Postmenopausal endometrial cancer

　　What causes postmenopausal endometrial cancer:

　　First, Etiology

　　1. Continuous stimulation of the endometrium by estrogen and anovulatory dysfunctional uterine bleeding, polycystic ovary syndrome, functional ovarian tumors, long-term single estrogen use after menopause, etc., without progesterone to counteract or insufficient progesterone, the endometrium lacks cyclic changes and remains in a state of hyperplasia for a long time.

　　2. Related to endometrial hyperplasia Simple hyperplasia of the endometrium has about 1% developing into endometrial cancer; complex hyperplasia has about 3%; and atypical hyperplasia has about 29% developing into endometrial cancer.

　　3. Physiological factors Endometrial cancer is more common in obese, hypertensive, and diabetic individuals, and obesity-hypertension-diabetes is generally referred to as the endometrial cancer triad. Unmarried and infertility are also high-risk factors for endometrial cancer.

　　5. Delayed menopause According to relevant reports, the risk of endometrial cancer in women with menopause age over 52 is higher than that in women with menopause age

　　4. Genetic factors Individuals with a family history of ovarian cancer, colorectal cancer, or breast cancer have a higher risk of endometrial cancer than those without a family history.

　　Second, Pathogenesis

　　1. Gross morphology: Under肉眼 observation, endometrial cancer can be divided into two types:

　　(1) Diffuse type: The endometrium is mostly or entirely invaded by cancer tissue, with the cancer mass often presenting as cauliflower-like growths from the surface of the endometrium and protruding into the uterine cavity, filling the uterine cavity even extending outside. The cancer tissue is grayish or pale yellow, with bleeding, necrosis, and sometimes ulceration. When the cancer tissue blocks the cervical canal, it can lead to pyometra in the uterine cavity.

　　(2) Localized type: The cancer foci are confined to the uterine cavity, more common in the fundus or cornu of the uterus,呈息肉状或小菜花状，with ulceration on the surface and prone to bleeding. Localized cancer foci are prone to invade the muscular layer, and sometimes the lesion is small, but it has already invaded the deep muscular layer.

　　2. Histological morphology Endometrial cancer has various histological types. According to the structural appearance of the cancer tissue and the degree of nuclear atypia, pathology can be divided into 3 grades: Grade I (highly differentiated); Grade II (moderately differentiated); Grade III (poorly differentiated).

　　(1) Endometrioid adenocarcinoma: Accounts for 80% to 90%, with highly atypical hyperplasia of endometrial glands, stratified epithelium, and the formation of sieve-like structures. The cancer cells are highly atypical, with large, irregular, deeply stained nuclei, active nuclear division, and poorly differentiated adenocarcinoma glands are fewer, and the glandular structure disappears, presenting as a solid area.

　　(2) Adenocarcinoma with squamous differentiation: The adenocarcinoma tissue contains squamous epithelial components. If the adenocarcinoma contains benign squamous epithelium, it is called acanthocarcinoma. If it contains malignant squamous epithelium, it is called squamous adenocarcinoma.

　　(3) Clear cell carcinoma: The cancer cells are arranged in solid sheet-like, tubular, or papillary patterns, with rich, clear cytoplasm, nuclear atypia centrally located, or composed of acinar cells. It has a high degree of malignancy and is prone to early metastasis.

　　(4) Serous adenocarcinoma: Complex papillary structure, cleft-like glands, and large nuclear atypia. It has a very high degree of malignancy, easily spreading widely to the muscular layer, blood vessels, or causing peritoneal dissemination.

　　(5) Undifferentiated cancer: It is rare. The cancer cells have neither glandular differentiation nor squamous epithelial differentiation tendency.

　　3. The routes of metastasis Most endometrial cancers grow slowly and are confined to the endometrium or uterine cavity for a long time. Some special pathological types of endometrial cancer, such as serous papillary adenocarcinoma, squamous adenocarcinoma, clear cell carcinoma, and poorly differentiated cancer, can develop rapidly and metastasize within a short period of time. The main routes of metastasis are direct spread and lymphatic metastasis, and hematogenous metastasis can occur in the late stage.

