Malignant ovarian tumors after menopause

　　First, etiology

　　Postmenopausal women have degeneration of ovarian function, low immune function, along with genetic factors, viral infection, reproductive factors, smoking, economic status, ethnicity, geographical environment, and other factors, all of which are related to the occurrence and development of tumors.

　　Second, pathogenesis

　　1. Histological classification The classification of ovarian tumors currently uses the histological classification method formulated by the World Health Organization (WHO, 1972). Common types include the following:

　　(1) Ovarian epithelial tumors: Ovarian epithelial tumors are tumors derived from the coelomic epithelium, accounting for 50% to 70% of ovarian tumors. Their malignant types are also known as primary ovarian cancer, which is the most common malignant ovarian tumor, accounting for 85% to 90%, mostly occurring in women aged 40 to 60. This type of tumor originates from the germinal epithelium on the surface of the ovary, which comes from the primordial coelomic epithelium and has the potential to differentiate into various müllerian epithelia. If it differentiates into fallopian tube epithelium, it forms serous tumors; if it differentiates into cervical mucosa, it forms mucinous tumors; if it differentiates into endometrial tissue, it forms endometrioid tumors.

　　(2) Ovarian germ cell tumors: Ovarian germ cell tumors are a group of tumors derived from the primordial ovarian germ cells, accounting for 20% to 40% of ovarian tumors. Germ cells have the function of forming all tissues. Undifferentiated ones are called dysgerminoma; pluripotent embryonal ones are called embryonal carcinoma; those that differentiate into embryonic structures are called teratomas; those that differentiate into extraembryonic structures are called endodermal sinus tumors, choriocarcinoma. Germ cell tumors are common in children and adolescents, with 60% to 90% occurring before puberty, and only 4% after menopause.

　　(3) Ovarian stromal tumors: Ovarian stromal tumors are derived from the sex cord and stroma tissues of the primordial gonads, accounting for 5% of ovarian tumors. The sex cord and stroma originate from the mesenchymal tissues of the coelom and can differentiate into male and female. The sex cord differentiates into granulosa or stromal cell tumors; the stroma differentiates into follicular theca cell tumors or stromal cell tumors. Such tumors often have endocrine functions and are therefore also called functional tumors.

　　(4) Metastatic tumors of the ovary: Metastatic tumors of the ovary account for 5% to 10% of ovarian tumors. Their primary sites are often the gastrointestinal tract, breast, and reproductive organs.

　　2. The metastatic pathways of ovarian malignant tumors mainly include direct spread and intraperitoneal implantation. Tumor cells can directly invade the capsule, affect adjacent organs, and widely implant on the surface of the omentum. Even in the case of localized tumors, there may be subclinical metastasis in the peritoneum, omentum, diaphragm, and other areas. The overall transdiaphragmatic metastasis rate of ovarian malignant tumors is 50%, and it increases with the advancement of the stage. Lymphatic metastasis is also an important pathway, with three types of methods:

　　① Along the course of the ovarian vessels, from the ovarian lymphatic duct to the para-aortic lymph nodes above the abdominal aorta.

　　② From the lymphatic duct at the hilum of the ovary to the internal and external iliac lymph nodes, and then through the common iliac to the para-aortic lymph nodes next to the abdominal aorta.

　　③ Along the round ligament into the external iliac and inguinal lymph nodes.

　　If ovarian tumors rupture or torsion of the pedicle often leads to severe abdominal pain, nausea, vomiting, and sometimes leads to internal bleeding, peritonitis, and shock, which is a common gynecological acute abdomen. About 3% of ovarian tumors may rupture, and traumatic rupture can be caused by abdominal blows, sexual intercourse, gynecological examination, puncture, etc.; rapid growth or invasive growth of the tumor that breaks through the cyst wall can cause spontaneous rupture. About 10% of ovarian tumors may develop torsion of the pedicle, at this time, venous return is受阻, there is severe congestion within the tumor or vascular rupture, and the tumor undergoes necrosis.

