Uterine sarcoma

　　The exact etiology of uterine sarcoma is unknown. Some believe from the perspective of histogenesis that it is related to the residue of embryonic cells and metaplasia of stromal cells. A history of pelvic radiotherapy and long-term stimulation by estrogens may be risk factors for the disease, but there is no clear evidence to prove the above inference. There are many primary cases, originating from the smooth muscle fibers of the uterine muscle layer or the smooth muscle layer of the uterine blood vessels, and some come from the uterine smooth muscle myoma.

　　The main routes of metastasis for uterine sarcoma are mainly three:

　　1. Hematogenous dissemination is the main route of metastasis, transferring through the blood circulation to various parts of the body such as the liver and lungs.

　　2. Direct infiltration of the sarcoma, which can directly invade the uterine muscle layer, even reaching the serous layer of the uterus, causing intraperitoneal dissemination and ascites.

　　3. Lymph node metastasis, less common in the early stage, more common in the late stage, and more common in those with high malignancy.

　　1. Abnormal vaginal bleeding:It is the most common symptom, manifested as abnormal menstruation or vaginal bleeding after menopause. It accounts for 65.5% to 78.2%.

　　2. Abdominal mass:It is more common in patients with uterine leiomyosarcoma. The mass increases rapidly, and if the sarcoma grows into the vagina, a mass protruding into the vagina is often felt. The uterus is often enlarged, irregular in shape, and slightly soft in texture.

　　3. Abdominal pain:It is also a relatively common symptom. Due to the rapid growth of the myoma, the patient may experience abdominal distension or dull pain.

　　4. Increased vaginal discharge:It can be serous, bloody, or white. In case of infection, it can be purulent and malodorous.

　　5. If the tumor is large, it can compress the bladder or rectum, causing irritation symptoms. Compression of veins can lead to lower limb edema.

　　6. Advanced patients may have weight loss, anemia, fever, systemic failure, pelvic mass infiltration of the pelvic wall, fixed and cannot move.

　　Gynecological examination:The uterus is significantly enlarged, presenting multiple nodular shapes, and is soft in texture. If the sarcoma protrudes from the uterine cavity through the cervical os or into the vagina, a purple-red mass can be seen. In case of infection, there may be purulent discharge on the surface. If it is a grape-like sarcoma, soft, friable, and hemorrhagic tumors may be found in the cervical os or vagina.

　　For benign pelvic lesions, it should be avoided to use radiotherapy without selection, excessive exposure to radiation may lead to the occurrence of sarcoma, which should not be ignored. In addition, due to the difficulty in the early detection and diagnosis of sarcoma, it is best for women before and after menopause to have a pelvic examination and other auxiliary examinations every six months. Any age of women, if there are abnormal vaginal discharge or lower abdominal discomfort, should be examined in a timely manner.

　　1. Ultrasound examination:It can show the internal structure of the uterine tumor, the edge situation, and low-resistance blood flow signals, etc.

　　2. Preoperative biopsy:It has a low diagnostic rate for uterine smooth muscle sarcoma, but has a high diagnostic value for endometrial stromal sarcoma and uterine malignant mesenchymal mixed tumor.

　　3. Specimen examination during surgery:The preoperative biopsy diagnosis of uterine smooth muscle sarcoma is rare. If the myoma and muscle layer are not clearly demarcated during the operation, and the vortex structure is absent, presenting as raw fish-like, and the tissue is crumbly, then rapid frozen section should be sent, but the postoperative paraffin pathological diagnosis still relies on it.

　　1. Suitable foods

　　1. Suitable foods include dandelion, melon, water chestnut, Job's tears, flos flos, prune, burdock, oyster, turtle, sea horse.

　　2. Hemorrhage should be treated with shark fin, abalone, shark, black fungus, mushroom, mushroom, clam, broad bean.

　　3. Edema should be treated with sturgeon, ulva, adzuki bean, corn, carp, leech, eel, fish, duck meat, lettuce, coconut milk.

　　4. Back pain should be treated with lotus seed, walnut meat, Job's tears, chive, plum, chestnut, taro, turtle, jellyfish, bee milk, horseshoe crab, and green crab.

　　5. Women with excessive leukorrhea should eat cuttlefish, clam, winkle, clam, oyster, turtle, jellyfish, sheep pancreas, sparrow, dolichos, white sesame, lotus seed, chestnut, taro, turtle, jellyfish, bee milk, scallops, and green crab.

　　6. Foods to prevent the side effects of chemotherapy and radiotherapy: tofu, pork liver, crucian carp, crucian carp, cuttlefish, duck, beef, toad, hawthorn, prune, mung bean, fig.

　　2. Taboo foods

　　1. Avoid smoking, alcohol, and spicy刺激性 food.

　　2. Avoid greasy, fried, moldy, and preserved foods.

　　3. Avoid warm foods such as lamb, chive, dog meat, pepper, ginger, cassia, etc.

　　1. Surgical treatment

　　The main treatment for uterine sarcoma is surgical treatment. The standard surgical treatment is the total hysterectomy plus bilateral salpingo-oophorectomy, but there are still some controversies about the specific surgical methods, mainly including whether to preserve the ovaries, the clinical significance of lymph node resection, whether it is necessary to perform lymph node resection, and the role of tumor cell reduction in advanced lesions.

　　1. Staging is a part of surgical treatment

　　In 2009, the FIGO issued the surgical staging criteria for uterine sarcoma. The standard surgical staging procedures for uterine sarcoma include total abdominal hysterectomy plus bilateral salpingo-oophorectomy, washing the abdominal and pelvic cavity for tumor cell pathology examination, and biopsying any suspicious areas of tumor infiltration. Some also advocate for the resection of the omentum. In order to accurately stage and evaluate the prognosis, surgical staging should be performed according to the staging steps.

