Multiple primary carcinomas in the female reproductive tract

　　1. Etiology

　　Why endometrium and ovary occur cancer simultaneously, this question has not been satisfactorily explained so far. Scully, Eifel, Matlock and others have put forward some theories to try to explain the etiology of this double cancer.

　　1. Extended mullerian duct system

　　(extenderMolltriansystem) During the process of embryonic development, the germinal epithelium of the ovary is closely related to the Mullerian duct. In adults, the derivatives of the Mullerian duct and the surface of the ovary can be regarded as a morphological unit, which responds to the surrounding environment. For example, during pregnancy, the stroma of the cervix, fallopian tubes, and ovaries will appear decidual reactions similar to those of the endometrium. Similarly, the epithelium of these structures will also undergo metaplastic changes (meta-plastic changes).

　　2. Theory of Malignant Transformation of Endometriosis

　　As early as 1952, Sampson pointed out that endometriosis can undergo malignant transformation, and reported 7 cases of ovarian cancer originating from endometriosis. His diagnostic criteria were: (1) Endometriosis and ovarian cancer coexist in the same ovary and have the same histological relationship, similar to the relationship between corpus cancer and benign endometrial tumors. (2) Ovarian cancer originates from the endometrial tissue of the ovary, rather than from the infiltration of other sites. In 1961, Campbell reported 5 cases of primary endometrial and ovarian adenoid cystic carcinomas, all of whom had endometriosis. The author believed that all ovarian adenoid cystic carcinomas originated from endometrial endometriosis because the pathological changes in the 5 cases completely met Sampson's diagnostic criteria. In 1966, Scully reported systematically on the malignant transformation of endometriosis, believing that the incidence rate was difficult to estimate, but the existence of malignant transformation was certain. In addition to endometrioid cancer, clear cell cancer, squamous cell cancer, carcinosarcoma, and stromal sarcoma can also originate from endometriosis. He also believed that ovarian cancer originating from endometriosis often accompanied corpus cancer, and sometimes corpus cancer was very small and often overlooked in clinical practice.

　　3, The mutation theory of cancer genes

　　With the continuous deepening of cancer gene research, it is now believed that the occurrence of cancer is related to cancer gene mutation. There are many reports of primary cancers in multiple sites with 'cloacogenic' multi-site carcinogenesis, which may have a common susceptible area, and this area has multiple responses to the same cancer gene. Tissues related to embryonic development show a high acceptance of the same cancer gene. The response of various tissues to cancer genes is not necessarily synchronous, and may be delayed in some areas, which may be the reason why some sites have obvious carcinogenesis while others only show in situ carcinoma.

　　2. Pathogenesis

　　1. Extended mullerian duct system

　　Gricouroff and Lauchlan et al. proposed the concept of the 'extended mullerian system' to describe the surface of the ovary, fallopian tubes, endometrium, and cervix. All the structures in this system have an important similarity, that is, they can form epithelial tumors of similar tissue types, and can also form mixed mesenchymal tumors with gynecological characteristics. Usually, corpus cancer is mostly well-differentiated adenocarcinoma, but serous papillary carcinoma, mucinous carcinoma, and clear cell carcinoma can also originate from the endometrium. Another important feature of the extended mullerian system is that the same or independent tumor or tumor-like proliferation phenomena can occur simultaneously in multiple anatomical sites. The most common example is bilateral ovarian tumors, one of which is benign and the other malignant. The most typical phenomenon is ovarian serous carcinoma accompanied by fallopian tube adenomatous atypical hyperplasia or 'in situ carcinoma'. In addition, it has been found that when the endometrium develops into adenocarcinoma, the ovary can be accompanied by endometrial and/or endometriosis, and the epithelial malignant tumors of the ovary are often accompanied by atypical hyperplasia of the endometrium. Based on the above theories and clinical pathological findings, many scholars believe that endometrial and ovarian primary double cancers have a common embryonic origin - the 'extended mullerian system'.

