Recurrent cervical cancer

　　1. Etiology

　　In addition to treatment, there are many factors that affect recurrence. Among 702 patients with complete uterine radical resection data, stage I b to II a, and follow-up for more than 5 years, ten factors were listed for individual analysis, and the Mantel-Cox test was used by computer scoring method, giving each factor a score based on the recurrence rate of individual factors. The higher the score, the higher the risk. A prediction is made before and after surgery to evaluate the recurrence rate after surgery and consider adjuvant treatment in order to reduce the recurrence rate. These 10 factors include the patient's age, FIGO staging, histological classification, cell differentiation, invasion of the uterus, parauterine invasion, vaginal invasion, lymphovascular space embolism, residual cancer cells at the edge of the specimen, and lymphatic invasion.

　　There have been studies on lymphatic invasion, exploring deep radical hysterectomy after surgery. The rate of lymphatic invasion in FIGO I b to II a is 20.8% (288/1383), and the rate of lymphatic invasion in II b patients is 41.6% (96/231). The recurrence rate in patients with lymphatic invasion is 63.8% (106/288), and the recurrence rate in patients without lymphatic invasion is 11.0% (120/1095). From the 288 patients with lymphatic invasion, the calculation of the number of lymphatic invasion showed that the recurrence rate was 26.6% (43/164) when the number of lymphatic invasion was ≤2, and the recurrence rate was 50.8% (63/124) when the number was ≥3 (P

　　This discussion indicates that the recurrence rate is highest in cases with lymphatic invasion, especially when the number is three or more, and adjuvant therapy should be considered. The aortic lymph nodes, especially those without enlargement, should not be removed and can help reduce postoperative small bowel obstruction and other complications.

　　2. Pathogenesis

　　In addition to the impact of the extent of surgical resection on the recurrence rate, especially the location of recurrence, in fact, even the largest surgery can only remove the tumor that is confined to the uterus or even the pelvic cavity. From the perspective of the spread of cervical cancer, lymphatic, blood, and direct spread are all possible, so the chance of recurrence is inevitable. Some scholars analyzed the presence of cancer cells in the blood of 84 patients with stage I b to II b before surgery, using PCR (Feversetranseriptase-PCR) to determine the cancer marker cytokeratin 19 in peripheral blood squamous epithelial cervical cancer (SCC). The results showed that 21.4% (18/84) had a positive reaction, which was significantly different from the 5.7% (2/35) in the benign cervical disease group and 0% (28) in the normal cervical group, indicating that cancer cells in cervical cancer patients have appeared in peripheral blood early, and the spread and metastasis through blood is possible. However, when the patients with positive reactions were analyzed together with all risk factors, including pelvic lymph node metastasis, there was no significant difference. This may suggest that these free cervical cancer cells in the blood may not survive for long, or it may be difficult to find an opportunity for survival. However, this finding may reduce distant metastasis or eliminate metastasis through the blood vessels in the long run.

　　The early symptoms of cervical cancer often include slight bleeding after sexual intercourse, irregular menstruation, or vaginal bleeding after menopause. At this time, a gynecological examination will reveal that patients with cervical cancer have a smooth or eroded cervix surface, hard texture, and easy bleeding upon contact. Late-stage recurrent cancer patients may exhibit systemic symptoms such as decreased appetite, weight loss, cachexia, and renal failure.

　　Symptoms and signs corresponding to the site of recurrence and the degree of the lesion appear, with early asymptomatic presentation. The main symptoms and signs of recurrent cervical cancer patients are often manifested as weight loss.

　　1. Central recurrence:The most common symptoms are irregular vaginal bleeding and/or increased leukorrhea.

　　2. Para-cervical (or pelvic wall) recurrence:Early symptoms may include discomfort in the lower abdomen, which may develop into pain in the affected lower limb, edema, pain in the sacroiliac (or hip) area, lower back pain, lower abdominal pain, difficulty in urination and defecation, and sometimes the presence of a mass in the lower abdomen or pelvis.

