Vaginal metastatic tumors

　　1. Etiology

　　The routes of metastasis of tumors originating from pelvic and abdominal cavity organs are mainly through surface implantation, direct infiltration, lymphatic and hematogenous metastasis to the vagina, while metastatic tumors from other parts of the body are mainly through hematogenous spread. The following mainly introduces the routes and methods of metastasis of common gynecological tumors at other sites to the vagina.

　　The routes of vaginal metastasis of cervical cancer include surface spread, surface implantation, and submucosal lymphatic vessel diffusion. Cervical cancer cells infiltrate downward to the vaginal fornix and vaginal wall, where the vaginal wall is infiltrated by cancer. They can reach the vagina alone or simultaneously through the vaginal mucosa, submucosa, and muscular layer, or can spread retrogradely with the help of the rich lymphatics of the vaginal mucosa, resulting in solitary nodules on the vaginal wall away from the primary tumor.

　　Ovarian cancer can be transferred to the vagina through blood, lymphatic vessel transfer, and direct invasion of the vagina or through fallopian tube and uterine cavity transfer from cancerous ascites. The vagina has abundant blood vessels and lymphatic vessels, and the venous plexus and lymphatic circulation of the female reproductive tract are richly connected. This may allow ovarian vein thrombus to retrogradely pass through the plexus to the vaginal venous plexus or reach the vagina through blood flow. After lymph node metastasis in the paraaortic region, it can retrogradely reach the vaginal lymphatic network and cause vaginal metastasis. The metastatic cancer in the lower segment of the vagina may mainly originate from lymph node metastasis. Direct invasion of the vagina by pelvic floor tumors is common after ovarian cancer debulking surgery, and the tumor often invades the vaginal stump.

　　Endometrial cancer cells can be transferred to the vagina through implantation from the uterine cavity, and can also be transferred through hematogenous spread. Most metastases are formed through the lymphatic vessel route. After the metastasis invades the cervix, the route of metastasis to the vagina is similar to that of cervical cancer.

　　Cancer cells from gestational trophoblastic tumors invade the uterine vein. Since the vaginal veins do not have valves, the blood from the uterine veins containing cancer cells can freely reflux into the vaginal venous plexus, forming tumor emboli in the vaginal veins, and then developing into vaginal metastatic nodules.

　　2, Pathogenesis

　　The gross morphology of vaginal metastases varies with different tumor origins. When cervical cancer spreads to the surface, it can present as a mushroom-like shape. When the tumor spreads through submucosal lymphatic vessels, it often causes diffuse hardening of the upper 1/2 vaginal mucosa. Surface implantation often forms isolated nodules on the anterior vaginal wall and the lower 1/3. About half of the vaginal metastatic adenocarcinomas present as exophytic cauliflower-like or polypoid changes; one-third infiltrate into the vaginal wall, causing the mucosal surface to be uneven and nodular, with a rigid texture; less commonly, it appears as granulation tissue; the least common is a cystic mass originating from ovarian cancer.

　　The lesions of vaginal metastatic trophoblastic tumors can be solitary or multiple, with sizes ranging from a few millimeters to several centimeters. Invasive mole lesions are dark red or purple-blue, with a few nodules being gray-white,脆质，易出血、坏死和感染，病灶切面可见葡萄状物。绒毛膜癌的转移灶可呈深蓝色出血性结节，海绵状，质地软，触之易出血，与周围组织分界清。

　　The microscopic morphological characteristics of metastatic cancer are the same as those of the primary cancer.

　　The lesions of vaginal metastatic trophoblastic tumors can be solitary or multiple, with sizes ranging from a few millimeters to several centimeters. Invasive mole lesions are dark red or purple-blue, with a few nodules being gray-white,脆质，易出血、坏死和感染，病灶切面可见葡萄状物。绒毛膜癌的转移灶可呈深蓝色出血性结节，海绵状，质地软，触之易出血，与周围组织分界清。The microscopic morphological characteristics of metastatic cancer are the same as those of the primary cancer. Common complications include infection and some cases of massive hemorrhage.

　　About half of the patients with vaginal metastatic tumors have no symptoms when discovered during follow-up, while about half of the patients experience symptoms such as vaginal bleeding and increased vaginal discharge. A few patients, especially those with gestational trophoblastic tumors, may experience massive vaginal bleeding due to the ulceration of vaginal metastatic nodules, and infected patients may produce smelly secretions.

