Postmenopausal cervical cancer

　　10. Causes of disease

　　9. Local cervical lesions Early marriage, early childbirth, and multiple deliveries can cause local trauma to the cervix, including cervical erosion, cervical polyps, cervical lacerations, and precancerous lesions, which are intrinsic factors leading to the occurrence of cervical cancer.

　　8. Factors related to sexual behavior To some extent, cervical cancer can be considered an infectious disease. Low age at first sexual intercourse, multiple sexual partners, male partners with multiple partners or those with a history of cervical cancer, frequent sexual activity, and lack of attention to sexual hygiene can all lead to the entry of certain viruses such as human papillomavirus (HPV), herpesvirus type II (HSV-2), chlamydia, bacteria, and others into the reproductive tract, causing repeated infections on the cervical erosion surface and triggering cervical cancer. Men with penile cancer, prostate cancer, or a former wife with a history of cervical cancer have a significantly higher risk of cervical cancer than other women.

　　7. Human Papillomavirus (HPV) infection In recent years, it has been found that HPV infection is the main risk factor for cervical cancer. More than 70 homologous HPV types have been identified, of which more than 20 types exist in the human reproductive tract. According to their carcinogenic risk, they can be divided into three groups.

　　(1) Very low or no cancer risk: HPV6, 11, 42 types.

　　(2) Moderate risk: HPV31, 33, 35, 51 types, widely present in CIN II and III.

　　(3) High risk: HPV16, 18, 45, 56 types, commonly seen in invasive cancer.

　　4. Other causes Smoking, low immune function, economic status, race, geographical environment, and other factors are related to the occurrence of cervical cancer.

　　2. Pathogenesis

　　1. Cervical Intraepithelial Neoplasia (CIN) consists of the cervical vaginal squamous epithelium and cervical canal columnar epithelium, with the junction located at the cervical external os, known as the squamocolumnar junction, which is a common site for cervical cancer. Postmenopausal women have low estrogen levels, and the squamocolumnar junction may shift upward into the cervical canal, which is one of its characteristics. The surface covering of the columnar epithelium in the transitional zone is gradually replaced by metaplastic squamous epithelium. The immature metaplastic squamous epithelium has active metabolism and can undergo poor cell differentiation, disordered arrangement, abnormal nuclei, increased mitosis, and form cervical intraepithelial neoplasia under the stimulation of substances such as sperm, seminal plasma histones, Trichomonas vaginalis, human papillomavirus, and others.

　　(1) Microscopic characteristics of cervical atypical hyperplasia: ① Cell nuclei are enlarged and deeply stained, with varying sizes and shapes. ② Chromatin increases, becoming coarse. ③ Nuclear-cytoplasmic ratio is abnormal. ④ Nuclear division increases. ⑤ Cell polarity is disordered or disappears.

　　(2) Cervical atypical hyperplasia can be divided into mild, moderate, and severe degrees. ① Mild atypical hyperplasia: Abnormal cells are limited to the lower 1/3 of the epithelial layer. ② Moderate atypical hyperplasia: Abnormal cells are limited to the lower 2/3 of the epithelial layer. ③ Severe atypical hyperplasia: Abnormal cells occupy more than 2/3 of the epithelial layer or reach the full layer.

　　(3) Microscopic characteristics of cervical in situ carcinoma: The cancer cells are limited to the epithelium, with an intact basement membrane, without stromal invasion. ① Cell arrangement is disordered and apolar. ② Cell nuclei are large, with an increased nuclear-cytoplasmic ratio. ③ Atypia is significant, with varying degrees of staining. ④ Abnormal nuclear division is frequent, found in all layers of the epithelium.

　　(4) CIN grading: CIN can be divided into 3 grades:

　　① CIN grade I, equivalent to very mild and mild atypical hyperplasia.

　　② CIN grade II, equivalent to moderate atypical hyperplasia.

　　③ CIN grade III, equivalent to severe atypical hyperplasia and in situ carcinoma.

　　2, Cervical invasive carcinoma: Most cervical carcinomas occur at the transitional zone between squamous epithelium and columnar epithelium, as the transitional zone in the elderly moves upward into the cervical canal, most of the elderly cancers are located in the cervical canal. The main pathological types of cervical invasive carcinoma are squamous cell carcinoma, adenocarcinoma, and undifferentiated carcinoma.