　　1. Site of recurrence:Predominantly in the pelvis, accounting for more than 60%.

　　(1) Recurrence after cervical cancer surgery: The most common site is the upper segment of the vagina and the original cervical site, accounting for 1/4 (Graham et al., 1962). Chinese scholars have reported that the local recurrence rate was 59.8%, and distant metastasis accounted for 40.2%, with the lung (16.9%), supraclavicular lymph nodes (12.0%), and bone, liver being more common.

　　(2) Recurrence after radiotherapy: Most reports show that recurrence within the pelvis is more common than pelvic external metastasis. Graham et al. (1962) reported that 43% occurred para-cervically (including the pelvic wall, 27% in the upper segment of the cervix, uterus, or vagina, 6% in the lower 2/3 of the vagina, 16% at a distant site, and 8% unknown). The Cancer Hospital of the Chinese Academy of Medical Sciences has made a series of reports, showing that among the cases failed after traditional radiotherapy for cervical cancer, recurrence within the pelvis accounted for 70%, distant metastasis accounted for 30%, and organ metastases outside the pelvis were most common in the lung, accounting for 2.4%, with a rate of supraclavicular lymph node metastasis of 1.62%, and bone metastasis accounted for 0.88%. Foreign reports range from 1.3% to 8.9% (lung), 2.97% (supraclavicular lymph node metastasis), and 5.0% (bone metastasis). After the rapid development of radiotherapy equipment and technology in the 1980s, Manetta et al. (1992) believed that central recurrence had decreased, Sun Jianheng (1993) reported that recurrence within the pelvis after intracavitary afterloading radiotherapy decreased to 41%, and distant metastasis accounted for 59%. Zhang Xiaochun et al. (1995) reported that the recurrence rate of cervical cancer after treatment was only 19.7%, of which 53.3% was pelvic wall recurrence, and 46.7% was central recurrence.

　　2. Recurrence time:Most foreign reports show that more than 60% occur within 2 years. According to the statistics of the Cancer Hospital of the Chinese Academy of Medical Sciences, among the 95 cases of recurrence after radiotherapy for cervical cancer, 42.1% occurred within the first year, 60% within 2 years, 10.5% after 5 years, and 6.3% after 10 years. Zhang Xiaochun et al. (1995) reported that 60.8% occurred within 2 years, and Li Mengda et al. (1992) reported that recurrence after cervical cancer surgery occurred within 36.9% within 1 year, 61.9% within 2 years, 72.8% within 3 years, and more than 93% within 5 years.

　　Three, distant recurrence and metastasis:If there is cough, chest pain and/or back pain, sputum, blood-streaked sputum or hemoptysis during lung metastasis, there is often fixed focal pain during bone metastasis, discomfort or pain in the liver area or liver enlargement during liver metastasis, and enlargement of supraclavicular lymph nodes.

　　Four, in the late stage of cachexia, patients may present with systemic consumption syndrome:Such as decreased appetite, rapid weight loss or emaciation in a short period of time, or even present with cachexia.

　　Cervical cancer is one of the common malignant tumors in women, and the cause of the disease is not yet clear. Women with early marriage, early childbirth, multiple deliveries, and irregular sexual life have a higher incidence. In the early stage, there are no symptoms, and abnormal vaginal bleeding may occur in the later stage. Currently, the main treatment methods are surgery and radiotherapy, and comprehensive treatment of traditional Chinese and Western medicine can also be adopted, but the cure rate of patients in the middle and late stages is very low. As women, they should maintain purity, strengthen health care, pay attention to regular gynecological examinations, discover symptoms, and seek medical attention in time. Prognosis: The prognosis of recurrent cervical cancer is poor. Manetta et al. (1992) reported that the 1-year survival rate was 10% to 15%, and the 5-year survival rate

　　1. Recurrence site and lesion size:Both of them significantly affect the prognosis. Central recurrence has a better prognosis than parametrial and extrapelvic recurrence. The prognosis is worse for those with distant metastasis, such as bone metastasis and supraclavicular lymph node metastasis, with an average survival of less than 10 months. Yu Gaozhi et al. (1994) reported that only 1 case of 130 cases of bone metastasis survived for more than 5 years. Coleman et al. (1994) reported that the 5-year survival rate after radical hysterectomy for recurrent lesions confined to the cervix, less than 2 cm in size, and with normal intravenous pyelogram (IVP) was significantly different from that of lesions larger than 2 cm, with 90% and 64% respectively, and the 10-year survival rate was 80% and 48%, with a median survival of 148 months and 87 months.