　　1. Symptoms

　　1. Early ovarian malignant tumors often have no symptoms, and are discovered incidentally during gynecological examination for other reasons. Once symptoms appear, they are often manifested as abdominal distension, palpable mass in the abdomen, and the appearance of ascites. The severity of symptoms depends on the following points:

　　(1) Size, location, and extent of invasion of adjacent organs: for example, the tumor mass of serous or mucinous ovarian cancer can be large; when a benign ovarian tumor turns malignant, the tumor rapidly increases in size and ascites may appear; if the tumor infiltrates or compresses surrounding tissues or nerves, it can cause abdominal pain, lumbar pain, or lower limb pain; if it compresses pelvic veins, lower limb edema may occur; in the late stage, it shows symptoms such as weight loss, severe anemia, and signs of malignancy.

　　(2) Histological type of tumor: functional tumors can produce symptoms of excessive estrogen or androgen, such as excessive menstrual bleeding and prolonged menstrual periods in perimenopausal women, and a small number of patients may also experience prolonged amenorrhea or irregular bleeding; while postmenopausal women may have postmenopausal bleeding, breast tenderness, and breast enlargement, etc.

　　2. Signs

　　Transvaginal examination can palpate scattered hard nodules in the pelvic cavity at the posterior fornix, with masses mostly bilateral, solid, or semi-solid, with an uneven surface and fixed in place, often accompanied by ascites. Sometimes, enlarged lymph nodes can be palpated in the inguinal, axillary, or supraclavicular areas. After the climacteric period, the vaginal fornix of women is shallow and flat, and it is generally not easy to find masses or posterior fornix metastatic nodules by bimanual examination. Therefore, it is emphasized that a three-part examination must be performed. In 1971, Barber first proposed the postmenopausal palpable ovarian syndrome (PMP0). The normal size of the ovary before menopause is about (3.5×2.0×1.5) cm3, and about (2.0×1.5×0.5) cm3 in 1-2 years after menopause, and about (1.5×0.75×0.5) cm3 after 2 years of menopause. If an enlarged ovary is found after menopause, it should be paid attention to and further diagnosis should be made.

　　1. About 70% of patients seek medical attention when they are already in the late stage, so the 5-year survival rate of ovarian malignant tumors is only 25% to 30%. With the progress of diagnosis and treatment of cervical cancer and endometrial cancer, ovarian cancer has become a tumor that seriously threatens women's lives. The incidence of ovarian malignant tumors has increased in recent years, and the mortality has ranked first among gynecological malignant tumors.

　　2. Prognosis: About 70% of patients seek medical attention when they are already in the late stage, so the 5-year survival rate of ovarian malignant tumors is only 25% to 30%. With the progress of diagnosis and treatment of cervical cancer and endometrial cancer, ovarian cancer has become a tumor that seriously threatens women's lives. The incidence of ovarian malignant tumors has increased in recent years, and the mortality has ranked first among gynecological malignant tumors.

　　One, Tumor marker examination

　　1. CA125 80% of patients with ovarian epithelial cancer have CA125 levels higher than normal. Since other tumors and non-tumor diseases such as endometriosis also have a positive possibility, it should be used in conjunction with other methods for differential diagnosis, and tracking and monitoring is more meaningful. More than 90% of the ups and downs of CA125 levels are consistent with the remission or deterioration of the condition, especially for serous adenocarcinoma.

　　2. AFP has specific value for immature teratoma, ovarian endodermal sinus tumor, and mixed anaplastic dysgerminoma.

　　3. HCG is specific for primary ovarian choriocarcinoma.

　　4. Granulosa cell tumors and theca cell tumors produce high levels of estrogen, and serous and mucinous tumors can also secrete a certain amount of estrogen at times.