　　(1) Direct spread: The lesion spreads along the endometrium and grows, upward can extend to the fallopian tube through the uterine cornu; downward can involve the cervical canal and continue to spread to the vagina. If the cancer tissue invades the muscular wall, it can reach the serous layer of the uterus, extend to the fallopian tube and ovary, and can be widely implanted in the pelvic peritoneum, the rectouterine pouch, and the omentum.

　　(2) Lymphatic metastasis: It is the main route of metastasis for endometrial cancer. When the tumor invades deeply into the myometrium or spreads to the cervical canal, or when the cancer tissue is poorly differentiated, lymphatic metastasis is more likely to occur. The route of metastasis is related to the growth site of the tumor. Cervical stromal cancer foci along the upper part of the broad ligament lymphatic network, through the pelvic fimbria ligament to the ovary, and upward to the para-aortic lymph nodes; Cervical cornu cancer foci along the round ligament to the inguinal lymph nodes; Lower uterine segment and cervical canal cancer foci have the same lymphatic metastasis route as cervical cancer, and can reach the parametrial, iliac internal, iliac external, and iliac common lymph nodes; The posterior uterine wall cancer foci can spread to the rectal lymph nodes along the uterine-sacral ligament; The anterior uterine wall cancer foci can spread to the bladder lymph nodes. Endometrial cancer can also be drained backward through the lymphatic vessels to the anterior vaginal wall.

　　(3) Hematogenous metastasis: In the late stage, it can metastasize via blood to various organs in the body, common sites being the lung, liver, and bone.

　　Most endometrial cancers grow slowly and are confined to the endometrium or uterine cavity for a long time. Some special pathological types of endometrial cancer, such as serous papillary adenocarcinoma, squamous adenocarcinoma, clear cell cancer, and poorly differentiated cancer, can develop rapidly and metastasize within a short period of time. The main routes of metastasis are direct spread and lymphatic metastasis, and hematogenous metastasis can occur in the late stage. In the late stage, hematogenous metastasis can occur to various organs in the body, with the common sites being the lung, liver, and bone. When peritoneal metastasis occurs, there may be abdominal masses, abdominal distension, ascites, and in the late stage, it can cause anemia, weight loss, cachexia, and systemic failure.

　　1. Abnormal uterine bleeding

　　It is the most common symptom of endometrial cancer, with an incidence rate of 88% to 96%. Postmenopausal bleeding manifests as bloody discharge or irregular vaginal bleeding, with little amount and rare massive bleeding. In the premenopausal period, it is often misdiagnosed as dysfunctional uterine bleeding, manifesting as prolonged menstrual periods, increased menstrual volume, or intermenstrual bleeding.

　　2. Vaginal discharge

　　Mostly the result of tumor exudation or secondary infection, which can be hemorrhagic fluid, serous secretion, or purulent secretion, with a foul smell. When the cervical canal is blocked, it can cause endometrial pus, and an increase in abnormal vaginal discharge often occurs simultaneously with uterine bleeding.

　　3. Pain

　　Mostly caused by infiltration of advanced cancer into surrounding tissues or compression of nerves, leading to lower abdominal pain, lumbar pain, which can also radiate to the legs. When there is pus in the uterine cavity, there can also be spasmodic lower abdominal pain.

　　4. Other

　　Advanced patients often have anemia, weight loss, and cachexia.

　　5. Clinical staging

　　The clinical staging system established by the International Federation of Gynecology and Obstetrics in 1971 is used, and the surgical-pathological staging system established in 1988 is used for surgical treatment.

　　How to prevent postmenopausal endometrial cancer

　　1. General treatment effect Due to its slow development, endometrial cancer has a good treatment effect, with a 5-year survival rate of generally 60% to 75%.

　　2. Recurrence issues Aalders analyzed 379 cases of recurrent endometrial cancer, with 50% having local recurrence, 28% having distant metastasis, and 21% having both local and distant metastasis. The average time from the first treatment to the diagnosis of recurrence is 14 months for local recurrence and 19 months for metastasis. 34% recurred within 1 year after treatment, 76% within 3 years, and 10% more than 5 years. 32% of local recurrences, 5% of metastases, and 2% of both local and distant metastases survived without cancer for 3 to 19 years after treatment.