　　The earliest time for bone metastasis to occur is 8 months after the first diagnosis, and the longest interval is 13 years. 69% of patients were diagnosed within 30 months after the first treatment, and 96% of patients died within 18 months.

　　Regarding the site of recurrent cancer and persistent recurrence, after radical surgery, 1/4 of recurrent cancers occur in the upper segment of the vagina or the preoperative cervical site. After radiotherapy, 27% occur in the cervix, uterus, or upper segment of the vagina, 6% in the upper 2/3 of the vagina, 43% in the parametrial connective tissue including the pelvic wall, 16% distant metastasis, and 8% unknown.

　　After radiotherapy, patients may present with ureteral obstruction, which was normal before treatment. Ureteral obstruction may be caused by fibrosis after radiotherapy, but 95% of obstructions are due to the progression of the disease. If the central lesion is not obvious, and there is no other cause for ureteral obstruction after treatment, laparotomy should be performed, and selective biopsy should be done to confirm the diagnosis of recurrent cancer. If there is no recurrent cancer but ureteral obstruction, it should be considered to perform urinary diversion.

　　2. Recurrence time:The interval between recurrences is long, and the tissue tolerance to reirradiation is relatively increased. Due to vascular repair and collateral reconstruction, the concentration of chemotherapeutic drugs at the local lesion is increased, which is beneficial to improve the efficacy of re-treatment for recurrence. Zhang Xiaochun et al. (1995) reported that the prognosis of recurrence 2 years later was significantly better than that of recurrence within 2 years, with median survival of 18 months and 10 months, respectively.

　　3. Initial treatment method:The prognosis is poor for those with a history of radiotherapy. Verma et al. (1994) reported that the response rate to chemotherapy for recurrent foci in the pelvic radiotherapy area was only 15% to 20%, and the response rate for chemotherapy for metastases outside the pelvis was 50%. Zhang Xiaochun et al. (1995) reported that the prognosis of patients who recurred after surgery was significantly better than that of patients who recurred after surgery combined with radiotherapy or simple radiotherapy, with median survivals of 24 months, 12 months, and 10 months, respectively. Long et al. (1995) applied combined chemotherapy for advanced recurrent cancer and found that the response rate was significantly different between those with and without a history of radiotherapy (61%∶83%), with 50% dying within one year and 85% dying within three years.

　　4. Additional treatment methods:Closely related to prognosis, the 5-year survival rate of recurrent cervical cancer treated by surgery is higher than that of other treatment methods. Liu Chiming (1994) comprehensively reported that the 5-year survival rate after pelvic clearing surgery was 22% to 58%. Zhang Xiaochun et al. (1995) summarized that the median survival after radiotherapy for recurrent cases was 24 months, while the prognosis of patients who recurred after radiotherapy and were treated with re-radiation and/or chemotherapy was poor, with a median survival of only 10 to 12 months.

　　1. Tumor markers:Currently, squamous cell carcinoma antigen (SCC) is a tumor marker that is meaningful for monitoring advanced and recurrent cervical cancer. Pectasides et al. (1994) reported that 92% of patients had an increase in SCC when the tumor recurred or progressed.

　　2. Vaginal shedding cytology examination:It is often difficult to estimate the findings of vaginal shedding cells after radiotherapy. From the perspective of radiation biology, viable cells refer to cells with the ability to continuously grow, while non-viable cells refer to cells that have lost the ability to proliferate but still have metabolic activity. After radiotherapy, cancer cells can resemble normal cells for several months, but biologically, these cells are non-viable. Therefore, cancer cells can still be found in the vaginal shedding cell smear after radiotherapy and may be mistaken for continued tumor spread. At the same time, it is also difficult to distinguish visually due to radiation reactions, which is called radiation effect. Therefore, the diagnosis of recurrent cancer must depend on pathological examination, and the slices should be at least performed 3 months after the end of treatment.