　　The timing and location of metastases vary with the primary disease. For patients with invasive mole, the time from the termination of the last pregnancy to the discovery of vaginal metastases does not exceed 1 year.绒毛膜癌出现稍迟一些，大部分在1年内出现，24％的患者在1～3年内发现阴道转移结节，转移结节多为多发，单发结节又以下段为多，82.4％患者合并有其他脏器的转移，肺转移最常见，在卵巢癌合并有阴道转移患者，阴道转移距卵巢癌诊断治疗的平均时间为11.4个月，转移部位以阴道上段为多，75％患者合并有盆腹腔，淋巴结及脏器实质的转移。

　　The metastatic sites of endometrial adenocarcinoma are mostly located in the lower segment of the vagina on both sides or solitary nodules below the urethra, located on the mucosa or submucosa.

　　Most vaginal cancers are metastatic tumors, and primary vaginal cancer is rare. Primary vaginal cancer does not involve the cervix or vulva. Most vaginal cancers are squamous cell carcinomas, which are common in women around the age of 50.

　　1. Direct dissemination to adjacent soft tissues and bone structures, including the area around the vagina, parauterine, bladder, urethra, rectum, and pelvic bones.

　　2. Lymphatic dissemination:The upper part of the vaginal lymph node drainage is similar to that of cervical cancer. It first reaches the pelvis, then the para-aortic lymph nodes, and the lower third of the vaginal drainage is similar to that of vaginal cancer, reaching the inguinal and femoral lymph nodes, and then the pelvic lymph nodes. There may be bidirectional drainage, especially in the middle segment.

　　3. Hematogenous dissemination:It occurs later, common metastases are lung, liver, and bone, with initial lymph node metastasis followed by hematogenous metastasis.

　　Prognosis

　　Patients with trophoblastic tumor who achieve complete remission after active treatment can survive for a long time. Literature reports that vaginal metastasis of ovarian cancer often occurs with widespread metastasis of ovarian cancer, and the prognosis is poor. Some scholars reported that after treatment, 71.4% of patients with vaginal metastasis of ovarian cancer had complete elimination of the tumor, 17.9% achieved partial remission, 10.7% were stable, and the 3-year and 5-year survival rates were 40.5% and 16.1%, respectively. The deceased all died due to the progression of pelvic and abdominal cavity tumors or combined with distant metastasis.

　　1. Laboratory examination
　　Tumor marker examination, secretion examination.
　　2. Other auxiliary examinations
　　Vaginal colposcopy.
　　Patients with a history of tumor diagnosis and treatment, or those undergoing cancer treatment, may experience an increase in vaginal discharge or vaginal bleeding. Gynecological examination may reveal typical cancer nodules in the vagina. Local biopsy shows that the tissue morphology and structure are the same as the primary cancer, and there is no evidence of primary vaginal cancer. Patients generally easily obtain a diagnosis. However, if vaginal metastatic cancer is the first manifestation of other tumors, it is first necessary to obtain the pathological biopsy result to determine whether it is adenocarcinoma or squamous cell carcinoma, and then purposefully search for the site of the primary tumor.

　　I. Therapeutic Diet for Vaginal Metastatic Tumor

　　1. Therapeutic Diet for Chemotherapy

　　(1) Goji and Turtle Lean Meat Soup: 30 grams of goji berries, one turtle (about 500 grams), and 150 grams of lean pork. First, place the turtle in hot water to allow it to urinate, then kill and cut it open, remove the internal organs, wash and cut into pieces. Add an appropriate amount of water, and boil with goji berries and lean pork until soft. Divide and consume 2 to 3 times.

　　(2) Fructus lycii and sea cucumber lean pork stew: 15g fructus lycii, 250g sea cucumber, 100g lean pork. Soak the sea cucumber first, clean and cut into slices, then cut the lean pork into slices. Add an appropriate amount of water, cook together until tender, season and eat, take in portions.

　　(3) Mushroom Cordyceps stewed chicken: 20g mushroom, 15g Cordyceps sinensis, one unlaying hen (about 1000g). Remove the mushroom stem, remove the chicken feathers, head, feet, and internal organs, put the mushroom and Cordyceps sinensis into the chicken belly, seal with bamboo skewers, add an appropriate amount of water, simmer for 2 hours, season and eat, can be taken 2-3 times.

　　(4) Milk egg white lotus seed paste: 250ml fresh milk, 2 fresh eggs, 50g stone lotus seed. Grind the stone lotus seed into powder, add an appropriate amount of water to cook the lotus seed powder into a paste, add rock sugar or white sugar for seasoning, then add milk and egg white, mix well, and boil before serving. Once a day or every other day.