　　3. Local recurrence can be considered for surgical resection, or surgery combined with radiotherapy or chemotherapy. Among the 29 patients cured, 24 received radiotherapy or radiotherapy combined with surgery, and 16 were also treated with gestational hormone drugs. The average survival time of patients treated with gestational hormone drugs for lung metastasis is longer than that of those not treated with hormone drugs, with the former being 9 months and the latter being 2 months.

　　There are many factors affecting prognosis, mainly related to clinical stage, lymph node metastasis, depth of endometrial muscle invasion, cell differentiation, tissue type, and patient age.

　　One, Cytological examination

　　1. Some authors report that approximately 60% of patients have a positive smear examination of the cervical canal and posterior fornix of the vagina. If benign endometrial cells are found in the cervical or vaginal smear of postmenopausal or postmenopausal women, it indicates a potential hidden endometrial cancer of 2% to 6%. Therefore, vigilance should be increased, and further examination should be carried out. However, endometrial cells are not easily shed in normal times, and once shed, they often show degenerative changes, making it difficult to identify. Therefore, it can only serve as an auxiliary diagnostic method. The smear examination of the uterine lavage fluid and aspiration fluid can improve the positive rate. Experienced cytologists can achieve a positive rate of 90% to 95% for endometrial cells, but a negative result does not exclude endometrial cancer, and it is not possible to perform cell grading. Finally, it is still necessary to perform segmental curettage.

　　2. In patients with endometrial cancer complicated with ascites, there may be cancer cells found in the ascites even in the absence of muscular layer invasion in stage I. Marris reported 3 cases of endometrial cancer complicated with ascites, with ages in their 70s, no vaginal bleeding, and a preoperative diagnosis of ovarian cancer. The endometrial cancer had not invaded the muscular layer and protruded into the uterine cavity. All three patients were elderly, with extremely atrophic fallopian tubes, which were more conducive to retrograde flow. Creasman also mentioned that 8% of patients without muscular layer invasion had positive pelvic lavage fluid cells.

　　Two, Endometrial examination

　　1. Segmental curettage is a necessary examination for diagnosing endometrial cancer. In order to determine whether the lesion involves the cervix, tissue should be obtained from both the cervix and the uterine cavity during curettage. The depth of the cervix should be estimated according to the size of the uterus and the length of the cervix. Cure the cervix first, then measure the depth of the uterine cavity, so as to determine the clinical stage, and then perform curettage of the body and fundus of the uterus. Pay special attention to scraping the endometrium of the uterine horns, carefully and comprehensively performing segmental curettage. If the scraped endometrial tissue is loose, greyish white bean curd-like tissue, it should be considered as cancer tissue, and the scraping should be stopped at this point to avoid uterine perforation and the resulting contamination of the peritoneal cavity with tumor cells, blood, and bacteria. Finally, the scraped tissue should be sent for pathological examination. Endometrial histological examination is the final basis for diagnosis, with a positive rate of 90%.

　　2. Endometrial biopsy: It can be used for outpatients to check, using the Novak curette to scrape the endometrium from the four walls of the uterine cavity. The positive rate is 80% to 90%, but a negative result does not exclude endometrial cancer. Sometimes, the tissue obtained is too little to meet the diagnostic requirements, and it is still necessary to perform segmental curettage.

　　Three, Tumor marker examination

　　1. CA19-9: Present in various gastrointestinal adenocarcinomas, the uterus and fallopian tubes derived from the müllerian duct also synthesize CA19-9 antigen. Scharl et al. reported that the CA19-9 antigen in endometrial adenocarcinoma was positive in 95/70 cases, while only 3/26 cases were positive in normal endometrium, making it a potential biomarker for endometrial cancer.

　　2. Determining the DNA content of cancer cells: The research results of New-bury indicate that DNA ploidy is related to the tissue grading of endometrial cancer. The higher the tissue grading, the higher the DNA ploidy. According to Izumis, 50% of the 68 cases of endometrial cancer were aneuploid, with 77.8% of aneuploid cells showing poor differentiation and only 33.5% showing highly differentiated. There is a negative correlation between the DNA index and the degree of tumor differentiation.