　　(1) Cervical squamous cell carcinoma: The most common, accounting for about 70%.

　　① Histological morphology: The tumor is divided into 3 grades based on the degree of differentiation.

　　A, Squamous cell carcinoma grade I (highly differentiated squamous cell carcinoma), large cells, with obvious keratinization pearls, visible cell bridges, with mild cell atypia, and rare nuclear division.

　　B, Squamous cell carcinoma grade II (moderately differentiated squamous cell carcinoma), large cells, with a small amount or no keratinization pearls, with不明显 cell bridges, with marked cell atypia, and frequent nuclear division.

　　C, Squamous cell carcinoma grade III (low differentiated squamous cell carcinoma), large cells or small cells, without keratinization pearls, without cell bridges, with frequent cell atypia and nuclear division.

　　② Gross morphology: The tumor growth pattern is divided into 4 types.

　　A, Erosive type: The tumor is not visible to the naked eye, with an eroded surface.

　　B, Nodular type: The tumor forms nodular masses on the cervical surface from the external orifice of the cervix, and belongs to exogenous tumors.

　　C, Cauliflower type: The tumor grows like cauliflower from the cervix into the vagina, and belongs to exogenous tumors.

　　D, Ulcerative type: The tumor grows invasively from the cervix into the uterine cavity, forming ulcers and cavities, and belongs to endogenous tumors.

　　(2) Cervical adenocarcinoma: There has been an increasing trend in recent years, accounting for about 20%. It includes cervical mucinous adenocarcinoma, endometrioid adenocarcinoma, clear cell carcinoma, cervical papillary serous adenocarcinoma, undifferentiated adenocarcinoma, cervical adenosquamous carcinoma, and others. Adenocarcinoma occurs more frequently in the cervical canal, with tumor cells exhibiting characteristics of glandular epithelial cells, forming glandular structures, and infiltrating the stroma.

　　What diseases can postmenopausal cervical cancer be complicated with:

　　After the appearance of typical symptoms and signs of cervical cancer, it is generally invasive cancer, and diagnosis is usually not difficult. Biopsy pathological examination can confirm the diagnosis. Late-stage postmenopausal cervical cancer can compress the ureter, causing ureteral obstruction and renal pelvis hydrops, eventually leading to renal failure. Repeated massive bleeding on the basis of long-term repeated bleeding can lead to hemorrhagic shock; anemia, secondary infection, pain, and chronic consumption can lead to cachexia and death.

　　First, symptoms

　　1. Increased leukorrhea: 80% to 90% of patients with cervical cancer have varying degrees of leukorrhea symptoms, which are similar to those of general inflammation. With the progression of the tumor, necrosis and shedding, and secondary infection, purulent leukorrhea with a foul smell can occur.

　　2. Vaginal bleeding: 80% to 85% of patients with cervical cancer have symptoms of vaginal bleeding, which can be manifested as contact bleeding, menstrual period, postmenopausal, or irregular vaginal bleeding. Contact bleeding in young women or vaginal bleeding in postmenopausal women are clinical symptoms that deserve special attention. The amount of vaginal bleeding is related to the early or late stage of the lesion and also related to the type of tumor growth. Large cauliflower-like exophytic tumors and ulcerous hollow-type tumors are more prone to massive vaginal bleeding.

　　3. Other symptoms: tumor infiltration and progression can cause lower abdominal pain, lumbar sacral pain, a feeling of descent in the lower abdomen and during defecation, hematochezia, difficulty defecating, frequent urination, hematuria, lower limb edema, and other symptoms. Advanced patients may also experience anemia, weight loss, and other symptoms of cachexia.

　　Second, signs and symptoms

　　Points for attention in staging:

　　1. Stage 0 includes atypical cells in the full thickness of the epithelium, but without stromal invasion.

　　2. Stage Ia should include the smallest stromal invasion and measurable microscopic cancer; both Ia1 and Ia2 are microscopic diagnoses, not visible to the naked eye.

　　3. Cervical cancer involving the corpus uteri does not affect the prognosis, so it is not considered in staging.

　　4. The thickening of para-cervical tissue does not necessarily indicate cancerous infiltration, which can be seen in inflammatory thickening; only when the para-cervical tissue is nodularly thickened, with poor elasticity and hardness not reaching the pelvic wall, can it be diagnosed as stage IIb. If it reaches the pelvic wall, it is diagnosed as stage IIIb.