　　(5) Chicken inner gold and ginger rabbit meat soup: 12g chicken inner gold, 30g sprout, 3 slices of ginger, 100g rabbit meat. Add an appropriate amount of water, cook together in a pot, season with a little salt, drink the soup and eat the meat. Once a day or every other day.

　　(6) Amomum fructus and山药stewed pork stomach: 15g amomum fructus, 50g山药, one pork stomach. Break the amomum fructus, wash the pork stomach clean and remove the fat. Put the amomum fructus and山药 into the pork stomach, add an appropriate amount of water, simmer slowly until the pork stomach is tender, season with a little salt, drink the soup or eat with food.

　　2. Radiotherapy food therapy formula

　　(1) Bird's nest braised ginseng: 6g bird's nest, 9g American ginseng. Soak the bird's nest in warm water, remove the bird's nest hair, slice the American ginseng, add an appropriate amount of water, steam for 12 hours, and take after serving.

　　(2) Pear juice sugarcane water caltrop dew: 1 part pear juice, 2 parts sugarcane juice, 1 part caltrop. Mix the three together and serve cold, or heat and serve warm.

　　(3) Astragalus and枸杞子 water fish pot: 30g astragalus, 20g fructus lycii, one water fish (about 500g). Wrap the astragalus in gauze, remove the scales and internal organs, wash clean and cut into pieces. Add an appropriate amount of water, simmer until tender, remove the astragalus residue, add a little oil and salt for seasoning, and take in portions.

　　(4) Turtle and pork trotter ginseng soup: one turtle (about 150g to 250g), 250g pork trotter, 10g ginseng. First, blanch the turtle with boiling water to expel urine, cut off the head and feet, remove the internal organs, wash clean, and cut into pieces. Add an appropriate amount of water, simmer slowly until tender, and take in portions.

　　Second, what is good to eat for patients with vaginal metastatic tumors

　　1. Eat more foods with anti-tumor effects: horseshoe crab, sea horse, turtle, dragon pearl tea, hawthorn.

　　2. For infection, eat eel, wenchang, water snake, needlefish, crucian carp,麒麟菜, celery, sesame, buckwheat, rapeseed, xiangchun, chidou, mung bean.

　　3. For abdominal pain and distension, eat pork kidney, myrica, hawthorn, jujube, hickory nut, and chestnut.

　　4. For bleeding, eat goat blood,螺蛳, conch, cuttlefish, spinach, lotus root, mushrooms, malan tou, shi er, huzi, shi pi.

　　Third, what foods are bad for the body with vaginal metastatic tumors

　　1. Avoid smoking and drinking.

　　2. Avoid greasy, fried, moldy, and salted foods.

　　3. Avoid eating warm and blood-activating foods such as mutton, dog meat, chive, and pepper.

　　First, traditional Chinese medicine treatment methods for vaginal metastatic tumors

　　1. Syndrome differentiation and prescription selection

　　After surgery, use Coptis 16, Salvia miltiorrhiza 20, Rehmannia 12, Dioscorea opposita 15, Cimicifuga 18, Astragalus 12, Osseous matter 16, Foshou 12, one dose per day, decocted in water for oral administration to enhance immunity, promote wound healing, and improve the quality of life. After the wound heals, you can use: Hemerocallis 50, Lycopodium 60, Poria 16, Pinellia ternata 15, Bambusa textilis 12, Ligustrum lucidum 15, Rehmannia 12, Carthamus tinctorius 6, Liquorice 8, one dose per day, decocted in water, taken for 5 consecutive days, then take the above formula for 4 more days, which is helpful to improve the efficacy.

　　2. Special and tested prescriptions

　　(1) External washing formula

　　①Sanpin formula: Arsenic sulfide 45g, Alum 60g, Realgar 7.2g, Myrrha 3.6g. Grind into fine powder and mix to make Sanpin cakes the size of a 5-cent coin (thickness 2mm, weight 0.2g), disinfect with ultraviolet light for standby. The patient lies on the gynecological examination bed, disinfect the vagina, and first protect the unbroken parts of the vagina and fornix with Vaseline gauze. Apply the Sanpin cake to the tumor, after 5-7 days, there will be necrotic tissue shedding. Before the Sanpin cake is absorbed, change the traditional Chinese medicine 'Shuangzi powder' (Scutellaria baicalensis, Viola yedoensis, Herba serissae, Huangbai, Herba Lysimachiae each 30g, a little Bingpian ground into fine powder and sterilized under high pressure) before the tissue falls off; the medicine should be taken from 5 to 7 days after menstruation to 5 days before menstruation; this method has the functions of disinfection, anti-cancer, reducing swelling, and removing blood stasis. Contraindicated for those with severe liver and kidney dysfunction.