　　3. The study of IedaM shows that DNA ploidy is related to myometrial invasion and staging. The rate of DNA aneuploidy in deep myometrial invasion and stages III and IV is higher than that in those without myometrial invasion and in stage I. The survival rate of patients with DNA aneuploidy is significantly lower than that of diploid patients, with 5-year survival rates of 65.9% and 87.6%, respectively, indicating that DNA ploidy is an important factor affecting prognosis.

　　4. Changes in SPF during the cell cycle phase of endometrial cancer cells: SPF is an important indicator reflecting the activity of cell proliferation. SPF is related to myometrial invasion and staging. With the increase of myometrial invasion depth and the improvement of staging, SPF increases significantly. Fribery et al. reported that the higher the SPF value, the worse the prognosis and the higher the mortality rate. Xue Fengxia et al. reported that the 5-year survival rate of SPF < 17% was 79.1%, while that of SPF > 17% was 50.4%.

　　5. Determination of serum CA125 value: Duk's data showed that the results of measuring serum CA125 in 110 patients with endometrial cancer were as follows:

　　(1) CA125 exists in all endometrial cancer tissues, especially in adenocarcinoma tissues.

　　(2) The incidence of CA125 elevation in endometrial cancer is 25%, and the incidence increases with the clinical stage. The incidence in stage I is 13%, and in stage IV it is 86%. In stage I and II, the elevation of CA125 is associated with vascular invasion and extension outside the uterus. When CA125 elevation is found in stage I and II, attention should be paid to redefining the clinical stage.

　　(3) The level of CA125 changes with the clinical course of the disease. CA125 is elevated before the development and recurrence of tumors, especially when there is a tumor in the abdominal cavity.

　　(4) If CA125 is elevated before treatment in stage I and II patients, almost all of them die of endometrial cancer, therefore, measuring CA125 before treatment is valuable for estimating the prognosis.

　　(5) QVX1 is a high molecular weight mucinous glycoprotein. XUFengji used a two-factor radioimmunoassay to determine the level of OVX1 in the serum of 45 patients with different stages of endometrial cancer, and simultaneously determined the level of CA125 in the patient's serum. The normal value of OVX1 in serum is (2.23±2.48) U/ml, and the cutoff value is below 2U/ml. The results show that the level of OVX1 in the serum of patients in all four stages is greater than 7.2U/ml, and the positive rate of OVX1 is significantly higher than that of CA125 in the corresponding stage. Moreover, OVX1 is related to the stage and tissue grade of early endometrial cancer. The positive rate of OVX1 in the serum of IA, IB, and IC patients increases in turn, and the higher the tissue grade, the higher the positive rate of OVX1. The positive rate of OVX1 in stage I endometrial cancer is 64%, which is higher than that of CA125. Because OVX1 and CA125 have no cross-reactivity, they can be used in combination to detect endometrial cancer. Therefore, the author believes that OVX1 can be used as a tumor marker for early endometrial cancer and can be combined with other more sensitive markers for screening high-risk populations for endometrial cancer.

　　Four, Hysteroscopy examination

　　1, Hysteroscopy can directly visualize the morphology, location, and scope of the lesions inside the uterine cavity, and perform localization biopsy or scraping of tissue for lesions, which is very meaningful for the discovery of smaller endometrial cancer. Therefore, hysteroscopy is a reliable method for the early diagnosis of endometrial cancer. At the same time, hysteroscopy can also observe whether there are infiltrative lesions in the cervical canal.

　　2, The observation of endometrial cancer under hysteroscopy has the following morphology:

　　(1) Polypoid type, with grayish-white rough and uneven polypoid protuberant tissue on the surface, with varicose blood vessels.

　　(2) Nodular type, with larger rough protuberances, with coiled blood vessels on the surface.

　　(3) Papillary type, with obvious nodular protuberances呈branch-like, grape-like, or fluffy-like.

　　(4) Ulcerative type, with suppurative infection, dirty, friable surface.

