Recurrent ovarian malignant tumors

　　(I) Etiology

　　The etiology of recurrent ovarian malignant tumors is related to genetics, internal and external environment, and treatment methods.

　　Risk factors for recurrence of ovarian cancer:

　　1. Clinical stage Early-stage cancer has a significantly higher 5-year survival rate than middle and late-stage cancer, with most patients experiencing recurrence within 1 to 2 years.

　　2. Pathological type Serous carcinoma and clear cell carcinoma are more likely to recur than mucinous carcinoma.

　　3. Cell grading Cell grading II to III is more likely to recur, which may be related to the degree of differentiation of tumor cells determining the speed of cell division and the ability to metastasize.

　　4. Size of residual lesions After surgery, if the residual lesions exceed 2 cm in diameter, they are more likely to recur and directly affect the sensitivity of chemotherapy.

　　5. Patients who choose chemotherapy regimens based on non-platinum chemotherapy have a significantly higher recurrence rate than those who receive platinum chemotherapy.

　　6. Patients with poor general condition, older age, or other complications.

　　7. Recent studies have found that changes in certain genes or tumor suppressor genes in ovarian tissue are related to recurrence, such as mutations in the p53 gene, the expression of multidrug resistance gene protein P-gp, and the study of C-erbB-2, which shows that its high expression level predicts earlier and more frequent recurrences.

　　(二)发病机制

　　(Two) Pathogenesis of onset

　　Recurrent ovarian malignant tumors are prone to what complications
　　1. Torsion of the pedicle is relatively common and is one of the gynecological acute abdominal conditions. It is more common in cystic tumors with long pedicles, medium size, high mobility, and a center of gravity biased to one side, often occurring during sudden changes in body position, in the early stages of pregnancy, or postpartum. After torsion of the pedicle, due to the obstruction of venous return, congestion occurs, turning purple or even causing bleeding due to vascular rupture. Necrosis and infection of the tumor can occur due to arterial obstruction. During acute torsion, patients suddenly experience severe lower abdominal pain, which may be accompanied by nausea, vomiting, and even shock. During examination, the affected side of the abdominal wall is tense, with marked tenderness and increased mass tension. Once diagnosed, the tumor should be surgically removed immediately. When operating, do not turn the twisted pedicle back, but instead, clamp and cut it near the site of torsion to prevent thrombus detachment into the blood circulation.
　　3. Infection is less common and often secondary to tumor pedicle torsion or rupture. The main symptoms include fever, abdominal pain, elevated white blood cell count, and varying degrees of peritonitis. Active infection control and planned surgical exploration should be carried out.

　　Common symptoms of recurrent ovarian malignant tumors:
　　1. The vast majority of recurrent sites are in the abdomen, pelvis, and vaginal stump, with a few metastases to the liver, lung, brain, and bone.

　　2. Self-reported symptoms include weight loss, decreased appetite, abdominal distension, abdominal pain, abnormal defecation, and gastrointestinal symptoms; some patients have vaginal bleeding.

　　3. Abdominal distension, intestinal distension, mass, or pleural and peritoneal effusion; some patients present with melena due to intestinal invasion. Pelvic examination is most important, especially digital rectal examination should not be neglected. The pelvic condition should be examined carefully and seriously. Thickened nodules or masses should be described in detail, especially the focus examination of the residual site of tumor resection.

　　4. Classification of recurrent ovarian cancer: For the convenience of clinical research design and the objective evaluation of the therapeutic efficacy of different units, it is recommended to classify patients with recurrent ovarian cancer.

　　(1) Recurrent ovarian cancer (possibly sensitive to platinum): Initially treated with platinum-based chemotherapy and achieved clinical confirmed remission, recurrence of the disease appears more than 6 months after discontinuation of medication, and is considered to belong to chemotherapy-sensitive patients.

　　(2) Drug-resistant ovarian cancer: Effective in the initial chemotherapy, but recurrence occurs within a relatively short period of time, within 6 months after the completion of chemotherapy, and should be considered as platinum-resistant.

　　(3) Persistent ovarian cancer: Refers to patients who have completed initial chemotherapy and achieved significant remission but have residual lesions, such as, CA125 elevation, microscopic lesions found in the second pathological examination, abnormal CT findings, and positive physical examination signs.

　　(4) Refractory ovarian cancer: Initial treatment does not achieve partial remission, including patients with disease stabilization or even continuous progression during treatment, accounting for about 20%. The remission rate of these patients to second-line treatment may be the lowest. In many studies and clinical practices, refractory patients with resistance, persistence, and refractoriness are often grouped together and separated from patients sensitive to platinum drugs.

　　Patients with recurrent ovarian malignant tumors may experience symptoms such as weight loss, decreased appetite, abdominal distension, abdominal pain, abnormal defecation, and other gastrointestinal symptoms. Some patients may have vaginal bleeding. The diagnosis of recurrent ovarian malignant tumors should be qualitative, locational, and typing, and individualized treatment should be carried out according to different situations. Measures to prevent the recurrence of ovarian malignant tumors: regular screening, early detection, early treatment, and good follow-up.