　　2. Selection of surgical treatment methods

　　The surgical treatment methods for uterine sarcoma mainly depend on the histological type of the sarcoma at present. The main controversial issue is whether young patients with early-stage disease can preserve the ovaries and whether lymph node dissection is needed.

　　(1) Uterine leiomyosarcoma: Surgical resection is the only proven curative treatment. The classic surgical procedure includes laparoscopic total hysterectomy and bilateral salpingo-oophorectomy. If extrauterine lesions are found during surgery, tumor cytoreduction should be performed. Although there are reports that extended hysterectomy or extensive hysterectomy is more effective, simple total hysterectomy is more suitable for most patients. There are reports of ovarian trans

　　The incidence of ovarian metastasis is 3.7%, so bilateral salpingo-oophorectomy for patients with uterine leiomyosarcoma has no significant impact on the progression of the disease. In addition, the incidence of lymph node metastasis is 3% to 9%, and patients in stages I and II usually do not have lymph node metastasis. Therefore, for premenopausal patients in stages I or II, it is considered to preserve the ovaries unless there are visible metastatic lesions in the ovaries. Whether to preserve the ovaries should be fully informed to the patients. A recent large-scale study including 1396 cases of uterine leiomyosarcoma also believes that bilateral salpingo-oophorectomy is not an independent factor affecting patient prognosis; in view of the low rate of lymph node metastasis in uterine smooth muscle, and lymph node metastasis is usually associated with other extrauterine lesions, whether to remove the lymph nodes and the extent of removal do not affect patient survival, therefore, pelvic lymph nodes and para-aortic lymph nodes are not definite indications for surgical resection, and routine lymph node dissection is not recommended after diagnosis unless preoperative CT or MRI shows enlarged lymph nodes, or abnormally enlarged lymph nodes are found during surgery or there are extrauterine metastatic lesions.

　　(2) Lowly malignant endometrial stromal sarcoma: The standard surgical procedure includes laparoscopic total hysterectomy and bilateral salpingo-oophorectomy. For patients with extrauterine metastatic lesions, tumor cytoreduction should be performed. For endometrial stromal sarcoma, bilateral salpingo-oophorectomy has become part of the standard surgery because estrogen may be a stimulator of endometrial stromal sarcoma, which has the effect of stimulating tumor growth and may increase the risk of tumor recurrence. However, whether to preserve ovarian surgery for early-stage patients is still a controversial issue. A recent study by Chan et al. on 831 cases of endometrial stromal sarcoma also believes that for stage I to II

　　(3) Highly malignant endometrial stromal sarcoma: It has a high degree of malignancy and is prone to occur extrauterine metastatic lesions, with poor prognosis. The surgical procedure includes total hysterectomy and bilateral salpingo-oophorectomy, and it is recommended to perform pelvic and para-aortic lymph node dissection. Lymph node metastasis is a significant prognostic factor, and the prognosis of patients with lymph node metastasis is significantly worse than that of patients without lymph node metastasis.

　　(4) Uterine adenomyoma: Uterine adenomyoma is a low-grade malignant potential tumor, with an incidence rate of distant metastasis of only 5%. The standard surgical procedure is total hysterectomy + bilateral salpingo-oophorectomy, and compared with other pathological types of uterine sarcoma, it has a better prognosis. However, this type of tumor has a tendency to locally recur late, with about 20% of patients experiencing vaginal, pelvic, or abdominal recurrence, so patients need long-term follow-up.

　　(5) Uterine carcinosarcoma: It has highly malignant biological behavior and has the dual biological behavior characteristics of cancer and sarcoma, and is very likely to metastasize outside the uterus via lymphatic and blood circulation, with a lymph node metastasis rate of up to 20% to 38%, with a very poor prognosis. The new surgical staging criteria are the same as those for endometrial cancer, with the surgical procedure being total hysterectomy + bilateral salpingo-oophorectomy + omentectomy + pelvic and para-aortic lymph node dissection, as well as tumor cell reduction surgery for metastatic lesions, and the number of lymph nodes removed is related to the patient's survival.

　　Two, Radiotherapy

　　Due to the low sensitivity of uterine sarcoma to radiation, literature reports indicate that there are very few 5-year survivors when radiotherapy is used alone. Radiotherapy is more effective for endometrial stromal sarcoma and uterine mixed mesenchymal sarcoma than for leiomyosarcoma. Gilbert believes that radiotherapy should be supplemented before and after surgery for endometrial stromal sarcoma. Many experts believe that postoperative radiotherapy is better than surgery alone. Badib reported a comparison of surgical treatment combined with radiotherapy and surgical treatment alone in various types of uterine sarcoma (clinical stage I) patients, with a 5-year survival rate increased from 57% to 74%. For patients with advanced sarcoma with metastasis or recurrence, radiotherapy can be considered as palliative treatment to prolong life.

　　Three, Chemotherapy

　　Many cytotoxic antineoplastic drugs have a certain therapeutic effect on the metastasis and recurrence of uterine sarcoma. Chemotherapy drugs can be used alone or in combination. The drugs recommended by the 2012 NCCN guidelines include doxorubicin, gemcitabine/doxorubicin, other single drugs that can be chosen include dacarbazine, docetaxel, epirubicin, gemcitabine, ifosfamide, liposomal doxorubicin, paclitaxel, temozolomide, etc. Hormonal therapy is only applicable to endometrial stromal sarcoma, including medroxyprogesterone acetate, megestrol acetate, aromatase inhibitors, GnRH antagonists, tamoxifen.