Vulvar adenosquamous carcinoma

　　1. Etiology

　　DNA of HPV (Human Papillomavirus) has been found in adenosquamous carcinoma. This suggests that vulvar adenosquamous carcinoma is related to human papillomavirus infection.

　　2. Pathogenesis

　　Carcinoma containing squamous cell carcinoma and adenocarcinoma components, i.e., bilaterally differentiated epithelial carcinoma. It originates from the vestibular gland or embryonic tissue of a single anal canal. Under the microscope, the cells of squamous epithelial carcinoma and adenocytic epithelial carcinoma, as well as intermediate types between them, can be observed. Squamous epithelial carcinoma cells can be undifferentiated spindle cells. Adenocytic cells contain mucus, and are positive for PAS and mucicarmine reactions. Electron microscopy reveals that some cells contain glycogen; some cells with microvilli contain mucous vesicles. In addition to squamous and adenocytic components, there are also transitional cell components under the microscope, which can be explained by the differentiation of residual幼稚 tissues in the vestibular gland, single anal canal, or urogenital sinus into urinary or intestinal epithelium.

　　The cancer focus of vulvar squamous cell carcinoma can occur at any part of the vulva, but generally the labia majora is most common, followed by the labia minora, clitoris, perineum, urethral orifice, anal periphery, etc. Early vulvar squamous cell carcinoma may have local papules, nodules, or small ulcer symptoms; late vulvar squamous cell carcinoma may show irregular masses, accompanied or not accompanied by erosion or papillary tumors. If the cancer focus has metastasized to the inguinal lymph nodes, then there may be enlargement of one or both inguinal lymph nodes. After the ulcer is formed, it is easy to cause infection, and the rate of inguinal lymph node metastasis is high.

　　Vulvar adenocarcinoma is sometimes called pseudo-glandular squamous cell carcinoma, a biphasic differentiated epithelial carcinoma. It has no specific clinical manifestations, may have itching, skin erosion in a few cases, and may form ulcers. The time of consultation for vulvar adenocarcinoma is relatively late.

　　Do a good job of prevention and treatment according to the three-level prevention of tumors.

　　1Epidemiology:Vulvar adenocarcinoma is rare, accounting for only 13% of vulvar cancer. Lasser et al. found that 30% of vulvar cancer patients have focal glandular changes, but only 4% of patients are mainly glandular carcinoma.

　　2Prognosis:The prognosis of vulvar adenocarcinoma is worse than that of squamous cell carcinoma, with a high rate of inguinal lymph node metastasis and a low 5-year survival rate.

　　The diagnosis of vulvar adenocarcinoma depends not only on clinical manifestations but also on the necessary auxiliary examinations. The examination methods are as follows:

     1, Vaginal secretion examination, human papillomavirus polymerase chain reaction, tumor marker examination.

　　2, Biopsy examination.

　　One, Dietetic recipe for vulvar adenocarcinoma

　　1, Mushroom 90 grams of fresh mushrooms, fried with a little vegetable oil and salt, then cooked into soup for consumption. It can be used for cancer prevention.

　　2, Oyster mushroom An appropriate amount of oyster mushroom, simmered in water, cooked, or ground into powder for oral administration.

　　3, Fresh water caltrop 20-30 pieces, add an appropriate amount of water, simmered into a thick soup, taken 2-3 times. It has certain efficacy in preventing cancer.

　　4, 300 grams of meat, 1 fresh river fish (500 grams), 1 white radish. Cut the lamb into large pieces and put it into boiling water, boil with sliced radish for 15 minutes, discard the soup and radish. Put the lamb into the pot, add water (about 2/3 of the pot capacity), scallion, 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 into the lamb pot and cook for 30 minutes. Add salt, coriander, green onions, and garlic sprouts to the soup, and it becomes a delicious and appetizing lamb and fish soup. It is mainly used for the postoperative care of vulvar adenocarcinoma.