　　2. Theory of Malignant Transformation of Endometriosis

　　It is well known that the normal endometrium can undergo cancerous transformation under excessive stimulation by estrogen. Is the malignant transformation of endometriosis also related to excessive estrogen stimulation? Studies have shown that ectopic endometrium can undergo periodic changes under the action of ovarian hormones, but these changes are not as obvious as those in normal endometrium, with most remaining in the early or middle proliferative phase and no longer developing. The synchronization rate of ovarian ectopic endometrium with the secretory phase changes of endometrium is 55%. The research results of Tamaya, Janne, and others also confirm the existence of estrogen and progesterone receptors in ectopic endometrium, indicating that the endometriotic lesions are hormone-dependent. The periodicity of symptoms and signs of endometriosis and the good effects of hormone treatment for this condition in many cases all support this point. Since both ectopic endometrium and normal endometrium are hormone-dependent, theoretically, excessive estrogen stimulation may play a certain role in the malignant transformation of endometriosis. However, this view has not been confirmed by anyone to date. Although the cause of malignant transformation is unclear, the phenomenon of malignant transformation is definitely present. There is literature that confirms that both uterine adenomyoma and pelvic endometriosis can undergo malignant transformation. Scully analyzed 950 specimens of ovarian endometriosis and found that the malignant transformation rate was less than 1%. However, Kuman and Craic reported that 11% of ovarian endometrioid carcinomas were associated with endometriosis. Cummins and others revealed that 25% of ovarian endometrioid carcinomas originated from endometriosis. The occurrence of endometrial and ovarian primary double cancers associated with endometriosis is also reported differently by various researchers. Ulbright and Rotl reported that the incidence was only 5%, while Deligoliach believed that 55.5% of endometrial and ovarian primary double cancers were associated with endometriosis. Campbell reported that all 5 cases were associated with endometriosis. In recent years, the incidence of endometriosis has been increasing, and it has become a common disease in the field of gynecology. The relationship between endometriosis and primary endometrial and ovarian double cancers is worthy of further study.

　　3, The mutation theory of cancer genes

　　Matlock and Deligolisch believe that the endometrium and ovaries are closely related in embryonic development and have the same 'susceptible region' of cancer genes. When this cancer gene mutates, primary dual cancer of the endometrium and ovaries occurs. In recent years, it has been found that the tumor suppressor gene p53 is closely related to gynecological tumors. Many studies have shown that cervical cancer, corpus cancer, and ovaries all have obvious p53 expression abnormalities.

　　1, Ascites:Free fluid accumulated in the peritoneal cavity. The normal peritoneal cavity can contain a small amount of fluid, which serves as lubrication for the viscera. Ascites can be caused by diseases such as heart disease, liver disease, kidney disease, tuberculosis, malignant tumors, and is a common clinical sign. It can be divided into exudative or transudative fluids according to its nature; and into serous, hemorrhagic, purulent, or chylous fluids according to its appearance.

　　2, Infection:The cause can be infectious or non-infectious (such as inflammation, tumor, immune disorder). The type of fever can be intermittent, that is, rising and then dropping back to normal levels every day, or persistent fever, that is, not returning to normal levels after rising. The elderly often have a decreased response to fever, and in some patients such as alcoholics, the elderly, or children, the fever response can be reduced during severe infection. Pyrogens are substances that cause fever, and there are two types: exogenous and endogenous.

　　Abnormal bleeding is the main symptom of primary dual cancer of the uterus and ovaries. Patients in Group A are younger, 50% have a history of infertility, and uterine muscle invasion and intrapelvic spread are rare, with rates of 6% and 12% respectively, while patients in Group B are older, 90% are postmenopausal women, and uterine muscle invasion and intrapelvic spread are more common, accounting for 63% and 45% respectively. Uterine muscle invasion and intrapelvic spread in Group A are 30% and 38%, and in Group B are both 50%. The results show that abnormal bleeding is the main symptom of primary dual cancer of the uterus and ovaries, accounting for 75.1%, and in postmenopausal women, postmenopausal bleeding accounts for 81.8%. The second most common symptom is abdominal pain or distension, accounting for 58.6%, primary infertility accounts for 31%. Apart from the older age of patients in Group B and the more common postmenopausal bleeding, there are no significant differences in clinical symptoms between the two groups (P>0.05). Abdominal mass is the most common sign of primary dual cancer of the uterus and ovaries, accounting for 89.3%, and uterine enlargement accounts for 44.48%.