　　Dietetic therapy for endometrial cancer after menopause:

　　1, Walnut branch and egg:Take 30 centimeters of fresh walnut kernel, 3 eggs, and decoct with water together. Boil the eggs and crack the shells, then boil for 4 hours. Eat 1 egg per time, 3 times a day, take the soup together. It has the function of clearing heat, detoxifying, and anti-cancer. Indicated for endometrial cancer and other cancers.

　　2, Mung bean and red date soup:Take 30 grams of white mung beans and 10 red dates, add 500 milliliters of water to decoct a soup, add an appropriate amount of rock sugar for seasoning after the beans are cooked. Drink the soup and eat the beans and dates, once in the morning and once in the evening. Indicated for endometrial cancer with spleen deficiency.

　　3, Pork stomach stewed mung beans:Add 100 grams of mung beans into 1 pork stomach, stew until tender and then cut into slices. Drink the soup and eat the beans and stomach slices, once a day. Indicated for endometrial cancer with spleen deficiency.

　　4, Stachys sieboldii cooked eggs:Take 100 grams of Stachys sieboldii and decoct with water, add 3 eggs (crushed) and cook. Eat the eggs and drink the soup. It has the function of clearing heat, detoxifying, and anti-cancer. Indicated for early endometrial cancer and other cancers.

　　5, Pork kidney and walnut:Take 1 pair of pork kidneys (pork kidneys) and remove the tendons, slice 30 grams of eucommia and add them to the pork kidneys, together with 30 grams of walnut kernel, cook with 800 milliliters of water. Then remove the eucommia, slice the pork kidneys and add them back to the soup, boil for 3 minutes until cooked. Drink the soup and eat the kidney slices and walnuts, once every other day. Indicated for endometrial cancer with kidney deficiency.

　　6, Cynanchum stauntonii wine:Take 300 grams of rhizoma Cynanchum stauntonii and soak in 1.5 liters of white wine for 24 hours, seal the bottle mouth, heat in water to 60-70℃ and stop the fire, then soak in cold water for 7 days after cooling. Take 100 milliliters/day. It has the function of clearing heat and detoxifying, and reducing swelling. Indicated for endometrial cancer with heat-toxin transformation.

　　7, Water caltrop meat soup:Take 30 raw water caltrop seeds (or 45 grams of caltrop stem leaves and fruit stalks), 30 grams of walnut branches, remove impurities, add an appropriate amount of water, and boil into a concentrated brown soup with low heat. 1 dose/day, take 2-3 times a day. It has the function of strengthening the stomach and calming the middle. Indicated for endometrial cancer with spleen and stomach weakness; symptoms include bland taste in the mouth, poor appetite.

　　8, Astragalus ointment:Scutellaria baicalensis 120 grams, fresh Polygonum multiflorum 12 grams, decocted for more than 10 boils, remove the dregs, take the juice 300 milliliters, add 6 grams of dried licorice powder and 10 grams of Chinese yam, decoct together, stir to prevent the medicine from sinking to the bottom, add 30 milliliters of honey when boiling, and boil for a moment. 1 dose/day, divided into 3 times for administration. It has the function of strengthening the stomach and benefiting Qi, cooling blood and relieving pain. Indicated for endometrial cancer; symptoms include vaginal bleeding accompanied by spleen deficiency; symptoms include poor appetite, fatigue, pale red blood, less amount, early treatment and dripping continuously.

　　9. Sour Pomegranate Juice:Grind half a sour pomegranate with the peel to make juice, take it at one time. 3 times per day, for 3-5 days per course, stop taking it when bleeding stops. It has the functions of generating fluid, coagulating blood, and stopping bleeding. It is indicated for endometrial cancer; symptoms include uncontrolled bleeding (note: not suitable for those with gastric or duodenal ulcers).

　　10. Fresh Lotus Root and Chinese Arborvitae Juice:Grind 250 grams of fresh lotus root and 60 grams of Chinese arborvitae leaves to make juice, dilute with cool water and take it. 2-3 times per day, for 7 consecutive days. It has the function of cooling blood and stopping bleeding. It is indicated for endometrial cancer of the blood-heat type; symptoms include excessive bleeding and red color.