　　5. 20 quail eggs, half an onion, 80 grams of carrots, 80 grams of asparagus, 4 tomatoes, 1 green pepper. Boil the eggs and use the shells. Cut the vegetables into small pieces. Boil the carrots just until they are tender. Put 200 milliliters of soup, 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 starch, in order into the bowl, mix well. Heat 30 milliliters of oil in a pot, stir-fry the eggs and vegetables, pour in the sauce and cook for a while, then it can be eaten. It is used to treat anemia caused by bleeding from vulvar adenosquamous carcinoma.

　　2. Foods that are good for the body in vulvar adenosquamous carcinoma

　　1. Eat more foods with anti-vulvar tumor properties, such as sesame, almonds, wheat, barley, cucumbers, black-bone chickens, cuttlefish, green mambas, pork pancreas, chrysanthemums, wild plums, peaches, lychees, purslane, chicken blood, eels, abalones, crabs, cuttlefish, sardines, clams, tortoises. For pain, eat cuttlefish, red crabs, lobsters, sea asparagus, sea cucumbers, tiger fish, beets, mung beans, radishes, chicken blood. For itching, eat amaranth, cabbage, rapeseed, taro, kelp, purple kelp, chicken blood, snake meat, pangolin.

　　2. For pain, eat cuttlefish, red crabs, lobsters, sea asparagus, sea cucumbers, tiger fish, beets, mung beans, radishes, chicken blood.

　　3. For itching, eat amaranth, cabbage, rapeseed, taro, kelp, purple kelp, chicken blood, snake meat, pangolin.

　　4. To enhance physical fitness and prevent metastasis, eat silver ear, black fungus, mushrooms, hedgehog mushrooms, chicken gizzards, sea cucumbers, Job's tears, walnuts, crabs, monitor lizards, needlefish, etc.

　　5. After vulvar adenosquamous carcinoma surgery, it consumes Qi and injures blood, so it is advisable to eat more Qi-nourishing and blood-nourishing foods, such as jujube, longan, adzuki beans, glutinous rice, lychee, mushrooms, carrots, quail eggs, lotus root powder, beans, etc.

　　6. Radiotherapy after vulvar adenosquamous carcinoma surgery: It consumes Yin and damages fluid, so it is advisable to eat more Yin-nourishing and fluid-nourishing foods, such as spinach, green vegetables, lotus root, carrots, watermelons, bananas, grapes, sea cucumbers, sugarcane, lilies, etc.

　　7. Chemotherapy after vulvar adenosquamous carcinoma surgery: It is easy to damage both Qi and blood, so it is advisable to often eat foods that nourish Qi and blood, such as black fungus, mushrooms, walnuts, mulberries, Job's tears congee, red dates, longans, sea cucumbers, etc.

　　3. Foods to avoid in vulvar adenosquamous carcinoma

　　1. Abstain from eating irritants. For example: fish, shrimp, crab, chicken heads, pork heads, goose meat, chicken wings, chicken feet, etc., which will aggravate the itching and inflammation of the perineum after eating.

　　2. Try to eat less spicy and刺激性 foods. For example: onions, pepper, chili, Sichuan pepper, rapeseed, fennel, etc.

　　3. Avoid eating fried and greasy foods. For example: fried dough sticks, butter, butter, chocolate, etc., which have the effect of moistening and increasing heat, which will increase the secretion of leukorrhea and is not conducive to the treatment of the disease.

　　4. Quit smoking and drinking, as well as caffeine and other stimulant drinks.

　　1. Precautions before the treatment of vulvar adenosquamous carcinoma

　　Prevention: Carry out prevention and treatment work according to the three-level prevention of tumors

　　2. Western Medical Treatment Methods for Vulvar Adenosquamous Carcinoma

　　1. The Treatment Principles of Vulvar Adenosquamous Carcinoma

　　(1) The selection of surgical plans must be individualized: Cancer has early and late stages, and there are differences in the condition due to the various biological behaviors of tumor tissues. Some cases do not require lymph node resection, or only require unilateral resection, while some cases must undergo bilateral lymph node resection. Regarding the local conditions of vulvar cancer, some may only require hemivulvectomy, or anterior hemivulvectomy or posterior hemivulvectomy, while some must undergo total vulvectomy, and it should not be uniform to use the traditional vulvar radical surgery and lymph node dissection.