　　5. When renal pelvis hydrops or renal dysfunction occur due to cancerous ureteral stenosis, it should be classified as stage III regardless of whether other examinations are only stage I or II.

　　6. Those with only bladder bullous edema cannot be classified as stage IV but as stage III. It is necessary to have malignant cells in the bladder lavage fluid or pathological evidence of submucosal infiltration in the bladder to be diagnosed as stage IV.

　　How to prevent cervical cancer after menopause:

　　1. According to WHO reports, there are approximately 500,000 new cases of cervical cancer worldwide each year, of which 135,000 are newly diagnosed in China, accounting for about one-third of the total. Each year, more than 200,000 women die from cervical cancer worldwide. Due to China's active prevention and screening work for cervical cancer, the mortality rate has decreased from 5.29/100,000 in the 1970s to 1.64/100,000 in the 1990s.

　　2. Due to the long precancerous lesion stage of cervical cancer, the age distribution of patients shows a bimodal distribution. The age of onset is between 35-64 years old, with an average age of 52.2 years.

　　3. The peak age of onset of cervical intraepithelial neoplasia (CIN) is 35-39 years old. The peak age of cervical invasive cancer is 20 or more years later, at 60-64 years old. Therefore, postmenopausal women with cervical cancer are more likely to have invasive cancer.

　　4. Prognosis: The prognosis of cervical cancer is related to the clinical stage, pathological type, and treatment method. Early cases can achieve good therapeutic effects with surgery or radiotherapy. The 5-year survival rate of surgery for stage I patients can reach over 90%, and for stage II, over 70%. The overall 5-year survival rate of radiotherapy is between 50% and 70%.

　　5. Cervical cancer patients should have strict regular follow-up after treatment. The first follow-up should be conducted one month after treatment, followed by a review every 2-3 months. After the second year of treatment, a review should be conducted every 3-6 months, and at least once a year thereafter. During follow-up, in addition to clinical examination, chest X-ray, blood routine, ultrasound, and cytological examination should also be performed.

　　First, tumor marker detection

　　70% of patients have elevated levels of serum squamous cell carcinoma antigen (SCC) and carcinoembryonic antigen (CEA), which are related to the size and stage of the tumor. Dynamic determination of their concentration can help monitor the condition.

　　Second, vaginal exfoliated cell examination

　　(Cervical scraping examination) Early cervical cancer patients often have no symptoms, and it is difficult to identify the presence of tumors by肉眼 observation during clinical examination. Cervical exfoliated cell examination is easy to collect samples and is the most effective examination method for detecting early cervical cancer. All married women should have this examination regularly during gynecological examination or cancer screening, as a method for screening cervical cancer. Attention should be paid to taking samples from the squamous-columnar junction, where cervical cancer is prone to occur, in order to improve the accuracy of diagnosis. Since the squamous-columnar junction of elderly women moves upward into the cervical canal, in addition to scraping cells from the cervical vaginal area, special attention should be paid to collecting samples from the cervical canal.

　　1. The reporting method of cytological examination is mostly adopted in China and abroad using the Papanicolaou five-level classification method, where Grade I is normal, Grade II is caused by inflammation, Grade III is suspicious, Grade IV is suspicious positive, and Grade V is positive. When the cervical scraping cytology examination is above Papanicolaou Grade II, a repeat smear or colposcopy should be performed. For those with Papanicolaou Grades III, IV, and V, cervical biopsy should be performed under colposcopy or iodine test.

　　2. Liquid-based ThinPrep cytology or ThinPrep cytology preparation (TCT): Specialized plastic scrapers and cervical brushes are used to collect exocervical and endocervical cells, which are then washed into special bottles containing cell preservation solution. After programmed processing, the mucus, blood, and inflammatory cells in the specimen are separated, leaving only the epithelial cells, which are then filtered to make thin-layer smears. Under the microscope, due to the concentration of the examined cells and the clear background, it is better to screen for abnormal cells.

　　3. Computer-assisted cytological examination technology (CCT): The use of AutoPap300QC system or PapNet system for screening is the introduction of computer reading methods, which can improve the accuracy of diagnosis, improve efficiency, and reduce workload.