　　3. Colposcopy:After radiotherapy, the colposcope can also see inactive cancer cells, which may be mistaken for recurrence of cancer. Attention must be paid to this, as it is difficult to make a correct diagnosis after radiotherapy due to the effects of radiation reactions.

　　4. Cervical biopsy and cervical canal scraping:Obtaining tissue for pathological examination is a commonly used method for definitive diagnosis. Needle biopsy is an effective method for obtaining tissue, which can directly puncture the lesion, or under X-ray fluoroscopy or under B-ultrasound guidance.

　　5. Renal pelvis venography, lymphography, and X-ray computed tomography may help in the diagnosis of deep-seated recurrent foci.

　　I. Dietetic Recipe for Cervical Cancer Recurrence

　　1. Five-flower Diuretic Tea

　　[Ingredients]15 grams each of honeysuckle, chrysanthemum, pueraria, egg flower, locust bean flower, and cotton flower; 30 grams each of rhizoma tiefa and raw coix seed; 6 grams of licorice.

　　[Preparation] Soak all the herbs in about 6 bowls of water for about 10 minutes, bring to a boil over high heat, then simmer over low heat for about 40 minutes, strain out the herb residue, and add an appropriate amount of rock sugar before serving. Drink as tea.

　　[Effects] Clear heat and detoxify, promote diuresis and anticancer.

　　[Indications] Used for cervical cancer, ulcer with infection, with symptoms such as increased leukorrhea, colorectal cancer, esophageal cancer, liver cancer, nasopharyngeal cancer, lung cancer, bladder cancer, etc., with symptoms of dampness and heat obstruction.

　　[Precautions] Use this when there is internal dampness and heat, with symptoms such as dry mouth and throat, constipation, yellow urine, red tongue, yellow coating, and rapid pulse. Avoid using it if the body is weak and there are obvious cold symptoms.

　　2, Yi Ren Qi Shi Winter Melon Soup

　　[Ingredients] Sheng Yi Ren 50 grams, Qi Shi 50 grams, pork ribs 100 grams, winter melon 500 grams.

　　[Preparation]

　　(1) First, wash Sheng Yi Ren and Qi Shi, soak them in clean water for 1 hour.

　　(2) Cut the pork ribs into pieces, and cut the winter melon into pieces.

　　(3) First, boil Sheng Yi Ren, Qi Shi and pork ribs in a clay pot over medium heat for about 1 hour, then add winter melon and cook for another half hour, add salt to taste before drinking.

　　[Effects] Strengthen the spleen and promote diuresis.

　　[Indications] Used for cervical cancer with symptoms of internal damp toxin obstruction, local ulcers or necrosis, discharge of yellow, smelly fluid, distension in the lower abdomen, decreased appetite. Other malignant tumors with symptoms of internal damp toxin obstruction can also be used.

　　[Precautions] This formula focuses on strengthening the spleen and promoting diuresis. Caution should be exercised if the patient has been ill for a long time, with extremely weak physique and cold symptoms, and diarrhea.

　　3, Guiling Soup

　　[Ingredients] 1 money turtle, 250 grams of fresh Tu茯苓, 50 grams of Sheng Yi Ren, three slices of ginger.

　　[Preparation]

　　(1) Boil the money turtle to death or kill it, clean out the intestines and clean it, then cut it into pieces.

　　(2) Wash Tu茯苓 and Sheng Yi Ren, cut into pieces, then put all the ingredients together in a clay pot, add 2000 milliliters of clear water, bring to a boil over high heat, then simmer over low heat for 2 hours, and season with salt to taste before drinking.

　　[Effects] Strengthen the spleen, promote diuresis, detoxify and anticancer.

　　[Indications] Used for middle and late stage cervical cancer, with symptoms such as weakness, emaciation, decreased appetite, pale tongue with tooth marks on the edges, white greasy coating, thin and slippery pulse. Other malignant tumors with symptoms of spleen deficiency and damp obstruction can also be used.