　　Before determining the surgical plan, patients can be classified into high-risk or low-risk groups based on high-risk factors related to lymph node metastasis, in order to adopt the corresponding reasonable treatment plan.

　　① Patients with the following conditions should be included in the high-risk group:

　　A. There are suspicious local manifestations of inguinal lymph node metastasis, i.e., N1 or N2.

　　B. The depth of infiltration of the tumor site >5mm.

　　C. The tumor differentiation degree is G3.

　　D. The tumor differentiation degree is G2, but the depth of infiltration >2mm.

　　E. There is dissemination of tumor cells in the lymphatic or vascular channels.

　　② Patients who meet the following conditions should be included in the low-risk group:

　　A. There are no suspicious local manifestations of inguinal lymph node metastasis, i.e., N0.

　　B. The tumor differentiation degree is G1 and the depth of infiltration ≤5mm, or the differentiation degree is G2 and the depth of infiltration ≤2mm.

　　C. There is no dissemination of tumor cells in the lymphatic or vascular channels.

　　To understand the above conditions, it is necessary to perform a local excision of the tumor before surgical treatment, in order to conduct a comprehensive and detailed pathological histological examination as the basis for classifying high-risk or low-risk groups. If the tumor is ≤4 cm, local excision generally does not present difficulties. If the tumor is too large or has extensive infiltration, it may be considered to take large block biopsies from multiple sites of the tumor. If the tumor is very small, local excision not only serves for diagnosis but may also achieve the purpose of treatment at the same time.

　　(2) The selection of surgical scope for vulvar surgery: In cases of low-risk vulvar cancer, if there is recurrence, it is often limited to the adjacent tissues near the original tumor site. Unless it is a multifocal tumor or a new tumor occurs many years later, the vast majority of recurrent tumors are on the same side as the primary tumor. Therefore, after excluding multifocal cancer through multiple biopsies before surgery, radical vulvectomy (Radicalvulvectomy) is not necessary, and partial radical excision (Radicallocalexcision) can be performed. The excision range includes normal skin and subcutaneous fat tissue 2-3 cm wide around the tumor site. For the peripheral tissues inside, they should not be damaged to the urethra or anus while at least 1 cm of normal tissue is excised. If the tumor is adjacent to the urethra or anus, injury is often unavoidable. Depending on the specific situation, either a larger surgery to excise part of the urethra or anus, or a comprehensive treatment approach combining preoperative and postoperative adjuvant radiotherapy to reduce the excision range of the urethra or anus, may be chosen. For midline tumors at the perineal site, partial radical vulvectomy can be performed without including the clitoris. It is an important principle to preserve the clitoris as much as possible without affecting the efficacy. However, if the tumor is located at the clitoris or nearby, of course, the clitoris should be excised.

　　For vulvar cancer in the high-risk group, the treatment of vulvar lesions is still advisable to be total vulvar radical surgery. However, for some young patients, in order to take care of the appearance of the vulva and psychological impact, or for elderly patients, in order to avoid complications caused by large surgery, partial vulvar radical resection can still be considered, and additional preoperative or postoperative radiotherapy can be added.

　　Whether the use of various modified vulvar radical surgeries, namely partial vulvar radical surgery, will affect the therapeutic effect is a concern of everyone. Hoffman has conducted an analytical study, comparing two groups of 45 cases each in terms of tumor location and clinical stage, which are very similar. Both groups do not include infiltration depth

　　It is necessary to ensure that the local lesions are resected thoroughly when using partial vulvar radical surgery instead of total vulvar radical surgery. It cannot be allowed that a small amount of cancer focus is left behind due to the reduction of the scope, affecting the therapeutic effect. Therefore, the vulvar specimens resected, including the skin and deep subcutaneous tissue, must be sectioned more at the edges for detailed pathological examination. If residual cancer cells are found, reoperation or radiotherapy should be performed again.