　　②Huangwu powder No. 1: Huangbai 64%, Qingfen 13%, Wugong 7%, Bingpian 3%, She Xiang 0.7%, Xionghuang 12.3%, respectively ground into powder and passed through a 100-mesh sieve, mixed evenly for standby. Use sterile tail line cotton balls, dip about 1g of medicine powder with a long forceps and send it into the damaged part of the vagina; for mild cases, once a week, for severe cases, 2-3 times a week. Avoid sexual life during the treatment period.

　　(2) Internal treatment

　　①Anti-cancer tablet: 5 catties of Strychnos nux-vomica, 5 catties of Trichosanthes kirilowii, 5 catties of Fritillaria thunbergii, 1 catty of Liquorice root. The Strychnos nux-vomica is peeled, fried with sesame oil until crisp, mixed with the other three drugs into a fine powder, added with starch to make tablets, each tablet 0.3g, taken 3 times a day; initially, 3 tablets per time, if there are no adverse reactions, increase to 5 tablets per time, without treatment courses, continue taking medicine. Most people have increased physical strength and appetite; symptoms such as tightness in hands and feet may occur with over dosage or long-term use, which will disappear after stopping the medicine. This prescription has the function of detoxifying, reducing swelling, and resolving blood stasis.

　　②Pinellia ternata formula: Appropriate amount of Pinellia ternata, made into oral tablets; taken orally, 3 times a day, the total amount is approximately 60g of crude drug, which has a significant effect of clearing heat, detoxifying and anti-cancer.

　　(3) Prevention and treatment of toxic and side effects of radiotherapy and chemotherapy: After chemotherapy and radiotherapy for malignant tumors, it is often easy to appear a series of toxic and side effects; such as local pain, adhesion, tissue necrosis, decreased blood cells and platelets in the whole body, disordered digestive function, damage to liver and kidney function, damage to the nervous system, etc. The application of traditional Chinese medicine prescriptions for the prevention and treatment of these toxic and side effects has a good effect. The following prescriptions can be selected.

　　①Shenqi Detoxification Decoction: Astragalus and Codonopsis each 30g. Schisandra, Eucommia ulmoides, Fried Atractylodes macrocephala each 15g, Ophiopogon japonicus 20g, Angelica sinensis, Poria, Citrus reticulata, and Pinellia ternata each 12g, decocted in water, taken once a day, divided into 2-3 doses for oral administration, starting 3 days before chemotherapy. This product has the functions of strengthening the body and anti-cancer, nourishing yin and blood, promoting Qi and drying dampness, harmonizing the spleen and stomach to stop vomiting, and resolving blood stasis and dispersing nodules, which can prevent toxic and side effects brought by chemotherapy and make chemotherapy proceed smoothly.

　　② Nourishing blood and increasing white cell饮: Dangshen, Huangqi, Danggui, Shudi, Nuzhenzi, Jixueteng, Tufuling each 15g, Jiaobaiqi, Buguzhi each 10g, Zhishan, Shenggancao each 6g, Jiaoshanzhi, Jiaoshentuan each 9g, add Shengdi, Guizhi each 15g for yin deficiency; add Baizhi, Xianmao each 12g for yang deficiency; add Suanzaoren, Yejiaoteng each 12g for insufficient heart qi; add Huangbai, Zexie each 10g for damp-heat. This formula has the effects of replenishing qi, strengthening the spleen, balancing yin and yang, and promoting blood circulation and detoxification, and is used for leukopenia caused by chemotherapy.

　　3. Other therapies

　　(1) Rubbing method: Apply Yimucong oil ointment, apply this ointment to the radiated area after each radiotherapy and let it dry, instruct the patient to wear loose underwear to prevent it from sticking to the skin; it is suitable for skin burns caused by radiotherapy.

　　(2) Traditional Chinese medicine injection method:

　　① Huaihua injection, 4ml each time, once a day, intramuscular injection, 30 days as a course, with the effects of clearing heat and dampness, detoxifying and reducing swelling.

　　② Add 10% Brucea javanica oil to the disinfected vagina. Use a 5ml high-pressure syringe connected with a needle. According to the lesion, puncture injection is given at the tumor body, twice a week, 5-10% Brucea javanica oil 4-8ml each time. After injection, stop medication based on the condition of lesion shedding, necrosis, and regeneration; it has the effect of removing decaying and necrotic cancer tissue and promoting new growth.