　　[Precautions] If fresh Tu茯苓 is not available, 60 grams of dried product can be used instead.

　　4, Shang Lu Cong Mi Porridge

　　[Ingredients] Shang Lu 10 grams, Cong Mi 100 grams, Da Zao 5 pieces.

　　[Preparation] First, boil Shang Lu in water for 40 minutes, remove the dregs and take the juice. Then add Cong Mi and Da Zao to cook into porridge. [Effects] Drain and reduce swelling.

　　[Indications] Used for advanced cervical cancer with ascites.

　　[Caution]

　　(1) Shang Lu has some toxicity, do not drink it for a long time.

　　(2) Take it on an empty stomach, do not exceed the dosage.

　　5, He Shou Wu Sheng Di Black Chicken Soup

　　[Ingredients] He Shou Wu 60 grams, Sheng Di 30 grams, black chicken 500 grams, ginger five slices.

　　[Preparation]

　　(1) Clean and cut the black chicken into pieces for later use.

　　(2) Wash and slice He Shou Wu and Sheng Di.

　　(3) Place all the ingredients in a clay pot, add an appropriate amount of water, simmer over low heat for 2 hours, and season with salt to taste. Drink the soup and eat the meat.

　　[Effects] Nourish Yin and replenish blood.

　　[Indications] Used for cervical cancer with Yin deficiency and blood deficiency, anemia, cachexia, with symptoms such as emaciation, sallow and lackluster complexion, pale nails, or irregular vaginal bleeding.

　　[Caution]

　　(1) This formula focuses on nourishing Yin and blood, and should be avoided if there is an external feeling of fever.

　　(2) Avoid using this for diarrhea.

　　6. Astragalus Porridge

　　[Ingredients] Astragalus 30 grams, Job's tears 30 grams, red beans 15 grams, chicken gizzards 9 grams, tangerine cake 2 pieces, glutinous rice 30 grams.

　　[Preparation]

　　(1) Wash Astragalus, Job's tears, red beans, chicken gizzards, and glutinous rice separately and keep them ready.

　　(2) First, boil Astragalus for 30 minutes with 1000 milliliters of water, remove the dregs, add Job's tears and red beans, and boil for another 30 minutes. Then add chicken gizzards and glutinous rice, cook into porridge, and take it twice a day, in the morning and evening. After taking it, chew one piece of tangerine cake, once a day.

　　[Effect] Suitable for patients with cancer体质虚弱, poor digestion. For patients with advanced cervical cancer or postoperative, or patients after chemotherapy, with symptoms such as fatigue, pale complexion, shortness of breath, poor appetite, pale tongue, thin white fur, and deep and thin pulse, it is particularly suitable.

　　[Caution] This formula is a compound Astragalus Milky Rice porridge created by the famous elderly Chinese medicine doctor Yue Meizhong, which has a good effect on nourishing the spleen and strengthening the body. Caution should be exercised if there is an external feeling of fever.

　　Second, what should cervical cancer recurrence patients eat to benefit their health

　　1. In the early stage of cervical cancer (that is, uterine cervical cancer), the impact on digestive function is generally small. The focus should be on enhancing the patient's ability to resist diseases and improving immune function, and try to provide nutrients such as protein, sugar, fat, and vitamins. When the patient has a lot of vaginal bleeding, some foods for blood-building, hemostasis, and anti-cancer should be taken, such as lotus root, Job's tears, hawthorn, black fungus, umeboshi, etc. When the patient has a lot of watery leukorrhea, it is advisable to take tonifying foods, such as turtle, pigeon eggs, chicken, etc. When the patient has a lot of sticky leukorrhea with an unpleasant smell, it is advisable to eat light and diuretic foods, such as Job's tears, red beans, white mugwort root, etc.

　　2. After surgery, diet should focus on replenishing Qi and nourishing blood, and can eat yam, longan, mulberry, goji, pork liver, turtle, sesame, donkey hide glue, etc.

