
restaging is an option
• In Type II Carcinoma endometrium re-staging is an option in selected cases to rule out
residual disease in the peritoneum or in the lymph nodes.
• In cases of patient preference to avoid re-surgery or if not fit for surgery appropriate
adjuvant therapy may be given

Follow-up:
• History & Clinical exam Q 3 monthly x 2yrs. Then Q 6 monthly

• Imaging if indicated
• Vault Smear annually
• Genetic counseling for Lynch Syndrome
• Fertility sparing
o Megestrol acetate (MA;160-320mg/day)
o Assessment of response @ 6 months with EB & imaging
o Maintanance therapy x 6 months if delay in pregnancy
o Hysterectomy non responders & after pregnancy
Note:
In stage I A grade I endometrial cancer(detected with a D&C) with no myometrial
invasion(using MRI) or metastasis, and high motivation for fertility preservation, hormonal
therapy may be considered. It should be counselled that fertility preservation is not the
standard of care.LNG IUCD or and Megesterol acetate may be used with 3monthly
sampling.Persistence of lesion or progression as assessed by Endometrial sampling at 6 and or
12month should prompt a hysterectomy .Definitive surgery should be undertaken after prompt
addressing of fertility issues in an expedite manner.
References:
1. Regional Cancer Centre ,Thiruvananthapuram Carcinoma Endometrium
Treatment Protocol ,
2. AIMS , Kochi Carcinoma Endometrium treatment Guidelines Flow Charts
3. National Cancer Grid Guidelines ,
https://tmc.gov.in/ncg/index.php/guidelines/search-by-cancer-type
4. NCCN Guidelines Version 3.2019 Uterine Neoplasms
https://www.nccn.org/professionals/physician_gls/pdf/uterine.pdf
5. Endometrial Cancer : ESMO Clinical Practise Guidelines
https://www.esmo.org/Guidelines/Gynaecological-Cancers/Endometrial-Cancer
6. ESMO-ESGO-ESTRO consensus conference on endometrial cancer
https://www.esmo.org/Guidelines/Gynaecological-Cancers/ESMO-ESGO-

ESTRO-Consensus-Conference-on-Endometrial-CancerDijkhuizen FP,
Brolmann HA, Potters AE, et al. The accuracy of transvaginal ultrasonography in
the diagnosisofendometrialabnormalities.ObstetGynecol1996;87:345-9.

GESTATIONAL TROPHOBLASTIC NEOPLASIA (GTN)

• Invasive Mole
• Choriocarcinoma
• Placental Site Trophoblastic Disease
• Epithelioid Trophoblastic tumour
Follow up of Hydatidiform mole :

• hCG value monitoring
• Weekly until 3 consecutive normal values
• Monthly - Until 6 consecutive normal values
Invasive mole:
• Most commonest GTN (60%)
• Hydatidiform mole which invade into myometrium or its blood vessels; there is marked
proliferation of the trophoblast, but avascular villi may also be found
• 5% metastasize to extrauterine tissue mostly lungs
Choriocarcinoma :
• A dimorphic population of cytotrophoblast and syncytiotrophoblast proliferation with
pleomorphism and anaplasia

• 30-40% of GTD
GTN diagnostic criteria :
Definition-at least one of the following
– B-hCG plateau for ≥ 4 values for ≥ 3 weeks
– B-hCG increase of ≥ 10% for ≥ 3 values for ≥ 2 weeks
– B-hCG persistence 6 months after molar evacuation
– Histopathologic diagnosis of choriocarcinoma

ABNORMAL REGRESSION CURVE:
STAGING
Stage
 I - Disease confined to uterus
 II- Extending outside uterus
 III- Extending to lungs with or withoutgenital tract involvement
 IV- All other metastasis sites
Pre-treatment evaluation:
 History
 Physical examination
 S. βhCG
 LFT, RFT, TFT
 CBC
 Metastatic workup to determine stage and FIGO SCORE
 CXR
 USG

 Lung Metastasis Noted on X ray - MRI Brain and CT Chest(Scoring based on Chest
Xray Only)
Low risk GTN – Methotrexate(MTX) Folinic acid rescue regime
Methotrexate 1mg/kg IM/IV Day 1,3,5,7
Folinic Acid 0.1-0.15 mg/kg IM Day 2,4,6,8

(30hrs after )
• Course is to be repeated at aninterval of 14 days

• Alternatively Pulsed Actinomycin-D 1.25mg/m2 IV, maximum dose limited to 2mg
repeated 2weekly
• First Line Chemotherapy administered until 3 negative test results for βhCG (less than
5mu/ml) in 3 consecutive weeks
• Consolidation chemotherapy for 3 cycles after normalization of βhCG
CRITERIA TO INITIATE OR CONTINUE:

 Platelet count more than 1,00,000.
 WBC more than 3000.
 Absolute neutrophil count between 1000-1500.
 Normal LFT, renal function.
NO RESPONSE TO MTX- MTX resistance:
• hCG every 2 week
• hCG does not decline by 1 log after 18 days of 1st course
• Plateauing of hCG(<10% change) over 3 consecutive cycles (over 6 weeks total)
•  in hCG titre over 2 cycles(over 4 weeks total)
RESISTANCE TO MTX :
Inadequate response to 2 courses
• Switch to Single agent Actinomycin D if hCG value is <300 mu/ml.
• If hCG value is >300 mu/ml Combination chemotherapy may be preferred.
ActD has higher cure rates than MTX (relative risk 0.65, 95% CI 0.57-0.95),
But with increased severe adverse events
• First-line chemotherapy in low-risk gestational trophoblastic neoplasia. AU Lawrie TA,
Alazzam M, Tidy J, Hancock BW, Osborne R SO. Cochrane Database Syst Rev. 2016
• Low-risk persistent gestational trophoblastic disease: outcome after initial treatment with
low-dose methotrexate and folinic acid from 1992 to 2000. McNeish IA1, Strickland

S, Holden L, Rustin GJ, Foskett M, Seckl MJ, Newlands ES. J Clin Oncol. 2002 Apr
1;20(7):1838-44.
SUB URETHRAL NODULE:

• Stage II disease
• Treatment of choice :Single agent chemotherapy
MANAGEMENT OF PATIENTS WITH BLEEDING - Sub urethral nodule:
• Vaginal packing + Chemotherapy
• Radiographic embolization
PULMONARY METASTASIS:
Mgt of Stage III – Low Risk
• Single agent chemotherapy
– Methotrexate Folinic Acid rescue regimen
– Actinomycin D
• Resistant cases
Combination CT
– EMA-CO
SURGICAL MANAGEMENT:
Hysterectomy:
• Placental site trophoblastic tumor (PSTT) and Epithelioid trophoblastic tumor (ETT) -
relatively resistant to chemotherapy-nonmetastatic PSTT and ETT treated with
hysterectomy
• Women with HM who are ≥40 years and have completed childbearing hysterectomy may
be considered
• Emergency situations such as hemorrhage into peritoneal cavity or via per vaginal route
Hysterectomy reduces Invasive mole but not metastatic disease and may reduce the number of
Chemotherapy cycles required
Other Surgical interventions:

• Thoracotomy - For persistent viable metastasis following chemotherapy
Pulmonary lobectomy
OR
Partial lobe resection
MANAGEMENT OF CEREBRAL METASTASIS :
• Intensive IV combination chemotherapy with high-dose Methotrexate at 1g/m2 or

addition of intrathecal Mtx
• Craniotomy – On an emergency situation –Decompression & to Control of bleeding
• Resection of solitary nodule that persist after chemotherapy

• Stereotactic radiotherapy is preferred for focal disease to minimise long term cognitive
morbidity.
• Steroids and other strategies to decrease raised intracranial pressure to be initiated
• Combination chemotherapy with irradiation (3000 CGy in 15 fractions) may be used in
rare situations
MANAGEMENT OF HEPATIC METASTASIS :

• Stage IV – High risk
• Rx of choice à Combination chemotherapy
• In resistant cases , Hepatic arterial infusion
• Hepatic arterial embolisation
• Hepatic resection if a/c Bleeding or focus of resistant tumour cells
• Liver Metastasis  whole liver radiation therapy 2000cGy over 10 days
High risk GTN
• EMACO regimen
• Remission rates of 80-95%.
• EMA-EP, TP/TE, BEP, VIP, ICE are all accepted regimes in special situations
Day Drug Dose
Week1 Etoposide 100 mg/m2, IV infusion over 30 min

Day 1
Mtx 100 mg/m2, IV bolus
200 mg/m2,infusion over 12 hr
Act D 350 μg/m2, IV bolus
Day2 Etoposide 100 mg/m2, IV infusion over 30 min
Act D 350 μg/m2, IV bolus
 First line Chemotherapy administered until 3 negative test results for βhCG (less than
5miu/ml) in 3 consecutive weeks or until intolerable side effects develop
 Consolidation chemotherapy for 3cycles after normalisation of βhCG
Resistant to EMA – CO EMA – EP

Prognosis
Low risk  almost 100%
High risk  70%
FOLLOW UP – GTN Low risk (Stage I,II,III) :
• 3 consecutive normal βhCG weekly
• Monthly βhCG until 12 months after normalisation of βhCG
• NB: For molar pregnancy only 6 months follow-up is required
FOLLOW UP – High risk-Stage IV :
• 3 consecutive normal βhCG weekly
• Monthly βhCG until 2 years after normalisation of βhCG
Contraception :
• Effective contraception during hormonal follow up
– until βhCG normalisation –Barrier method
- Post βhCG normalisation – low dose OCP
• Radiographic studies when clinically indicated
PLACENTAL SITE TROPHOBLASTIC TUMOUR (PSTT) :

• Intermediate cytotrophoblast
• hPL is the tumor marker
• Low malignant potential, Lymphatic metastasis
• Chemo-resistant
MANAGEMENT OF PSTT :
 Hysterectomy with Lymphadenectomy– ovaries may be conserved
 In case of metastasis , Interval from index pregnancy >2years, elevated tumour markers
on follow-up EMA – EP to be administered
 Follow up : Follow-up with hCG is effective
- hPL monitoring may not be done routinely
 Life long follow-up required as patient can manifest late secondaries
Epithelioid Trophoblastic tumour :

• Treatment principles same as that of PSTT
Special situation :
• Fertility preservation in GTN- In very selective patients with isolated nodules, excision
may be done preserving oncology principles; this is not a standard recommendation.
Final histopathology and/or follow-up may mandate further surgery or treatment
• Ultra-high risk-FIGO >12- extensive metastatic lesions especially requiring ventilator
support –Low dose EP to avoid early deaths followed by EP/EMA

Key Points :
• Initial treatment should be suction evacuation. Routine second evacuation increases risk
of subsequent chemotherapy and should be avoided.
• GTN is diagnosed be based on hCG&or abnormal radiology. Histological confirmation
not needed except if there is a suspicion of PSTT.
• Type of chemotherapy based on FIGO scoring
• Hysterectomy in PSTT and certain selected cases
• Dedicated Tumour registry with optimal follow-up is the key in management.
References:
1) IMCH GTN treatment Protocol Institute of Maternal and Child Health ( IMCH ) , Govt.
Medical College , Calicut
2) FIGO CANCER REPORT 2018 : Update on the diagnosis and management of
gestational trophoblastic disease Hextan Y.S. Ngan ,Michael J. Seckl ,Ross S. Berkowitz
,Yang Xiang,François Golfier ,Paradan K. Sekharan ,John R. Lurain,Leon Massuger

OVARIAN CANCERS
CLINICAL PRESENTATIONS AND WORK-UP
Clinical Suspicion of Ovarian Cancer

 Symptoms of bloating, dyspepsia, nausea, constipation, distension,
abdominal or pelvic pain, urinary frequency orurgency
 Palpable pelvic or abdominalmass
 Ascites/pleuraleffusion
WORK UP
 Personal and familyhistory
 Thorough clinicalexamination
 Haematological and biochemicalinvestigations
 Serum tumor markers: CA-125, CEA
 Ultrasound and CECT Abdomen and Pelvis
 Xray Chest
 Upper and Lower GI endoscopy in case of bilateral, solid tumours , CA125/CEA
ratio< 25 and also when clinicallyindicated
 Ascitic fluid/ pleural fluid cytology with cell block and Core biopsy of omental
cake/metastasis / ovarian mass for advanced cases not planned for primary
surgery
PRIMARY TREATMENT

PRIMARY TREATMENT
Clinically Early Stage Clinically Advanced Stage
Surgery* – Surgery* - 3-6 NACT

Staging Primary Cytoreduction ( Selected Stage 3c
Laparotomy /4)
Low Risk ¶ High Risk ¶¶ Surgery* -

Interval
Cytoreduction
Observati 6 cycles of Adjuvant

on Chemotherapy ( CT )** Adjuvant CT
**
Follow Up ***
¶ Low Risk- Stage IA/IB , Grade 1, Non-Clear cell Histology

¶¶ High Risk – Stage IA/IB, Grade 2/3, Clear cell histology, Stage IC, Stage II
<<3 – 6 #NAC followed by interval cytoreduction (3-6 cycles, Reassess preferably with CECT
after 3 cycles of NAC and decision regarding ICR or continuation or to be made )

Notes:
FIGO (International Federation of Gynaecology & Obstetrics) Staging for Ovarian

Cancer 20132
Ovarian malignancies are staged surgico-pathologically. Patients with stage I and II are
considered early stage disease, whereas stage III and IV fall into the category of advanced
stage disease. Stage IIIc is the most common stage of presentation
Stage I: Tumor confined to ovaries orfallopiantube(s)T1-N0-M0

IA: Tumor limited to 1 ovary (capsule intact) or fallopian tube; no tumor on ovarian or
fallopian tube surface; no malignant cells In the ascites or peritoneal washings
T1a-N0-M0
IB: Tumor limited to both ovaries (capsules intact) or fallopian tubes; no tumor on ovarian or
fallopian tube surface; no malignant cells in the ascites or peritoneal washings
T1b-N0-M0
IC: Tumor limited to 1 or both ovaries or fallopian tubes,with any of the following:
IC1:Surgicalspill
T1c1-N0-M0
IC2: Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface
T1c2-N0-M0
IC3: Malignant cells in the ascites or peritoneal washings
T1c3-N0-M
Stage II: Tumor involves 1 or both ovaries or fallopian tubes with pelvic extension
(below pelvic brim) or primaryperitonealcancer
T2-N0-M0
IIA: Extension and/or implants on uterus and/or fallopian tubes and/or ovaries
T2a-N0-M0
IIB: Extension to other pelvic intraperitoneal tissues
T2b-N0-M0
Stage III: Tumor involves 1 or both ovaries or fallopian tubes, or primary peritoneal
cancer, with cytologically or histologically confirmed spread to the peritoneum outside
the pelvis and/or metastasis to the retroperitoneal lymph nodes
T1/T2-N1-M0
IIIA1: Positive retroperitoneal lymph nodes only (cytologically or histologically
proven): IIIA1(i) Metastasis up to 10mm in greatest dimension
IIIA1(ii) Metastasis more than 10mm in greatest dimension
IIIA2: Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without
positive retroperitoneallymphnodes T3a2-N0/N1-M0
IIIB: Macroscopic peritoneal metastasis beyond the pelvis up to 2cm in greatest dimension,
with or without metastasis to the retroperitoneal lymph nodes
T3b-N0/N1-M0
IIIC: Macroscopic peritoneal metastasis beyond the pelvis more than 2 cm in greatest
dimension, with or without metastasis totheretroperitoneallymph nodesT3c-N0/N1-M0
Stage IV: Distant metastasis excluding peritoneal metastases

Stage IVA: Pleural effusion with positive cytology
Stage IVB: Parenchymal metastases and metastases to extra-abdominal organs (including

inguinal lymph nodes and lymph nodes outside of the abdominal cavity)
Any T, any N,M1 Extension of tumor from omentum to spleen or liver (stage IIIC)
should be differentiated from isolated parenchymal metastases (stageIVB).
II . SURGERY
Early Stage Disease
 Primary surgery for diagnosis, staging and treatment is themainstay.

 The surgery should entail peritoneal fluid cytology, systematic exploration of the
abdomen and pelvis, multiple peritoneal biopsies,total abdominal hysterectomy with
bilateral salpingo- oophorectomy, omentectomy ( infracolic omentectomy if omentum is
grossly normal ) , pelvic and para-aortic lymphadenectomy. Conservativesurgery i.e.
unilateral salpingo-oophorectomy with preservation of the normal contralateral ovary and
uterus may be considered in young patients desirous of child bearing with stage IA, low
grade disease or borderline tumours. Close surveillance is essential in these cases.In
presumed Stage IA/IB ovarian cancer, Frozen section(FZ) is desirable. In cases where FZ
is not done or if not available conservative surgery may be done if fertility preservation is
desired. Frozen Section may not be always accurate . Hence , Final Histopathology report
will determine the need for restaging or completion surgery . In Ovarian malignancy the
Standard of care is still open surgery even in early stages. All effort has to be made to
avoid capsular rupture especially in Stage IA/IB tumours especially if chemotherapy is
planned to be avoided. In select expert centres with experience, MIS may be done with
strict adherence to Oncology principles,ie without any intraperitoneal spillage .
Avoidance of intraperitoneal spillage is very difficult especially in large tumours . Also in
situations where patient prefer MIS it may be undertaken. But Whenever MIS is planned
it should be after proper counselling that it is still not the standard of care and after
discussing the possible outcomes and alternatives . It is to be discussed in MDT as well.
Advanced Stage Disease
 Cytoreductive surgery includes systematic exploration of the abdomen and pelvis, total
abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and
debulking of enlarged pelvic and para- aortic lymph nodes and removal of all
metastaticdisease.
 The optimal goal of cytoreductive surgery is to leave behind no visible or palpable residual
disease but the minimum goal is to leave behind less than 1cm (preferably less than 0.5
cm) residual disease at any givensite.
III. CHEMOTHERAPY

Six cycles of paclitaxel and carboplatin every 3 weekly is the standard adjuvant
chemotherapy and is the standard of care . In select cases, weekly paclitaxel/carboplatin
for 18 cycles may be considered. Docetaxel may be substituted for paclitaxel in patients

with peripheral neuropathy.


Single agent carboplatin may be used in select cases can alternative regimens.

Neoadjuvant chemotherapy (3-4 cycles) , followed by Interval debulking surgery and
adjuvant chemotherapy (2-3 cycles, total of 6 cycles if received < 6 cycles as neoadjuvant)

Intraperitoneal chemotherapy may be considered in patients with optimal cytoreduction
only in centres withexperience .

HIPEC may be considered In carefully selected patients with optimal cytoreduction , after
thorough counselling only in centres with experience
IV FOLLOWUP
o History and clinical examination every 3 monthly for 2 years, 6 monthly upto
5 years and then yearly lifelong
o Tumour Markers at every visit especially if initiallyelevated
o Imaging as clinically indicated( ultrasound / CT / Chest Xray)
o Hematological and biochemical investigations as clinicallyindicated

RELAPSED OVARIAN CANCER
RELAPSED OVARIAN CANCER
*Platinumrefractory/resistant 
**PlatinumSensitiveRelapse 
*Single agent CT/Best supportivecare

***Consider addition of Bevacizumab ** Platinum based combination CT
Treat until best response or unacceptable toxicity. Duration of

chemotherapy unclear. Patients can receive subsequent lines of
chemotherapy or best supportive care depending on their performance
status.
*No response or progression on previous platinum therapy or progression within 6 months of

its completion
** Progression more than 6 months after completion of previous platinum chemotherapy

Notes:
I.
The standard management of platinum refractory or resistant relapse is single agent
chemotherapy or best supportive care. This is based on six randomized trials showing lack
of benefit from combination therapy in this setting. Appropriate single agents include
pegylated liposomal doxorubicin (PLD), oral etoposide, gemcitabine, weekly paclitaxel and
topotecan.
II.
The standard management of platinum sensitive relapse comprises combination
chemotherapy. This is based on randomized trials showing survival benefit over single
agents in this setting. Appropriate combination regimens include PLD plus carboplatin,
paclitaxel or docetaxel plus carboplatin, gemcitabine plus carboplatin.
III. Surgical resection of relapsed disease may be considered in patients with a long disease-free
interval and localized relapse.
IV.
The addition of bevacizumab to combination chemotherapy can be considered in patients
with platinum sensitive relapse. However, physicians should be cognizant of the possibility
of severe adverse effects including intestinal perforation.
V.
Other targeted agents such as Olaparib should be restricted to a carefully selected subset
after proper counselling
VI. **** Patients with isolated serological relapse (CA 125 rise), can be observed until
symptomatic or radiologic progression (1).However, this decision needs to be
individualized.

References
1) National Cancer Grid Guidelines , https://tmc.gov.in/ncg/index.php/guidelines/search-by-
cancer-type
2) NCCN Guidelines Version 1.2019 : Ovarian Cancer including Fallopian Tube Cancer and
Primary Peritoneal Cancer

BORDERLINE EPITHELIAL OVARIAN TUMORS
(Tumours of Low Malignant Potential)
Suspected low
malignant potential
tumour
Fertility desired Fertility not desired
Conservative surgery USO/ cystectomy TAH with BSO with

with comprehensive surgical staging1 comprehensive
Surgical Staging
Invasiveimplants Confined to ovary/Non

invasiveImplants
Observation to be individualised , Observe In those where

to be done in carefully selected comprehensive staging
cases done

FOLLOW UP
 History and clinical examination 6 monthly for 3 years thenyearly
 Completion surgery after completion of family to bediscussed
 Imaging as clinically indicated (ultrasound / CT / Chest Xray)
 Hematological and biochemical investigations as clinicallyindicated
RELAPSED DISEASE
Surgical Evaluation and debulking ( Consider options for fertility preservation if

decided for comprehensive surgical staging
Non Invasive Implants Invasive implants
observe Treat as epithelial ovarian cancer
Chemotherapy may be considered after aggressive surgical debulking if invasive

implants are identified. ‖
Discussion
 In all suspicious tumours ( imaging /tumour markers ) adherence to strict oncological

principles is a must ie no tumour fragmentation and no intraperitoneal spill
 Ovarian cystectomy – may be done especially if bilateral and nulliparous after proper
counselling
 For all practical purposes , Borderline ovarian tumours and atypical proliferative tumours
are synonymous and to be managed alike eventhough reported as differently by
somepathologists
 If surgery is done Frozen section(FZ) may be done intra-operatively and if FZ is not
available or situations where FZ was not possible, a conservative surgery to be done in
those who desire to preserve fertility.
 Nodal dissection is not a component of Comprehensive surgical staging in BOT; but
enlarged nodes must be removed.

 It should be noted that BOT is always a histopathologic diagnoses, final HPR would
determine further treatment such as restaging with completion surgery.
Conservative Surgery for Borderline Ovarian tumours :

o Primary surgery for diagnosis, staging and treatment is the mainstay.
o The surgery should entail peritoneal fluid cytology, systematic exploration of the
abdomen and pelvis, multiple peritoneal biopsies,total abdominal hysterectomy with
bilateral salpingo- oophorectomy, omentectomy,excision of enlarged and suspicious
pelvic and paraaortic nodes .
o Conservative surgery i.e. unilateral salpingo-oophorectomy with preservation of the
normal contralateral ovary and uterus may be considered in young patients desirous of
child bearing . Close observation is essential in these cases.Ovarian cystectomy may be
done in nulliparous patients especially in bilateral tumours after proper counselling and
explaining the possible outcomes and prognosis.
o In Ovarian tumour with possibility of malignancy, the Standard of care is still open
surgery. All effort has to be made to avoid capsular rupture especially in Stage IA/IB
tumours especially if chemotherapy is planned to be avoided. In select expert centres
with experience, MIS may be done if strict adherence to Oncology principles is
possible, such as avoiding intraperitoneal tumour spillage. Also in situations where
patient prefer MIS it may be undertaken. But Whenever MIS is planned it should be
after proper counselling that it is still not the standard of care and after discussing the
possible outcomes and alternatives . It is to be discussed in MDT as well.

