Endometrial stromal sarcoma

　　Endometrial stromal sarcoma is a type of sarcoma that originates from the stromal cells of the endometrium. Most highly malignant endometrial stromal sarcomas originate from the endometrial stroma; lowly malignant endometrial stromal sarcomas only grow along expanded lymphatic or blood vessels, and they still originate from the stromal cells of the endometrium. The etiology and mechanism of this disease are not yet clear.

　　Low-grade malignant endometrial stromal sarcoma is particularly common in paracervical vascular tumor thrombus and lung metastasis, followed by local infiltration and lymph node metastasis. Highly malignant endometrial stromal sarcoma has strong local invasive ability, often with myometrial infiltration and destructive growth. With the increase of the tumor size, its blood supply weakens, causing ischemia and necrosis of the tumor. It often complicates bacterial infection, forming purulent secretions with a foul smell.

　　The clinical symptoms and signs of endometrial stromal sarcoma patients, who present with irregular vaginal bleeding, increased menstrual flow, uterus enlargement, and formation of vaginal discharge, are described as follows.

　　1. Irregular vaginal bleeding, increased menstrual flow, vaginal discharge, anemia, lower abdominal pain, etc.

　　2. Uterus enlargement, the early pelvic examination findings are similar to those of uterine wall leiomyoma.

　　3. Soft, friable, and bleeding polypoid masses are found at the cervical os or in the vagina.

　　4. Ulceration and infection of the mass, with extremely foul vaginal discharge.

　　The etiology and mechanism of endometrial stromal sarcoma are not yet clear, so it is not possible to prevent it according to the cause. The main method of prevention is regular physical examination, that is, early detection, early diagnosis, and early treatment. Due to the high recurrence rate of the disease, regular follow-up should be done.

　　The examination of endometrial stromal sarcoma includes hysteroscopy, uterine curettage, color Doppler measurement, and ultrasound examination. The specific examination methods are described as follows.

　　1. Microscopic characteristics

　　The endometrial glands are scattered, reduced, and even completely disappear.

　　Tumor cells are uniformly dense,呈梭形、圆形或多角形，nuclei are large, and there are few giant tumor cells. Nuclear division is frequent, and the cytoplasm is variable. In rare cases, they are somewhat similar to decidual cells and may exhibit glandular differentiation.

　　The heterogeneity of sarcoma cells varies, with small atypicality. The infiltrative growth of tumor cells and nuclear division are the main criteria for diagnosing sarcoma. When the heterogeneity of tumor cells is large, there may be abnormal nuclei, giant nuclei, and multinucleated cells. When performing silver staining, each tumor cell is within the silver fiber.

　　The cytoplasm of tumor cells resembles early proliferative phase endometrial stromal cells.

　　2. Preoperative curettage

　　It has certain value for endometrial stromal sarcoma, but the base of the polypoid lesion is wide, and curettage has certain limitations.

　　3. Color Doppler measurement

　　Detect the blood flow signal and blood flow resistance of the uterus and tumor. For those with low resistance blood flow, a high degree of suspicion of uterine sarcoma should be entertained.

　　4. Ultrasound examination

　　The uterus is significantly enlarged, the tumor boundary is irregular, the boundary with the myometrium is unclear, and the echo is uniform low echo, or呈网格状蜂窝样强弱不均回声，similar to hydatidiform mole.

　　Patients with endometrial stromal sarcoma can consume silver ear and lotus root starch soup, two fresh soups, and tumor-removing eggs, etc. Patients should avoid foods that cause heat; avoid smoking, drinking, and spicy刺激性 food, etc. The specific food therapy formula, diet taboo is described as follows.

　　I. Food therapy recipe

　　1. Silver ear and lotus root starch soup

　　25 grams of silver ear, 10 grams of lotus root powder, and appropriate amount of rock sugar. After the silver ear is soaked and softened, add appropriate amount of rock sugar and simmer until烂, then mix with lotus root powder and take it.

　　Effects: It has the effects of clearing heat, moistening dryness, and stopping bleeding.

　　Indications: Menorrhagia with bright red menstrual blood.

　　2. Double fresh soup

　　120 grams of fresh lotus root sliced, 120 grams of fresh scutellaria root chopped, boiled into juice to be taken as tea.

　　Effects: Nourish yin and cool blood, remove blood stasis and stop bleeding.

　　Indications: Menorrhagia, blood-heat and blood stasis type.

　　3. Tumor-reducing egg

　　Two eggs, five geckos, 9 grams of rhizoma curcumae, boiled together with 400 grams of water. After the eggs are cooked, peel them and boil them again, discard the medicine and eat the eggs, taken once a night.

　　Effects: Dissipate nodules and relieve pain, dispel wind and calm惊.

　　Indications: Qi-stagnation and blood stasis type.

　　4. Ivory jade milk:30 grams of ivory powder, taken with soy milk.

　　5. Decoction of walnuts:6-8 walnuts, 30 grams of magnolia bark, boiled with honey, discard the medicine and eat the walnuts.