　　Two, B-ultrasound examination

　　It can detect the location, size, shape, and nature of the mass, understand whether the mass comes from the ovary, suggest whether the mass is cystic or solid, benign or malignant, and can differentiate ovarian tumors, ascites, and tuberculous encapsulated effusion. The clinical diagnostic coincidence rate of B-ultrasound examination is more than 90%, but the diameter

　　Three, Radiological examination

　　When there is an ovarian teratoma, the abdominal plain film can show teeth and bone, the wall of the cyst is a dense calcified layer, the cyst cavity is a radiolucent shadow, intravenous pyelography can understand pelvic, renal, and ureteral obstruction or displacement, barium swallow examination, barium enema air contrast imaging, or breast soft tissue photography can understand whether there is a tumor in the gastrointestinal tract or breast, lymphography can judge whether there is lymph node metastasis, improve the accuracy of staging, CT, MRI can more clearly show liver, lung nodules, and retroperitoneal lymph node metastasis.

　　Four, Laparoscopic examination

　　The general condition of the mass can be directly observed, and the entire pelvic and abdominal cavity, diaphragmatic area can be observed. Multiple biopsies can be performed at suspicious sites, and abdominal fluid can be aspirated for cytological examination. However, laparoscopy cannot observe retroperitoneal lymph nodes, and laparoscopic examination is contraindicated for large masses or adhesive masses.

　　Food should be as diverse as possible, eat more high-protein, high-vitamin, low-animal-fat, easily digestible foods, as well as fresh fruits and vegetables. Avoid eating stale, deteriorated, or stimulating foods, as well as carbonated drinks and other gas-producing foods. Eat less smoked, roasted, pickled, fried, or salty foods. Mix coarse and fine grains as staple foods to ensure nutritional balance, prevent abdominal distension, diarrhea, and constipation; it is advisable to eat more blood and meat, such as animal organs, egg yolks, lean meat, fish, eels, chickens, bones, etc.; at the same time, it can be配合 with medicated diet, such as Dang Shen, Huang Qi, Dang Gui, red dates, peanuts, etc.; edible香菇, mushrooms, monkey head mushrooms, mushrooms, etc. foods.

　　1. Syndrome differentiation and treatment

　　1. 气血瘀滞型

　　(1) Syndrome: Abdominal mass, hard in texture, not movable when pushed, not dispersible when pressed, lower abdominal pain, feeling of坠胀, dark complexion, emaciated body, rough skin, fatigue, lack of energy, lack of appetite, difficulty in defecation, dark purple tongue with ecchymosis, fine and涩脉 or wiry and fine pulse. It is often seen in middle and late stage patients.

　　(2) Treatment method: Activating blood circulation to remove blood stasis, regulating Qi to relieve pain, and tonifying the body to strengthen the constitution.

　　(3) Prescriptions: Self-prescribed formula. 15g of San Lie, 15g of Shai Zhu, 20g of Dan Shen, 15g of Chi Shao, 15g of Chuan Lian Zi, 20g of Qi Ye Yi Yi Hua, 30g of Shi Jian Chuan, 15g of Yuan Hu, 10g of Wu Yao, 10g of Mu Xiang, 15g of Dang Shen, 50g of Huang Qi, 15g of Ji Nei Jin. Decocted for internal use, one dose per day.

　　2. 痰湿凝聚型

　　(1) Syndrome: Abdominal mass, large abdomen (ascites) like carrying a child, abdominal distension and fullness, fatigue, lack of appetite, pale tongue, white greasy coating, slippery pulse. It is often seen in middle and late stages with ascites.

　　(2) Treatment method: Strengthening the spleen and promoting diuresis, resolving phlegm and softening hard masses.

　　(3) Prescriptions: Modified Cang Fu Dao Tan Tang. 15g of Cang Zhu, 15g of Fu Ling, 10g of Ban Xia, 15g of Fu Zi (boiled first), 10g of Dan Nan Xing, 10g of Chen Pi, 30g of Yi Yi Ren, 15g of San Lie, 15g of Shai Zhu, 15g of Ji Qiao, 10g of Xiang Fu, 40g of Huang Qi, 15g of Dang Shen, 40g of Jiao Gu Lan. Decocted for internal use, one dose per day.

　　3.湿热瘀毒型

　　(1) Syndrome: Abdominal mass, abdominal distension, bitter taste in the mouth and dry throat without desire for drinking, dry stools, burning sensation in urine, or accompanied by irregular vaginal bleeding, dark red tongue, or red and purple, thick and greasy or yellow greasy coating, wiry and slippery pulse or slippery and rapid pulse. It is often seen in the late stage of ovarian cancer.