GERM CELL TUMORS OF OVARY

Germ cell tumours predominantly occur in young females; hence preservation of fertility is an
important issue.
Work up and staging manoeuvres is similar to that for epithelial ovarian cancer. Additional
tumour markers include AFP, β HCG and LDH.
Conservative surgery with preservation of normal contralateral ovary and uterus is

recommended wherever feasible.
MANAGEMENT
SURGERY
Fertilitydesired Fertility
notdesired
Fertility sparingsurgery*and Staging

( COG Surgical Guidelines for Ovarian MGCT in Complete comprehensive
pediatric group)# surgicalstaging
Observation **Chemotherapy
Stage1Dysgerminoma Stage II-IVdysgerminoma
Stage 1 grade 1immatureteratoma Stage I Grade II/III & Stage II-
(And Also in special situations for IV mmatureteratoma
carefully selected cases of Stage 1B,C All embryonal carcinoma, yolk
D
sac tumour , choriocarcinoma
y
,mixed GCT with these
components s
g
e
r
m
i
n
o
m
s
in Stage 1 grade 2-3, Stage 1B,C immature
t
e
r
a
t
o
Kerala Cancer Grid m Page 180 of 346
a
Notes:
* Every effort should be made to undertake fertility sparing surgery in young patients with
ovarian tumors.
** Chemotherapy recommended is Bleomycin, etoposide and cisplatin (BEP regimen) X 3-4

cycles.Etoposide plus cisplatin (EP) X 4 cycles can also be considered in some patients
with dysgerminoma
*** In advanced cases, with unresectable disease or in surgically unfit patients, neoadjuvant
chemotherapy with 3-4 cycles of BEP followed by interval cytoreduction and adjuvant
chemotherapy is a suitable option
# Children‘s Oncology Group Surgical Guidelines for Ovarian Malignant Germ Cell
Tumours
Collection of peritoneal fluid or washings for cytology
Examination of peritoneal surfaces with biopsy of abnormal areas
Palpate retroperitoneal lymph nodes ; biopsy only if abnormal ( firm /enlarged )
Inspect omentum ; biopsy only if abnormal
Complete resection of the involved ovary intact ( no capsule entry on field )
Follow up Schedule:
0-2 years After 2 years
Physical Examination
Every 2-4 months Yearly
Malignant germ cell tumour
Serum tumour markers

Every 2-4 months May be omitted
Malignant germ cell tumour
Radiographic Imaging As clinically indicated for those As clinically
Malignant germ cell tumour without an initially evaluated indicated for those
tumour marker without an initially
evaluated tumour
marker
Table 5. AcAA

Active Surveillance programme **of ovarian GCTs
Time Examination Pelvic US Tumour markers Chest X- CT chest,

period ray abdomen pelvis
1st year monthly 2 monthly every 2 weeks 2 monthly 1 montha

(first 6 months) 3 monthsb
and then 12 months
monthly
2nd year 2 monthly 4 monthly 2 monthly 4 monthly *
3rd year 3 monthly 6 monthly 3 monthly 6 monthly *
4th year 4 monthly * 4 monthly 8 monthly *
5th to 10th 6 monthly * 6 monthly annually *

year
*Imaging may be done as clinically indicated as and when required in the subsequent years .
** For those who haven‘t received chemotherapy
aIf not carried out preoperatively.
bIf clear—second look laparoscopy if inadequate staging/immature teratoma.
CT, computed tomography; GCT, germ cell tumour; US, ultrasound.
( Ref : ESMO guidelines ; Suggested surveillance programme based on Mount Vernon
proposal.)
References :
1. Surveillance After Initial Surgery for Pediatric and Adolescent Girls With Stage I Ovarian
Germ Cell Tumors: Report From the Children's Oncology Group ; J Clin Oncol 2014 Feb
10; 32(5): 465–470 ;Deborah F. Billmire, John W. Cullen, Frederick J. Rescorla, Mary
Davis, Marc G. Schlatter, Thomas A. Olson,Marcio H. Malogolowkin, Farzana
Pashankar, Doojduen Villaluna, Mark Krailo, Rachel A. Egler,Carlos Rodriguez-
Galindo, and A. Lindsay Frazier
2. NCCN Guidelines Version 2.2018 , Malignant germ cell and sex cord stromal tumours
3. Gynecol Oncol 2017 Jul;146(1):3-10. An update on post-treatment surveillance and
diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic
Oncology (SGO) recommendations. Salani R, Khanna N, Frimer M, Bristow RE, Chen LM.
Principles of surgery
Principles of Surgery: Gynae Oncology
General Principles:
 The most important principle while dealing with gynaecological malignancy and also
presumably/potentially malignant is adhering to strict oncological principles.
 Gynaecological cancers detected in early stages are potentially curable with an adequate

initial surgery and the restaging and completion surgeries will not improve the outcome in
case of inadequate and improper initial surgery.
 A thorough evaluation of all adnexal masses with imaging and tumour markers is a must
and all suspicious tumours are preferably be operated by those who can do a complete
staging procedures.
 Minimally invasive procedures for suspicious adnexal masses are better avoided and if done
should be carried out with no intraperitoneal spill .
 And also in situations where inadvertent spill or tumour fragmentation has occurred it
should be clearly documented.
 All cases of postmenopausal bleeding , perimenopausal AUB , Anovulatory AUB especially
obese and PCOS , AGUS in Pap Smear are potential cases of Carcinoma Endometrium .
Hence careful assessment of appearance and thickness of endometrium by Trans Vaginal
Ultrasound ( TVS ) and Endometrial Sampling with pipelle aspiration device is a must
before conservative or surgical management . And if office endometrial procedures yield
an inconclusive report, D and C and /or Hysteroscopy should be done .
 If minimally invasive surgeries are done in all potential cases of Cancer Endometrium and
all cases of endometrial hyperplasia especially with atypia , no tumour fragmentation or
intraperitoneal spillage should occur . Morcellation or Subtotal hysterectomy should be
avoided
 All abnormal Cervical cancer screening tests ( Pap Smear/HPV testing /VIA ) should be
evaluated properly preferably by colposcopy ( +/- punch / LEEP Biopsy) as per national (
FOGSI GCPR ) or international guidelines.
 All warning symptoms of Gynaecological malignancies should be evaluated properly to
avoid an unplanned surgery and also proper imaging and adequate pre op workup as the
case necessitates will help in avoiding having unexpected findings in surgery or HPR.
Cervical Cancer :
Principles of treatment
Adherence to single modality treatment either surgery or Radiotherapy

Combination of surgery and radiotherapy- doubles complications
Ideal patient selection for radical hysterectomy
Radical hysterectomy
Radical hysterectomy requires en bloc resection of the uterus, parametrium, and upper vagina in
varying degrees of radicality. Central dissection facilitated by development of pelvic spaces.
Dissection along natural planes,Correct development of pelvic spaces – avoids injury, minimum
bleeding. Nerve sparing technique preferred to minimise morbidity
Type of surgery is stratified depending on the stage of the disease.
Satge1A1
 Diagnosed on cone biopsy and If margins are positive for invasive Cancer / dysplasia a
repeat cone biopsy or trachelectomy may be considered to evaluate depth of invasion to
rule out stage IA2,IB1
 Type I Extrafascial hysterectomy ,Vaginal/open/minimally invasive is sufficient for
Stage 1 A1 without LVSI
 Modified Radical hysterectomy or Trachelectomy + bilateral pelvic lymphadenectomy
should be done in Stage 1 A 1 with LVSI

Stage 1A2
 Radical hysterectomy (type B ) with bilateral pelvic lymphadenectomy is the treatment of
choice in those who are fit for surgery
 Laparoscopic (or extraperitoneal) pelvic lymphadenectomy or radical abdominal,
vaginal, or laparoscopic trachelectomy with pelvic lymphadenectomy are the options if
fertility preservation is required.
Stage IB1, IB2, and IIA1
 Type C radical hysterectomy with bilateral pelvic lymphadenectomy is the surgery of
choice
 In young women desiring fertility sparing, a radical trachelectomy may be performed in
Stage IA2–IB1 tumors measuring less than or equal to 2 cm in largest diameter
Cancer Endometrium
Principles of Surgery:
Primary Treatment Modality- Surgical staging
Steps of Staging :
 Peritoneal fluid/wash cytology
 Extrafascial Hysterectomy + Bilateral SalpingoOopherectomy + Bilateral Pelvic Lymph
node dissection + Paraaortic lymph node dissection+/- Omentectomy +/- Peritoneal
biopsy
 In presumed low risk cases, Lymph node dissection ( LND ) is not required.LN
dissection can be omitted in Endometroid Ca IA Grade 1 / Grade 2 less than 2
cm.However uncontrollable variables such as change in grade, depth and histology make
this preoperative decision difficult and lymphadenectomy may be undertaken on a
selective basis.
 In presumed High intermediate and High risk cases LND will help tailor the selection of
appropriate adjuvant treatment
 In Type II and Stage II cancer LND should be undertaken as part of staging. Para-aortic
lymphadenenctomy may be done in selected cases.
 Ovarian preservation
o can be considered in < 45 years + Stage IA Grade I Endometroid Ca with no
extrauterine disease
o Not recommended in Lynch and BRCA carriers
 Omentectomy should be done if
 Clear cell carcinoma
 Serous carcinoma
 Upper abdomen disease/ omental deposit
 Peritoneal biopsy of any suspicious lesion
 Minimally invasive procedures are the method of choice in expert hands and are to be
done without compromising on oncological safety. It is important is to adhere to
oncological principles ie to remove the tumour / uterus in toto without intraperitoneal
morcellation or tumour fragmentation.
 Radical hysterectomy is not often required unless there is gross cervical involvement and
a type B (type2) RH is often sufficient in these cases. Suggestion of cervical involvement

only in MRI and if there is no gross tumour clinically, RH is not usually needed in order
to avoid the complications of multi modal treatment as these patients receive adjuvant
RT.
 SLN biopsy, even though category 2B as per NCCN guidelines, may be practiced and
strict adherence to SLN algorithm is a must in such cases. Even though the recommended
method is cervical injections both deep and superficial, combined fundal and cervical
injections may be given especially if the growth is limited to fundus.
Ovarian Cancer:
General Principles:
 All cases of suspicious ovarian cancers should preferably done― by those who can perform
comprehensive surgical staging
 It is preferable to discuss about the possibility of bowel resection and also informed
consent for colostomy in case primary anastomosis is not feasible.
Early Stage Disease :

Staging Laparotomy : Primary surgery for diagnosis, staging and treatment is
themainstay.
 A midline Vertical incision is the standard incision for staging. The surgery should entail
peritoneal fluid cytology, systematic exploration of the abdomen and pelvis, multiple
peritoneal biopsies,total abdominal hysterectomy with bilateral salpingo- oophorectomy,
omentectomy (infracolic omentectomy if omentum is grossly normal), pelvic and para-
aortic lymphadenectomy.
 All peritoneal surfaces should be carefully inspected. Any suspicious areas or adhesions
likely to harbour tumour deposits should be excised or biopsied . Random biopsies may
be taken if no suspicious areas seen.
 Conservativesurgery i.e. unilateral salpingo-oophorectomy with preservation of the
normal contralateral ovary and uterus may be considered in young patients desirous of
child bearing with stage IA, low grade disease or borderline tumours. Close surveillance
is essential in these cases.
 In presumed Stage IA/IB ovarian cancer, Frozen section (FZ) is desirable. In cases where
FZ is not done or if not available conservative surgery may be done if fertility
preservation is desired.
 Frozen Section may not be always accurate. Hence, the need for restaging or completion
surgery will be determined by the Final Histopathology report.
In Ovarian malignancy, the standard of care is still open surgery even in early stages. All
effort has to be made to avoid capsular rupture especially in Stage IA/IB tumours. In
select expert centres with experience, MIS may be done with strict adherence to oncology
principles, ie without any intraperitoneal spillage.It should be remembered that avoidance
of intraperitoneal spillage is very difficult especially in large tumours. MIS may be done
in situations where patient prefers MIS. But whenever MIS is planned it should be after
proper counselling that it is still not the standard of care and after discussing the possible
outcomes and alternatives. It is to be done only after discussion and decision in MDT.

Advanced Stage Disease:
 Cytoreductive surgery includes systematic exploration of the abdomen and pelvis, total
abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and
debulking of enlarged pelvic and para- aortic lymph nodes and removal of all
metastaticdisease.

The optimal goal of cytoreductive surgery is to leave behind no visible or palpable
residual disease but the minimum goal is to leave behind less than 1cm (preferably
less than 0.5 cm) residual disease at any givensite.

Bowel resection, and occasionally, partial or complete resection of other organs
may be required in order to achieve optimal cytoreduction

Debulking of enlarged pelvic and para‐aortic lymph nodes
Borderline Ovarian Tumours :
 In all suspicious tumours ( imaging /tumour markers ) adherence to

strictoncological principles is a must ie no tumour fragmentation and no
intraperitonealspill should occur.
 Ovarian cystectomy – may be done especially if borderline ovarian tumours are
bilateral especially in nulliparous after propercounselling
 If surgery is done Frozen section (FZ) may be done intra-operatively and if FZ is
not available or situations where FZ was not possible, a conservative surgery to be
done in those who desire to preserve fertility.
 Nodal dissection is not a component of Comprehensive surgical staging in BOT;
but enlarged nodes must be removed.
 It should be noted that BOT is always a retrospective diagnosis, final HPR would
determine further treatment such as restaging or completion surgery.
.
Germ Cell Tumours:
 Germ cell tumours predominantly occur in young females; hence preservation of fertility is
an important issue.
 Conservative surgery with preservation of normal contralateral ovary and uterus is

recommended wherever feasible
 Principles of comprehensive surgical staging is essentially the same as in Epithelial

Ovarian Cancers .
 COG Surgical Guidelines for Ovarian MGCT to be adapted for pediatric age group
(Children‘s Oncology Group Surgical Guidelines for Ovarian Malignant Germ Cell
Tumours)

Procedure
o Collection of peritoneal fluid or washings for cytology
o Examination of peritoneal surfaces with biopsy of abnormal areas
o Palpate retroperitoneal lymph nodes ; only if abnormal ( firm /enlarged )
nodes need to be biopsied
o Complete resection of the involved ovary intact ( no capsule entry on field )
Principles of Chemotherapy
Epithelial Ovarian Cancer
Adjuvant Therapy – Regimens
Paclitaxel 175 mg/m2 IV over 3 hours every 3 weekly followed by Carboplatin AUC-5-6 IV
over 1 hour on Day 1. Repeat every 3 weeks for 6 cycles.
Paclitaxel 60 mg/m2 IV over 1 hour followed by Carboplatin AUC-2 IV over 30 mins weekly for
18 weeks
Paclitaxel 80 mg/m2 IV over 1 hour on Day 1, 8 and 15 followed by Carboplatin AUC-5-6 IV

over 1-hour Day 1. Repeat every 3 weeks for 6 cycles
IP/IV Regimen for optimally debulked stage II-IV disease
Paclitaxel 135 mg/m2 IV continuous infusion over 3 hours Day1; Cisplatin 75-100 mg/m2 IP
Day 2 after IV Paclitaxel; Paclitaxel 60 mg/m2 IP Day 8. Repeat every 3 weeks for 6 cycles or,
Paclitaxel 135 mg/m2 IV continuous infusion over 3 hours Day1; Carboplatin AUC-6 IP Day 1
after IV Paclitaxel; Paclitaxel 60 mg/m2 IP Day 8. Repeat every 3 weeks for 6 cycles
In elderly Carboplatin AUC-5 every 3 weeks for 6 cycles is also an option
Neoadjuvant Regimens
Any of the above regimens may be used
Recurrent Ovarian Cancer
Platinum Sensitive Ovarian Cancer
Any of the following regimens may be used
Paclitaxel with Carboplatin

Gemcitabine with Carboplatin
Liposomal Doxorubicin with Carboplatin
Bevacizumab may be added with any of the above regimens in platinum sensitive ovarian cancer
whenever possible

Platinum Resistant Ovarian Cancer
Etoposide – oral
Gemcitabine
Liposomal Doxorubicin
Topotecan
Weekly Paclitaxel
Docetaxel
Bevacizumab may be added to weekly Paclitaxel/Topotecan/Liposomal Doxorubicin in platinum

resistant ovarian cancer whenever possible
Malignant Germ Cell Tumors
BEP
Bleomycin 30 U weekly, Etoposide 100 mg/m2 for Days 1-5 and Cisplatin 20 mg/m2 Days 1-5.
Repeat every 3 weeks for 3-4 cycles depending upon risk
Etoposide – Carboplatin – In highly selected cases of Stage IB-III dysgerminoma where

minimizing toxicity is critical
Etoposide 120 mg/m2 IV Day 1,2 and 3 with Carboplatin 400 mg/m2 IV on Day 1 , every 4
weeks for 3 cycles
Recurrent Germ Cell Tumor
TIP – Paclitaxel, Ifosphamide and Cisplatin (Preferred first line Salvage option)
Other options in recurrent setting (Second line and beyond)

VeIP – Vinblastine, Ifosphamide and Cisplatin
VIP – Etoposide, Ifosphamide and Cisplatin
Endometrial Cancer
Chemotherapy Regimens
Paclitaxel – Carboplatin - Paclitaxel 175 mg/m2 IV over 3 hours every 3 weekly followed by
Carboplatin AUC-5-6 IV over 1 hour on Day 1. Repeat every 3 weeks for 6 cycles.
This regimen is preferred in both adjuvant and in metastatic settings
Second Line Regimens
Liposomal Doxorubicin
Topotecan
Bevacizumab

Hormonal Agents
Progestational agents - Megesterol acetate or Medroxyprogesterone acetate

Aromatase Inhibitors
Tamoxifen
Cervical Cancer
Chemoradiation
Cisplatin – 40 mg/m2 IV weekly concurrently during radiation

Carboplatin – Only if cisplatin intolerant; AUC-2 IV weekly
Recurrent or Metastatic Disease
Cisplatin/Paclitaxel
Carboplatin/Paclitaxel
Topotecan/Paclitaxel
Bevacizumab may be added to any of above regimens whenever possible
Gestational Trophoblastic Neoplasia
Low risk GTN
Methotrexate – 0.4 mg/kg/day IM or IV (Max 25 mg/day) daily for 5 days. Repeat every 14
days. Or
Methotrexate 1 mg/kg IM on Days 1,3,5 and 7 alternating with Leucovorin 15 mg PO every

other day, 30 hours after each methotrexate dose on Days 2,4,6 and 8. Repeat every 14 days.
Alternatively in selected cases
Dactinomycin – 10-12 mcg/kg (or 0.5 mg flat dose) IV daily for 5 days every 14 days or
Dactinomycin – 1.25 mg/m2 (Max 2 mg) IV pulse every 14 days
High Risk GTN
EMACO –
Etoposide 100 mg/m2/ day IV on Days 1 & 2
Dactinomycin 0.5 mg IV push on Days 1 & 2
Methotrexate 100 mg/m2 IV push followed by 200 mg/m2 IV infusion over 12 hrs
Leucovorin 15 mg PO or IM every 12 hours for 4 doses starting 24 hours after start of
Methotrexate
Cyclophosphamide 600 mg/m2 IV on Day 8

Vincristine 1 mg/m2 IV push (Max 2 mg) on Day 8
Other Regimens
EP/EMA or EMA/EP - For selected High risk cases.
Second Line Regimens
BEP – Bleomycin, Etoposide and Cisplatin

VIP – Etoposide, Ifosphamide and Cisplatin
TIP – Paclitaxel, Ifosphamide and Cisplatin
ICE – Ifosphamide, Etoposide and Carboplatin

HEAD & NECK CANCERS


AJCC Staging: Head and neck cancers
CA ORAL CAVITY
Tx Primary tumor cannot be assessed
T1 Tum or< 2 cm, < 5 mm depth of invasion (DOI)
T2 Tumor < 2 cm, DOI > 5 mm and < 10 mm or tumor > 2 cm but < 4 cm, and <
10 mm DOI
T3 Tumor>4 cm or any tumor> 10 mm DOI
T4 Moderately advanced and very advanced local disease
T4a Moderately advanced local disease (lip) Tumor invades through cortical bone
orinvolves the inferior alveolar nerve, floor of mouth, or skin of face (i.e., chin
or nose) (oral cavity) Tumor invades adjacent structures only (e.g., through
cortical bone of the mandible or maxilla, or involves the maxillary sinus or skin
of the face)
T4b Very advanced local disease Tumor invades masticator space, pterygoid plates,
or skull base and/or encases the internal carotid artery
Nx Regional lymph nodes cannot be assessed
No No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest

dimension and EN E (-)
N2 Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm
in greatest dimension and ENE(-);
or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in
greatest dimension and ENE(-);
or in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest
dimension and ENE(-)
N2a Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm
in greatest dimension and ENE(-)
N2b Metastasis in multiple ipsilateral nodes, none larger than 6 cm in greatest
N2c Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in
greatest dimension and ENE(-)
N3 Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-);

or metastasis in any node(s) and clinically overt ENE(+)

N3a Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-)
N3b Metastasis in any node(s) and clinically overt ENE(+)
CA OROPHARYNX (HPV +ve)
T0 No primary identified
T1 Tumor 2 cm or smaller in greatest dimension
T2 Tumor larger than 2 cm but not larger than 4 cm in greatest dimension
T3 Tumor larger than 4 cm in greatest dimension or extension to lingual surface of

epiglottis
T4 Moderately advanced local disease.
Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard
palate, or mandible or beyond.*
* Mucosal extension to lingual surface of epiglottis from primary tumors of the
base of the tongue and vallecula doesnot constitute invasion of the larynx
N0 No regional lymph node metastasis
N1 One or more ipsilateral lymph nodes, none larger than 6 cm

N2 Contralateral or bilateral lymph nodes, none larger than 6 cm
N3 Lymph node(s) larger than 6 cm
CA OROPHARYNX (HPV -ve)
T1 Tumor 2 cm or smaller in greatest dimension
T2 Tumor larger than 2 cm but not larger than 4 cm in greatest dimension
T3 Tumor larger than 4 cm in greatest dimension or extension to lingual surface of

epiglottis

T4a Moderately advanced local disease.

Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard
palate, or mandible.*
T4b Very advanced local disease.
Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx,
or skull base or encases carotid artery.
N1 Metastasis in a single ipsilateral lymph node, 3 cm orsmaller in greatest dimension

and EN E (-)
N2 Metastasis in a single ipsilateral node larger than 3 cmbut not larger than 6 cm in
greatest dimension andENE(-);
or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest
dimension andENE(-);
or in bilateral or contralateral lymph nodes, nonelarger than 6 cm in greatest
N2a Metastasis in a single ipsilateral node larger than 3 cm butnot larger than 6 cm in
N2b Metastasis in multiple ipsilateral nodes, none largerthan 6 cm in greatest
N2c Metastasis in bilateral or contralateral lymph nodes,none larger than 6 cm in
N3 Metastasis in a lymph node larger than 6 cm in greatestdimension and ENE(-);
N3a Metastasis in a lymph node larger than 6 cm in greatestdimension and ENE(-)


T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility
T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or

glottis or región outside the supraglottis (e.g., mucosa of base of tongue,
vallecula, medial wall of pyriform sinus) without fixation of the larynx
T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the
following: postcricoid area, preepiglottic space, paraglottic space, and/or
inner cortex of thyroid cartilage
T4 Moderately advanced or very advanced
T4a Moderately advanced local disease Tumor invades through the outer cortex
of the thyroid cartilage and/or invades tissues beyond the larynx (e.g.,
trachea, soft tissues of neck including deep extrinsic muscle o f the tongue,
strap muscles, thyroid, or esophagus)
T4b Very advanced local disease Tumor invades prevertebral space, encases
carotid artery, or invades mediastinal structures
GLOTTIS
T1
Tumor limited to the vocal cord(s) (may involve anterior or posterior
commissure) with normal mobility
T1a
Tumor limited to one vocal cord
T1b
Tumor involves both vocal cords
T2
Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal
cord mobility
T3 Tumor limited to the larynx with vocal cord fixation and/or invasión of
paraglottic space and/ or inner cortex o f the thyroid cartilage
T4a Moderately advanced local disease Tum or invades through the outer cortex
of the thyroid cartilage and/or invades tissues beyond the larynx (e.g.,
trachea, cricoid cartilage, soft tissues o f neck including deep extrinsic

muscle o f the tongue, strap muscles, thyroid, or esophagus)
T4b Very advanced local disease Tumor invades prevertebral space, encases
SUBGLOTTIS
T1 Tumor limited to the subglottis
T2 Tumor extends to vocal cord(s) with normal or impaired mobility
T3 Tumor limited to larynx with vocal cord fixation and/or invasión of

paraglottic space and/or inner cortex of the thyroid cartilage
T4a Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the
larynx (e.g., trachea, soft tissues o f neck including deep extrinsic muscles o
f the tongue, strap muscles, thyroid, or esophagus)
T4b Very advanced local disease Tum or invades prevertebral space, encases
N1 Metástasis in a single ipsilateral lymph node, 3 cm or smaller in greatest
dimensión and E N E (-)
N2 Metástasis in a single ipsilateral node, larger than 3 cm but not larger than 6
cm in greatest dimensión and E N E (-); or metastases in múltiple ipsilateral
lymph nodes, none larger than 6 cm in greatest dim ensión and E N E (-); or
metástasis in bilateral or contralateral lymph nodes, none larger than 6 cm in
greatest dimensión and E N E (-)
N2a Metástasis in a single ipsilateral node, larger than 3 cm but not larger than 6
cm in greatest dimensión and E N E (-)
N2b Metastases in múltiple ipsilateral nodes, none larger than 6 cm in greatest
N2c Metástasis in bilateral or contralateral lymph nodes, none larger than 6 cm in
greatest dimensión and E N E (-)
N3 Metástasis in a lymph node, larger than 6 cm in greatest dimensión and
E N E (-); or metástasis in any lymph node(s) with clinically overt ENE(+)
N3a Metástasis in a lymph node, larger than 6 cm in greatest dimensión and

E N E (-)
N3b Metástasis in any lymph node(s) with clinically overt ENE(+)
CA HYPOPHARYNX
T1 Tumor limited to one subsite of hypopharynx and/or2 cm or smaller in
greatest dimension
T2 Tumor invades more than one subsite of hypopharynxor an adjacent site, or
measures larger than 2 cm butnot larger than 4 cm in greatest dimension
without
fixation of hemilarynx
T3 Tumor larger than 4 cm in greatest dimension or withfixation of hemilarynx
or extension to esophagus
T4a Moderately advanced local disease

Tumor invades thyroid/cricoid cartilage, hyoid bone,thyroid gland, or central
compartment soft tissue*
T4b Very advanced local disease
Tumor invades prevertebral fascia, encases carotidartery, or involves
mediastinal structures
*Note: Central compartment soft tissue includes prelaryngeal strap muscles and subcutaneous fat
N1 Metastasis in a single ipsilateral lymph node, 3 cm or
smaller in greatest dimension and EN E (-)
N2 Metastasis in a single ipsilateral node larger than 3 cmbut not larger than 6
cm in greatest dimension and
ENE(-);
or m etastases in multiple ipsilateral lymph nodes,none larger than 6 cm in
greatest dimension andENE(-);
or in bilateral or contralateral lymph nodes, nonelarger than 6 cm in greatest
N2a Metastasis in a single ipsilateral node larger than 3 cm butnot larger than 6
cm in greatest dimension and ENE(-)
N2b Metastasis in multiple ipsilateral nodes, none largerthan 6 cm in greatest
N2c Metastasis in bilateral or contralateral lymph nodes,none larger than 6 cm in
N3 Metastasis in a lymph node larger than 6 cm in greatest
dimension and ENE(-);
N3a Metastasis in a lymph node larger than 6 cm in greatestdimension and ENE(-

)
MAXILLARY SINUS:
T category T criteria
Tx Primary Tumor cannot be assessed

T1 Tumor limited to maxillary sinus mucosa with no erosion or destruction of

bone
T2 Tumor causing bone erosion or destruction of including extension in to the
hard palate and /or middle nasal meatus, except extension to posterior wall of
maxillary sinus and pterygoid paltes
T3 Tumor invades any of the following: bone of the posterior wall o the
maxillary sinus, subcutaneous tissues, floor or medial wall of the orbit,
pterygoid fossa, ethmoid sinuses
T4 Moderately advanced or very advanced local diseases
T4a Moderately advanced or very advanced local diseases
Tumor invades anterior orbital contents, skin of cheek, pterygoid plates,
Infratemporal fossa, cribiform plates, sphenoid or frontal sinuses
T4b Very advanced local diseases
Tumor invades any of the followings: Orbital apex, dura, brain, middle
cranial fossa, cranial nerves other than maxillary division of the trigeminal
nerve(v2), nasopharynx or clivus
NASAL CAVITY AND ETHMOID SINUS

T1 Tumor restricted to any one subsite, with or without bony invasion
T2 Tumor invading two subsites in a single region or extending to involve an

adjacent region within the nasoethmoidal complex, with or without bony
invasion
T3 Tumor extends to invade the medial wall or floor of the orbit, maxillary
sinus, palate, or cribriform plate
Tumor invades any of the following: anterior orbital contents, skin of nose or
cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid
or frontal sinuses.

Tumor invades any of the following: orbital apex, dura, brain, middle cranial
fossa, cranial nerves other than (V2), nasopharynx, or clivus.
N category N criteria
N1 Metastasis in single ipsilateral node, 3cm or smaller in greatest dimension
and ENE(-)
N2 Metastasis in single ipsilateral node larger than 3cm,but not larger than 6cm
in greatest dimension and ENE(-);
Or metastasis in multiple ipsilateral lymph node, none larger than 6cm, in
Or in bilateral or contralateral nodes, none larger than 6cm in greatest
N2a Metastasis in single ipsilateral lymph node larger than 3cm but notb larger
than 6cm in greatest dimension and ENE(-)
N2b Metastasis in multiple ipsilateral nodes, none larger than 6cm and ENE(-)
N2c Metastasis in bilateral or contralateral lymph nodes, none larger than 6cm in
N3 Metastasis in lymph node larger than 6cm in greatest dimension and ENE(-);
or metastasis in any node(s) with clinically overt ENE (+)
N3a Metastasis in lymph node larger than 6cm in greatest dimension and ENE(-)
N3b or metastasis in any node(s) with clinically overt ENE (+)
T N M Stage group
Tis N0 M0 0
T1 N0 M0 I
T2 N0 MO II
T3 N0 MO III
T1,T2,T3 N1 MO III
T4a N0,N1 MO IVA
T1,T2,T3,T4a N2 MO IVA
Any T N3 MO IVB
T4b Any N MO IVB
Any T Any N M1 IVC
MAJOR SALIVARY GLAND:
T0 No evidence of Primary Tumor
T1 Tumor 2cm or smaller in greatest dimension without extraparenchymal
extension
T2 Tumor larger than 2cm but not larger than 4cm in greatest dimension without

extraparenchymal extension
T3 Tumor larger tha 4cm and/or tumor having extraparenchymal extension
Tumor invades skin, mandible, ear canal, and/or facial nerve
Tumor invades skull base and/or pterygoid plates and/ or encases carotid artery
Extra parenchymal extension is clinical or macroscopic evidence on invasion of
soft tissues. Microscopic evidence alone does not constitute extra parenchymal
extension for classification purpose
N category N criteria
N1 Metastasis in single ipsilateral node, 3cm or smaller in greatest dimension and
ENE(-)
N2 Metastasis in single ipsilateral node larger than 3cm,but not larger than 6cm in
greatest dimension and ENE(-);
Or metastasis in multiple ipsilateral lymph node, none larger than 6cm, in
Or in bilateral or contralateral nodes, none larger than 6cm in greatest
N2a Metastasis in single ipsilateral lymph node larger than 3cm but notb larger than
6cm in greatest dimension and ENE(-)
N2b Metastasis in multiple ipsilateral nodes, none larger than 6cm and ENE(-)
N2c Metastasis in bilateral or contralateral lymph nodes, none larger than 6cm in
N3 Metastasis in lymph node larger than 6cm in greatest dimension and ENE(-); or
metastasis in any node(s) with clinically overt ENE (+)
N3a Metastasis in lymph node larger than 6cm in greatest dimension and ENE(-)
N3b or metastasis in any node(s) with clinically overt ENE (+)
T N M Stage group
Tis N0 M0 0
T1 N0 M0 I
T2 N0 MO II
T3 N0 MO III
T0, T1,T2,T3 N1 MO III
T4a N0,N1 MO IVA
T0,T1,T2,T3,T4a N2 MO IVA
Any T N3 MO IVB
T4b Any N MO IVB
Any T Any N M1 IVC

CA NASOPHARYNX
T1 Tumour confined to nasopharynx, or extension to oropharynx and/or nasal
cavity without
parapharyngeal involvement
T2 Tumour with extension to parapharyngeal space, and/or adjacent soft tissue

involvement
(medial pterygoid, lateral pterygoid, prevertebral muscles)
T3 Tumour with infiltration of bony structures at skull base, cervical vertebra,

pterygoid
structures, and/or paranasal sinuses
T4 Tumour with intracranial extension, involvement of cranial nerves,

hypopharynx, orbit,
parotid gland, and/or extensive soft tissue infiltration beyond the lateral
surface of the
lateral pterygoid muscle
N1 Unilateral metastasis in cervical lymph node(s) and/or unilateral or bilateral
metastasis in
retropharyngeal lymph node(s), 6 cm or smaller in greatest dimension, above
the caudal
border of cricoid cartilage
N2 Bilateral metastasis in cervical lymph node(s), 6 cm or smaller in greatest

dimension,
above the caudal border of cricoid cartilage
N3 Unilateral or bilateral metastasis in cervical lymph node(s), larger than 6cm in

greatest
dimension, and/or extension below the caudal border of cricoid cartilage
T N M Stage Group
Tis N0 M0 0
T1 N0 M0 I
T2 N0 MO II
T3 N0 MO III

T0, T1,T2,T3 N1 MO III

T4 N0,N1 MO IVA
T0,T1,T2,T3,T4 N2 MO IVA
Any T N3 MO IVA
Any T Any N M1 IVB
CA THYROID
TNM MEDULLARY THYROID CANCER
FOR DIFFERENTIATED,POORLY DIFFRENTIATED AND

ANAPLASTIC THYROID CA
T1 Tumor < 2 cm in greatest dimensión limited to the thyroid
T1a Tumor < 1 cm in greatest dimensión limited to the thyroid
T1b Tumor >1 cm but < 2cm in greatest dimention limited to thyroid
T2 Tumor >2 cm but <4 cm in greatest dimensión limited

to the thyroid
T3 Tumor >4 cm limited to the thyroid, or gross extrathyroidal extensión
invading only strap muscles
T3a Tumor >4 cm limited to the thyroid
T3b Gross extrathyroidal extensión invading only strap muscles (sternohyoid,

sternothyroid. thyrohyoid, or omohyoid muscles) from a tumor of any
size
T4 Includes gross extrathyroidal extensión
T4a Gross extrathyroidal extensión invading subcutaneous soft tissues,
larynx, trachea, esophagus, or recurrent laryngeal nerve from a tumor o f
any size
T4b Gross extrathyroidal extensión invading prevertebral fascia or encasing
the carotid artery or mediastinal vessels from a tumor of any size

T1 Tumor < 2 cm in greatest dimensión limited to the thyroid
T1a Tumor < 1 cm in greatest dimensión limited to the thyroid
T1b Tumor >1 cm but < 2cm in greatest dimention limited to thyroid
T2 Tumor >2 cm but <4 cm in greatest dimensión limited

to the thyroid
T3 Tumor >4 cm limited to the thyroid, or gross extrathyroidal extensión

invading only strap muscles
T3a Tumor >4 cm limited to the thyroid
T3b Gross extrathyroidal extensión invading only strap muscles (sternohyoid,

sternothyroid. thyrohyoid, or omohyoid muscles) from a tumor of any
size
T4 Includes gross extrathyroidal extension
T4a Gross extrathyroidal extensión invading subcutaneous soft tissues,

larynx, trachea, esophagus, or recurrent laryngeal nerve from a tumor o f
any size
T4b Gross extrathyroidal extensión invading prevertebral fascia or encasing
the carotid artery or mediastinal vessels from a tumor of any size
No No evidence of locoregional lymph node metastasis
Noa One or more cytologically or histologically confirmed benign lymph
nodes
Nob No radiologic or clinical evidence o f locoregional lymph node
metastasis
N1 Metastasis to regional nodes
N1a Metastasis to level VI or VII (pretracheal, paratracheal, or
prelaryngeal/Delphian. or upper mediastinal) lymph nodes. This can be
unilateral or bilateral disease.
N1b Metastasis to unilateral, bilateral, or contralateral lateral neck lymph
nodes levels I, II. III. IV, or V) or retropharyngeal lymph nodes

No No evidence of locoregional lymph node metastasis
Noa One or more cytologically or histologically confirmed benign lymph
nodes
Nob No radiologic or clinical evidence o f locoregional lymph node
metastasis
N1 Metastasis to regional nodes
N1a Metastasis to level VI or VII (pretracheal, paratracheal, or
prelaryngeal/Delphian. or upper mediastinal) lymph nodes. This can be
unilateral or bilateral disease.
N1b M etastasis to unilateral, bilateral, or contralateral lateral neck lymph
nodes levels I, II. III. IV, or V) or retropharyngeal lymph nodes
NODAL STAGING OF CARCINOMA OF UNKNOWN PRIMARY
N1 Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest
N2 Metastasis in a single ipsilateral node larger than 3 cm but not larger than
6 cm in greatest dimensión and E N E (-); or m etastases in múltiple
ipsilateral lymph nodes, none larger than 6 cm in greatest dimensión and
E N E (-); or in bilateral or contralateral lymph nodes, none larger than 6
cm in greatest dimensión, E N E (-)
N2a Metastasis in a single ipsilateral node larger than 3 cm but not larger than
6 cm in greatest dimensión and E N E (-)
N2b Metastasis in múltiple ipsilateral nodes, none larger than 6 cm in greatest
N2c Metastasis in bilateral or contralateral lymph nodes, none larger than 6
cm in greatest dimensión and E N E (-)
N3 Metastasis in a lymph node, larger than 6 cm in greatest dimensión and
E N E (-); or metástasis in any lymph node(s) with clinically overt
ENE(+)
N3a Metastasis in a lymph node, larger than 6 cm in greatest dimensión and
E N E (-)
N3b Metastasis in any lymph node(s) with clinically overt ENE(+)

ORAL CAVITY CANCERS- GENERAL
Evaluation
Performance status
Nutritional status
Dental evaluation and prophylaxis
General examination
1) In early cases, USG neck and CT scan if clinically indicated.
2)In advanced cases,
CT scan neck preferred for Buccal mucosa, Gingiva and RMT
subsites.
MRI neck preferred in Oral Tongue and Floor of mouth.
3)Chest X ray for all
4)CT thorax, only in lower nodal disease and advanced nodal disease

Buccal mucosa
T1/ T2 N0
Surgery
OR
In very selective cases ,brachytherapy
T1/T2N+
Surgery followed by adjuvant Radiotherapy (preferred)
OR
Chemo-Radiotherapy/Radical RT
Oral Tongue
T1 and T1N0
T2
Surgery (preferred)
OR
Brachy
(If brachytherapy is chosen, neck to be closely
monitored)
T1 N+ and T2 N0/N+-
Surgery followed by adjuvant RT based on standard
indications*
Floor of Mouth
T1T2 N0
Surgery (preferred)
OR
RT(in very selective cases)
T1 N+ and T2 N0/N+
indications*
Gingiva/ RMT
T1N0 and T2N0
Surgery (preferred)
OR
RT (in very selective cases)
T1N+ and T2N+
Surgery followed by adjuvant RT based on standard indications*
Restrict treatment as far as possible to single modality
Adjuvant treatment for standard indications*


indications*(Preferred)
Chemo-RT as other option (Only in Buccal Mucosa
T3 N0-2 subsite)
T4aN0-2, Surgery followed by adjuvant RT/CTRT for standard

Operable indications*
N3
T4b/Inoperable N3-In general palliative.

Radical approach in selected pts – Primary surgery if one can
achieve negative surgical margins, Neoadjuvant chemo f/b
T4b, surgery and RT
Inoperable Borderline inoperable T4a/Inoperable –NeoadjuvantChemo
N3 followed by surgery and RT/CTRT
Foot notes
1.In case of close or involved margins – option of revision surgery should be
explored unless there are other indications for RT
2. If surgery, neck dissection to be done except for very thin lesion clinically, For
N0, levels 1 to 3 and for and N+ levels 1to 4 at least, should be cleared
3. In Oral cavity sub sites, for stage 3 and 4 tumours, neoadjuvant
chemotherapy may be given as an initial treatment in specific clinical situations
after discussion in the multidisciplinary tumor board(MDT).
4. Standard Indications for Adjuvant RT/ Chemo RT

Adjuvant Chemo RT : Positive margin(if not considered for reexcision) , Extracapsular
nodal extension
Adjuvant RT: Pathological node positive, pT3 or pT4,
For other adverse features like perineural invasion, vascular invasion and lymphatic
invasion decision should be made in MDT
5. Follow up recommendation in general
Year 1 : 2-3 monthly
Year 2 : 3-4 monthly
Years 3-5: 4-6 monthly
After 5 years : annually
Thyroid function in 1,2,5 years if neck has been irradiated

ORAL CAVITY- LIP

Evaluation
1)USG neck for early disease

2)In advanced disease ,CT scan neck (skull base to clavicle)
3)Chest X ray for all
4)CT thorax, only in lower nodal disease and advanced nodal disease
Performance status
Nutritional status
General examination
Surgery
T1,T2N0 OR
Radical RT
Neck to be addressed from T2 onwards
T1,T2N1-2 Surgery followed by RT/CTRT

OR
ChemoRT
Surgery followed by RT/CTRT (Preferred if bone is

T3,T4a, any N involved)
OR
Chemo RT
In general,Palliative.
Radical approach in selected pts – Primary surgery if
T4b/Inoperable
one can achieve negative surgical margins,
N3
Neoadjuvant chemo f/b surgery and RT
Borderline inoperable T4a/Inoperable – Neoadjuvant
Chemo followed by surgery and RT/CTRT
Notes:
1. Neck to be addressed for tumours, T2 and upwards

OROPHARYNX
Evaluation
Performance status
Nutritional status
General examination
USG neck/CECT/ CEMRI
--Biopsy with p16 IHC if available
Definitive RT
T1 T2 N0 OR
Surgery +Neck Dissection if expertise is available
Adjuvant RT/CTRT depending on the adverse pathological
factors
RT
T1T2N1
OR
CTRT
Salvage surgery if residual disease
CTRT
T3T4a N0, Salvage surgery if residual disease
N1 Frank bone erosion in T4 disease –surgery should be the
preferred option
CTRT
Salvage surgery if residual disease
T1-T4a,
Frank bone erosion in T4 disease –surgery should be the
N2,N3
preferred option
Palliative
T4b, Radical approach in selected pts—(young patient, Good PS)
Inoperable
N3
Notes
1. If the patient not fit for concurrent cisplatin, the options are Monoclonal ab + RT OR
Radical RT, the decision to be made in MDT.
2. Neoadjuvant chemotherapy in selected patients after MDT discussion

LARYNX
Evaluation
CECT Neck except for T1a mid cord lesion

X ray Chest for all
CT THORAX—in advanced nodal disease or if clinically indicated
Performance status
Nutritional status
General examination
ENT Evaluation- endoscopic assessment includesprimary site evaluation and
biopsy
T1,T2 Glottis – RT OR Transoral Laser Surgery(TOLS)

T1N0 OR open partial laryngectomy
T2N0 T1,T2 Supraglottic- RTORTOLSORopen partial
laryngectomy
Bilateral neck to be addressed if any surgical option is
opted
T1,T2 Subglottis –RT
T1- Concurrent Chemo RT(CTRT)

T2,N+, T3 dysfunctional larynx irrespective of N status, Surgery
T3,N0- followed RT/CTRT
N+
T4a with cartilage destruction– Surgery followed by

T4a,N0/ adjuvantRT/CTRT
N+ T4 with extra laryngeal spread without cartilage
destruction and without dysfunction- Concurrent Chemo
RT(CCRT) may be done
T4bor Inoperable T4b/Inoperable N3-Palliative

N3
Radical approach in selected pts—young pts, Good PS
Foot notes
1. If the patient not fit for concurrentcisplatin, the options areMonoclonal ab + RT
ORRadical RT, the decision to be made in MDT.