　　11. Winter Melon Seed Drink:Grind 30 grams of winter melon seeds, add 30 grams of rock sugar, place in a bowl, pour in 300 milliliters of boiling water, and simmer with low heat. Take 1 dose per day, 7 days per course. It is indicated for endometrial cancer of the damp-toxin type.

　　12. Tianqi Lotus Root Pudding:Mix 5 grams of Tianqi (Panax notoginseng) powder with 1 egg to make a paste. Cut 250 grams of fresh lotus root into pieces, squeeze the juice (about 30 milliliters), add 30 milliliters of water, boil, and then add the Tianqi powder and egg paste, add a moderate amount of salt. Take 1 time per day. It is indicated for endometrial cancer of the blood-stasis type.

　　13. Whitebait and Winter Melon Seed Decoction:Boil 10 whitebait, 30 grams of winter melon seeds, 15 grams of lotus seed meat, and 1.5 grams of pepper together in a pot, add 2 liters of water, bring to a boil with high heat, and then simmer with low heat until the whitebait and lotus seeds are soft. Take it in divided doses, 2-3 times per day, 1 dose per day. It has the functions of invigorating the spleen and promoting diuresis, and stopping vaginal discharge. It is indicated for endometrial cancer; symptoms include vaginal discharge.

　　14. Sheep Sorrel and Date Decoction:Boil 30 grams of sheep sorrel and 10 Chinese dates in water, and take it as a decoction. 1 dose per day. It has the function of clearing heat and detoxifying. It is indicated for endometrial cancer of the heat-toxin type.

　　15. Tofu and Egg:Boil 60 grams of tofu pot, 1 piece of tofu skin, and 1 egg in water, add a moderate amount of sugar and eat. It has the function of clearing heat and promoting diuresis. It is indicated for endometrial cancer; symptoms include vaginal discharge.

　　16. Ejiao and Chinese Wolfberry Porridge:Boil 20 grams of Chinese wolfberry and 60 grams of glutinous rice in 500 milliliters of water, add 20 grams of Ejiao (Chinese wolfberry glue) to dissolve it after it is cooked, and then boil for another 2-3 minutes. Take 1 time per day, 15 days per course. It can be taken for a long time. It is indicated for anemia after surgery for endometrial cancer.

　　17. Bitter Melon Tea:Cut the top of 1 bitter melon, remove the pith, add a moderate amount of green tea, and hang the melon in a ventilated place to dry in the shade. Then wash and dry the outer surface of the dried bitter melon, chop it together with the tea leaves, and mix well. Take 10 grams per time, infuse with boiling water, and drink as tea daily. It has the functions of clearing heat and detoxifying, relieving summer heat, and quenching thirst. It is indicated for cervical cancer and endometrial cancer; symptoms include dry mouth and thirst.

　　一、Treatment

　　1. Surgical treatment

　　（1）Stage I: Total hysterectomy with bilateral salpingo-oophorectomy, and selective pelvic lymph node and para-aortic lymph node dissection and/or debridement should be performed in one of the following conditions:

　　①The pathological type is clear cell carcinoma, serous carcinoma, squamous cell carcinoma, undifferentiated carcinoma, G2, G3 endometrioid adenocarcinoma.

　　②The depth of myometrial invasion is ≥1/2.

　　③The cancer involves more than 50% of the uterine cavity or there is a significant increase in serum CA125.

　　(2) Stage II: Extensive hysterectomy and bilateral adnexectomy, pelvic and para-aortic lymph node dissection.

　　After the operation enters the abdominal cavity, the ascites or peritoneal lavage fluid should be collected for cytological examination first, and a comprehensive exploration should be conducted during the operation. After the uterus and adnexa are resected, the uterus should be immediately dissected to understand the range of the cancer focus, the depth of infiltration into the muscle layer, and to send for frozen section examination to determine whether there are extrapelvic lesions. The cancer tissue should be routinely tested for estrogen and gestagen receptors, which serve as the basis for selecting auxiliary treatments after surgery.