　　4. Improvement of cytological examination report methods: For a long time, most of China has followed the Papanicolaou five-grade classification method as the report method for cytological examination. With the progress of cytopathology, it has gradually been felt that the Papanicolaou grading method cannot meet the clinical requirements of disease diagnosis. In 1988, WHO proposed to use a descriptive reporting system, and the same year, American pathologists proposed the Bethesda System reporting method (TBS) to gradually replace the Papanicolaou five-grade classification method. This method mainly emphasizes the quality of the smear, descriptive diagnosis, and communication between clinical and cytopathology. China has now started to adopt TBS.

　　Three, Iodine Test

　　Apply a 2% iodine solution to the cervix and vaginal mucosa, observe the staining condition. The normal cervical vaginal squamous epithelium contains abundant glycogen and is easily stained brown by iodine solution. The unstained areas are positive and can help determine the biopsy site.

　　Four, Colposcopy

　　All patients with vaginal cytology examination showing grade II or above, with suspicious symptoms and signs, such as contact bleeding, moderate or severe cervical erosion, or erosion that does not heal after long-term treatment, should undergo colposcopy to observe whether there is atypical epithelium or early cancer on the surface of the cervix. The purpose is to select the biopsy site and improve the accuracy of diagnosis.

　　Five, Cervical and Cervical Canal Biopsy

　　It is the most reliable and indispensable method for diagnosing cervical cancer and its precancerous lesions. The sampling should be selected at the 3, 6, 9, and 12 o'clock positions of the cervical squamocolumnar junction, take 4-point biopsy, or take samples from the suspicious areas observed under colposcopy or iodine test. The sampling should have a certain depth, and the tissue taken should have both epithelial tissue and stromal tissue. It should be noted that even if the local lesion looks very much like a tumor, a cervical biopsy should be performed to confirm the diagnosis, because some benign lesions such as chronic cervicitis, cervical tuberculosis, etc., look very much like tumors, and it is difficult to distinguish them by肉眼 alone. It is necessary to confirm the diagnosis by histological examination. If there is no tumor on the surface of the cervix, and the cervical smear is grade III or above, then it is necessary to use a small spatula to scrape the tissue inside the cervical canal for pathological examination.

　　Six, Cervical Conization

　　1. When the cervical smear is positive multiple times, but the cervical biopsy is negative; or the biopsy is in situ carcinoma but cannot exclude invasive carcinoma, cervical conization can be performed. The excised cervical tissue is divided into 12 pieces, and 2 to 3 sections are made for each piece to confirm the diagnosis.

　　2. After the diagnosis of cervical cancer, chest X-ray, cystoscopy, rectoscopy, renal pelvis angiography, lymphography, CT scan or MRI examination should be performed according to the patient's condition to assist in determining the clinical stage.

　　One: Postmenopausal Cervical Cancer Food Therapy

　　1. Lotus Seed and Turtle Soup: 50 grams of white lotus seeds (with the core removed), 1 turtle (about 500 grams), 10 grams of mushrooms. Kill the turtle, remove the internal organs and mushrooms, and put them in a pot, stew with low heat for 2 hours, add a little MSG, and season with salt before eating.

　　2. Fresh Abalone and American Ginseng Soup: 250 grams of fresh abalone, 7 grams of American ginseng, 70 grams of lean pork. Clean and crush the shell of the raw abalone, put the shell and meat in a pot, add appropriate amounts of ginger, tangerine peel, American ginseng, lean pork, and water, stew with low heat for 2 hours, add appropriate amounts of salt and other seasoning ingredients, and it can be taken, drink the soup and eat the meat.

　　3. Dried Grape and Cuttlefish Stewed in Wine: 70 grams of dried grapes, 150 grams of lean pork, 5 fresh little cuttlefish, appropriate amounts of peanut oil, soy sauce, salt, sugar, and wine. Pull out the head of the cuttlefish, remove the mud and debris inside, do not cut open the cuttlefish, soak it in a little soy sauce and wine, sauté the lean pork and dried grapes, stuff them into each cuttlefish, and stew the cuttlefish in the pot with low heat, then add the soy sauce and wine soaked in the cuttlefish, stew until cooked, and it can be eaten.

　　4. Fungus and Finger Citron Snake Meat Soup: 50 grams of dried fungus, 10 grams of finger citron, 250 grams of snake meat, boil with herbs and eat. 1-2 times a day.