HYPOPHARYNX
Evaluation
 Performance status
 Nutritional status
 Dental evaluation and prophylaxis
 General examination
 ENT Evaluation-endoscopic assessment includes
 primary site evaluation andbiopsy
Staging CECT neck

Evaluation X ray Chest for all
CT THORAX—in advanced nodal disease or if clinically
indicated
Radical RT
T1-T2,N0 OR
Trans oral Surgery with ND
OR
Openpartial laryngopharyngectomy with ND
T1-2,N1-2
Radical Concurrent Chemoradiotherapy (CTRT)
Concurrent Chemo RT(CTRT)

OR
T3,N0-N2 Induction chemotherapy and re-assessment,
If, complete remission/partial remission-RT/CTRT
If not, Surgery followed by adjuvant RT/CTRT
OR
Surgery followed byadjuvant RT/CTRT

NASOPHARYNX
Evaluation
 Performance status
 Nutritional status
 Dental evaluation and
prophylaxis
 General examination
 EBV titres optional
 Audiometry and visual
fields if indicated
ENT Evaluation- Local staging by CEMRI/CECT

T3-4,N2-3: work up for distal
endoscopic
Staging Evaluation metastasis- Chest X-ray/USG
assessment includes abdomen/Bone scan
primary site
PET CT optional
evaluation
andbiopsy CT thorax in indicated
T1N0MO Radical RT alone
cases
T1N1,T2N0/N1M0 Radical RT
OR
CTRT
T3-T4N0M0/ Neoadjuvant CT followed by CTRT

Any T2-4, N2-3 OR
CTRT
Any T Any N M1 1. Platinum based CT and

reassessment of metastatic lesion
2. In case of CR , Radical CTRT,If
not, palliative RT
Follow-up 2)Palliative
Examination of Nasopharynx and neck
treatment
 Imaging as clinically indicated
 Thyroid function at 1,2,5 years

PARANASAL SINUSES (MAXILLO-ETHMOIDAL)

Performance status
Nutritional status
General examination
ENT Evaluation- endoscopic assessment includes
primary site evaluationand
biopsy
CECT/CEMRI
PET-CT if clinically indicated
Biopsy with immunohistochemistry
Management
Surgery
OR
RT
In Adeno carcinoma, Minor salivary gland tumor,
T1/T2 Esthesioneuroblastoma,Adenoid cystic carcinoma, Surgery should
be preferred
T3,T4 Surgery * +
a Adjuvant
RT/CTRT
-Palliative treatment
T4b -Radical treatment in selected
patients

Management of Neck
Patients with positive nodes on clinical or radiological evaluation should undergo neck
dissection.
Prophylactic neck dissection (N0) may be done in high grade tumors and T3,T4 tumors.
Notes:
1. In surgery, attempt to be made to achieve negative margins, Measured, 5 mm margin on
pathology may not be possible, but to include tumor free tissue from the adjacent
uninvolved anatomical layer as a margin. May require teaming up with neurosurgical
team.
2. Surgery can be open or endoscopically accomplished, adhering to oncological principles
of margin as above
3. Adjuvant RT for high risk features include positive margins, high grade lesions
4. Neo adjuvant Systemic therapy should be considered in Sino-nasal Undifferentiated
Carcinoma (SNUC)

DIFFERENTIAL THYROID CANCER
Symptomatology
Swelling in front of the neck
Persistent change in voice
Difficulty in swallowing
Difficulty in breathing
Evaluation of thyroid nodule

TSH
FNAC/USG Guided FNAC
Vocal cord evaluation
USG TIRADS-desirable.
Staging Evaluation
CT/MRI in fixed/bulky/substernal
lesions
CT neck and Thorax in extensive nodal
disease
FNAC: Bethesda
Category I Repeat FNAC
Category II Follow up
Category III Repeat FNAC/Lobectomy
Size more than 4 cm, Category IV Hemi/Total Thyroidectomy
Gross extrathyroidal Category VI Hemi/Total Thyroidectomy
extension(cT4),
Clinical Nodes(cN+), Size> 1 cm, < 4 cm, No extra
Multifocal Size less than 1cm, No
thyroidal extension, No
extrathyroidal
Bilateral lobe Clinical Nodes
extension, cN0,
involvement Unifocal,
No h/o prior H&N RT,
No family h/o DTC
Older age >55 years,

Contralateral nodules,
History of radiation to
head and neck, Family
h/o DTC
If above history absent Hemithyroidecto

Total Thyroidectomy in low risk my

Neck Management
N0 clinically and radiology,T1,T2 No neck dissection
Node positive (N+) Therapeutic neck dissection
T3,T4 Prophylactic central neck

dissection
lateral neck nodes positive(c N1b) Prophylactic central +Lateral neck

dissection
Adjuvant Radio Iodine

Treatment
1.ATA low-risk* patients

2.Unifocal papillary microcarcinomas after Hemi/total
Not routinely thyroidectomy in the absence of other adverse features
recommended
3.Multifocal papillary microcarcinomas in the absence of
other adverse features
After total thyroidectomy in ATA intermediate risk*

Should be considered patients
ATA high risk* patients

Routinely recommended

Follow up
Serial Thyroglobulin with Antithyroglobulin Antibody,
Neck USG,
Diagnostic radioiodine scanning
TSH suppression as indicated
Role of EBRT
Limited,
Unresectable loco-regional recurrences
Residual Inoperable disease with no radio-iodine uptake
Inoperable disease

*ATA Initial Risk Stratification.
ATA low Papillary thyroid cancer (with all of the following):

risk  No local or distant metastases;
 All macroscopic tumor has been resected
 No tumor invasion of loco-regional tissues or structures
 The tumor does not have aggressive histology (e.g., tall cell,
hobnail variant,columnar cell carcinoma)
 If 131I is given, there are no RAI-avid metastatic foci outside the
thyroid bed onthe first posttreatment whole-body RAI scan
 No vascular invasion
 Clinical N0 or less than or equal to 5 pathologic N1
micrometastases (< 0.2 cm in largest dimension)
Intrathyroidal, encapsulated follicular variant of papillary thyroid
cancer
Intrathyroidal, well differentiated follicular thyroid cancer with
capsular invasion and no or minimal (< 4 foci) vascular invasion
Intrathyroidal, papillary microcarcinoma, unifocal or multifocal,
including BRAFV600E mutated (if known)
ATA  Microscopic invasion of tumor into the perithyroidal soft tissues
intermediate  RAI-avid metastatic foci in the neck on the first posttreatment
risk whole-body RAI scan
 Aggressive histology (e.g., tall cell, hobnail variant, columnar cell
carcinoma)
 Papillary thyroid cancer with vascular invasion
 Clinical N1 or > 5 pathologic N1 with all involved lymph nodes
< 3 cm in largest dimension
 Multifocal papillary microcarcinoma with ETE and
BRAFV600E mutated (if known)
ATA high  Macroscopic invasion of tumor into the perithyroidal soft tissues
risk (gross ETE)
 Incomplete tumor resection
 Distant metastases
 Postoperative serum thyroglobulin suggestive of distant
metastases
 Pathologic N1 with any metastatic lymph node more than or
equal to 3 cm in largest dimension
 Follicular thyroid cancer with extensive vascular invasion (> 4
foci of vascular invasion)

SUB-SITE: MEDULLARY THYROID CANCERS
FNAC
SerumCalcitonin
Evaluation of a USG Neck and Thyroid
nodule Vocal cord evaluation
Staging
Evaluation CT/MRI Neck and Chest
Total Thyroidectomy in all patients

Surgery
Therapeutic central
neck dissection plus
Rule out MEN ipsilateral /bilateral
Node positive lateral neck dissection
Management of
Neck
Node Negative Prophylactic Central

neckdissection
Adjuvant Treatment Low volume Follow-up

disease,complete
resection
EBRT
Multiple nodes with
ECS
R2 resections
Follow up
 S. Calcitonin
 Neck USG,
 CT scan in selected cases
 Familial screening and
management as appropriate

SUB-SITE: ANAPLASTIC THYROID CANCERS
Staging Evaluation
 TSH
 FNAC
 USG Neck and Thyroid
 Vocal cord evaluation
 CT/MRI Neck and
Chest
Surgery + Radiotherapy
Resectable intrathyroidal disease
Unresectable/ Metastatic Palliation
Palliation Airway management/

tracheostomy
Radiotherapy/ Chemotherapy

SUB-SITE: MALIGNANT MAJOR SALIVARY
Staging Evaluation
USG
CT/MRI
FNAC/ USG Guided
FNAC
Chest X ray
Parotidectomy / Wide excision(Level

1 Clearance for Submandibular tumor)
Surgery
Node positive Neck Dissection

Management of Neck
Node Negative
Prophylactic neck dissection/
Elective neck irradiation may be
consideredin High grade* and High
stage tumors
Adjuvant Radiation High stage tumor (T3,

T4, N+)
Positive cut margin
High grade tumors*
Inoperable tumors  Palliative RT

 -Best supportive
care

Grading of salivary tumors

High grade Low grade
Intermediate or High grade Muco-epidermoid Acinic cell carcinoma
Adenoid cystic Low grade muco-epidermoid
carcinoma
Carcinoma ex-pleomorphic adenoma Polymorphous adeno carcinoma
Oncocytic carcinoma
Salivary duct carcinoma
Undifferentiated carcinoma

SUB-SITE: UNKNOWN PRIMARY WITH NECK NODE
Evaluation: Symptom
– Neck swelling
Clinical examination
Office endoscopy
Neck USG/ USG Guided FNAC
p16 IHC if available on nodal tissue
CT/ MRI
OR
PET-CT Scan if available
Single node, no
adverse Observation
features
Single clinical node
cN1 Neck
dissection
Adjuvant
Multiple node, RT/CTRT
adverse
features
RT Followup
N2a, Surgery followedby RT/CTRT

N2b OR
CT RT
N3 Surgery followed by RT or CTRT

(preferred)
OR
ChemoRT
Negative-
CT/MRI
Observation
Follow-up PET-CT(If
available)
Positive-Salvage
neck dissection

Principles of Surgery
It is critical that the treatment decision regarding a particular patient is taken in the
multidisciplinary tumor board(MDTB) prior to initiation of treatment. In general surgery is the
preferred primary treatment of oral cavity, paranasal sinus, salivary tumors, thyroid tumors. It is
indicated as primary treatment in laryngeal and hypopharyngeal tumors with through and
through cartilage involvement. It primarily serves as salvage treatment for oropharyngeal and
nasopharyngeal cancers and other recurrent cancers after primary non-surgical treatment.
Primary tumor resection
1. Resection should be planned based on the extent of the tumor as ascertained by clinical
examination and imaging.
2. In oral cavity tumors, wherever possible a gross clinical margin of 1-1.5 cm should be
taken to achieve a measured microscopic margin of 5mm.
3. In positive or close margins, attempt for re-resection of margins should be done if there are
no other indications for adjuvant treatment.
4. Tumors abutting the mandible may require a marginal mandibulectomy to achieve
margins, whereas significant cortical erosion and medullary involvement will require a
segmental mandibulectomy.
5. Preservation ofmandibular continuity should be attempted whenever possible. It is not
appropriate to perform mandibulectomy for access or to provide space to insert flaps.
6. For tumors of the larynx, the decision to perform either laryngectomy or conservative
laryngeal surgery should be decided by the MDTB but must adhere to the principles of
complete tumor extirpation. In cases of laryngeal cancers, where laser surgery is done, 1-2
mm of margins for glottic cancers is sufficient.
7. In Maxillo-ethmoid tumors surgery, attempt to be made to achieve negative margins,
Measured, 5 mm margin on pathology may not be possible without causing undue
morbidity. To achieve tumor free margins, tissues from the adjacent uninvolved
anatomical layer may be taken margin. May require teaming up with neurosurgical team.
8. Surgery in maxilla-ethmoid tumors can be open or endoscopically accomplished, adhering
to oncological principles of margin as above.
9. In advanced oropharyngeal cancers, with gross bone involvement, surgery should be the
preferred option.
10. In parotid cancers, the extend of parotidectomy should may be tailored to remove the
tumor completely with a cuff of normal tissue around without necessarily removing the
entire lobe. Whenever the facial nerve is functioning before surgery, attempts should be
made to preserve the nerve, except in cases where there is encasement of the nerve.
11. The extent of surgery in differentiated thyroid cancers is based on the risk-group
stratification with is included in the guidelines.

Management of the Neck

1. The surgical management of the neck is dictated by the extent of the tumor, the site of the
primary tumor and the nodal status determined by clinical and radiological assessment.
2. Neck dissection is usually performed as part of primary surgical treatment. In general
patients undergoing surgery for primary treatment will undergo ipsilateral neck
dissection.
3. Elective neck dissection should be based on the risk of occult metastasis in the
appropriate primary area. All oral cavity tumors except very thin tumors (< 3mm), should
undergo an elective neck dissection.
4. Elective neck dissections (for N0 tumors) are generally selective neck dissections,
preserving all major structures, unless operative findings dictate otherwise. For oral
cavity tumors, at least Levels I-III should be cleared. For oropharynx - II-IV, For larynx
and hypopharynx, II to IV at least and level VI when appropriate.
5. For node positive cases, a comprehensive neck dissection may be performed. There is
also evidence for performing selective neck dissection in node positive cases, but the
decision has to done by the operating surgeon appropriately. Those patients undergoing
selective neck dissection for node-positive cases, if require adjuvant radiotherapy, the
field of radiation should cover all five levels, either ipsilateral or bilateral, depending on
the clinical scenario.
Reconstruction
1. Reconstruction of the defects after primary tumor surgery has to be performed along with
ablative surgery, as determined by the surgeon.
2. The reconstructive option should attempt to restore form and function
3. The technique needs to be tailor made based on an individual patient and available
infrastructure
Management of recurrences
1. Resectable recurrent primary tumors should undergo salvage surgery with curative intent
if feasible. Neck nodal recurrences also should be addressed with formal neck dissections
or modifications as appropriate.
2. Re-radiation when feasible should be considered
Principles of Radiothetrapy and Chemotherapy

Pre-Radiotherapy assessment:
All patients should undergo nutritional assessment and appropriate correction prior to initiating
RT.
Dietary assessment and generation of an appropriate diet plan.
Pre-radiotherapy dental evaluation and prophylaxis.
All patients should be counselled regarding acute and late radiotherapy side effects, care during
and after radiotherapy, as well as neck and swallowing exercises.
Thorough review of endoscopic and clinical findings, imaging studies and surgical notes+ final
HPR in case of post op-radiotherapy should be done prior to radiotherapy planning.
Radiotherapy technique:
Conventional 2D technique, or conformal techniques like 3DCRT or IMRT may be used

IMRT/3DCRT is preferred for treating primaries of Nasopharynx, Nasal cavity and paranasal
sinuses, if facilities are available.
Patient setup and simulation:
Use of immobilisation with neck rest and thermoplastic shell is preferred in all head and neck
cases.
CT simulation with slice thickness 2.5-3mm and use of IV contrast preferable for patients
undergoing conformal radiotherapy.
Co-registration with MRI/FDG PET images may be done for tumour delineation, when
available.
Contouring of target volumes should be done after careful review of clinical, endoscopic and
radiological findings. The contouring guidelines for various subsites as well as consensus
statement for nodal volumes may be used.
Organ at risk contouring should include spinal cord, brain, Brainstem, parotids, optic apparatus
and swallowing structures.
Radiotherapy Dose prescription in head and neck cancers:
LIP
EBRT 66-70 Gy (2.2-2Gy/#)
3D CRT/IMRT/VMAT
LDR+ EBRT
BRACHYTHERAPY +EBRT 20-35Gy + 50Gy (EBRT)
DEFINITVE (RT ALONE) HDR+ EBRT
21Gy, 3Gy/# +40-50 Gy
(EBRT)
BRACHYTHERAPY ALONE LDR

60-70Gy
HDR
40-50Gy, 3-6Gy/#
CONCURRENT EBRT 70 Gy (2Gy/#)
(DEFINITVE) 3D CRT/IMRT/VMAT
ADJUVANT EBRT 60-66 Gy (2Gy/#)
3D CRT/IMRT/VMAT

ORAL CAVITY
EBRT 66-70 Gy (2.2-2Gy/#)
2D/3D CRT/IMRT/VMAT
CONCOMITANT BOOST 72 Gy/6 weeks (1.8 Gy/#,

3D CRT/IMRT/VMAT large field; 1.5 Gy boost as
second daily fraction during
last 12 treatment days)
OR
66–70 Gy (2.0 Gy/fraction; 6
#/wk accelerated)
DEFINITVE (RT ALONE)
HYPERFRACTIONATION 81.6 Gy/7 weeks (1.2 Gy/#,

twice daily)
LDR+ EBRT
BRACHYTHERAPY +EBRT 20-35Gy + 50Gy (EBRT)
HDR+ EBRT
21Gy, 3Gy/# +40-50 Gy
(EBRT)
BRACHYTHERAPY ALONE LDR

60-70Gy
HDR
40-50Gy, 3-6Gy/#
(DEFINITVE) 2D/3D CRT/IMRT/VMAT
2D/3D CRT/IMRT/VMAT
OROPHARYNX
EBRT 66-70 Gy (2.2-2Gy/#)
2D/3D CRT/IMRT/VMAT
CONCOMITANT BOOST 72 Gy/6 weeks (1.8 Gy/#,

large field; 1.5 Gy boost as
second daily fraction during
OR
66–70 Gy (2.0 Gy/#; 6 #/wk
accelerated)
DEFINITVE (RT ALONE)
twice daily)

OR
69.96 Gy (2.12 Gy/#)
3D CRT/IMRT/VMAT
HYPOPHARYNX
3D CRT/IMRT/VMAT 66-70 Gy (2.2-2Gy/#)
72 Gy/6 weeks (1.8 Gy/#,
large field; 1.5 Gy boost as
CONCOMITANT BOOST second daily fraction during
OR
DEFINITVE (RT ALONE) 66–70 Gy (2.0 Gy/#; 6 #/wk
accelerated)

twice daily)
3D CRT/IMRT/VMAT
NASOPHARYNX
DEFINITVE (RT ALONE) 3D CRT/IMRT/VMAT 66-70.2 Gy (2.2-2Gy/#)
CONCURRENT EBRT 70 -70.2 Gy (1.8-2Gy/#)
GLOTTIC LARYNX
DEFINITVE (RT ALONE) 3D CRT/IMRT/VMAT T1-T2 N0M0
66- 70Gy/33-35#
52.5Gy/15#
≥T2, N+
66- 70Gy/33-35#

3D CRT/IMRT/VMAT
SUPRAGLOTTIC LARYNX
DEFINITVE (RT ALONE) 3D CRT/IMRT/VMAT T1-T3, N0-1 M0
66- 70Gy/33-35#
52.5Gy/15#
≥T2, N+
66- 70Gy/33-35#


3D CRT/IMRT/VMAT
MAXILLARY SINUS
DEFINITVE (RT ALONE) 3D CRT/IMRT/VMAT 66- 70Gy/33-35#
CONCURRENT EBRT 70-70.2 Gy (1.8-2Gy/#)
ADJUVANT EBRT 60-66 Gy (1.8- 2Gy/#)
3D CRT/IMRT/VMAT
 Whereever 2D planning is possible and accepted, it shall be done
Systemic therapy schedules in head and neck cancer:

Chemotherapy:
Docetaxel+ Cisplatin+ 5FU(TPF)
Cisplatin + 5FU(PF)
Cisplatin+Etoposide(neuroendocrine carcinoma )
Methotrexate(2 weekly)
Single agent Docetaxel/Paclitaxel-3 weekly
Weekly Docetaxel
Gemcitabine
Adriamycin+ Ifosphamide (sarcomatoid tumours)
Metronomic Chemotherapy with Methotrexate +/- Celecoxib +/- Erlotinib
Biological therapy:
Cisplatin + 5FU+ Cetuximab
Cetuximab
Gefitinib/Erlotinib

SARCOMA


EWINGS SARCOMA
Imaging
Local x Ray
MRI of the local part is the preferred modality
Biopsy
 Biopsy diagnosis is mandatory
 Biopsy to be done only after all local imaging is completed
 In most cases a core needle biopsy is adequate
 Ideally perform at this centre which will do definitive management of disease
 Immunohistochemistry confirmation mandatory(VIMENTIN, CD99, LCA)
 Additional molecular studies in doubtful cases(FISH for t(11;22)(q24;q12))
Serological Investigations
Lactate dehydrogenise (LDH) for prognostic
Staging
1. CT chest
2. Bone scan
3. Bone Marrow aspiration & biopsy
4. PET CT(optional)
5. If PET not available-CT chest-plain study+bone scan

Induction chemotherapy (multi agent chemotherapy VAC/IE) for atleast 9 weeks prior to
local therapy
Reimaging with MRI
Evaluation for local therapy between week 9 to 12
Limb sparing surgical resection possible with adequate oncologic

margins
No
Yes
Or
Limb sparing surgery CentroAxial Lesion
Definitive Radiotherapy
Adjuant chemotherapy for

48 weeks/17 cycles

EWING SARCOMA-METASTATIC AT PRESENTATION
To evaluate for intent of treatment based on site and number of

metastasis.
Curative intent
Chemotherapy (as for non-metastatic

disease)
Evaluation for response/restaging
Non progression of Progression of

disease disease
Local control (as for non-metastatic

disease)
Metastectomy+/- Lung bath

(Radiotherapy) Best supportive care with palliative
intent
Chemotheraphy to continue

Principles of chemotherapy- Ewing Sarcoma

First Line Therapy/Neoadjuvant Therapy/Adjuvant Therapy
VDC/IE – Vincristine, Doxorubicin and Cyclophosphamide alternating with Ifosfamide and

Etoposide
VAI – Vincristine, Adriamycin and Ifosfamide
VIDE – Vincristine, Ifosfamide, Doxorubicin and Etoposide
Therapy for Metastatic Disease at presentation
VDC - Vincristine, Doxorubicin and Cyclophosphamide

VDC/IE - Vincristine, Doxorubicin and Cyclophosphamide alternating with Ifosfamide and
Etoposide
VAI - Vincristine, Adriamycin and Ifosfamide
VIDE - Vincristine, Ifosfamide, Doxorubicin and Etoposide
Second Line Therapy
Cyclophosphamide and Topotecan

Irinotecan and Temozolomide
Gemcitabine and Docetaxel

CHONDROSARCOMA
Suspicious signs suggestive of a sarcoma:
 The commonest symptom of a primary bone sarcoma is non mechanical pain
 The presence of pain or a palpable mass arising from any bone should be viewed with
suspicion
 The presence of any of the following on the X-ray is suggestive, but not diagnostic of a
bone sarcoma:
 Bone destruction
 New bone formation
 Periosteal swelling
 Soft tissue swelling
CHONDROSARCOMA
 One of the most common bone sarcomas of adulthood, characterized by the production of
tumor cartilage
 Though commonest in the long bones they also occur in flat bones such as pelvis, rib and
scapula
 Secondary chondrosarcomas can arise in pre-existing benign lesions such as
osteochondroma and enchondroma
 Rare subtypes of chondrosarcoma include mesenchymal chondrosarcoma and clear cell
chondrosarcoma
 Conventional chondrosarcomas may rarely ―dedifferentiate‖ into a very high-grade
tumor with a dismal prognosis so called dedifferentiated chondrosarcoma.
BIOPSY
 In most cases a core needle biopsy is adequate (it may need to be image guided
depending on anatomical location of lesion)
 Ideally performed at centre which will do definite management of disease
STAGING
 Local X Ray
 MRI
 CT scan chest
 Bone scan

CHONDROSARCOMA
Limb sparing surgical resection possible with adequate oncologic margins
Yes No
Limb sparing surgery

Extremity Lesion Centro Axial Lesion
Amputation Radiotherapy
Evaluation of margins
If positive margins to consider

additional local therapy/amptation
-dedifferentiated chondrosarcomas may receive multiagent chemotherapy similar to high grade

osteosarcoma
-mesenchymal chondrosarcoma may receive multiagent chemotherapy similar to Ewing
sarcoma
 Local examination, chest and local imaging every 3 to 6 months for first 2 years,
every 6 months for next 3 years and annually after year 5 is suggested.
 Extended surveilliance may be necessary to identify and address potential late effects
of surgery, radiation and chemotherapy for long term survivors

SOFT TISSUE SARCOMA

TNM staging

TI Tumor 5 cm or less in greatest dimensión
T2 Tumor more than 5 cm and less than or equal to 10 cm in greatest
dimensión
T3 Tumor more than 10 cm and less than or equal to15 cm in greatest
dimensión
T4 Tumor more than 15 cm in greatest dimensión
NO No regional lymph node metástasis or unknown lymph node status
N1 Regional lymph node metástasis

MO No distant metástasis
Definition of Grade (G)

FNCLCC Histologic Grade - see Histologic Grade (G)
G G Definition
GX Grade cannot be assessed
G1 Total differentiation, mitotic count and necrosis score of 2 or 3
G2 Total differentiation, mitotic count and necrosis score of 4 or 5
G3 Total differentiation. mitotic count and necrosis score of 6, 7, or 8
AJCC PROGNOSTIC STAGE GROUPS

T N M Grade Stage
TI NO M0 Gl, GX IA
T2, T3. T4 NO M0 Gl, GX IB
TI NO M0 G2, G3 11
T2 NO M0 G2, G3 IIIA
T3,T4 NO M0 G2, G3 IIIB
Any T NI M0 Any G IIIB
Any T Any N MI Any G IV
HISTOLOGIC GRADE (G)

The FNCLCC grade is determined by three parameters: differentiation,mitotic activity, and
extent o f necrosis. Each parameter is scored as follows: differentiation (1-3), mitotic activity (1-
3),and necrosis (0-2). The scores are added to determine the grade.
Tumor differentiation is histology specific and is generally scored as follows:

Differentiation Score - Definition

1 - Sarcomas closely resembling normal adult mesenchymal tissue (e.g.,
low grade Leiomyosarcoma
2 - Sarcomas for which histologic typing is certain (e.g.,
myxoid/round cell liposarcoma0
3 - Embryonal and undifferentiated sarcomas, sarcomas of
doubtful type, synovial sarcomas soft tissue osteosarcoma, Ewing
sarcoma / primitive neuroectodermal tumor (PNET) of soft tissue
Mitotic Count
In the most mitotically active area o f the sarcoma, 10 successive high power fields (HPF; one H
P F at 4 0 0 x magnification= 0.1 7 3 4 mm2) are assessed using a 4 0 x objective
Mitotic Count Score Definition
1 0-9 mitoses per 10 HPF
2 10-19 mitoses per 10 HPF
3 >20 mitoses per 10 HPF
Tumor Necrosis
Evaluated on gross examination and validated with histologic sections.
Necrosis Score Definition
0 No necrosis
1 <50% tumor necrosis
2 >50% tumor necrosis

Any soft tissue lump exhibiting any of the following clinical features should be considered to be
malignant until proved otherwise
Increasing in size
Size>5 cm
Deep to the deep fascia
If any of the above clinical features are present an opinion of oncologist must be sought
An important dictum may be that ―any tumor found deep to the deep fascia or larger than 5 cm
should be regarded as a soft tissue sarcoma until proven otherwise.‖
IMAGING
MRI (preferred) / CT Scan
BIOPSY
Biopsy diagnosis is mandatory
Biopsy to be done only after all local imaging is completed
In most cases a core needle biopsy is adequate (it may need to be image guided depending on
anatomical location of lesion)
Ideally performed at centre which will do definitive management of disease
Immunohistochemistry confirmation desirable, may need additional cytogenetic and molecular
studies
If core needle biopsy is not possible, refer to oncology centre for open biops

STAGING
X ray chest / CT Scan (CT chest recommended in high grade sarcomas)
USG abdomen pelvis (consider abdomino pelvic CT) in myxoid / round cell liposarcoma,
angiosarcoma, leiomyosarcoma, epithelioid sarcoma and synovial sarcoma
 Tumors referred after prior excision with inadequate or unknown margins need to be
considered for re excision with similar guidelines as primary tumors
 Radiotherapy may be delivered either as pre or post operative radiotherapy
Whenever radiotherapy is indicated, it is preferred in a pre operative setting especially for
retroperitioneal sarcoma.
Yes No
Discuss role of preoperative radiotherapy and/or chemotherapy
(depends on tumor site/ size/ histology) MDTdiscussion
Reevaluate clinically and with imaging if limb sparing surgical

Limb sparing surgery
resection possible with adequate oncologic margins
Yes No
Limb sparing surgery Amputation
Indications for post-operative radiotherapy (EBRT/Brachytherapy)

 All high grade lesions
 All recurrent lesions
 Low grade lesions if deep seated /or > 5cm /or margin + (17 re wide excision not
possible)
Chemotherapy may be offered to patients with high grade lesions > 5cm or recurrent
lesions after discussion in multidisciplinary (clinic preferably in a trial) setting

EXTREMITY SOFT TISSUE SARCOMA – METASTATIC AT PRESENTATION
To evaluate for intent of treatment based on site and number of metastasis
Complete resection possible at all sites
Yes No
Discuss in multidisciplinary clinic Best supportive care with palliative intent
(Palliative chemotherapy / RT)

Local control (as for non metastatic disease) and metastectomy / node dissection
Indications for radiotherapy and chemotherapy as for non-metastatic disease
Post treatment surveillance

 Relapses most often occur to the lungs
 Risk assessment based on tumor grade, tumor size and tumor site may help in choosing
the most suitable follow-up policy
 Local examination, chest xray every 3 to 6 months for first 2 years, every 6 months for
next 3 years and annually after year 5 is suggested.
Local imaging (MRI) is done only if recurrence is suspected on clinical examination
 Extended surveillance may be necessary to identify and address potential late effects of
surgery, radiation and chemotherapy for long term survivors

Principles of Surgery
Preferable to perform surgery in specialised centres/ centers with expertise
Unplanned excision( Whoop‘s procedure) has to be avoided in suspicious soft soft tissue masses
which are deep, hard or fast growing and 5cm or more than 5cm in greatest dimensions.
Principles of Tissue diagnosis:

Biopsy should be done only after local imaging –MRI (preferable) or CECT
Trucut biopsy is the most ideal procedure for tissue diagnosis. This need to be carefully planned
so that the biopsy site is resected with the final specimen. Incision biopsy is permitted only if
trucutbiopsy( at least done twice) fails to produce a diagnosis and needs to be done only in
specific centres and by the experts.
Image guided core needle biopsy: If significant necrosis is found in tumor or imaging, it is
preferable to do core needle biopsy under image guidance
Excision biopsy only for superficial tumors and less than 3 cm
Incision biopsy: Only if repeated trucut biopsy failed to provide diagnosis.