　　I. Prognosis status

　　Many studies have confirmed that the prognosis of double cancers is good. Eifel reported that the 5-year survival rate of primary double cancers of endometrium and ovary is 69.3%, with Group A at 100%, and Group B at 45%. Zaino reported that the overall 5-year survival rate of double cancers is 66%, with Group A at 69% and Group B at 38%. Shen's data show that the overall survival rate is 72.4%, with Group A at 80% and Group B at 55.5%. According to the survival curve of ovarian cancer, the 3-year survival rate of stage I ovarian cancer is 68% to 80%. Stage II ovarian cancer is 50% to 60%, and the survival rate of stage III endometrial cancer is lower than that of stage II ovarian cancer. The survival rate of primary double cancers of endometrium and ovary shown in the research is similar to the results of Eifel and Zaino's studies, all the same as stage I ovarian cancer. The treatment effect of primary double cancers is good, which is related to early detection and early treatment. Due to endometrial lesions, most patients have irregular vaginal bleeding, and 76% of patients seek medical attention mainly due to irregular vaginal bleeding, which may lead to early detection. Among the patients, 55.6% of double cancers are localized in endometrial and ovarian cancer. Although the cancer has affected both the uterus and ovaries, the lesions are still in the early stage, without vascular and lymphatic invasion, so the treatment effect is good.

　　II. Factors affecting prognosis

　　1. Degree of tumor invasion:It is widely known that tumor staging is an important factor affecting the prognosis of ovarian cancer and endometrial cancer. However, tumor staging seems to be not very suitable for primary double cancers of endometrium and ovary, as these two cancers are relatively independent. Although most tumors are localized in the endometrium and ovary, sometimes ovarian tumors can also be accompanied by pelvic invasion, even abdominal and omentum metastasis. This situation is more common in Group B. If diagnosed as stage II or III ovarian cancer, it means that endometrial cancer may be a secondary lesion, but in fact, both endometrial cancer and ovarian cancer are primary tumors in terms of pathological findings and histological types. Therefore, the degree of tumor invasion is used as an indicator to judge its impact on the prognosis of double cancers. The research results show that the prognosis of double cancers localized in the endometrium and ovary is good, with a survival rate of up to 100%. However, if accompanied by pelvic invasion, the survival rate drops to 66.6%, and if accompanied by abdominal and omentum metastasis, the survival rate is 0. The degree of tumor invasion is an important factor affecting the prognosis of double cancers.

　　2. Tumor grading:The degree of differentiation of the tumor is one of the factors affecting the prognosis of dual cancers. The research by Zaino shows that both dual cancers are highly differentiated tumors, with a survival rate of 85.7%; when one tumor is moderately differentiated, the survival rate is 64.3%; when one tumor is poorly differentiated, the survival rate is 33.3%. There are also results showing that highly differentiated dual cancers have a survival rate of 100%; moderately differentiated dual cancers have a survival rate of 78.9%; and there were 4 cases of poorly differentiated dual cancers, none of which survived. The histological grading of the tumor is a statistically significant prognostic factor.

　　3. Histological type:The study by Eifel and Zaino shows that the typical endometrial adenocarcinoma and ovarian endometrioid adenocarcinoma (Group A, with a better prognosis, survival rate up to 70% to 100%; but if the tumor is of two different histological types B group, the prognosis is poor, with a survival rate of 38% to 45%.)