　　5. Coix Seed and Bitter Gourd Soup: 25 grams of coix seed, 60 grams of bitter gourd meat, 10 grams of finger citron, 100 grams of glutinous rice, cook together with water to make porridge, add a little salt for seasoning and eat, 2-3 times a day.

　　6. 300 grams of meat, 1 fresh river fish (500 grams), 1 white radish. Cut the mutton into large pieces, put it in boiling water, and boil it with sliced radish for 15 minutes. Discard the soup and radish. Put the mutton in a pot, add water (about 2/3 of the pot capacity), scallions, ginger, and wine, and cook until tender. If the soup is too little, add some boiling water. After the fish is fried with soybean oil, put it in the pot with the mutton and cook for 30 minutes. Add salt, coriander, green onion, and minced scallion to the soup, and it becomes a delicious and tasty mutton and fish soup. It is mainly used for postoperative recuperation after cervical cancer surgery.

　　7. Quail eggs 20 pieces, half an onion, carrot 80 grams, asparagus 80 grams, 4 tomatoes, 1 green pepper. Boil the eggs and use the shells. Cut the vegetables into small pieces. Boil the carrots until just cooked. Put 200 milliliters of soup ingredients, 40 grams of sugar, 45 milliliters of vinegar, 15 milliliters of wine, 20 grams of tomato sauce, 5 milliliters of sesame oil, 10 grams of five-spice powder in turn in the bowl, and mix well. Heat 30 milliliters of oil in a pot, add the eggs and vegetables and stir-fry for a second, then pour in the sauce and cook for a while before serving. It is mainly used for anemia caused by chronic bleeding from cervical cancer.

　　Two: What is good for postmenopausal cervical cancer patients

　　1. Foods should be as diverse as possible, with an emphasis on high-protein, high-vitamin, low-animal-fat, and easily digestible foods, as well as fresh fruits and vegetables. Avoid stale, deteriorated, or刺激性 things, and do not consume carbonated drinks or gas-producing foods. Eat less smoked, roasted, pickled, fried, or overly salty foods. Mix coarse and fine grains for staple foods to ensure nutritional balance and prevent bloating, diarrhea, and constipation.

　　2. To prevent a decrease in white blood cells and platelets caused by chemotherapy, it is recommended to eat more blood and meat, such as animal offal, egg yolks, lean meat, fish, eels, chickens, and bones; at the same time,配合medicated diets such as Dangshen, Huangqi, Danggui, Dazao, peanuts, etc.

　　3. To enhance the immune function, foods such as mushrooms, shiitake mushrooms, erinaceous mushrooms, and black fungus can be eaten.

　　4. To increase appetite and prevent vomiting, it is recommended to change the diet, change cooking methods, add color, fragrance, and taste to food; eat small and frequent meals, eat some fresh and cool mixed vegetables; add ginger to the diet to stop vomiting; also, use medicated diets to invigorate the spleen and stomach, such as hawthorn meat cubes, Huangqi, Shanyao, radish, Chenpi, etc.

　　3. Foods to avoid for postmenopausal cervical cancer patients

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

　　2. Avoid moldy, pickled, fried, and fatty foods.

　　3. Avoid animal offal, goose meat, pork head meat, and other stimulants.

　　4. Avoid刺激性 foods such as scallions, garlic, peppers, and cinnamon.

　　5. Avoid fatty, fried, moldy, and pickled foods.

　　Precautions before the treatment of cervical cancer in postmenopausal women:

　　1. Differentiation and selection of formulas

　　1. Qi stagnation and blood stasis

　　Treatment method: Promote Qi, warm Yang, and remove blood stasis.

　　Prescription: Modified Shaofu Decoction. 20g Danggui, 15g Chishao, 10g Chuanxiong, 15g Lingzhi, 15g Puhuang, 10g Yanhusuo, 15g Muyao, 10g Anxiang, 10g Ganjiang, 15g Rougui. Add Chenpi and Xiangfu for obvious Qi stagnation; add Fuling and Baizhu for obvious leukorrhea; add Baihua She舌cao and Huangjing for severe illness to detoxify and remove blood stasis.

　　2. Damp-heat蕴toxin

　　Treatment method: Clear heat and remove dampness, detoxify and resolve masses.