The incision should be in line of future resection incision.
Smaller but adequate incision should be placed
There should not be any dissection of soft tissue laterally or raising of flaps.Stright down to
tumor.
Hemostasis should be ensured- avoid hematoma
Adequate tissue for
A] Histopathology
B] Immunohistochemistry
C] Molecular studies
Any soft tissue tumor with following features should be suspected of Soft tissue sarcoma
A] Tumors 5cm or more than 5 cm in greatest dimension
B] Adherent to or deep to deep fascia
C] Rapidly growing tumors
D] Symptomatic tumors
Before biopsy ,opinion of an oncologist should be obtained. Incision biopsy shall be planned(if
required) only in consultation with an oncologist or a dedicated oncology centre.
Improper biopsy incisions, unplanned excisions without appropriate evaluation leads to
significant morbidity to patients
Surgical principle:
Wide local excision is recommended with a three dimensional normal tissue margin of 2-3 cm.
Fascia, adventitia of the vessels, perineurium, periosteum or perichondrium will serve as
effective barrier for tumour spread and are considered adequate margin. Biospy scar needs to be
involved in the resection. Routine lymphadenectomy is not recommended in sarcoma.
Lymphadenectomy:
1. Positive regional nodes
2. Sarcomas in axilla,inguinal regions ( not a systematic one unless positive nodes found)
Amputation:
1. Functionally useful limb can not be ensured after limb salvage surgery

Relative indication: Large painful / large fungating or bleeding tumor in extensive metastatic
setting as palliative procedure( not controllable with traditional management)
Principlef of chemotherapy

IA – Ifosfamide -mesna and Adriamycin (Doxorubicin)
MAID – Mesna, Adriamycin, Ifosfamide and Dacarbazine
Following Single agents may be used in Palliative setting

Ifosfamide
Doxorubicin
Gemcitabine
Dacarbazine
Second line/Options in recurrent sarcoma

Gemcitabine - Docetaxel (If not used in first line setting)
Eribulin
Trabectedin
Pazopanib
Temozolomide
Radiotherapy dose
TECHNIQUE DOSE FRACTIONATION
2D PLANNING 50- 50.4 Gy in 1.8-2 Gy/
3DCRT fraction
IMRT/VMAT
If R1 resection 16-18 Gy EBRT in 1.8-2
Gy/ fraction
16-18Gy-LDR
NEOADJUVANT brachytherapy
RADIATION 14-16 Gy in 3-4Gy/# BID –
HDR brachytherapy
10-12.5Gy- IORT
If R2 resection 20-26 Gy EBRT in 1.8-2
Gy/ fraction
20-26 Gy-LDR
brachytherapy
18-24 Gy in 3-4Gy/# BID –
HDR brachytherapy
15Gy- IORT
2D PLANNING 50- 50.4 Gy in 1.8-2 Gy/
3DCRT fraction
IMRT/VMAT
For negative margin: 10-
BOOST DOSE 16Gy- EBRT

R1 resection: 16-18Gy
R2 resection: 20-26Gy
ADJUVANT RADIATION IORT + EBRT 10-16Gy (IORT) + 50- 50.4
Gy in 1.8-2 Gy/ fraction
(EBRT)
BRACHYTHERAPY + EBRT R1: 16-20Gy (LDR)/14-
(for positive margins) 16Gy (HDR)+ 50- 50.4 Gy
in 1.8-2 Gy/ fraction
(EBRT)
Brachytherapy alone (negative 45 Gy LDR equivalent/
margin) 36Gy HDR (3.6Gy/# X 10
fractions)

OSTEOSARCOMA
 The commonest symptom of a primary bone sarcoma is non mechanical pain
 The presence of pain or a palpable mass arising from any bone should be viewed
with suspicion
 The presence of any of the following on the X ray is suggestive, but not diagnostic
of a bone sarcoma:
 Bone destruction
 New bone formation
 Periosteal swelling
 Soft tissue swelling
BIOPSY
 In most cases a core needle biopsy is adequate (it may need to be image guided
depending on anatomical location of lesion)
 Ideally performed at centre which will do definite management of disease
If incision biopsy is required, it should be done in consultation with oncology centre.
Serological Investigations
 Though there are no specific laboratory tests for diagnosis some maybe of
prognostic value; eg. Alkaline phosphatise (ALP) and lactate dehydrogenase (LDH)
Further Staging
 MRI/CT Scan (of the local region)

 Xray chest – CT chest
 Bone scan
Stage Grouping
T N M Grade Stage
TI NO MO Gl or GX 1A
T2 NO MO G l or GX IB
T3 NO MO G l or GX IB
TI NO MO G2 or G3 HA
T2 NO MO G2 or G3 IIB
T3 NO MO G2 or G3 III
Any T NO M1a Any G IVA
Any T NI Any M Any G IVB
Any T Any N M lb Any G IVB

HIGH GRADE OSTEOSARCOMA – METASTATIC AT PRESENTATION
To evaluate for intent of treatment based on site and number of metastasis

(MDT Decision)
Curative intent
Chemotherapy (as for non-metastatic disease)
Evaluation for response / restaging
No progression of disease Progression of disease
Local control (as for non-metastatic disease)

and metastectomy Best support care with
palliative intent
Chemotherapy (in poor responders no change of

chemotherapy outside a trial setting)

HIGH GRADE OSTEOSARCOMA – NON METASTATIC AT PRESENTATION
Neoadjuvant chemotherapy (chemotherapy is multiagent) 2 to 4 cycles prior to

local control
Evaluation for local therapy (reimaging with MRi recommended)
Yes No
Limb sparing sugery

Extremity Lesion CentroAxial Lesion
Amputation RT if surgical
Resection is
Evaluation of margins and
possible
necrosis
If Positive margin, further

treatment based on MDTdecision
Adjuvent chemotherapy (in poor responders no change of chemotherapy outside a
trial setting)
* Osteosarcomas diagnosed as low grade on initial biopsy (parosteal / low grade intramedullary) are
treated with wide excision only. If after definitive surgery a high grade component is identified
they receive multiagent adjuvant chemotherapy
* Periosteal osteosarcomas are currently treated similar to high grade osteosarcomas

Post treatment surveillance:

 Relapses most often occur to the lungs
 Local examination, chest and local imaging every 3 to 6 months for first 2 years, every 6
months for next 3 years and annually after year 5 is suggested.
 Extended surveillance may be necessary to identify and address potential late effects of
surgery, radiation and chemotherapy for long term survivors
Preferable to perform surgery in specialised centres/ centres with expertise
Principles of Tissue diagnosis:

Biopsy should be done only after local imaging –MRI (preferable) or CECT
Trucut biopsy is the most ideal procedure for tissue diagnosis. This need to be carefully planned
so that the biopsy site is resected with the final specimen.
Image guided core needle biopsy: If significant necrosis is found in tumor on imaging, it is
preferable to do core needle biopsy under image guidance
Incision biopsy: Only if repeated trucut biopsy failed to provide diagnosis and needs to be done
in centres with expertise.
The incision should be in line of future resection incision.Smal but adequate incision should be
placed
There should not be any dissection of soft tissue laterally or raising of flaps.Stright down to
tumor. Hemostasis should be ensured- avoid hematoma. Do not place drain.
Improper biopsy incisions, unplanned excisions without appropriate evaluation leads to
significant morbidity and possible limb loss to patients
Surgical principle:
Surgery is planned after 2-4 cycles of neoadjuvant chemotherapy. Limb salvage surgery has to
be done if functionally useful limb can be preserved.. Bone is excised with 3cm margin from the
farther most point of marrow involvement in MRI. Three dimensional soft tissue margin should
be obtained. Fascia, adventitia of the vessels, perineurium, periosteum or perichondrium will
serve as effective barrier for tumour spread and are considered adequate margin. If adjacent joint
cavity is involved, extra-articular resection needs to be considered. Biospy scar needs to be
involved in the resection. Routine lymphadenectomy is not recommended in osteosarcoma.
Bony reconstruction may be done using modular prosthesis or custom made prosthesis.
Adequate soft tissue cover should be ensured to avoid prosthesis exposure.
Amputation is indicated if
1. Functionally useful limb cannot be ensured after limb salvage surgery
2. Involvement of major neurovascular bundle.
3. Adequate soft tissue cover cannot be achieved around the prosthesis.
Relative indication:
Large painful / large fungating or bleeding tumor in extensive metastatic setting as palliative
procedure( not controllable with traditional management)

Metastatectomy
In patients with limited lung metastasis, resection of all the lesions may be considered after
NACT.
Principles of chemotherapy

IAP – Ifosfamide, Adriamycin and Cisplatin
MAP – Methotrexate, Adriamycin and Cisplatin
AP – Adriamycin and Cisplatin
Second Line Therapy

Cyclophosphamide and Topotecan
Ifosphamide, Carboplatin and Etoposide

THORACIC CANCER


ESOPHAGEAL CANCER
AJCC Staging- 8th Edition

Squamous Cell Carcinoma and Adenocarcinoma
TX Tumor cannot be assessed
Tis High grade dysplasia, defined as malignant cells
confined to the epithelium by the basement membrane
TI Tumor invades the lamina propria, muscularis mucosae, or submucosa
T ía Tumor invades the lamina propria or muscularis mucosae
T lb Tumor invades the submucosa
T3 Tumor invades adventitia
T4 Tumor invades adjacent structures
T4a Tumor invades the pleura, pericardium, azygos vein,
diaphragm, or peritoneum
T4b Tumor invades other adjacent structures, such as
the aorta, vertebral body, or airway
Definition of Regional Lymph Nodes (N)

Category N Criteria
NO No regional lymph node metástasis
N1 Metástasis in one or two regional lymph nodes
N2 Metástasis in three to six regional lymph nodes
N3 Metástasis in seven or more regional lymph nodes

Definition of Histologic Grade (G)
G G Definition
GX Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated, undifferentiated

Definition of Location (L)

Squamous Cell Carcinoma
Location plays a role in the stage grouping o f esophageal squamous cancers.
Location Category Location Criteria
X Location unknown
Upper Cervical esophagus to lower border of azygos vein
Middle Lower border o f azygos vein to lower border ofinferior pulmonary
vein
Lower Lower border o f inferior pulmonary vein to stomach, including
gastroesophageal junction
Note: Location is defined by the position of the epicenter of the tumor in the esophagus.

Clinical (cTNM)
When cT is. And cN is And M is Stage group
Tis NO MO 0
TI N0 -1 MO I
T2 N0-1 MO II
T3 NO MO II
T3 NI MO III
Tl-3 N2 MO III
T4 NO-2 MO IVA
Any T N3 MO IVA
Any T Any N MI IVB
Pathological (pTNM)
When pT And pN is And M is And G is And location Stage Group
is is
Tis NO MO N/A Any 0
T1a NO MO Gl Any IA
T1a NO MO G2,3 Any IB
T1a NO MO GX Any IA
Tlb NO MO G l,3 Any IB
Tlb NO MO GX Any IB
T2 NO MO Gl any IB
T2 NO MO G2,3 Any IIA
T2 NO MO GX Any IIA
T3 NO MO Any Lower IIA
T3 NO MO Gl Upper/middle IIA
T3 NO MO G2,3 Upper/middle: IIB
T3 NO MO GX Any IIB
T3 NO MO Any Location X IIB
TI NI MO Any Any IIB
TI N2 MO Any Any IIIA
T2 NI MO Any Any IIIA
T2 N2 MO Any Any 1IIB
T3 N l,2 MO Any Any IIIB

T4a N0,1 MO Any Any IIIB

T4a N2 MO Any Any IVA
T4b NO,2 MO Any Any IVA
Any T N3 MO Any Any IVA
Any T Any N 1 M Any Any IVB
Postneoadjuvant Therapy (ypTNM)

When yp T is And yp N is And M is Stage Group
TO,2 NO MO 1
T3 NO MO II
TO- 2 NI MO IIIA
T3 NI MO IIIB
T 0-3 N2 MO IIIB
T4a NO MO IIIB
T4a N l,2 MO IVA
T4a NX MO IVA
T4b NO-2 MO IVA
Any T N3 MO IVA
Any T Any N MI IVB
Adenocarcinoma
Clinical (cTNM)
Pathological (pTNM)
When cT is And cN is And M is Stage Group
Tis NO MO 0
TI NO MO I
TI NI MO IIA
T2 NO MO IIB
T2 NI MO III
T3 NO,1 MO III
T4a NO,1 MO III
T 1-4A N2 MO IVA
T4b NO-2 MO IVA
Any T N3 MO IVA
Any T Any N MI IVB
When pT is And pN is And M is And G is Stage Group

Tis NO MO N/A 0
T 1a NO MO Gl IA
T 1a NO MO GX IA
T 1a NO MO G2 IB
T lb NO MO G l,2 IB
T lb NO MO GX IB
TI NO MO G3 IC
T2 NO MO G l,2 IC
T2 NO MO G3 IIA

T2 NO MO GX IIA
TI NI MO Any IIB
T3 NO MO Any IIB
TI N2 MO Any IIIA
T2 NI NO Any IIIA
T2 N2 MO Any IIIB
T3 N l, 2 MO Any IIIB
T4a NO, 1 MO Any IIIB

T4a N2 MO Any IV A

Dysphagia or persistent heartburn
Malignant
Upper GI scopy with multiple (6-8) biopsies

CECT scan lower neck, thorax, abdomen (pelvis also for GE
junction tumours)
Bronchoscopy (optional if indicated)
Nutritional support
Optional investigations (after MDTB discussion)
Endoscopic ultrasonography (borderline operable/early cases) if
available, PET-CT
Metastatic
Early, Localized
(T1, 2, N0, disease
preferably confirmation
Management Any T, any N, M1
with EUS)
Loco-
regionally TABLE A
advanced Options
T3, 4 or N+ve Pall RT –EBRT or ILRT
or Endoscopic
Surgery Unfit for Stenting
- Definitive surgery Palliative
chemo-RT for NACTRT or NACT (Both
or chemotherapy
cervical and squamous or adeno)) Followed
refusing by reevaluation with Pain management
proximal and nutritional
esophagus / surgery CECT/PET-CT. Resectable
disease: Surgery support
surgery in select
cases Unresectable: CTRT or
palliative procedures( see table
A)
Radical CHEMO Radical chemo-RT in cervical

and proximal esophagus
RT Surgery – open /
laparoscopy /
robotic
R-0 resection: No adjuvant treatment
R-+ resection or +ve margins: Adjuvant RT

Radiotherapy dose prescriptions in esophageal cancer
NEOADJUVANT 2D/3DCRT/IMRT/VMAT 41.4-50.4Gy in 23-28#, 1.8-2Gy/#

50-50.4Gy, 1.8-2Gy/#
DEFINITIVE 2D/ 3D RT/IMRT/VMAT
ADJUVANT 2D/ 3D RT/IMRT/VMAT 45-50.4Gy, 1.8-2Gy/#

LUNG CANCER
CARCINOMA LUNG TNM Staging
T staging
T X Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells
insputum or bronchial washings but not visualized by imaging or bronchoscopy
TIS Carcinoma in situ
Squamous cell carcinoma in situ
Adenocarcinoma in situ: adenocarcinomawith pure lepidic pattern, <3 cm in greatestdimension
TITumor <3 cm in greatest dimension,surrounded by lung or visceral pleura, without

bronchoscopic evidence of invasion moreproximal than the lobar bronchus (i.e., not inthe main
bronchus)
T1 mi Minimally invasive adenocarcinoma- adenocarcinoma (<3 cm in greatest dimension)with

a predominantly lepidic pattern and<5 mm invasion in greatest dimension
T1a Tumor <1 cm in greatest dimension. A superficial, spreading tumor of any size
whoseinvasive component is limited to the bronchialwall and may extend proximal to the
mainbronchus also is classified as T 1a , but these
tumors are uncommon.
T1b Tumor >1 cm but<2 cm in greatestdimension
T1c Tumor >2 cm but <3 cm in greatest dimension
T 2 Tumor >3 cm but <5 cm or having any of thefollowing features:
• Involves the main bronchus regardless ofdistance to the carina, but without involvementof the
carina
• Invades visceral pleura
• Associated with atelectasis or obstructivepneumonitis that extends to the hilar region,involving

part or all of the lung
T2a >3cm < 4 cm in greatest dimension
T2b >4 cm but <5 cm in greatest dimension

T 3 Tumor >5 cm but <7 cm in greatest dimension or directly invading any of the following:
parietal pleura , chest wall (includingsuperior sulcus tumors), phrenic nerve, parietal
pericardium, or separate tumornodule in the
same lobe as the primary
T 4 Tumor >7 cm or tumor of any size invading oneor more o f the following:
diaphragm,mediastinum, heart, great vessels, trachea,recurrent laryngeal nerve, esophagus,
vertebralbody, or carina, separate tumor nodule in anipsilateral lobe different from that of
theprimary
N Staging
NI Metastasis in ipsilateral peribronchial and/oripsilateral hilar lymph nodes and

intrapulmonarynodes, including involvement by direct extension
N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node
N3 Metastasis in contralateral mediastinal, contralateralhilar, ipsilateral or contralateral

scalene, or supraclavicular lymph node
M Staging
M 1a Separate tumor nodule in a contralaterallobe; tumor with pleural or pericardial nodulesor

malignant pleural or pericardial effusion
M lb Single extrathoracic metastasis in a singleorgan (including involvement of a

singlenonregional node)
M lc Multiple extrathoracic metastases in a singleorgan or in multiple organs
Stage grouping
T N M Stage
TX NO MO Occult carcinoma
Tis NO MO 0
T1mi NO MO IA1
T1a NO MO IA1
T1a NI MO IIB
T1a N2 MO IIIA
T1a N3 MO IIIB
T1b NO MO IA2
T1b NI MO IIB

T1b N2 MO IIIA
T1b N3 MO IIIB
T1c NO MO IA3
T1c NI MO IIB
T1c N2 MO IIIA
T1c N3 MO IIIB
T2a NO MO IB
T2a NI MO IIB
T2a N2 MO IIIA
T2a N3 MO IIIB
T2b NO MO IIA
T2b NI MO IIB
T2b N2 MO IIIA
T2b N3 MO IIIB
T3 NO MO IIB
T3 NI MO IIIA
T3 N2 MO IIIB
T3 N3 MO IIIC
T4 NO MO IIIA
T4 NI MO IIIA
T4 N2 MO IIIB
T4 N3 MO IIIC
Any T Any N M1a IVA
Any T Any N M1b IVA
Any T Any N M1c IVB
Symptoms
 Cough
 Hemoptysis
 Dyspnea
 ChestPain
Initial Evaluation
• Pathology-Tissue diagnosis- biopsy/cytology &cell block (adequate tissue for IHC

and or molecular testing)
• Blood-CBC,Biochemistry panel
• CECT Chest with upper abdomen, including adrenals

• Co-Morbidity-PFT,ECHO
• Smoking Cessation Counseling
• Palliative Care Integration
• DLCO if clinically indicated.
Initial Evaluation
• Bronchoscopy- If curative treatment is planned
• MRI Brain-If curative treatment is planned
• CT Brain with contrast if MRI is not possible
• PET CT –If curative treatment is planned
• If PET is not available-CECT Thorax,Abdomen and bone scan.

STAGE I ,II
MEDIASTINAL EVALAUTION
NO N++ ALTERNATEPATH
OPERABLE MEDICALY
INOPERABLE
SURGERY SBRT/ Chemo RT

STAGE III A –T3 N1
SURGERY POSSIBLE SURGERY NOT POSSIBLE
CHEMO
ADJUVANT CHEMOTHERAPY RADIATION
(IF >IB stage) WITH PLATINUM
DOUBLET
R1 RESECTION POST OP RT
INVOLVED N2 NODE
LYMPH NODE SAMPLING

INADEQUATE-after MDTdiscussion

STAGE III A excluding

T3N1
Non bulky single stage

N2
INDUCTION NEOADJUVANT
CHEMO CHEMORT DEFENITIVE
CHEMO RT
SURGERY± LOBECTOMY
POST OPRT

STAGE III B
DEFENITIVE PALLIATIVE
CHEMO RADIATION IF PS IS RADIATION
GOOD
Ifnot possible
PALLIATIVE
CHEMOTHERAPY

STAGE III C
N3 NODE EVALUATION
+ N3 NODE - N3 NODE
DEFINITIVE CONCURRENT TREAT AS PER STAGE I – III A

CHEMORADIATION
Either palliative chemotherapy
If not
possible Or palliative Radiation
STAGEIII C T4N3
MEDIASTINAL NODE
EVALUATION
N3 -
N3 +
N2+ N2 -
DEFINITIVE -
CONCURRENT
CHEMORADIATION
If not possible either TREAT AS STAGE IIIA T4 N0-1

palliative chemotherapy or
palliative radiation

SUPERIOR SULCUS TUMOUR
• T3-T4 N0-N1(RESECTABLE)---PRE OPCHEMO

RT-SURGERY-ADJ CHEMO
• SURGERY-POST OPRT
• DEFINITIVECHEMORADIATION.