　　4. Uterine muscle layer infiltration:The infiltration of the uterine muscle layer is also an important factor affecting the prognosis of endometrial cancer, which is well known. The research by Zaino and others also indicates that the infiltration of the uterine muscle layer is an important factor affecting the prognosis of dual cancers, with the following results: The survival rate of patients with deep muscle layer infiltration of dual cancers is 22.2%; while those with only superficial muscle layer infiltration or no muscle layer infiltration have a survival rate of 91.6%, among whom 24 had superficial muscle layer infiltration, 20 survived, accounting for 83.3%. There were 5 cases with deep muscle layer infiltration, and only 1 survived, accounting for 20%. Therefore, the infiltration of the deep muscle layer of the uterus has a significant impact on the survival rate of dual cancers. Lurain and Kennedy and others believe that in early endometrial cancer, positive peritoneal lavage fluid cytology does not increase the recurrence rate or affect survival. The significance of peritoneal lavage fluid cytology examination for primary dual cancers of the endometrium and ovary has never been reported in the literature. Shen's results show that the survival rate of patients with negative peritoneal lavage fluid cytology in dual cancers is 93.3%; while those with positive peritoneal lavage fluid cytology have a survival rate of 40%, and positive peritoneal lavage fluid cytology is one of the indicators of poor prognosis in dual cancers with statistical significance.

　　1. Tumor marker examination, secretion examination.

　　2. Ultrasound examination: It has a high diagnostic rate for pelvic masses, reaching 94%, a diagnostic rate of 77% for ascites, but a relatively low diagnostic rate for uterine enlargement, only 39%.

　　3. Histopathological examination: Diagnostic curettage is very helpful for the diagnosis of primary double cancer of the uterus and ovary. All patients undergo curettage before surgery and obtain histological evidence of endometrial cancer. Therefore, all patients with pelvic mass and irregular vaginal bleeding should undergo curettage to exclude endometrial cancer. Cervical scraping has little significance for double cancer and preoperative diagnosis, with a positive rate of only 17.4%.

　　4. Laparoscopic examination, etc.

　　First, food therapy recipes

　　1. Aiye egg

　　Two eggs, 250g Aiye, an appropriate amount of clean water.

　　Preparation: Boil Aiye and eggs with low heat in an earthen pot (do not use iron utensils), boil the eggs until cooked, remove the shell and boil for another 10 minutes.

　　Functions: Warm the meridians and stop bleeding, dispel cold and relieve pain.

　　2. Chenxiang beef

　　15g Xiangfu Zi, 30g Chenpi, 500g beef, scallions, ginger, and salt in appropriate amounts.

　　Preparation: Boil 2000 grams of water with Chenpi and Xiangfu Zi for half an hour, strain the dregs, add beef with scallions, ginger, salt, and other spices, stew with low heat until tender, cool, cut into slices and eat.

　　Functions: Soothe the liver and regulate qi, invigorate the spleen and benefit the qi.

　　3. Tufuling Luoken Shu Zi She She Cao pork soup

　　40g Luoken, 40g Kui Shu Zi, two dates, 40g Bai Hua She She Cao, Tufuling, 240g pork, a little fine salt.

　　Preparation method:

　　(1) Soak Luoken, Kui Shu Zi, Bai Hua She She Cao, and Tufuling with clean water separately.

　　(2) Wash all the materials with clean water, put them in a pot, add an appropriate amount of water, bring it to a boil with high heat first, then change to medium heat to boil for about 2 hours, and season with a little fine salt.

　　4. Wuzhenzi Dongchong Xiacao E jelly lean pork soup

　　One piece of Chenpi, 40g Wuzhenzi, Dongchong Xiacao, Shanyao, 40g Huajiao, 20g Du Zhong, 120g lean pork, a little fine salt.

　　Preparation: Simmer for about 4 hours, remove all the above materials (can be served as side dishes), then add E jelly, continue to heat until dissolved, and season with a little fine salt, then it can be drunk.