　　(3) Selection of lymph node resection scope:

　　①No lymph node resection: Although clinical practice has already proven that a large amount of tumor infiltration depth ≥1mm but

　　②Unilateral inguinal lymph node resection: Tumor infiltration depth >1mm but

　　③Complete inguinal lymph node resection: Complete inguinal lymph node resection refers to the simultaneous resection of superficial inguinal lymph nodes and deep inguinal lymph nodes. It is generally called the femoral lymph node dissection. The traditional surgical method is to resect the superficial inguinal lymph nodes on the surface of the fascia lata first, followed by the need to resect a part of the fascia lata, expose the free femoral artery and vein, and剥除二者之间及其附近的脂肪组织和淋巴结。The wound is large, and even forms a cavity. Due to poor skin blood supply, or subcutaneous ineffective cavity and effusion, it affects wound healing, so the complications of wound dehiscence after surgery are common, and there is still the困扰 of lower limb edema in the late stage, causing great burden to the patients. Since Borgno proposed the view that there are only deep inguinal lymph nodes on the inner side of the femoral vein based on the anatomical results of inguinal lymph nodes from autopsies, many authors have narrowed the surgical anatomical scope during deep lymph node resection, that is, only exposing the femoral vein and stripping the lymph nodes on its inner side. In this way, not only is the surgical scope small, but also the complications of postoperative wound dehiscence and late lower limb lymphedema are reduced.

　　If the great saphenous vein is preserved after surgery without ligation, it can also greatly reduce the postoperative complications in the short or long term, such as cellulitis and lower limb lymphedema.

　　④The treatment of pelvic lymph nodes has reached a relatively consistent view in recent years, which holds that there is rarely a pelvic lymph node metastasis in patients with negative inguinal lymph node metastasis. For those with positive inguinal lymph node metastasis, the survival rate after additional radiotherapy combined with surgery is almost the same as that after pelvic lymph node dissection. Therefore, pelvic lymph node dissection does not benefit the patients and is no longer considered as an option for surgical scope in recent years.

　　(4) Application of radiotherapy: In recent years, due to improvements in radiation equipment and treatment techniques, radiotherapy has also been given attention in its treatment. For primary lesions of the external genitalia, radiotherapy is generally not used as a curative treatment method, but only as a means of comprehensive treatment with surgery. For lesions that are large, deeply invasive, involve the urethral orifice or anal orifice and their adjacent tissues, preoperative radiotherapy can reduce the size of the lesion, increase the thoroughness of surgery at the edge of the lesion, and possibly preserve the urethra and anus. Preoperative radiotherapy usually uses 60Co or an accelerator to vertically irradiate the lesion, and for lesions with a large outward projection, tangential irradiation can also be used. When using this technology, the tumor base should be cut into during irradiation positioning, and attention should be paid not to include too much external genital tissue to reduce the external genital radiation reaction. The dose is generally given at 30Gy/3～4 weeks. During the irradiation period, attention should be paid to the cleanliness and dryness of the external genitalia, to reduce local infection, and treatment should be suspended if the reaction is obvious. After completing treatment, rest for two weeks before surgery. For cases where the surgical margin is not completely resected or the tumor margin is too close to the incision, postoperative irradiation can be performed, with a local dose of 20～30Gy/3～4 weeks. For cases suspected of having urethral orifice tumor invasion but not undergoing resection, postoperative treatment with a 180～220kV X-ray endocavity tube can be performed, with a tube diameter of 2～3cm, directly targeting the urethral orifice. The local dose can be initially given at 40Gy/4 weeks, at this time, the patient may feel urethral orifice pain, and can rest for 2 weeks, and then the treatment can be resumed after the symptoms improve. Some cases can continue to increase 20Gy/2 weeks, with a total dose that can reach 60Gy. Treatment can be 5 times a week, or 3 times, or can also use an accelerator, but it is often also not possible.