　　2. Radiotherapy

　　(1) Preoperative radiotherapy: It can reduce the tumor size, create surgical conditions, or eliminate hidden metastatic lesions. For stage II or III patients with poor cell differentiation, intracavitary or extracavitary irradiation can be added before surgery. After intracavitary radiotherapy is completed, surgery should be performed within 1-2 weeks, and surgery should be performed 4 weeks after extracavitary irradiation is completed.

　　(2) Postoperative radiotherapy: It is used for lesions that were not completely resected by surgery, or for areas suspicious of metastatic cancer, with the addition of radiotherapy after surgery to supplement the insufficient surgical range and reduce postoperative recurrence. For stage II patients, if cancer cells are found in the ascites or deep muscle layer has cancer infiltration, and lymph nodes have metastasis, radiotherapy is required after surgery. External irradiation with 60Co or linear accelerator.

　　(3) Simple radiotherapy: Although adenocarcinoma is not sensitive to radiation, radiotherapy still has a certain effect in elderly patients or those with severe complications who cannot tolerate surgery, as well as in patients with stage III or IV cancer who are not suitable for surgery.

　　3. Medication therapy

　　(1) Gestagen therapy: It is commonly used for patients with advanced or recurrent cancer who cannot be surgically resected. It has a good effect on endometrial cancer with good differentiation, positive estrogen and gestagen receptors. It is recommended to use it in high doses for a long time. Methyldienestrol acetate (medroxyprogesterone acetate) 160mg daily orally; hydroxyprogesterone caproate 500mg, twice a week, intramuscularly. Gestagens act on cancer cells by binding to gestagen receptors to form complexes that enter the nucleus of cancer cells, delaying DNA and RNA replication, and inhibiting the growth of cancer cells. Long-term use may have side effects such as water and sodium retention, edema, or drug-induced hepatitis, which can recover after discontinuation.

　　(2) Antiestrogenic agent therapy: Tamoxifen (tamoxifen, TAM) is a non-steroidal antiestrogenic agent with a slight estrogenic effect. It is used for the indications of endometrial cancer that are the same as those for gestagen therapy. Tamoxifen (TAM) 10-20mg, twice daily, orally. Tamoxifen (TAM) can increase the level of gestagen receptor, and for those with low receptor levels, tamoxifen (TAM) can be used first to increase the content of gestagen receptor before gestagen therapy or both can be used simultaneously, which may improve the efficacy. Side effects are similar to those of perimenopausal syndrome, such as hot flashes, irritability, etc., and slight vaginal bleeding or amenorrhea.

　　(3) Chemotherapy medication: One of the comprehensive treatment measures for advanced or recurrent cancer, also used for the treatment of high-risk factors for recurrence after surgery, in order to reduce extrapelvic recurrence. Commonly used chemotherapy drugs include doxorubicin (adriamycin, ADM), cisplatin (DDP), cyclophosphamide (CTX), fluorouracil (5-Fu), mitomycin (MMC), etoposide (VP-16), and others. They can be used alone, or in combination with several drugs, or can be used in combination with gestagens.

　　2. Prognosis

　　1. General treatment effects

　　Endometrial cancer, due to its slow development, has good treatment effects, with a 5-year survival rate of generally 60% to 75%.

　　2. Recurrence issues

　　(1) Aalders analyzed 379 cases of recurrent endometrial cancer, with 50% local recurrence, 28% distant metastasis, and 21% both local and distant metastasis. The average time from the first treatment to the confirmation of recurrence was 14 months for local recurrence and 19 months for metastasis. 34% recurred within 1 year after treatment, 76% within 3 years, and 10% more than 5 years. 32% of those with local recurrence, 5% with metastasis, and 2% with both local and distant metastasis were still alive without cancer from 3 to 19 years after treatment.

　　(2) Local recurrence can be considered for surgical resection, or combined surgery with radiotherapy or chemotherapy. Among 29 cured patients, 24 received radiotherapy or combined radiotherapy and surgery, and 16 were also treated with gestational hormone drugs. The average survival time of patients with lung metastasis treated with gestational hormone drugs was longer than that of those without hormone drugs, with 9 months for the former and 2 months for the latter.

　　3. Factors affecting prognosis

　　There are many factors related to prognosis, mainly including clinical stage, lymph node metastasis, depth of myometrial invasion, cell differentiation, tissue type, patient age, and other factors.