Stage IV NSCLC

Stage IV NSCLC


SCLC INITIAL EVALUATION
• Pathology-tissue diagnosis—biopsy or cytology cell block

• Blood-CBC, Biochemistry panel
• CECT Chest with upper abdomen, including adrenals
• PET CT for limited stage
• MRI Brain-CECT if MRI is not possible
• For limited stage if PET is not done
• Bone scan
• Bone marrow study
• Co-Morbidity-PFT,ECHO
• Smoking Cessation Counseling
• Palliative Care Integration

TREATMENT ALGORITHM FOR LUNG CANCER SCLC

T1N0 – Lobectomy +/- Systematic mediastinal lymphadenectomy. Segmentectomy may be
considered in selected cases. Mediastinal lymphadenectomy may be omitted in small peripheral
lesions.
T1N1, T2/T3 N0/N1 – Mediastinoscopy is done before surgery if EBUS is not done prior or
EBUS results are inconclusive.The nodes are sent for frozen section evaluation. If mediastinal
nodal involvement is absent, proceed with Lobectomy or Pneumonectomy with systematic
mediastinal lymphadenectomy.
Metastatectomyis recommended in oligometastatic disease as mentioned in the guidelines.
Curative treatment for oligometastatic disease is considered only after ruling out mediastinal
nodal involvement.Metastasectomy shall be performed with at least 1cm margin all around and
pathologically negative margins
Principles of Systemic Chemotherapy

Adjuvant Chemotherapy
Four cycles of platinum based doublet chemotherapy is the standard.
Commonly used regimens are
1. Etoposide 100 mg/m2 D1-D3,Cisplatin 25 mg/m2 D1-D3 Q3 every 21 days *
2. Cisplatin (75 mg/m2) on D1 /Vinorelbine (25 mg/m2) on D1 and D8 Every 21 days *
3.Cisplatin 75 mg/m2 /Docetaxel 75 mg/m2 every 21 days *
4.Cisplatin (75 mg/m2 )on D1 / Gemcitabine 1250 mg/m2 D1 and D8 every 21 Days
5.Cisplatin (75 mg/m2) /Pemetrexed (500 mg/m2) (For Adenocarcinoma only) Every 21 days
6.Paclitaxel ( 200 mg/m2)/Carboplatin (AUC-5) Every 21 days
7. Paclitaxel (200 mg/m2)/ Cisplatin (75 mg/m2)* Every 21 days
8.Pemetrexed (500 mg/m2) /Carboplatin (AUC-5 ) Every 21 days
All these regimens can be used in neoadjuvant setting also.
Concurrent chemotherapy Regimens
1.Cisplatin (50 mg/m2) on D1 ,D8,D29,D36 and Etoposide 100 mg/m2 on D1-D5 and 29-33
2.Cisplatin 25 mg/m2 D1-D3 ,Etoposide 100 mg/m2 D1-D3 Every 21 days
3.Paclitaxel (50 mg/m2) and Carboplatin (AUC2) every week
4.Pemetrexed(500 mg/m2) and Carboplatin (AUC5) D1 every 21 days x 4 cycles
Metastatic Disease
Chemotherapy
Adenocarcinoma
Combination Chemotherapy (Preferably in patients with PS 0-1)
Pemetrexed /Cisplatin * Gemcitabine/Docetaxel
Pemetrexed /Carboplatin Etoposide/Cisplatin*
Paclitaxel/Carboplatin Etoposide/Carboplatin*
Paclitaxel/Cisplatin* Docetaxel*
Gemcitabine Gemcitabine /Vinorelbine*
Albumin bound paclitaxel Paclitaxel

Paclitaxel/Carboplatin Etoposide/Carboplatin*
Paclitaxel/Cisplatin* Gemcitabine/Carboplatin
Gemcitabine Gemcitabine /Vinorelbine*
Albumin bound paclitaxel Paclitaxel
Docetaxel*
Note:
 * - To consider myeloid growth factor support for these regimes. For the other regimens
growth factors can be considered based on the patienst related factors.
 Pemetrexed maintenance (500 mg/m2 IV Every 21 days) can be used in patients with
adenocarcinoma achieving partial response or stable disease after 4-6 cycles of
pemetrexed/platinum doublet ,till progression or development of toxicity.
 Patients on Pemetrexed should receive vitamin B12 injections every 3 monthly and folic
acid supplements daily during the treatment period.
 Single agent chemotherapy may be considered in patients with PS2 status.
 Immunotherapy ( Pembrolizumab/Atezolizumab) can be added to platinum doublet in
suitable patients
 Bevacizumab may be added to platinum doublet in suitable patients with
Adenocarcinoma
Targeted Therapy
EGFR sensitising mutation
Geftinib/Erlotinib
Other options : Afatinib/Osimertinib
ALK Rearrangement positive

Crizotinib
Other options- Ceritinib/Alectinib
Immunotherapy
Nivolumab/pembrolizumab/Atezolizumab
SMALL CELL LUNG CANCER

Limited Stage
4-6 cycles of platinum based regimen
1) Cisplatin 25 mg/m2 D1-D3 ,Etoposide 100 mg/m2 D1-D3 Every 21 days
2) Cisplatin 75 mg/m2 D1,Etoposide 100 mg/m2 D1-D3 Every 21 days
3) Carboplatin (AUC 5-6) ,Etoposide 100 mg/m2 Every 21 days ( In patients who are not
eligible for cisplatin)
 Along with RT etoposide/cisplatin is the preferred regimen.
 Growth factors are not recommended during concurrent chemoradiation .
Extensive Stage
Etoposide /Carboplatin
Etoposide/Cisplatin
Carboplatin /Irinotecan
Cisplatin/Irinotecan

Recurrence
Second line therapy can be considered in patients with PS 0-2
PFS > 6 months – Rechallenge with the initial regimen
PFS < 6 months – Topotecan/Irinotecan/Docetaxel/Vinorelbine/Temozolomide
Radiotherapy dose prescriptions in lung cancer
NSCLC
NEOADJUVANT 2D/3DCRT/IMRT/VMAT/Image 45-54Gy, 1.8-2Gy/#
gated RT
DEFINITIVE 2D/ 3D RT/IMRT/VMAT 60-70Gy, 2Gy/#
ADJUVANT 2D/ 3D RT/IMRT/VMAT R0: 50-54Gy, 1.8- 2Gy/#
R1: 54-60Gy, 1.8- 2Gy/#
R2: 60-70Gy, 2Gy/#
SCLC
DEFINITIVE 2D/3DCRT/IMRT/VMAT 60-70Gy, 2Gy/#
45 Gy in 30 #, 1.5Gy BID
PCI 2D/ 3D RT 25Gy in 10#, 2.5Gy/#
30Gy in 15#

UROLOGICAL CANCER


BLADDER CANCER

Ta Noninvasive papillary carcinoma
Tis Urothelial carcinoma in situ: "fíat tumor‖
TI Tumor invades lamina propria (subepithelial connective tissue)
T2 Tumor invades muscularis propria
pT2a Tumor invades superficial muscularis propria (inner half)
pT2b Tumor invades deep muscularis propria (outer half)
T3 Tumor invades perivesical soft tissue
pT3a Microscopically
pT3b Macroscopically (extravesical mass)
T4 Extravesical tumor directly invades any of the following: prostatic
stroma. seminal vesicles, uterus.vagina, pelvic wall. abdominal wall
T4a Extravesical tumor invades directly into prostatic stroma. uterus,
vagina
T4b Extravesical tumor invades pelvic wall, abdominal wall
Definition of Regional Lymph Node

NX Lymph nodes cannot be assessed
NO No lymph node metástasis
N1 Single regional lymph node metástasis in the true pelvis
(perivesical, obturator. internal and external iliac, or sacral lymph
node)
N2 Múltiple regional lymph node metástasis in the true pelvis
(perivesical, obturator. internal and external iliac, or sacral lymph
node metástasis)
N3 Lymph node metástasis to the common iliac lymph nodes

M1 Distant metástasis
M1a Distant metástasis limited to lymph nodes beyond the common
iliacs
MI b Non lymph node distant metastases


T N M Stage
Ta NO MO Oa
Tis NO MO Ois
TI NO MO I
T2a NO MO II
T2b NO MO II
T3a, T3b, T4a NO MO IIIA
Tl - T4a NI MO IIIA
Tl - T4a N1, N3 MO IIIB
T4b NO MO IVA
Any T Any N Mía IVA
Any T Any N Mlb IVB
Presenting symptoms
Hematuria
Frequency of urine
Reduced bladder capacity
Lower abdominal pain.
Evaluation
Urine cytology, Cystoscopy,
CT/MRI Abdomen+ pelvis and Imaging of upper urinary tract.
CT thorax in invasive cancer
TURBT (transurethral resection of bladder tumour)
Nonmuscle invasive bladder cancer (NMIBC)

Intravesical mitomycin instillation
Indicated in NMIBC immediately after TURBT. This is given atleast within 12 hours.
(Exceptions- patients with suspected perforation or active bleeding or muscle invasive disease is
strongly suspected)
Intravesical
treatment
cTa, low cTa, high cT1, high cTis

grade grade grade
observation re TURBT* re TURBT* – intravesical

intravesical BCG intravesical BCG. BCG
(induction followed by (consider
maintenance BCG). cystectomy if
multifocal,
associated with Tis,
large lesion)

Muscle invasive bladder cancer (MIBC)

CECT Abdomen and Pelvis
CT chest
Bone scan if symptomatic/ALKP raised
Treatment options
Stage II
Surgery/CTRT
Willing for Surgery Chooses CTRT/not fit for

Unfit for NACT
surgery
Fit for NACT Maximal TURBT

CTRT
Rad RT if not fir for
Upfront surgery CTRT
Radical cystectomy+BPLND
Assess for adjuvant

chemo if T3/Node
posuitive

Stage IIIa
T3N0, T1-T3 N1 T4a N0/N1
NACT followed by Radical NACT followed by Radical

cystectomy + BPLNDorCTRT cystectomy +BPLND
Stage IIIB
T1-T3 N2/N3 T4a N2/N3
NACT NACT
Complete/partial Stable
response Disease/progression
Complete/partial
response
Radical Cystectomy + Plliative management

Radical cystectomy +
BPLND or
BPLND
CTRT
If CTRT is given in stage II or III, check cystoscopy at 2-3 months and there is residual invasive
disease consolidation with surgery is chosen.
If residual NMIBC, intravesical BCG is an option.

Stage IV a
Systemic chemotherapy
Stable disease/progression
Complete/partial
response
Palliative management
Consider consolidation with Rad
cystectomy/CTRT
Stage IVb – Palliative management as per MDT discussion.
Nonurothelial cancers
Adenocarcinoma, squamous cell carcinoma, urachal carcinoma and sarcoma are rarely found in
the bladder. Radical cystoprostatectomy is the recommended treatment adenocarcinoma and
squamous cell carcinoma. The adjuvant treatment found beneficial in urothelial cancer are not
proven to be beneficial to this heterogenous group. Small cell carcinoma is treated with
neoadjuant chemotherapy followed by cystectomy or CTRT.
Follow up
NMIBC
Upto 2 years –three monthly clinical follow up, cystoscopy, urine cytology
2-5 years - six monthly clinical follow up, cystoscopy, urine cytology
>5 years – yearly follow up
MIBC
Upto 2 years –three monthly clinical follow up, urine cytology, CBC, RFT.
2-5 years - six monthly clinical follow up, urine cytology, CBC, RFT.
>5 years – yearly follow up

Recurrence after treatment of muscle invasive bladder cancer
Cystectomy
Localised (Individualise)
recurrence / Invasive
persistence with
preserved bladder
Undergo TURBT
Tis, Ta, T1
Recurrence Cystectomy or
Intravescial
TURBT BCG/Chemotherapy
Metastatic disease
Chemotherapy
&/or
CT-RT/RT
Post cystectomy
(Selected
cases)

PROSTATE CANCER
AJCC Staging 8th Edition Carcinoma Prostate
T staging
TI Clinically inapparent tumor that is not palpable
T 1a Tumor incidental histologic finding in 5% or lessof tissue resected
Tlb Tumor incidental histologic finding in more than5% of tissue resected
T 1 c Tumor identified by needle biopsy found in one orboth sides, but not palpable
T2 Tumor is palpable and confined within prostate

T2a Tumor involves one-half of one side or less
T2b Tumor involves more than one-half of one side butnot both sides
T2c Tumor involves both sides
T3 Extraprostatic tumor that is not fixed or does notinvade adjacent structures
T3a Extraprostatic extension (unilateral or bilateral)
T3b Tumor invades seminal vesicles
T4 Tumor is fixed or invades adjacent structures other than seminal vesicles such as
external sphincter,rectum, bladder, levator muscles, and/orpelvic wall
N staging
NX Regional nodes were not assessed
NO No positive regional nodes
N1 Metastases in regional node(s)
M staging
M1 a Nonregional lymph nodes
Mlb Bones
M1 c Other sites with or without bone disease

Stage grouping
T N M PSA Grade Stage

cTla-c, cT2a NO MO < 10 1 I
pT2 NO M0 < 10 1 I
cTla-c, cT2a NO M0 > 10 <20 1 IIA
cT2b-c NO M0 <20 1 IIA
Tl-2 NO M0 <20 2 IIB
Tl-2 NO M0 <20 3 IIC
Tl-2 NO M0 <20 4 IIC
Tl-2 NO M0 >20 1-4 IIIA
T3-4 NO M0 Any 1-4 IIIB
Any T NO M0 Any 5 IIIC
Any T NI M0 Any Any IVA
Any T NO MI Any Any IVB
Symptoms
LUTS
Screening:
Population based screening is not recommended.
PSA screening should be avoided in men above 70 years.
High risk population with genetic predisposition may be screened.
Clinical Exam and Evaluation:

Performance status & Co morbidities to be recorded.
PSA
Gleason score (GS)
Isotope Bone scan
For localized disease- MRI pelvis.
CT scan of Abdomen and Pelvis for high risk patients & CXR
PSMA PET Scan recommended for biochemical failure after curative local treatment only.

Management of localized or loco-regional

disease
High Risk
Intermediate
Low risk
risk
Active surveillance Radical Radiotherapy with 2

Radical prostatectomy Prostatectomy/Radical years ADT/ Radical
Radical RT Radiotherapy +ADT 6 prostatectomy + LN
(Similar survival with all months/selected cases dissection in selected
three, to be discussed with for Surveillance patients (like young T3A
patient) disease).

Post Op Radiotherapy:
Discuss with patients regarding adjuvant versus Salvage treatment.
(Adjuvant considered if adverse features present; pathological ECE, positive surgical margin &
Seminal vesicle invasion.
Salvage treatment preferably done before PSA > .5 ng/ml
Patients Biochemical failure after local radiotherapy may be candidates for intermittent ADT if
radiological evidence of disease is absent
Metastatic disease
HNPC
Extensive Stage* Limited Burden

disease
ADT +/- 6 cycles of Docetaxel ADT+/- 6 cycles of Docetaxel+

**Abiraterone + ADT is also an Radiotherapy
option **Abiraterone + ADT is also an option
* (Burden defined based on presence of visceral metastasis or ≥ 4 bone lesions with ≥1 beyond
the vertebral bodies and pelvis)
** Less preferred option as this is prolonged and expensive treatment and could be given at a
later date after chemotherapy
Castration Resistant Prostate Cancer:

Bicalutamide withdrawal/ Bicalutamide /Dexamethasone 0.5 mg/ in asymptomatic or minimal
symptoms.
Docetaxel, if not received earlier.
Abiraterone or Enazlutamide
Second line chemotherapy with Cabazitaxel
Fosfestrol.
Bone Targeted therapy
Zoledronic acid. Indicated for castration resistant disease.
Palliative RT for bone pain
Radionuclide therapy for bone pain.
Palliative care.

RENAL CELL CARCINOMA

T1 < 7 cm in greatest dimensión, limited to the kidney
T1a Tumor < 4 cm in greatest dimensión, limited to the kidney
T lb Tumor > 4 cm but < 7 cm in greatest dimension limited to the kidney
T2 Tumor > 7 cm in greatest dimensión, limited to the kidney
T2a Tumor > 7 cm but < 10 cm in greatest dimensión, limited to the kidney
T2b Tumor > 10 cm. limited to the kidney
T3 Tumor extends into major veins or perinephric tissues. but not into the
ipsilateral adrenal gland and not beyond Gerota‘s fascia
T3a Tumor extends into the renal vein or its segmental branches. or invades the
pelvicalyceal system. Or invades perirenal and/or renal sinus fat but not
beyond Gerota‘s fascia
T3b Tumor extends into the vena cava below the diaphragm
T3c Tumor extends into the vena cava above the diaphragm or invades the wall
of the vena cava
T4 Tumor invades beyond Gerota‘s fascia (including contiguous e xtensión
into the ipsilateral adrenal gland)

NO No regional lymph node metástasis
NI Metástasis in regional lymph node(s)

T N M Stage
TI NO MO I
TI NI MO II
T2 NO MO II
T2 NI MO III
T3 NO MO III
T3 NI MO III
T4 Any N MO IV
Any T Any N MI IV

Symptoms
Hematuria
Abdominal pain
Flank mass
Fever
Anemia
Baseline evaluation:
 History and physical examination
 S.Creatinine, Hemoglobin, leukocyte and platelet counts, lymphocyte to neutrophil ratio,
lactate dehydrogenase and serum-corrected calcium (for prognostication).
 CECT chest, abdomen and pelvis.
 Bone scan / CT Brain (or MRI) – if indicated.
 Renal mass core biopsy – if planned for upfront systemic therapy.
Staging: UICC TNM 8 staging of RCC

T – Primary Tumour
TX - Primary tumour cannot be assessed
T0 - No evidence of primary tumour
T1 - Tumour 7 cm or less in greatest dimension, limited to the kidney
T1a - Tumour 4 cm or less
T1b - Tumour more than 4 cm but not more than 7 cm
T2 - Tumour more than 7 cm in greatest dimension, limited to the kidney
T2a - Tumour more than 7 cm but not more than 10 cm
T2b - Tumour more than 10 cm, limited to the kidney
T3 - Tumour extends into major veins or perinephric tissues but not into the ipsilateral adrenal
gland and not beyond Gerota fascia
T3a - Tumour extends into the renal vein or its segmental branches, or tumour invades the
pelvicalyceal system or tumour invades perirenal and/or renal sinus fat (peripelvic) fat but not
beyond Gerota fascia
T3b - Tumour extends into vena cava below diaphragm
T3c - Tumour extends into vena cava above the diaphragm or invades the wall of the vena
cava

T4 - Tumour invades beyond Gerota fascia (including contiguous extension into the ipsilateral
adrenal gland)
N – Regional Lymph Nodes
NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Metastasis in regional lymph node(s)
M – Distant Metastasis
M0 - No distant metastasis
M1 - Distant metastasis

Management of localized /
locoregional disease
T2 (> 7 cm)
T1 (≤ 7 cm) T3 and T4
Radical nephrectomy.
Partial nephrectomy in
Partial Radical Radical
selected patients
nephrectomy +/- hilar nephrectomy+/-
Hilar lymphadenectomy
lymphadenenctomy retroperitoneal
Paraaortic/paracaval
lymphadenectomy.
lymphadenectomy in left/right
Multivisceral
lesions respectively, if
resection in
enlarged/suspicious nodes are
selected patients
present in imaging.
Management of metastatic disease:

As per risk categorization: International Metastatic RCC Database Consortium (IMDC) score
Karnofsky performance status (PS) < 80%
Haemoglobin level below the lower limit of normal
Time from diagnosis to treatment < 1 year
Corrected calcium above the upper limit of normal
Platelets greater than the upper limit of normal
Neutrophils greater than the upper limit of normal.
 Favourable risk group – 0 risk factor

 Intermediate risk group - 1–2 risk factors
 Poor risk group - ≥3 risk factors

Management of metastatic
RCC
Favourable risk / Good PS, Intermediate / Poor risk

potentially resectable
primary
Renal biopsy and systemic

Cytoreductive nephrectomy.
therapy (till progression or
If completely resected, follow up.
unacceptable toxicity) as per
Systemic treatment upon progression.
histology.
For isolated late relapses,
metastatectomy may be considered.
*Note – Ideal time to start systemic therapy is not defined. A brief period of observation can be
considered as an option for the subset of indolent RCC with limited tumor burden and few
symptoms.

Systemic therapy of clear cell (cc) RCC (first

line):
Good risk Intermediate risk Poor risk
Immunotherapy or TKI
Tyrosine Kinase Inhibitor Immunotherapy or TKI
like Pazopanib , Sunitinib, or mTOR inhibitor
or anti VEGF,
Bevacizumab + IFN
Second line treatment of ccRCC (second

line)
Immunotherapy or another TKI or mTOR

inhibitor
Systemic treatment of non

ccRCC
TKI or MDT decision

Bone targeted therapy

 Zoledronic acid
 Palliative RT for bone pain
Follow-up
mRCC patients during

High-risk patients Low-risk patients systemic therapy
CT thorax and abdomen Annual CT scan for 2 4-6 month follow-up with
every 6 monthly for the years CT scan is advised.
first two years or earlier Then, if clinically
if symptomatic indicated
Yearly till five years

TESTICULAR TUMOUR
AJCC staging Clinical cT
cTX Primary tumor cannot be assessed
cTO No evidence of primary tumor
cTis Germ cell neoplasia in situ
cT4 Tumor invades scrotum with or without vascular/lymphatic invasion
Except for Tis confirmed by biopsy and T4. The extent of the primary tumor is classified by
radical orchiectomy.
TX may be used forother categories for clinical staging.
Pathological T (pT)
pTX Primary tumor cannot be assessed
pTO No evidence of primary tumor
pTis Germ cell neoplasia in situ
pTI Tumor limited to testis (including rete testis invasion) without lymphovascular invasion
Sub classification of t1 only for pure seminoma
pTla Tumor smaller than 3 cm in size
pT 1 b Tumor 3 cm or larger in size
pT2 Tumor limited to testis (including rete testisinvasion) with lymphovascular invasion
OR
Tumor invading hilar soft tissue or epididymis orpenetrating visceral mesothelial layer covering
theexternal surface of tunica albuginea with or
without lymphovascular invasion
pT3 Tumor invades spermatic cord with or withoutlymphovascular invasion
pT4 Tumor invades scrotum with or withoutlymphovascular invasion
Clinical N
cNX Regional lymph nodes cannot be assessed
cNO No regional lymph node metastasis
cN 1 Metastases with a lymph node mass 2 cm or smaller

in greatest dimension
OR
Multiple lymph nodes, none larger than 2 cm in
greatest dimension
cN2 Metastasis with a lymph node mass larger than 2 cm

but not larger than 5 cm in greatest dimension
OR
Multiple lymph nodes. any one mass larger than
2 cm but not larger than 5 cm in greatestdimension
cN3 Metastasis with a lymph node mass larger than 5 cm

in greatest dimension
Pathological N (pN)
pNX Regional lymph nodes cannot be assessed
pNO No regional lymph node metastasis
pN 1 Metastasis with a lymph node mass 2 cm or smallerin greatest dimension and less than or
equal to five nodes positive none larger than 2 cm in greatest
dimension
pN2 Metastasis with u lymph node mass larger than 2 cmbut not larger than 5 cm in greatest
dimension; or more than five nodes positive, none larger than 5 cm, or evidence of extranodal
extension of tumor
pN3 Metastasis with a lymph node mass larger than 5 cmin greatest dimension
M staging
MO No distant metastases
MI Distant metastases
M1a Non-retroperitoneal nodal or pulmonary metastases
Mlb Non-pulmonary visceral metastases
S Category
SX Marker studies not available or not performed
S0 Marker study levels within normal
S1 LDH < 1.5 x N(UPPER LIMIT OF NORMAL)

hCG (mlU/mL) < 5000 and
AFP (ng/mL) < 1,000

S2 LDH 1.5-10 x N
hCG (mlU/mL) 5,000-50,000
AFP (ng/mL) 1,000-10,000
S3 LDH > 10 x N
hCG (mlU/mL) >50,000
AFP(ng/mL) > 10.000
STAGE 0 pTis NO M0 SO
STAGE 1 pTI-T4 NO M0 SX
STAGE 1 A pTI NO M0 SO
STAGE 1B pT2 NO M0 SO
STAGE 1B pT3 NO M0 so
STAGE 1 B pT4 NO M0 so
STAGE 1 S Any pT/TX NO M0 Sl-3
STAGE 2 Any pT/TX NI-3 M0 SX
SAGE 2A Any pT/TX NI MO SI
STAGE 2B Any pT/TX N2 M0 SO
STAGE 2 B Any pT/TX N2 M0 SI
STAGE 2C Any pT/TX N3 M0 S0
STAGE 2C Any pT/TX N3 M0 S 1
STAGE 3 Any pT/TX Any N MI SX
STAGE 3 A Any pT/TX Any N M1a S0
STAGE 3 A Any pT/TX Any N M1a SI

STAGE 3 B Any pT/TX NI-3 M0 S2
STAGE 3B Any pT/TX Any N M1a S2
STAGE 3C Any pT/TX NI-3 MO S3
STAGE 3C Any pT/TX Any N M1a S3
STAGE 3 C Any pT/TX Any N Mlb Any S

Symptoms
Testicular swelling
Scrotal pain
Evaluation
Testicular ultrasound (USS)
Serum tumour markers (αFP and βHCG). These should be measured preoperatively in all
patients.
If a tumour is confirmed, patient should undergo high inguinal orchidectomy
 In patients who have very high marker levels or in those whom the burden of metastatic
disease is high, surgery can be deferred until after chemotherapy
Other investigations
 CT scan of the chest, abdomen and pelvis preferably before orchidectomy
 MRI of the brain may be considered if choriocarcinoma or βHCG levels are high.
 Sperm count and sperm banking to be offered.