　　For cases with vaginal involvement, posterior implant therapy can be performed using a vaginal cylindrical container (vaginal plug). The diameter of the plug is generally 1.5～2.5cm, and a dose of 20Gy can be administered to the involved part of the vagina before and after surgery, divided into 3 fractions and completed within 2 weeks.

　　Direct interstitial implantation of tumor tissue in the external genitalia undoubtedly has advantages, although some units in China have already started using this method, but experience needs to be accumulated.

　　Radiotherapy for lymphatic drainage areas has been noted since the clinical use of 60Co. For cases that do not undergo lymph node dissection, lymphatic drainage area irradiation can be performed after biopsy. The irradiation uses two inguinal fields, with the field axis equivalent to the inguinal ligament. The upper and lower boundaries are parallel to the ligament, extending medially to the pubic tubercle. The field size is (8～12)cm×(12～14)cm, and when using 60Co irradiation, a dose of 60Gy/6 weeks can be administered. For accelerator irradiation, high-energy X-ray beams are first used to complete 40Gy/4 weeks, followed by B-line irradiation, which provides 20Gy/2 weeks. For cases requiring irradiation of the pelvic lymphatic area, the upper field edge can be appropriately adjusted, and additional irradiation can be performed using two rectangular posterior fields of the pelvis after inguinal irradiation is completed. The field size is (6～8)cm×(14～15)cm, with a midpoint dose of 10Gy/2 weeks. For cases with lymph node dissection and lymphatic metastasis, further radiotherapy seems to have little benefit, and certain complications such as edema caused by lower extremity circulatory disorders will definitely increase.

　　(5) Combined Radiotherapy and Chemotherapy: The combined treatment of radiotherapy and chemotherapy for advanced vulvar cancer has been reported in many papers in recent years, some as the main treatment method, most as preoperative treatment, all achieving relatively satisfactory results, with a remission rate of 90% to 94% and a complete remission rate of 42% to 78%. Vulvar adenocarcinoma is less sensitive to anticancer drugs, and the use of cisplatin (DDP), bleomycin, and dacarbazine (dacarbazine) has certain efficacy and can be used as an adjuvant therapy for surgery. When pelvic lymph node metastasis has occurred, intravenous chemotherapy can be performed.

　　In some cases, surgery is performed after comprehensive treatment, and the specimen removed has no residual cancer. Therefore, radiotherapy and chemotherapy combined treatment is not only to some extent palliative, but also can have a positive effect on surgical treatment.

　　Radiotherapy tumor dose 40-65Gy, chemotherapy starts in the first or second week of radiotherapy, most of the drugs used in chemotherapy are fluorouracil (5-Fu) and cisplatin combined chemotherapy, 4 days as a course, a total of 2 courses, 28 days apart.

　　Fluorouracil (5-Fu): 1g (24hrs) continuous intravenous infusion for 4 or 5 days.

　　Cisplatin: 100mg intravenous injection on the first or second day [or 50mg/(m2?d) on the first and second days].

　　2. Treatment for Recurrent Cancer

　　(1) The prognosis for those who relapse within 2 years is poor, while for those who relapse after more than 2 years, the prognosis is better, and the recurrence site is mostly the vulva.

　　(2) The site of recurrence is the most important factor affecting the prognosis. For those with recurrence limited to the vulva, the survival rate after treatment is 62% to 79%. The survival rate for those with recurrence in other areas (such as the inguinal area or outside the vulva) is only 0% to 12%.

　　(3) For those with recurrence limited to the vulva, there is a good survival rate after large local resection, reaching about 51% to 60%, while recurrence in other areas (inguinal, pelvic, or lung, etc.) even after various treatments, the prognosis is still very poor.