　　(1) Clinical stage: The earlier the stage, the better the prognosis. Zhang Xiyin's analysis of 561 cases shows that the 5-year survival rates for stages I, II, III, and IV are 74%, 68%, 36%, and 0%, respectively; Tiiti-nen analyzed 881 cases of endometrial adenocarcinoma and found that the overall 5-year survival rate is 82.1%, with 89.2% for stage Ia, 82.9% for stage Ib, 72.8% for stage II, and 0% for stage IV.

　　(2) Lymph node metastasis: The prognosis is poor for those with lymph node metastasis. Berman's comprehensive data is shown in Table 3.

　　(3) Depth of myometrial invasion: In stage I endometrial cancer, there is a close relationship between the depth of myometrial invasion and lymph node metastasis and prognosis. The lymph node metastasis rate of superficial myometrial invasion cancer is low, while the metastasis rate of deep myometrial invasion is high. At the same time, the recurrence at the vaginal fornix and distant metastasis are also increased. Cohen reported that the 5-year survival rate for no myometrial invasion and superficial myometrial invasion is 80% to 85%, and for deep myometrial invasion is 60%. The data from Peking Union Medical College Hospital prove that the 5-year survival rate for no myometrial invasion is 88.2%, for superficial myometrial invasion is 86.2%, and for deep myometrial invasion is 47.3%.

　　(4) The relationship between cell differentiation degree and prognosis: It is extremely close. The cancer with low cell differentiation has a higher muscle layer invasion depth, lymph node metastasis, cervical metastasis, vaginal metastasis, and distant metastasis, and the prognosis is poor. Tumors with low differentiation have a higher possibility of hematogenous dissemination. Tiitinen reported that the 5-year survival rate in stage I is 80.7%, 81%, and 50.5% for grades 1, 2, and 3, respectively. In stage II, it is 73.5%, 59.1%, and 48.4% for grades 1, 2, and 3, respectively. It is obvious that the prognosis of grade 3 is worse than that of grades 1 and 2.

　　(5) Tissue Type: It is now universally recognized that adenocarcinoma and simple adenocarcinoma have a better prognosis, while adenocarcinoma, papillary serous adenocarcinoma has a poor prognosis. Chen Yinan reported on 149 cases of endometrial cancer, with 5-year survival rates of 75% and 84.6% for adenocarcinoma and adenocarcinoma, respectively, while for adenosquamous carcinoma, it is only 37.5%. The majority of clear cell carcinoma tissues have poor differentiation, so the prognosis is poor, and the 5-year survival rate of stage I patients is only 42%.

　　(6) Age: The older the age, the worse the prognosis. According to foreign reports, the 5-year survival rate of patients under 60 years old is 90%, while for those over 60, it is only 65%. The possible reasons are: ① Most tumors in the elderly are poorly differentiated; ② Cases with poor differentiation require aggressive treatment, but the elderly often cannot tolerate it well.

　　(7) Steroid Hormone Receptors: Ehrlich reported that the use of DCC to measure sex hormone receptors found that progesterone receptor is more useful than estrogen receptor. If the progesterone receptor is negative, the recurrence rate of stage I patients is significantly higher than that of positive progesterone receptor, with a ratio of 37.2% to 7%. For estrogen receptor-negative patients, the recurrence rate is 41.2%, and for positive patients, 12.7%. In general, the survival rate of patients is related to the content of progesterone receptor, and the survival rate of positive progesterone receptor patients is significantly higher than that of negative patients.

　　(8) Relationship between exogenous estrogen and prognosis: Recently, it has been noted that the prognosis of endometrial cancer patients who have used estrogen is better than those who have not used it. Smith analyzed 173 cases of endometrial cancer, including 62 cases without estrogen use and without obesity, diabetes, and other conditions. These patients have a later clinical stage and poorer cell differentiation than those who have used estrogen, with a higher mortality rate, a total of 13 deaths within 5 years, 10 deaths among those without estrogen use, and only 3 deaths among those with estrogen use.

　　(9) Other Factors: Patients with cancer emboli in blood vessels or positive peritoneal cytology have poor prognosis.