Seminoma
Stage I
Risk factors present Risk factors absent

(Rete testis infiltration/size
>4cm)
Observation
Single course of carboplatin (AUC
7) or
Paraaortic radiation 20 Gy in 10
fractions
Stage II
Stage IIa/IIb StageIIb/ IIc
Radiotherapy 30Gy or 3 cycles BEP or 4 cycles EP

Single course
carboplatin

Residual mass post chemotherapy in seminoma

o Lesions less than < 3 cm should be observed.
o Lesions > 3 cm should undergo a PET-CT scan which should be performed not
earlier than 8 weeks after chemotherapy.
Non-seminoma
Stage I
Stage I NSGCT
High Inguinal Orchidectomy
Chemotherapy with 1 BEP

Nerve sparing RPLND**
if risk factors present*or
Surveillance
pN0 pN3
Surveillance or 3 BEP or 4 EP
Chemotherapy with 1
BEP if risk factors
present
pN1 or pN2
2 BEP
Surveillance (not preferred if there is

lymphovascular invasion or histology is
embryonal carcinoma)
*Risk factors – LVSI and component of embryonal carcinoma

** Selected cases, where expertise is available for nerve sparing procedure and after discussion
in MDT.

Stage IS
Stage IS NSGCT
3 BEP or 4 EP
Complete Response Persistant elevated tumor

- Normal tumor markers -
markers and Salvage chemotherapy
negative imaging (especially if rising tumor
markers)
Follow up

Stage IIa and IIb
Stage II NSGCT
Stage IIA without Stage IIA with

tumor marker marker elevation
elevation and all Stage IIB
RPLND 3 BEP or 4 EP
Negative Persistant
pN1/N2 pN3 markers markers
RPLND if Salvage
2 BEP 3 BEP or 4 EP residual mass Chemo and
> 1 cm on then surgery
imaging (Desperation
RPLND)
pN0 - Follow up only

Surveillance if teratoma or
necrosis else 2
EP

Stage IIc/III NSGCT/ Seminoma stage III
Advanced NSGCT/Seminoma
Stage III
Good risk Intermediate and Poor risk
4 BEP or 4 VIP (especially if

3 BEP or 4 EP underlying lung problems)
Surgical resection of all residual Surgical resection of all

mass if > 1 cm and if tumor residual mass if > 1 cm and if
markers have normalised else tumor markers have
salvage chemo normalised else salvage
chemo
Follow up after surgery - only if Follow up after surgery - only

teratoma or necrosis else 2 if teratoma or necrosis else 2
more cycles EP chemotherapy more cycles EP chemotherapy

FOLLOW UP
Recommended minimal follow up for seminoma Stage I on active surveillance or

following adjuvant chemotherapy or radiotherapy
Modality Year 1 Year 2 Year 3 Year 4+5 After 5 years
Tumor 2 times 2 times 2 times I time Individualise
markers
with H&P
Abdominal 2 times 2 times 1 at 36 1 at 60 -
CECT months months
Recommended minimal follow up for non-seminoma Stage I on active surveillance

Tumor 4 times 4 times 2 times I – 2 times Individualise
markers
with H&P
Chest X 2 times 2 times 1 if LVI At 60 months -
ray present if LVI
present
Abdominal 2 times At 24 At 36 months At 60 months -
CECT months (Optional) (Optional)
Recommended minimal follow up after adjuvant treatment or after complete remission in

advanced NSGCT
Tumor 4 times 4 times 2 times 2 times Individualise
markers
with H&P
Chest X 1-2 times 1 time 1 time 1 time -
ray
Abdominal 1-2 times At 24 At 36 months At 60 months -
(+/- pelvis) months (Optional) (Optional)
CECT
Note – Thoracic CT to be considered at same times as abdominal CT if there were
pulmonary metastasis initially
H&P – History and Physical examination

Recurrent GCT
Recurrence
Previous Chemotherapy
(EP/BEP/VIP)
No (or only SA
Yes
Carboplatin)
Salvage Chemotherapy Treat with chemotherapy as

and/or Surgery per IGCCG risk
(Tumor BoardDiscussion) (Tumor Board Discussion
Recurrence/Progression
Salvage Chemotherapy and/or sugery

Best supportive Care is also an option
(Consider High dose chemotherapy with
Autologous stem cell transplant)

Renal cancer
T1/T2 N0 - Partial nephrectomy whenever feasible. Margin negative resection is sufficient.
Intraoperative ultrasound scan may be utilised if required.
T2/T3 N0 - Radical nephrectomy is recommended if partial nephrectomy is not feasible. This
includes resection of the kidney with Gerota‘s fascia and all the fat within it. Adrenalectomy is
recommended if adrenal gland is involved with the disease. In cases with renal vascular
invasion, thrombectomy is recommended.
T4 - Multivisceral resection may be done in selected cases if disease is infiltrating adjacent
organs like colon, adrenal, and tail of pancreas or spleen.
In T2/T3/T4 cases, ipsilateralhilar lymphadenectomy needs to be done.
Paraaortic (for left sided lesion) and paracaval (for right sided lesion) nodes are to be cleared in
T3/T4 or patients with significant nodes in the above areas respectively.The role of Prophylactic
paraaortic nodal clearance is unclear
Metastatectomy benefits patients with limited metastasis involving lung.
Cytoreductive nephrectomy has role in patients with limitedmetastasis(oligo metastasis), good
general condition and easily resectable primary disease.
Minimally invasive approach is preferable in selected cases over open wherever facility and
expertise is available. This reduces surgical morbidity significantly.
Bladder cancer
Trans Urethral Resection of Bladder Tumor (TURBT) is the initial procedure. If muscle invasion
is identified after TURBT or in the initial imaging (T2/T3/T4) more radical procedure needs to
be done after neo-adjuvant treatment.It is necessary to resect underlying muscle to stage the
tumor.Re-TURBT if adequate muscle not available for staging, residual tumor left behind, large
volume and multiple tumor(possibility of residual tumor left behind),preferably if intravesical
treatment is planned after TURBT.
Partial cystectomy can be done in suitable cases- Small single tumor in dome of bladder. Radical
cystoprostatectomy with bilateral extended pelvic lymph node dissection is the standard
procedure when partial cystectomy is not feasible. Ileal conduit, neobladder reconstruction or
any procedure described for continent diversion may be used for urinary diversion. Frozen
section analysis of the urethral margin is useful to decide the need for urethral resction.Frozen
section analysis of ureteral margins should be done.
Minimally invasive approach or open procedure wherever facility and expertise is available.

Prostate cancer
T1/T2 and selected T3 N0/N1 - Radical prostatectomy with bilateral pelvic lymph node
dissection is the standard surgical procedure in operable prostatic cancer.
Minimally invasive approach oropen approach based on expertise
In metastatic prostate cancer, surgical castration may be achieved with bilateral scrotal
orchiectomy.
Testicular cancer
High inguinal orchiectomy is recommended when testicular tumour is suspected /diagnosed
based on serum markers and in the imaging.
In non-seminomatous germ cell tumour (NSGCT), stages I and IIa, upfront nerve sparing
retroperitoneal lymph node dissection (RPLND) covering a modified template may be
considered.
Salvage RPLND covering the standard template is done if there is/are residual nodes ≥ 1cm, in
case of NSGCT after chemotherapy. In seminoma, if residual disease is more than 3cm, a PET
scan has to be done. If PET scan shows uptake suggesting possible residual disease, a standard
template RPLND has to be done.
Minimally invasive approach or open procedure based on expertise and suitability of the case
Principles of Systemic Therapy

Common Chemotherapeutic Regimens in Urologic Cancers
Renal Cell Carcinoma
Clear Cell Histology
Pazopanib
Sunitinib
Recurrent Renal Cell Carcinoma (Clear Cell Histology)
Nivolumab
Cabozantinib
Axitinib
Everolimus
Sunitinib (If not used earlier)
Pazopanib (If not used earlier)
Sorafenib
Non clear cell histology
Sunitinib (Preferred)

Cabozantinib
Everolimus
Axitinib
Nivolumab
Pazopanib
Bevacizumab
Urinary Bladder
Perioperative Chemotherapy/Adjuvant Therapy
Dose Dense MVAC (Methotrexate, Vinblastine, Doxorubicin and Cisplatin) with growth factor
support – 3-4 cycles
Gemcitabine-Cisplatin - 4 cycles
CMV – Cisplatin, Methotrexate and Vinblastine for 3 cycles
Note –
 Neoadjuvant chemotherapy is preferred over adjuvant therapy whenever possible.
 Carboplatin should not be substituted for cisplatin in perioperative setting.
Palliative Chemotherapy regimens
Any of the following regimens may be considered -
Dose Dense MVAC (Methotrexate, Vinblastine, Doxorubicin and Cisplatin) with growth factor
support
Gemcitabine-Cisplatin
In Cisplatin Ineligible cases, following regimens may be considered
Gemcitabine – Carboplatin
Immunotherapy – Atezolizumab/Pembrolizumab
Gemcitabine
Gemcitabine – Paclitaxel
Note - The presence of both non nodal metastasis and ECOG PS of 2 or worse strongly predict
poor outcome with chemotherapy.
Second Line Options (Post Platinum)
Immunotherapy – Pembrolizumab/Atezolizumab/Nivolumab
Paclitaxel or Docetaxel
Gemcitabine (If not previously exposed)
Pemetrexed
Intravesical therapy
Following options may be considered – To be individualised

BCG
Gemcitabine
Mitomycin
Radiosensitising chemotherapy for organ preserving chemoradiation
Options include -
Cisplatin – 5 FU
Cisplatin – Paclitaxel
5 FU – Mitomycin
Cisplatin alone
Testicular Cancer
BEP
Bleomycin 30 U weekly, Etoposide 100 mg/m2 for Days 1-5 and Cisplatin 20 mg/m2 Days 1-5.
Repeat every 3 weeks for 3-4 cycles depending upon risk
EP – For Good risk GCT and certain other selected cases only
Etoposide 100 mg/m2 for Days 1-5 and Cisplatin 20 mg/m2 Days 1-5. Repeat every 3 weeks for
3-4 cycles depending upon risk
VIP (In upfront setting – selected cases only)
Etoposide 75 mg/m2 Days 1-5

Ifosfamide 1200 mg/m2 on Days 1-5
Mesna 240 mg/m2 IV before Ifosfamide and then at 4 and 8 hours after start of Ifosfamide dose
daily on Days 1-5
Cisplatin 20 mg/m2 on Days 1-5
Treatment option in recurrent testicular cancer/Salvage Regimens
TIP – Paclitaxel, Ifosfamide and Cisplatin (Preferred first line Salvage option)
Other options in recurrent setting (Second line and beyond)

VeIP – Vinblastine, Ifosfamide and Cisplatin
VIP – Etoposide, Ifosfamide and Cisplatin
Prostate Cancer
Androgen Deprivation Therapy
Orchiectomy
LHRH Agonists – Leuprolide, Goserelin
LHRH Antagonists – Degarelix
Antiandrogens – Bicalutamide, Flutamide

Secondary Hormonal Therapy
Abiraterone acetate with Prednisolone (or Methyl prednisolone)

Enzalutamide
Ketoconazole
Corticosteroids
Chemotherapy
Docetaxel – Both for Hormone naïve and Castration resistant prostate cancer.
Cabazitaxel – In Castration resistant prostate cancer only
Reference
1. NCCN Guidelines
Radiotherapy dose prescriptions in urological cancers
PROSTATE
72-80 Gy, 2Gy/#
EBRT 75.6 Gy-81Gy, 1.8Gy/#
70Gy, 2.5Gy/#
60Gy, 3Gy/#
SBRT 40Gy, 8Gy/#
36.25Gy, 7.25Gy/#
37Gy, 7.4Gy/#
BRACHYTHERAPY Implants:
RADICAL (MONOTHERAPY) I 125: 145Gy
Pd 103:125Gy
HDR:
27Gy, 13.5Gy in 2 implants
38Gy, 9.5Gy/#, BID in 2 implants
EBRT+BRACHYTHERAPY 45-50.4Gy in 1.8-2 Gy/#
+
I 125: 110-115Gy
Pd 103: 90-100Gy
HDR: 21.5Gy, 10.75Gy X 2
ADJUVANT/ EBRT 64-72Gy in 1.8-2Gy/#
SALVAGE POST
PROSTATECTOMY
CARCINOMA URINARY BLADDER
RADICAL CTRT 3DCRT 39.6-50.4Gy IN 1.8-2GY PER
2D PLAN FRACTION FOLLOWED BY
IMRT BOOST UPTO 60-66Gy
TOTAL DOSE
ADJUVANT 3DCRT 45-50.4Gy IN 25-28#
RADIATION 2D PLAN FOLLOWED BY BOOST
IMRT UPTO 54-60Gy TOTAL DOSE


NEUROLOGICAL CANCER


BRAIN TUMOUR
DIAGNOSIS OF A BRAIN TUMOUR: POSSIBLE SYMPTOMS
 A new seizure in an adult

 Gradual loss of movement or sensation in an arm or leg
 Unsteadiness or imbalance, especially if it is associated with headache
 Loss of vision in one or both eyes, especially if the vision loss is more peripheral
 Double vision, especially if it is associated with headache
 Hearing loss with or without dizziness
 Speech difficulty of gradual onset
 Nausea or vomiting that is most severe in the morning, confusion and disorientation, and
memory loss.
 The following symptoms are usually not caused by a brain tumor, but may sometimes be
as a headache, abnormal change in behavior, infertility or amenorrhea.
Based on the above mentioned symptomatology which is always backed up with a sound history
taking, the next eminent step is the diagnostic imaging techniques that have evolved immensely
over the past years and have become a valuable adjunct to the sphere of Neuro-oncology
DIAGNOSTIC IMAGING: Contemporary imaging modalities
Imaging Remarks Pros Cons
Good anatomic
CT scan First line visualization Limited reconstruction ability
With Cheaper & Faster
imaging Exposure to ionizing radiation
contrast* More widely available
modality Can be used with metal Poor resolution
objects
Contrast reaction
Gold
MRI with standard Unparalleled resolution Susceptible to motion artifacts
contrast**
§ imaging True multiplanar imaging Cannot be used with metal objects
No exposure to ionizing
modality radiation Claustrophobic, noisy, long times
Expensive

* If the clinical suspicious is very strong, the first diagnostic imaging should be an MRI, if
available
**MRI with standard sequences. If a lesion is detected, an additional and special
sequences likespectroscopy and perfusion is indicated
§ If imaging suspicious for being a metastasis, then additional screening is required to
detect the primary source. This would include a whole body PET-CT if available, failing
which CT of chest, abdomen and pelvis may be done.

NON-INFILTRATIVE LOW GRADE GLIOMA (LGG)/

GLIONEURONAL TUMOURS
(Juvenile Pilocytic Astrocytoma / Dysembryoblastic Neuro Ectodermal Tumours /
Ganglioglioma / Subependymal Giant cell Astrocytoma/ Neurocytoma)
Typical imaging of non-

infiltrative LGG
Resectable lesion Lesion in eloquent area

(Non eloquent cortex)
Surgery +/-
Maximal safe resection electrophysiologic
al guidance
Stereotactic/open/imag Not amenable

e guided biopsy to STBx*
If large residual
GTR/NTR tumor left
behind
Observation
with imaging
Re-surgery if If not amenable
amenable safely to re surgery
Progression
Confirmed non-infiltrative LGG on H&E
IHC markers (IDH, p53and ATRX)
1p19q co-deletion studies (Optional)
Repeat Chemotherapy+
Close-clinico-radiological Surgery
Progression Radiation
observation
GTR-gross total resection

NTR-near total resection
Bx-biopsy
*Appropriate informed consent necessary for treatment

of histological unverified Gliomas (See chart A)

Chart A:
Histologically unverified
Gliomas*
Radiologically low grade Radiologically high grade
Observation Radiation Observation Radiation

with serial +/- with serial +/- Chemotherapy
imaging Chemotherapy imaging Chemotherapy
*All attempts to be done to get a biopsy

INFILTRATING LOW GRADE GLIOMAS INCLUDING

OLIGODENDROGLIOMAS (ODG)
Imaging features of infiltrative LGG
Resectable Lesion (non Lesion in eloquent area

eloquent area)
Awake surgery with
electrophysiological
Maximal safe resection guidance
Not
amenable to
Stereotactic Bx Stereotactic
GTR/NTR Debulking Bx
Large residual
Tumor
Infiltrative LGG
Confirmed infiltrative LGG on H&E

IHC markers (IDH, p53, and ATRX)
1p19q co-deletion studies (Optional)
Expected good compliance Poor compliance, and /

to surveillance imaging and or unfavorable
favorable pignatti’s score & pignatti’s score and/or
low MIB-1 index and 1p/19q high MIB-1
co-deletion Index
Radical radiotherapy-
Focal conformal
Close clinico- Progression technique 50.4-
radiological observation 54Gy/28-30#) 6wks
& deferred RT at +adjuvantchemotherap
progression Repeat surgery if y
feasible
Progression with RT (59.4Gy/33#+Adjuvant

transformation chemotherapy
to higher grade
*pignatti’s criteria (unfavorable if score is three or more :)

1. Age>40 yrs
2. Neurological deficits at presentation
3. Size>6cm * see chart A
4. Crossing midline
5. Astrocytoma histology

ANAPLASTIC ASTRO/ ANAPLASTIC ODG
Imaging features of Anaplastic

Astro or Anaplastic ODG
Rsectable lesion (non Lesion in

eloquent cortex) Surgery +/- eloquent area
guidance
Maximal safe
resection Stereotactic Bx
Confirmed Anaplastic astro or Anaplastic ODG

IHC markers (IDH, p53 and ATRX) 1p19q co- Not amenable to surgery
deletion studies (Optional) Or stereotactic biopsy*
Consider Radical Radiotherapy Good Poor performance

(60Gy/30#/6wks or 59.4 Gy/33#/6.5wks) performance Status
+ Chemotherapy status
Best
Progression Observation supportive
care
Re-surgery if feasible Poor PS, not

amenable to further
therapy
High precision
Reirradiation may be
considered if feasible
Best supportive
care
Salvage chemotherapy
*see chart A

GLIOBLASTOMA (GBM )
Imaging feature of
GBM or Variants
Resectable lesion (non Lesion in eloquent

eloquent cortex) area
Surgery +/-
guidance
Maximal safe
resection Stereotactic Bx Not amenable
stereotactic Bx*
Confirmed GBM or variant on H&E

(IHC markers may be done for
prognostic information)
Good Poor
Radical Chemo Radiation performance performance
60Gy/30#/6wks or 59.4 Gy/33#/6.5wks status status
Concurrent and Adjuvant chemotherapy
Observation Best supportive

care
Progression
Variants
Poor performance
Good status
performance Variants
status
Variants
Best supportive
Re-surgery if care
feasible Variants Variants
High precision Chemotherapy Chemotherapy/ Bevacizumab *see chart A

Reirradiation with (TMZ/PCV) In selected cases
TMZ in selected
cases

EPENDYMOMA
Ependymal tumor after maximal
safe resection
Low grade Ependymoma High grade Ependymoma
Anaplastic
GTR confirmed on Incomplete
Ependymoma
MR imaging Resection
Post-operative adjuvant Neuroaxis staging:

Radiological follow- MRI spine
focal conformal
up CSF cytology
54Gy/30#/6wks
Recurrence Negative MRI Positive MRI

Recurrence spine and CSF spine and CSF
Repeat surgery Post-operative CSI (36

focal conformal RT Gy/20#)+local tumor
59.4Gy/33#/6.5wks boost upto 59.4 Gy
Post-operative
focal conformal RT Progression
54Gy/30#/6wks
Repeat surgery if
feasible
Reirradiation if
feasible

BRAIN STEM GLIOMA
Brain Stem Glioma
Tectal plate Focal/Dorsal Diffuse Infiltrative

Exophytic pontine Glioma
(Radiology
Rx of Surgery Electrophysiology guided

hydrocephalus resection/biopsy
RT 54 Gy/30#/6wks
Observation GTR Biopsy only
Progression
Observation
Progression
RT 54
Pilocytic Grade 2, 3, 4 Gy/30#/6wks
Biopsy if Chemotherapy
Observation RT Supportive In selected cases
amenable
Grade2: 54 care
Gy/30#/6wks
Grade 3, 4
55.8Gy/31#
Asymptomatic Symptomatic /6.5wks
Or
59.4Gy/33#/
6.5 wks
Observation RT 54
Gy/30#/6wks

PRIMITIVE / EMBRYONAL CNS TUMOURS
Primitive/Embryonic CNS tumours
Neuraxis staging
Medulloblastoma ATRT
Maximal safe resection MSR (if surgically feasible)

(Molecular profile may be done
for prognostication)
CSI (36Gy/20#/4wks
+
Average-risk disease High-risk disease
Tumor Bed Boost (19.8
Age>3yrs/Residual Age <3yrs/Residual
Gy/11#/2½wks)
tumor<1.5cm3/M0 tumor≥1.5cm2and /or
+/-
M+
Adjuvant systemic
chemotherapy
CSI (23.4 Gy/13#/3wks CSI (36Gy/20#/4wks)

+ +
Tumor Bed Boost PF Boost (19.8Gy/11#2½wks
(30.6Gy/17#/3½wks) +
+ Boost to gross metastatic deposits
Concurrent weekly VCR followed (5.4-9Gy/3-5# concurrent weekly
by six cycles of adjuvant VCR followed by 6cycles of
chemotherapy adjuvant systemic chemotherapy)