　　CA125 is a tumor marker that is relatively sensitive to ovarian epithelial tumors, and it is emphasized that dynamic observation is helpful for judgment. The elevation of CA125 in the early stage of recurrence is not very significant, and there are some fluctuations.

　　The retest time of CA125 should be shortened, and vigilance should be increased. If there is progressive elevation of CA125, although not very significant, clinical intervention should be considered, and further examinations should be conducted.

　　Most patients, due to the long course of the disease, have some understanding of the changes in the disease, and therefore are particularly sensitive to tumor markers, which seriously affects their mood. However, CA125 has the possibility of false positives (such as inflammation) and false negatives, so the explanation by the attending physician is extremely important.

　　Routine examinations include: laparoscopy, tomography, CT examination, tumor marker detection, cytochemical staining, immunopathological examination, etc.
　　1. Tumor marker examination:CA125 is a tumor marker that is relatively sensitive to ovarian epithelial tumors, and it is emphasized that dynamic observation is helpful for judgment. The elevation of CA125 in the early stage of recurrence is not very significant, and there are some fluctuations.

　　2. Imaging examinations:The value of ultrasonic examination is not very high, with an accuracy of about 60%, CT and MRI examinations can clearly determine the location of the lesion, the extent of organ involvement, and the feasibility of surgery; Positron Emission Tomography (PET) suggests abnormal hypermetabolic foci in the pelvis and abdomen, which are all confirmed as ovarian cancer recurrence by pathology, with a positive predictive value of 100%; The positive predictive value of CA125 at the same time is 88.9%; The positive predictive values of pelvic and abdominal ultrasound and CT are 11.1% and 14.3%, respectively; Therefore, PET, as a non-invasive examination method, with clear imaging, accurate localization, high sensitivity, and specificity, may become an important method for early diagnosis and localization of recurrent ovarian epithelial cancer.

　　3. Other auxiliary examinations:Laparoscopic examination, histopathological examination.

　　Dietary taboos for recurrent ovarian malignant tumors

　　(1) Avoid smoking and drinking.

　　(2) Avoid刺激性食物 such as scallions, garlic, peppers, and cassia bark.

　　(3) Avoid greasy, fried, moldy, and salted foods.

　　(4) Avoid warm and activating blood foods such as mutton, dog meat, chives, pepper, etc.

　　Foods suitable for recurrent ovarian malignant tumors

　　(1) Eat more foods with antitumor effects: horseshoe crab, hippocampus, turtle, dragon pearl tea, hawthorn.

　　(2) Hemorrhage should eat goat blood, snails, conch, cuttlefish, shepherd's purse, lotus root, mushrooms, malan head, stone ear, hickory, persimmon cake.

　　(3) Infection should eat eels, warty clams, water snakes, needlefish, carp,麒麟菜, celery, sesame, buckwheat, rapeseed, toon, red beans, mung beans.

　　(4) Abdominal pain and distension should eat pork kidneys, myrica, hawthorn, tangerine cake, walnuts, chestnuts.

　　1. Surgical Treatment
　　The effectiveness of secondary surgery for recurrent ovarian malignant tumors mainly depends on whether there is no gross residual cancer after surgery, so it is crucial to correctly select suitable patients. When selecting patients, various factors should be considered, such as the size of the residual cancer after the initial surgery, past chemotherapy history, the time interval from clinical remission to recurrence, the site of tumor recurrence, the histological grade of the tumor, whether there are sensitive chemotherapy drugs available for continued chemotherapy after surgery, the general condition of the whole body, and the impact of the symptoms caused by recurrence on the patient. Patients who meet the following criteria should consider surgical treatment: ① Patients aged ≤75 years; ② Patients with a remission period of ≥6 months after the initial treatment; ③ Isolated resectable lesions that can be achieved satisfactory resection, preferably without gross residual; ④ No unresectable extraperitoneal or liver metastases; ⑤ No intestinal obstruction (palliative surgery performed to relieve intestinal obstruction does not belong to the scope of treatment for recurrence); ⑥ No clinical surgical contraindications; ⑦ Karnofsky score ≥60; ⑧ Patients agree and can afford chemotherapy or radiotherapy after surgery recovery financially.
　　2. Chemotherapy
　　Chemotherapy is often the first-line treatment for recurrent ovarian malignant tumors and plays an important role.
　　3. Radiotherapy
　　Radiotherapy is only suitable for local lesion treatment and has the disadvantages of severe side effects, long duration, increased difficulty in subsequent surgery, and increased incidence of complications, so it is now rarely used. The role of radiotherapy in the treatment of recurrent ovarian cancer is mainly as a supplement to surgery and chemotherapy. It is now mostly used for certain special cases and palliative treatment in the late stage.