　　6. Mugwort and egg:Two eggs, 10 grams of mugwort, boiled together, discard the mugwort and eat the eggs.

　　II. Dietary taboos

　　1. It is advisable to eat dandelion greens, melon, burdock, lotus seeds, jujube, oyster, turtle, sea horse, etc.

　　2. Increase the intake of walnuts, lotus seeds, Job's tears, mushrooms, jellyfish, etc. Prefer foods that have a bidirectional regulatory effect on hormones, such as sea cucumber, sea asparagus, humpback whale,燕鳐鱼, etc.

　　3. Foods to prevent and treat the side effects of chemotherapy and radiotherapy: tofu, pork liver, freshwater fish, mackerel, squid, duck, beef, frog, hawthorn, black plum, mung bean, fig, etc.

　　4. For excessive leukorrhea: It is advisable to eat cuttlefish, sea asparagus, clam, clam, oyster, turtle, sheep pancreas, sparrow, jellyfish, cowpea, white sesame, walnut, lotus seed,芡实, celery, etc.

　　5. For lumbar pain: It is advisable to eat lotus seeds, walnuts, Job's tears, chive, plum, chestnut, taro, turtle, jellyfish, bee milk, horseshoe crab, etc.

　　6. For edema: It is advisable to eat sturgeon, sea asparagus, adzuki bean, corn, carp, mackerel, loach, clam, eel, duck meat, lettuce, coconut milk, etc.

　　7. For hemorrhage: It is advisable to eat shark fin, black fungus, sea cucumber, manta ray, mushrooms, shiitake, sea asparagus, broad bean, etc.

　　8. Avoid irritants such as roosters.

　　9. Avoid smoking, alcohol, and spicy刺激性 foods.

　　10. Avoid greasy, fried, moldy, and salted foods.

　　11. Avoid warm and spicy foods such as lamb, chive, pepper, ginger, cinnamon, etc.

　　The treatment for endometrial stromal sarcoma includes surgery, chemotherapy, radiotherapy, and hormonal therapy, with the specific treatment methods described as follows.

　　I. Surgical treatment

　　For patients diagnosed with uterine sarcoma, timely surgical treatment should be considered.

　　1. The surgical scope for low-grade malignant endometrial stromal sarcoma includes the removal of the whole uterus and both adnexa, and it is not advisable to retain the ovaries. Even in cases of widespread metastasis, the lesions should be removed as cleanly as possible. Lung metastasis patients may undergo lung lobectomy.

　　2. High-grade malignant endometrial stromal sarcoma is prone to recurrence after surgery. For advanced patients, palliative surgery can be performed to alleviate symptoms, followed by adjuvant radiotherapy and chemotherapy.

　　II. Chemotherapy

　　1. The treatment for low-grade malignant endometrial stromal sarcoma mainly includes the regimen of cisplatin (DDP) or ifosfamide every 3 weeks.

　　2. Highly malignant endometrial stromal sarcoma uses the IAP regimen (ifosfamide + ADM + as described below cisplatin).

　　Three, Radiotherapy

　　Indications: patients with residual lesions after surgery, stage I and above patients, highly malignant endometrial stromal sarcoma.

　　1. The treatment plan for postoperative external irradiation needs to be formulated according to the postoperative residual tumor and metastasis, and the field setting for postoperative external irradiation is roughly the same as that for postoperative prophylactic pelvic irradiation.

　　(1) Residual sarcoma at the central pelvic area:The whole pelvic irradiation dose for the tumor is increased to 40Gy, and the central lead shielding four-field irradiation is still 15Gy.

　　(2) Large pelvic wall mass:After completing the whole pelvis and four-field irradiation, a further field reduction can be performed with a dose of 10-15Gy.

　　(3) Positive paraaortic lymph nodes:Another field is set, with an irradiation dose of 45-55Gy, 8.5Gy per week, completed within 4-6 weeks.

　　When the range of the lesion exceeds the pelvic range, an additional field can be added to the upper abdomen, the size of the irradiation field is determined according to the range of the lesion, and lead shielding is needed for the liver and kidney areas. If the range of lung metastases is small, external irradiation can be performed on the lung metastases.

　　2. Remote-controlled afterloading intracavitary radiotherapy is used before intracavitary radiotherapy.

　　Based on the reference point (A point) of intracavitary radiotherapy for cervical cancer, 15-20Gy is appropriate, and it is best to ensure uniform distribution of the dose to the uterus.

　　When there is residual sarcoma at the vaginal stump after surgery, after the whole pelvic irradiation in vitro, it can be supplemented with intracavitary irradiation at the same time as the four-field pelvic irradiation after the whole pelvic irradiation, with a dose reference point of 0.3cm submucosa, a total dose of 24-30Gy can be given, completed in 3-5 times, with an interval of 4-7 days.

　　Four, Progesterone-containing Drug Treatment

　　1. Indications:Patients with positive progesterone receptor and estrogen receptor.

　　2. Precautions:Long-term use is recommended, generally advocating for more than 1 year.

　　3. Commonly Used Medications:

　　(1) Oral acetate medroxyprogesterone, long-term maintenance.

　　(2) Oral medroxyprogesterone, long-term maintenance.

　　(3) Intramuscular injection of hydroxyprogesterone caproate, or long-term maintenance with the above oral medications.

　　For patients with negative progesterone receptor, tamoxifen is initially used to increase the sensitivity of tumors to progesterone-containing drugs, and then medroxyprogesterone acetate (MPA) is applied.