CRANIOPHARYNGIOMA
Craniopharyngioma
Maximal resection
GTR/NTR STR (residual)
Observation Adjuvant focal

Close observation Conformal RT-
54 Gy/30#/ 6wks
Progression
Repeat surgery if feasible

Direct RT
followed by RT

PITUITARY ADENOMA
Pituitary Adenoma
Visual Symptoms No visual symptoms & non

secretory
Maximal resection
Observation
secretory Non-secretory
STR (residue) GTR (noresidue) GTR (noresidue) STR (residue)
Medical Close Close Adjuvant RT-Focal

Management observation observation Conformal
(Cabergoline for 45 Gy/25#/5wks
prolactinomas)
(Octreotide for GH
secreting)
Recurrence re-
surgery if feasible Observation
Progression
Progression
Surgery if
required and
feasible Surgery if
required and
feasible
RT 50.4 Gy/28#
RT 50.4 Gy/28#

MENINGIOMA
Imaging features of meningioma or

Variants inclusive of HPC
Not amenable to
MSR
biopsy
GTR/NTR STR
Pathological Pathological Pathological Adjuvant RT

Grade I Grade II Grade III 59.4Gy/33#/6½
wks or
SRS/SRT
Observe Observation Adjuvant
RT 59.4
Gy/33#/
6½w
Recurrence
RT Observation
50.4 Gy to 54Gy/28-
Re-surgery if feasible
30# or SRS/SRT
+
Adjuvant RT if indicated

VESTIBULAR SCHWANNOMA
Vestibular schwannoma
Audiometry
Familial (Bilateral) (NF-2)

Sporadic (Unilateral) On clinic-radiological
Surveillance
< 3cm > 3cm

Surgery (Larger Observation
tumor, worse
hearing)
Surgery SRS Maximal
Resection
GTR/NTR STR
GTR/NTR Residual
Observation <2.5cm >2.5cm
Observe Small Large

Observation / Resurgery if
RT feasible
Observation / RT
SRS Observe Resurgery if RT 54
feasible Gy /30#/ 6wks

PRIMARY CNS GERM CELL TUMORS / PINEAL TUMORS
Pineal tumors
MRI suggestive of
Germ cell tumors
Pineocytoma PPTID Pineloblastoma
CSF Positive for CSF markers

AFP and or negative GTR STR GTR STR GTR STR
Beta HCG
indicating Non
Germinoma Hydrocephalus
Observation RT Observation RT
50- 50-
55Gy 55Gy
Yes No
Hydrocephalus
(ETV/VP CSI (36Gy/20#/4wks
shunt/Biopsy/Surgery Local site boost up to
Yes ) 54Gy+chemotherapy
ETV/VP
shunt/surgery
Germinoma Non Germinoma
Chemotherapy
followed by CSI
(36 Gy CSF Positive CSF Negative
/20#/4wks Local CSI (36 Gy
site boost up to /20#/4wks Local
54Gy site boost up to
CSI (36 Gy /20#/4wks Combination therapy 54Gy
Local site boost up to 2-4 cycles +
54Gy chemotherapy followed Chemotherapy
+ by RT (whole
Chemotherapy ventricular/whole brain
depend on site

PRIMARY CNS LYMPHOMA
Clinico-radiological Neuraxial &

suspicion of PCNSL Systemic staging
Withhold steroids
Steriotatic or open
biopsy
Histology other than PCNSL

high-grade lymphoma
Treat appropriately Immunocompetent

as per histology host
Immunocompromised Age<60y Age>60y Very

host poor PS
WBRT 45Gy in 25# High-dose High-dose Palliative

+ MTX based MTX based WBRT or best
Boost 9 Gy in 5# chemo* chemo alone supportive
Chemo if counts +/- care
and performance WBRT
status allow with/without
boost
*Autologous Stem Cell Transplantation in Selected Cases

Spinal cord tumors
Astrocytoma Ependymoma Meningioma
GTR STR Observatio GTR STR Observatio GTR STR Observatio

n with n with n with
serial serial serial
imaging imaging imaging
Low grade/ Adjuvant Low grade Radiation Observatio RT

Young age/ RT Observation (45-55.8 n (52.2-54 Gy)
Good PS Low grade High grade Gy) Or
(45-50.4 Adjuvant RT Close
Gy) Observation
High grade
(55.8-59.4
Observatio Gy)
n with
serial
imaging

Radiotherapy dose prescriptions in brain tumors
ADULT LOW GRADE 3D RT/IMRT/VMAT 45-54Gy, 1.8Gy/#

GLIOMA
IDH WILD TYPE ADULT 3D RT/IMRT/VMAT 45-54Gy, 1.8Gy/#
LOW GRADE GLIOMA
ANAPLASTIC GLIOMA 3D RT/IMRT/VMAT 60Gy in 30#,
59.4 Gy in 33 #
Or
46 Gy in 23 # followed by
boost 14 Gy in 7#
GLIOBLASTOMA 3D RT/IMRT/VMAT 60Gy in 30#,
59.4 Gy in 33 #
or
46 Gy in 23 # followed by
boost 14 Gy in 7#
or
54-55.8Gy, 1.8-2Gy# (Large
tumors, if dose constraints not
met)
GLIOBLASTOMA (POOR 3D RT/IMRT/VMAT 50Gy in 20#
PERFORMANCE STATUS) 40.05Gy in 15#
34Gy in 10#
30Gy in 10#
25Gy in 5 #
20Gy in 5 #
ADULT INTRACRANIAL 3D RT/IMRT/VMAT 54-59.4Gy, 1.8-2Gy/#
AND SPINAL
EPENDYMOMA
CSI FOR EPENDYMOMA 3D RT/IMRT/VMAT 36Gy, , 1.8Gy/# to spine
Followed by boost to brain
upto 54-59.4Gy, 1.8Gy/#
MEDULLOBLASTOMA 3D RT/IMRT/VMAT 30-36Gy, 1.8Gy/# (CSI)

54-55.8Gy, 1.8Gy/# (boost)-
for high risk
OR
23.4Gy in 1.8Gy/# (CSI)
54-55.8Gy, 1.8Gy/#
(boost)(For average risk)

PRIMARY CNS 3DCRT/IMRT/VMAT CR post chemo

LYMPHOMA 23.4Gy in 1.8Gy/#
<CR post chemo
30-36Gy + boost to 45Gy,
1.8Gy/#
PRIMARY SPINAL CORD 3DCRT/IMRT/VMAT Above Conus medullaris

TUMORS 45-54Gy,1.8Gy/#
Below Conus medullaris
60Gy, 2Gy/#
MENINGIOMA
GRADE 1 3DCRT/IMRT/VMAT 45-54Gy,1.8Gy/#
SRS 12-16Gy, Single Fraction
25Gy, 5Gy/#
GRADE 2 3D CRT/IMRT/VMAT 54-60Gy, 1.8Gy-2 Gy/#
GRADE 3 3D CRT/IMRT/VMAT 59.4-60Gy, 1.8Gy-2 Gy/#
BRAIN METS 3DCRT 20-40Gy in 5-20#
SRS 27Gy in 3 #
30Gy in 5#
16-20 Gy in single fraction

Principles of Chemotherphy
1. Chemotherapy for Gliomas

a. Temozolomide
Concurrent  75 mg/m2 daily concomitant with radiation , 7 days /week ( D 1-42
Adjuvant
150 – 200 mg/m2 day 1-5 , six to twelve cycles
b. PCV Regimen
Dru Dose Route of Administered on day

g administration (s)
Procarbaz 60 PO Days 8 through 21
ine mg/
m2
Lomustin 110 PO Day 1
e mg/m
2
Vincristin 1.4m IV Days 8 & 29

e g/m2
2. Chemotherapy for Medulloblastoma & other Embryonal tumors

a. Concurrent chemotherapy  Concurrent weekly vincristine (1.5mg/m2) given as an
intravenous bolus throughout the course of RT
b. Adjuvant chemotherapy should start at least 3 weeks after (preferably at 4‐ weeks, but
definitely within 6‐ weeks) completion of RT to allow for myelo‐ recovery
c. Adjuvant chemotherapy  A total of 6‐ 8 cycles of should be administered generally
cycled at 3‐ 6 weekly intervals (depending upon the regimen used)
d. The regimen (drugs, doses, cycling) of adjuvant chemotherapy is largely independent
of risk‐ stratification
e. Therapeutic regimens for infant medulloblastoma have included multi‐ agent
chemotherapy Including carboplatin/cisplatin, etoposide, cyclophosphamide,
vincristine with or without the use of systemic high dose methotrexate and/or
intrathecal methotrexate.
Drug Dosage Days and route of administration

Regimen I (Packer's regimen)
Cisplatin 75 mg/m2 Day 1 only (intravenously) Day 1 only
Lomustine Vincristine 75 mg/m2 (per orally)
1.5 mg/m2 Days 1,8 and 15 (intravenously)
Regimen II
Cisplatin 75 mg/m2 Day 1 only (intravenously)
Cyclophosphamide 1000 mg/m2 Days 1 and 2 (intravenously)
Vincristine 1.5 mg/m2 Days 1, 8 and 15 (intravenously)
Regimen III
Cisplatin 75 mg/m2 Day 1 only (intravenously) in cycle 2, 4
and 6 only

Cyclophosphamide 1000 mg/m2 Days 1 and 2 (intravenously) in cycle 1, 3

and 5
Days 2 and 3 (intravenously) in cycle 2, 4
and 6
Vincristine 1.5 mg/m2 Days 1 and 8 (intravenously) in all 6
cycles
Adjuvant chemotherapy regimen for Infant medulloblastoma (<3 years of age)
Carboplatin 600 mg/m2 Day 1 only (intravenously) Day 1 only
Cyclophosphamide Etoposide 1000 mg/m2 (intravenously)
2
100 mg/m Days 1, 2 and 3 only (intravenously)
3. Chemotherapy for Germ cell tumors

The optimal chemotherapy regimen has not been defined. The available literature
recommends platinum-based regimens
Drug Dose Route Schedule

Carboplatin (AUC) 5 Day 1 IV Cycle 1, 3, 5
Etoposide 100 mg/m2 Day 1-3
Carboplatin (AUC) 5 Day 1 IV Cycle 2,4,6
Ifosfamide Mesna 2
1gm /m Day 1-3 400 mg (0-4-8 hrs)
4. Chemotherapy for Primary CNS Lymphoma (PCNSL)

a. RTOG PROTOCOL for Primary CNS Lymphoma
Methotrexate 2.5 gm/m2 IV D1 Week 1, 3, 5, 7,
9
Calcium Leucovorin 20 mg PO/IV Q6H x 12
doses Starting 24 hrs
after MTX infusion
VCR 1.4 mg/m2 IV D1 Week
1,3,5,7,9
Procarbazine 100mg/m2/day PO D1-7 week
1,3,5,9
Dexamethasone 16mg PO D1-7
Reduce to 12, 8, 6, 4 over next 5 weeks
Whole brain XRT 45 Gy Week 11-15. In patients who responded completely to induction
chemotherapy, dose reduced to 36 Gy
Post XRT
Cytarabine 3 gm/m2 IV D1&2
Week 16, Week 19
b. Ferreri / IELSG Protocol for Primary CNS Lymphoma (21 days)

Methotrexate 500mg/m2 IV (over 15 mts) D1

3000mg/m2 IV (over 3 hrs) D1
Cytarabine 2000mg/m2 IV BD D2&D3
c. MATRix Regimen for Primary CNS Lymphoma (21 days)

Rituximab 375mg/m2 IV D-5 & 0
Methotrexate 500mg/m2 IV(over 15 mts) D1
3000mg/m2 IV(over 3 hrs) D1
Calcium Leucovorin 15 mg/m2 Q6H D2
Starting 24 hours from start of MTX
Cytarabine 2 g/m2 IV BD D2&D3
Thiotepa 30mg/m2 IV D4

APPENDIX


GUIDELINES ON MULTIDISCIPLINARY TUMOR BOARD

Introduction:
For effective management of cancer, many therapeutic, diagnostic and supportive
disciplines and experts are involved. A multidisciplinary approach to the care of cancer patients
is commonly incorporated in almost all major cancer centres around the globe. Multidisciplinary
Tumor Boards (MDT) have become an important asset for the management and treatment of
cancer patients, leading to significant improvement in the quality of medical services offered and
possibly to better outcome. Studies have reported significant improvement in the survival of
patients managed through MDT compared to those who were not. Studies also have
demonstrated that demonstrated different treatment plan evolved after discussion in MDT.
MDTs are formal, regularly-scheduled meetings in which a group of specialists involvedin the
care of cancer patients meet to review individual cancer patients in a prospective manner to
discuss the diagnosis and formulate management plans using an evidence-based approach that is
individualized to a patient and deliverable in the treatment setting. These meetings typically
involve core groups of medical oncologists, radiation oncologists, surgeons, radiologists, Pain
and palliation specialists and pathologists, as well as other ancillary members of the healthcare
team and other allied healthcare professionals. Evidence suggests that MDTs can improve
diagnostic accuracy, adherence to clinical practice guidelines, and clinical outcomes (1,2,3).
In India, multidisciplinary tumor boards exist in almost all major cancer centres and
academic institutions for management of cancer. The multidisciplinary tumour board which goes
under different names in various institutions such as Tumour board, Disease management
groups, multi-speciality boards etc should be an essential component of any centre managing
cancers. The tumour boards may be site specific or general (common for all sites), depending on
the volume of cases at that centre.This document is a general guideline for functioning of MDT
in institutions in Kerala where cancer treatment plan of patient is initiated.
Composition of a MDT:
The composition of MDT includes specialists in therapeutic, diagnostic and ancillary and
supportive services. But there are certain practical difficulties in bringing all such divisions in
every institution for lack of manpower, non- existence of departments, volume of patients
involved etc. Hence this guideline has divided the members into two groups.
A] Mandatory members
B] Preferred members
Mandatory Members:
1. Radiation oncologist
2. Medical oncologist /Oncologist practicing chemotherapy
3. Surgical oncologist or surgeon practicing cancer surgery or with expertise in specific
type of cancer surgery
4. Pathologist
5. Radiologist
Preferred Members:
1. Palliative care specialist
2. Rehabilitation specialist
3. Medical Social Worker

Chairman:
The chairman shall be a senior specialist belonging to Medical, Surgical or Radiation disciplines.
The quorum:
It is ideal to have both mandatory and preferred members for all MDT meetings. For
proper functioning of a MDTB, it should have at least 2 members from the mandatory
therapeutic specialty group ie two from medical/radiation/surgical oncology and pathologist and
radiologist and 1 member from the preferable group. The quorum should be a minimum of 3
different specialists with two of them belonging to therapeutic departments. The MDT
recommendation should be signed by the chairperson and one member from the radiation,
medical or surgical departments.
In centres where all three oncology specialities are not available, the MDTB shall be
conducted under any of the oncology departments. It‘s the responsibility of each institution to
develop Standard Operating Practice (SOP) for smooth functioning of MDT in the institution
based on its strengths and weaknesses.
Constitutionof MDT:
The frequency of MDT can be decided based on the volume of cases handled by the
unit/institution. Generally the frequency shall not be less than once a week. Ideally all cases of
malignancy should be discussed before initiation of curative treatment; however in centres with
large volume and where the proposed treatment is similar to that adopted in that institution, it is
necessary only to list the patients and mention the planned intent of treatment and basic
treatment plan. The general protocol of treatment of different sub-site for the institution should
be developed and approved by the MDT of that particular institution.The list of all patients must
be recorded in the MDT records. Individual institution can incorporate necessary modification in
SOP based on what is practical in the institution, without compromising the oncologic outcome
of the individual patient. Following are the general guidelines of MDT functioning-
1. All cases before initiation of treatment especially those patients that require complex and
multidisciplinary treatment should be discussed individually. This includes bone and soft
tissue sarcomas of all sites, pediatric tumours and recurrent patients offered curative
intent treatment. Even if protocol exists, these groups shall be brought to MDT before
starting treatment.
2. During treatment if any deviation from protocol is required, it is to be brought to the
attention of MDT and reason for deviation should be documented.
3. Patients on follow up requiring additional treatment for recurrence
4. Those patients with diagnostic or management dilemma
Documentation:
All tumour board discussions and decisions should be documented, preferably in the case
record as a dedicated tumor board report, or in the case record itself. The essential
documentation of MDT shall include (1) Diagnosis, (2) Stage, (3) Intent of treatment, (4)
Indented sequence and modality of treatment.A list of attendees of the MDT should be recorded
for each of the meetings. A format for documentation is given below. The document should be
signed by the designated chairperson and one other member of the mandatory group.
Compliance monitoring:
1. It is desirable to audit whether all the cases were discussed or documented in the MDT in
an institution and to study the gaps in effective implementation

2. In academic institutions, MDT can be quasi-academic meetings for post graduate

students. Hence if adequate time provided for them to work on the literature related to
such cases, the quality MDT discussions can improve

Format for MDT*
Date: Patients name: Age/ Sex:
Diagnosis:
Stage:
Performance Status:
Brief case history, findings and investigation reports (Relevant for the case):
Major comorbidities:
Questions/Discussion in the tumour board:
Treatment recommendations:
Intent of treatment: Curative/ Palliative/ Indeterminate
Treatment modalities and sequence of treatment:
Any major anticipated morbidities:
Please state whether the decision is compliant to KCG guidelines:
 If not, the reason
Signature:
Chairperson:
Primary physician:
Medical/ Radiation/ Surgery Specialits:
*Each institution shall prepare the format as per SOP

References:
1) MacDermid E, Hooton G, MacDonald M, McKay G, Grose D, Mohammed N, Porteous
C: Improving patient survival with the colorectal cancer multi-disciplinary team.
Colorectal Dis 11: 291-295 https://doi.org/10.1111/j.1463-1318.2008.01580.x.
2) Richardson B, Preskitt J, Lichliter W, Peschka S, Carmack S, de Prisco G and Fleshman

J: The effect of multidisciplinary teams for rectal cancer on delivery of care and patient
outcome: Has the use of multidisciplinary teams for rectal cancer affected the utilization
of available resources, proportion of patients meeting the standard of care, and does this
translate into changes in patient outcome? Am J Surg 211: 46-52, 2016.
3) Lesslie, M.D.; Parikh, J.R. Multidisciplinary tumor boards: An opportunity for

radiologists to demonstrate value. Acad. Radiol. 2017, 24, 107–110

FREQUENTLY ASKED QUESTIONS (FAQs)
1. In centres with large number of patients, how can every patient be discussed in
MDT?
Ideally every patient with cancer before initiation of treatment after work up should be
discussed in MDT.But there are high volume institutions where such practice may not be
possible.In such centres with large volume and where there is an accepted protocol(in
compliant with KCG guidelines) for straightforward cases, only those cases needing
deviation from the protocol shall be discussed. The per-protocol cases shall ideally be
seen and agreed on protocol management by at least two therapeutic specialists of
different streams before initiating treatment.But individual institution shall take decision
suitable based on the circumstances in the institution and it shall be mentioned in SOP.
2. Some patients are diagnosed cancer after surgery. How can they be involved in
MDT discussion?
There are situations where patients may be diagnosed to have cancer after resection. This
should be an exception rather than rule. All cases should be brought to MDT before
attempting resectionespecially any bone and soft tissue sarcomas. Primary diagnosis can
avoid unnecessary morbidity of re-resection following previous non-oncologicprocedure.
This will help in planning further treatment in a more organised manner. It is to be noted
that emergency treatment should not be denied awaiting pathologic diagnosis or MDT
decision. For e.g. brain or neural cord compression, impending airway obstruction.
3. In institutions like medical colleges and multi-speciality hospitals where the
oncology wing is separate, once the patient is diagnosed as cancer in departments
other than oncology, they may get referred to another centre. Can MDT be involved
in referral pathway?
Yes.Ideally such patients shall be discussed in MDT.This will enable other departments
involved in such treatment to provide further inputs on management. There is a high
possibility that patient need not be referred to another centre,but treated in the same
institution. This may avoid out of pocket expenditure for the patient. The decision on
such practice shall be taken at individual institution and incorporated in SOP of MDT. In
addition, the authorities may be involved to improve the facility in the institution to cater
to such patients
4. If the treatment is straight forward, should the patient be discussed in MDT?
Yes. Ideally all patients should be discussed or listed in MDT. Unseen intricacy may be
brought by colleagues and decision may change.
5. In district hospitals and general hospitals under Government, setting up of MDT is
difficult and almost impractical. But cancer patients are treated in such institutions.
How can this be solved?
It is always better to get the opinion from a tertiary cancer centre such as medical
colleges or apex cancer centres in the state before proceeding with primary treatment of
cancer. Providing primary treatment without discussion in MDT is strongly discouraged
for the benefit of patient. If there is difficulty in referring the patient to higher centre for

opinion, telemedicine facility shall be used to get opinion and this shall documented. It is
also advised to have a tie up with higher centres to get involved in their MDT.
6. Should MDT discussion /decision document required for insurance claim?
This decision shall be taken at policy making level.
7. If chairperson is not available for signing the document, who is authorised to sign?
Next senior member in MDT attended on the day shall sign.
8. If a patient on follow up develops recurrence, but he/she is not offered any
treatment except supportive care.Should this patient be brought for MDT
discussion?
Ideally yes.The MDT may change the decision based on factors not considered by
primary physician. This may generally be beneficial for the patient. SOP of each
institution may address this.
9. Can patient be seen and examined in MDT?
This decision shall be taken at institution level based on its policy. All measure to ensure
privacy of patient need be overemphasized.


Cancer Care

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cancer Care

Uploaded by

Copyright:

Available Formats

FOREWORD

Sri. Rajeev Sadanandan IAS,

Rajeev Sadanandan IAS

KERALA CANCER GRID

The Standard Treatment Guidelines is not a medico-legal document and no claim on

2 Dr. Abhay Khattepure

3 Dr. Acka Priya Varghese

4 Dr. Adarsh Anand

7 Dr. Aju Mathew

8 Dr. Akhil P.Suresh

9 Dr. Amrutha Ramachandran

12 Dr. Anitha Mathews

15 Dr. Anupama Rajan Babu

16 Dr. Aravidh S Anand

17 Dr. Arun Chandrasekharan T

18 Dr. Arun Peter Mathew

20 Dr. Arun Sankar S

22 Dr. Aruna T.H

24 Dr. Ashwathy Krishnan

25 Dr. Aswathy P.Sivaram

26 Dr. Aswin Kumar

36 Dr. Binitha T Thomas

37 Dr. Bipin T Varghese

38 Dr. Boben Thomas

40 Dr. Chandran K Nair

43 Dr. Deepa Susan Joy Philip

44 Dr. Dhanya Dinesh

45 Dr. Dileep Damodharan

46 Dr. Dileep Panicker

48 Dr. Dinesh Makkuni

52 Dr. Divya R Prasad

53 Dr. Durga Prasanan

54 Dr. Elizhabeth Mathew Iype

55 Dr. Flowerlit Thomas

56 Dr. Francis V James

57 Dr. V.P. Gangadharan

58 Dr. K.V. Gangadharan

59 Dr. Geetha G Nair

62 Dr. Geethi M.H

65 Dr. Greeshma K.E

66 Dr. Guna Prasad C.S

67 Dr. Harish Sugathan

68 Dr. Jacob K.J.

69 Dr. K.K. Jayakumar

70 Dr. P.G. Jayaprakash

75 Dr. Jem Prabhakar

77 Dr. Jithin T.K

79 Dr. John Joseph

80 Dr. Joneetha Jones

82 Dr. Jubie Roy

84 Dr. Kandathil Joseph Philip

88 Dr. Kurien Cherian

89 Dr. Lakshmi Haridas K

90 Dr. Leelamoni S.Y

92 Dr. Lissiamma George

93 Dr. Madhu Muralee

95 Dr. Malu Rafi

97 Dr. Manoj Kumar R

98 Dr. Manu Prasad.A

99 Dr. Mathew Abraham

100 Dr. Megha Jayaprakash

102 Dr. Mini C. H.

103 Dr. Mira S Wagh