　　(2) Treatment method: Clear heat and promote diuresis, detoxify and disperse phlegm.

　　(3) Prescriptions: Modified Wu Ling San. 15g of Bai Zhu, 15g of Ze Xie, 20g of Zhu Ling, 10g of Guizhi, 15g of Long Kui, 20g of Ban Zhi Lian, 20g of Bai Hua She Tong Cao, 15g of Da Fu Pi, 10g of Che Qian Zi, 15g of Bai Ying, 15g of Qu Mai, 30g of Yi Yi Ren, 30g of Huang Qi, 10g of Yao Zhu, 30g of Shuai Zhu, 15g of Shui Fen, 10g of Xiang Fu, 40g of Huang Qi, 15g of Dang Shen, 40g of Jiao Gu Lan. Decocted for internal use, one dose per day.

　　2. Drug treatment

　　1. It is the main adjuvant treatment

      Due to the high sensitivity of ovarian malignant tumors to chemotherapy, even if widely metastasized, a certain therapeutic effect can be achieved. It can be used for both the prevention of recurrence and for those who have not been completely resected by surgery, where patients can obtain temporary relief, even long-term survival. For patients at an advanced stage who cannot undergo surgery, chemotherapy can reduce the size of the tumor, creating conditions for future surgery.

　　2. Common drugs include platinum drugs

      Cisplatin and carboplatin. Alkylating agents: cyclophosphamide, ifosfamide, thiotepa, and phenylalanine mustard (melphalan). Antimetabolites: fluorouracil. Antitumor antibiotics: actinomycin D, pingyangmycin, etc. Antitumor plant extracts: vincristine, taxol, etc. In recent years, they are mostly used in combination, with platinum drugs as the main drugs. The combination regimen of taxol and carboplatin is currently the ideal first-line treatment for advanced ovarian cancer, with a clinical efficacy rate of up to 73%. Intraperitoneal chemotherapy can control ascites and can also make the implanted lesions shrink or disappear. The drugs can directly act on the tumor, with a local concentration significantly higher than that in plasma.

　　3. Surgical Treatment

      Once a malignant tumor is suspected, an early laparotomy should be performed. During the operation, abdominal fluid or peritoneal lavage fluid should be aspirated for cytological examination; then, a comprehensive exploration of the pelvis and abdomen should be performed, including the diaphragm, liver, spleen, digestive tract, retroperitoneal lymph nodes, and internal reproductive organs. Tissue samples should be taken from multiple suspicious lesions and sites prone to metastasis for histological examination. The tumor stage and surgical scope should be determined based on the findings of the exploration.

　　4. Scope of Surgery

      In stages Ia and Ib, total hysterectomy and bilateral salpingo-oophorectomy should be performed. In stage Ic and above, omentectomy should be performed simultaneously. Tumor cytoreduction surgery refers to the removal of the primary tumor and metastatic lesions as much as possible in patients with advanced stages (II and above), so that the residual tumor lesions have a diameter of ≤2cm. Partial resection of the intestine may be required if necessary, and colostomy, cholecystectomy, or splenectomy may be performed. Currently, it is mostly advocated to perform routine retroperitoneal lymph node dissection simultaneously (including paraaortic and pelvic lymph nodes).

　　5. Other Treatments

      Radiation therapy is an adjuvant treatment for surgery and chemotherapy. Germ cell tumors are the most sensitive to radiotherapy, and even in advanced cases, good efficacy can still be achieved. Granulosa cell tumors are moderately sensitive, and epithelial carcinomas also have a certain degree of sensitivity. Radiotherapy is mainly applied with 60Co or linear accelerators for external irradiation, and radioactive nuclides can also be infused into the peritoneal cavity for internal irradiation, commonly using 32P. The prognosis of ovarian malignant tumors is related to clinical stage, histological classification and grading, patient age, and treatment methods. Elderly patients have low immune function and poorer prognosis than young patients. Ovarian cancer is prone to recurrence and should be followed up and monitored for a long time.