　　Prescription: Modified Zhida Decoction. 20g Fuling, 20g Zhuli, 15g Zexie, 10g Chishao, 10g Danpi, 10g Yinchen, 10g Huangbai, 10g Zhizi, 10g Niuxi, 15g Cheqianzi, 25g Baihua Shecaogao, 15g Tufuling. Add Gongying and Diding for increased leukorrhea.

　　3. Deficiency of both the heart and spleen

　　Treatment: Tonify the heart and spleen.

　　Prescription: Modified Guipi Decoction, 15g Dangshen, 20g Huangqi, 15g Baizhu, 20g Fuzi, 10g Suanzaoren, 10g Guiyuanrou, 10g Muxiang, 10g Zhigancao, 15g Danggui, 10g Yuanzhi, 10 pieces of Dazao, 3 slices of ginger. Add Shudihuang for blood deficiency; omit Dangshen and add Renshen for qi deficiency.

　　2. Special formulas and prescriptions

　　1. Hongsheng Dan

       Red mercuric oxide powder for external use. Suitable for early-stage patients with mild illness, and also for patients in the late stage who cannot undergo surgery. Action: Remove necrotic tissue, draw out toxins.

　　5. Huaxie Huiheng Tablet

       Honey pill, 6 grams per pill, one pill per time, twice a day, taken after meals with warm wine or warm water. Function: Dissipate masses and remove blood stasis. Used for blood stasis in the postoperative recovery period.

　　3. Other therapies

　　Early atypical hyperplasia or early stages of malignancy, with good cell differentiation, in order to maintain organ integrity; or to maintain fertility, methods such as electrocoagulation can be used to kill the malignant cell tissue.

　　1. Cervical intraepithelial neoplasia

　　For patients diagnosed with CIN I, temporary treatment as inflammation should be provided, and follow-up of cervical scraping should be conducted every 3 to 6 months. If necessary, re-biopsy should be performed, and continuous observation should be made if the lesion remains unchanged.

　　For patients with CIN II, electrocautery, laser, cryotherapy, or cervical conization should be selected for treatment, and follow-up should be conducted once every 3 to 6 months after surgery.

　　For patients with CIN III, total hysterectomy should be performed, and regular follow-up should be conducted after surgery.

　　2. Cervical Invasive Cancer

　　(1) Surgery: Surgery is suitable for patients with cervical invasive cancer at stages Ia to IIa, without serious medical and surgical complications, and without contraindications for surgery. Elderly patients, even if over 70 years old, can choose surgery as long as the overall condition can tolerate the operation. For obese patients, it should be determined according to the surgeon's experience and anesthetic conditions.

　　(2) Radiotherapy: Radiotherapy is suitable for all stages of cervical invasive cancer. In some cases, such as in elderly patients and those not suitable for surgery, radiotherapy can also be performed for in situ cancer and early invasive cancer.

　　(3) Radiotherapy includes intracavitary and extracavitary irradiation. Intracavitary irradiation often uses after-loading therapy machines, used to control local lesions, with radioactive sources such as cesium-137 (137Cs), iridium-192 (192Ir), etc. Extracavitary irradiation often uses linear accelerators, cobalt-60 (60Co), etc., used to treat lesions in the pelvic lymph nodes and parametrial tissues, etc. Early cases mainly use intracavitary radiotherapy, with extracavitary irradiation as auxiliary. For advanced patients, extracavitary irradiation is mainly used, with intracavitary radiotherapy as auxiliary.

　　(4) Chemotherapy: Chemotherapy for cervical cancer is mainly used for patients in the advanced stage or with recurrence and metastasis. In recent years, chemotherapy has also been used as adjuvant treatment for surgery or radiotherapy, such as preoperative chemotherapy for locally large tumors, or for comprehensive treatment of cases with poor prognosis such as non-squamous cervical cancer (such as cervical adenocarcinoma, adenosquamous carcinoma, clear cell carcinoma, and small cell carcinoma).

　　3. Drug Treatment

　　Common effective drugs include cisplatin, carboplatin, cyclophosphamide, ifosfamide, bleomycin, mitomycin, vincristine, etc., among which cisplatin has a better efficacy. Generally, combined chemotherapy is used, such as PVB regimen (cisplatin, vincristine, bleomycin), BIP regimen (bleomycin, ifosfamide, cisplatin). For adenocarcinoma, PM regimen (cisplatin, mitomycin) and FIP regimen (fluorouracil, ifosfamide, cisplatin) are used.