　　5. Ma鞭 bitter melon Shengyimi pork soup

　　Four dates, 40g Ma鞭草, 80g Shengyimi, 500g bitter melon, 240g pork, a little fine salt.

　　Preparation method:

　　(1) Cut open the bitter melon and remove the seeds.

　　(2) Soak the Ma鞭草 and Shengyimi with clean water separately.

　　(3) Wash all the materials with clean water.

　　(4) Add an appropriate amount of water to the pot, bring it to a boil with high heat first, then add all the above materials, wait for the water to boil again, and then change to medium heat to continue boiling for about 2 hours, add a little fine salt for seasoning.

　　Functions: Clear heat and detoxify, diuretic and dampness-relieving, stop leucorrhea and itching

　　Indications: For diseases such as cancer of the reproductive system, mixed discharge of red and white, continuous dripping, fishy smell, lower abdominal pain, vulvar itching, insomnia with dreams, and jaundice of urine.

　　Contraindications: Not suitable for people with weak spleen and stomach or pregnant women to drink.

　　6. Foshou Eguoshu Bai Nian fish soup

　　15g Kuncao, 30g Eguoshu, 60g Foshou, 250g white eel.

　　Preparation method:

　　(1) Clean the Foshou and Eguoshu, soak for half an hour. Clean the Kuncao and wrap it in gauze. Remove the head and internal organs from the eel, and clean it.

　　(2) Put all the ingredients together in a pot, add an appropriate amount of water, boil with high heat, then simmer for 2 hours with low heat, remove the chrysanthemum grass, and season with salt.

　　Second, Diet Taboos

　　1. Eat more dandelion, melon, Job's tears, lotus root, fuki, mokanshō, burdock, plum, oyster, turtle, seahorse.

　　2. Eat more foods to prevent and treat the side effects of chemotherapy and radiotherapy

　　Tofu, pork liver, crucian carp, bluefish, cuttlefish, duck, frog, beef, hawthorn, mung bean, loquat, fig.

　　3. Hemorrhage: Eat more shark fin, sea cucumber, manta ray, black fungus, mushroom, oyster, broad bean.

　　4. Back pain: Eat more lotus seed, walnut meat, chive, Job's tears, plum, taro, turtle, chestnut, jellyfish, royal jelly, skate, spider crab.

　　5. Edema: Eat more sturgeon, ulva, pancreas fish, adzuki bean, carp, bream, corn, lettuce, mud eel, clam, duck meat, coconut milk.

　　6. Leucorrhea: Eat more cuttlefish, whelk, clam, clam, oyster, turtle, jellyfish, sheep pancreas, broad bean, sparrow, white sesame, lotus seed, walnut, chuanxiong, celery.

　　7. Avoid foods that cause allergies: such as lamb, crab, shrimp, salted fish, eel, blackfish, etc.

　　8. Avoid hot, coagulating, and hormone-containing foods: such as longan, ejiao, jujube, royal jelly, etc.

　　9. Diet should be light, avoid spicy foods such as chili, Sichuan pepper, green onions, garlic, white wine, and frozen foods with stimulating properties.

　　First, Prevention

　　Regular physical examinations, early detection, and timely treatment and follow-up are well done.

　　Second, Preoperative Preparation

　　1. Check all preoperative biochemical reports, and cooperate to do routine examination, heart, liver, and kidney function examination, chest X-ray and gynecological examination to understand whether the patient has any contraindications to surgery.

　　2. Vaginal preparation: Use 0.5% polyvinyl pyrrolidone iodine vaginal irrigation and medication three days before surgery.

　　3. Skin preparation: Prepare for skin preparation, skin test, and blood sampling one day before surgery, and cross-match blood for reserve.

　　4. Bowel preparation: Take oral senna leaves 30g as a tea drink one day before surgery, eat liquid food one day before surgery, clean the bowel with clean water the night before and in the morning of the day of surgery. Fast for 10 hours before surgery and 8 hours of water restriction before surgery.