　　II. Western medical treatment methods for vaginal metastatic tumors

　　1. Treatment

　　(1) Management of vaginal metastases from trophoblastic tumors: For patients with low-risk conditions, monotherapy can be used. For high-risk patients, the commonly used combined drug regimen is 5-Fu + KSM double therapy, ACM triple sequential chemotherapy, and EMA/CO regimen. Local fluorouracil injection is administered. At the same time as systemic chemotherapy, vaginal packing is performed, and selective arterial embolization treatment can be performed if conditions permit. In necessary cases, ligation of the high position of the iliac internal artery, removal of the uterus and adnexa, and attention to the prevention and treatment of infection should be taken.

　　(2) Management of vaginal metastases from other solid tumors: Most cases of vaginal metastases from tumors are already in the advanced stage and often accompanied by metastases to other organs. Therefore, different treatment methods should be adopted based on the source of the primary tumor and the condition at the time of consultation.

　　① Management of initial treatment patients: For patients with ovarian tumors, fallopian tube tumors, and endometrial cancer who have vaginal metastases at the time of initial treatment, active postoperative chemotherapy or chemotherapy combined with radiotherapy should be performed after tumor reduction surgery to achieve a relatively satisfactory effect. For patients with cervical cancer, radiotherapy combined with chemotherapy is often used to treat both the primary cancer and the vaginal metastases.

　　② Management of retreated patients: For patients with malignant tumors who develop vaginal metastases after surgery, chemotherapy, or radiotherapy, it is often due to vaginal recurrence of the tumor. Aggressive treatment can still make the tumor disappear or shrink, achieving a certain therapeutic effect.

　　(3) Radiotherapy: The radiotherapy method for vaginal metastatic cancer is similar to that for primary vaginal cancer, involving external beam radiotherapy and intracavitary irradiation. For patients with a hysterectomy, whole pelvic irradiation combined with intracavitary brachytherapy is performed. For patients with advanced vaginal cancer, intracavitary irradiation may be difficult, and initial external beam radiotherapy such as whole pelvic irradiation or equidistant irradiation can be performed, followed by intracavitary irradiation based on the regression of the tumor.

　　① Intracavitary Radiotherapy: For vaginal upper segment tumors, in addition to focusing on cervical irradiation, intracavitary radiotherapy (A point dose 25-30Gy) should also be given. For fornix lesions, intracavitary radiotherapy can be given as for cervical cancer. Other primary lesions can be treated with vaginal cylindrical containers (tampons) or intravaginal pelvic irradiation, and exophytic tumors can be treated with interstitial implantation radiotherapy. For vaginal middle and lower segment tumors or total vaginal lesions, vaginal tampons or interstitial implantation radiotherapy can be used. If the tumor is only located on one side of the vagina and is large, interstitial implantation radiotherapy can be performed to reduce the size of the tumor, followed by vaginal tampon irradiation, and appropriate lead blocking can be used for areas not requiring irradiation. The dose reference point is generally chosen at the base of the tumor. Traditional low-dose rate intracavitary radiotherapy generally gives 50-60Gy at the base of the tumor, while high-dose rate afterloading intracavitary radiotherapy generally gives 30-40Gy at the base of the tumor.

　　② External Beam Radiotherapy: Mainly supplements the dose in the lymphatic metastasis area. For upper segment tumors, pelvic external beam radiotherapy is used, with whole pelvis (14-16CMX18-20CM) or/and lead挡 (7X14CM) external beam radiotherapy, and the dose to the paracervical tissue is 40-50Gy/6 weeks. For lower segment tumors, irradiation should be performed on the inguinal region. The irradiation field parallel to the inguinal ligament can be 8-12CM-14CM, and 6-8MV X-ray irradiation Dm40Gy/4 weeks can be given first, followed by electron beam irradiation Dm20Gy/2 weeks.

　　(4) Chemotherapy: Select a chemotherapy regimen effective for a specific metastasis based on the nature of the primary tumor. Chemotherapy routes can include systemic and selective arterial catheterization chemotherapy methods. Superselective interventional chemotherapy of the internal iliac artery can increase the local drug concentration in the vagina, directly kill tumor cells, and achieve good efficacy. Common drugs include cisplatin (PDD), pingyangmycin (BLM), mitomycin (MMC), 5-fluorouracil (5FU), cyclophosphamide (IFO), and so on. Combined chemotherapy regimens include: PVB, PIB, PDD+MMCPDD+5FU+CTX, and so on.

　　2. Prognosis

　　Adverse prognostic factors include the size and differentiation of large primary tumors.