　　4. During radiotherapy, diet should focus on nourishing blood and moistening the Yin, and can eat beef, pork liver, lotus root, mushrooms, spinach, celery, pomegranate, water chestnuts, etc.; if radioactive cystitis and radioactive proctitis occur due to radiotherapy, then dietary adjustment with清热利湿, nourishing Yin and detoxifying should be given, such as watermelon, Job's tears, red beans, water chestnuts, lotus root, spinach, etc.

　　3. During chemotherapy, diet should focus on strengthening the spleen and kidney, and can use yam powder, Job's tears porridge, animal liver, placenta, ejiao, turtle, mushrooms, goji, lotus root, banana, etc. When digestive tract reactions such as nausea, vomiting, and loss of appetite occur, dietary adjustment should be made with foods that strengthen the spleen and stomach, such as sugarcane juice, ginger juice, umeboshi, banana, and tangerine.

　　5. In the late stage of cervical cancer, high-protein and high-calorie foods such as milk, eggs, beef, turtle, red beans, mung beans, fresh lotus root, spinach, winter melon, apples, etc., should be chosen.

　　7. Vitamin malnutrition. Some observations have shown that the level of beta-carotene in the blood of cervical cancer patients is lower than that in the control group, and low intake of beta-carotene is a risk factor for cervical cancer. In addition, vitamin C is also related to the incidence of cervical cancer. Chinese investigations show that when the intake of vitamin C increases, the risk of cervical cancer decreases.

　　8. Trace elements. It has now been found that trace elements such as copper, zinc, and selenium are related. The Guizhou Cancer Prevention and Treatment Institute found that there were significant differences in cervical cancer and breast cancer, and the plasma copper in patients with significant recurrence was significantly higher than that in patients with non-recurrence and normal people. The plasma copper in patients with long-term recurrence was significantly higher than that in the non-recurrence group. The copper ratio was highest in the long-term recurrence group. The copper-zinc ratio in the current group was also significantly higher than that in the normal and non-recurrence groups. Plasma copper and copper-zinc ratio can be used as indicators for diagnosing cervical cancer and malignant tumors and prognosis. Some studies have shown that the incidence of cervical cancer is related to high copper intake, which may be due to the antagonistic effect of copper on selenium, and high doses of copper can produce selenium deficiency symptoms in animals. Therefore, attention should be paid to supplementing vitamins in daily diet, and appropriate attention should be paid to supplementing foods containing zinc and selenium.

　　Third, what should cervical cancer recurrence patients avoid eating for their health

　　1. Avoid spicy and刺激性 foods, do not smoke, drink alcohol, do not eat greasy, seafood, and other fishy foods

　　2. Cervical cancer is caused by blood and Qi stasis, phlegm and dampness accumulation, and toxic heat congestion. Diet should avoid fatty, sweet, spicy, aromatic, and oil-fried and roasted foods that produce dampness, phlegm, and dry heat, which are easy to cause bleeding.

　　3. When patients have a lot of watery leukorrhea, avoid cold and raw foods, fruits, cold foods, and hard-to-digest foods; when leukorrhea is thick and has an unpleasant smell, avoid nourishing foods.

　　The formulation of treatment plans is related to the patient's age, general condition, the scope of the lesion, the presence of concurrent symptoms and their nature. Therefore, a comprehensive physical examination must be conducted on the patient before treatment, and a treatment plan should be formulated after considering the results of the examination of the function of each organ and system and the clinical stage. The treatment of cervical cancer is mainly surgery and radiotherapy. Especially squamous cell carcinoma is sensitive to radiotherapy. In recent years, the rapid development of anticancer chemical drugs has made chemotherapy, which was previously believed to be ineffective for cervical cancer, become a commonly used method of adjuvant treatment, especially in advanced cases or recurrences. Chemotherapy is used before surgery or radiotherapy, and after the tumor has shrunk or partially shrunk, surgery or radiotherapy is performed, or chemotherapy is added after surgery or radiotherapy, which can improve the efficacy. Interventional surgery such as bilateral uterine artery angiography and embolization chemotherapy 10-14 days before stage 1 and 2 cervical cancer surgery can reduce bleeding during surgery and improve the long-term survival rate.