Primary ovarian choriocarcinoma

　　First, etiology

　　Primary ovarian choriocarcinoma originates from pluripotent cells in the ovarian germ cells, developing into extraembryonic structures (trophoblasts or yolk sac, etc.). Gestational choriocarcinoma is caused by the malignant transformation of gestational trophoblasts. Most gestational choriocarcinoma of the ovary is metastatic from uterine or fallopian tube gestational choriocarcinoma, and rarely originates from ovarian gestation.

　　Second, pathogenesis

　　Characteristics of primary ovarian choriocarcinoma:Tumors are mostly unilateral, with the right side being more common than the left. The tumor diameter ranges from 8 to 30 cm, and it is a hemorrhagic mass with a capsule, solid consistency, soft texture, and fragile, easily broken nature. It is mostly brown-red, with extensive hemorrhage and necrosis, and a small amount of viable tumor tissue is often found at the edge of the tumor. The morphology is the same as that of uterine choriocarcinoma, and mixed types may exhibit morphologies of other germ cell tumors.

　　1. Under the microscope:The structure is composed of strands or reticular structures mixed with trophoblastic and syncytiotrophoblastic cells, where syncytiotrophoblastic cells can secrete HCG. Under the microscope, the morphology is similar to that of uterine choriocarcinoma, consisting of trophoblastic and syncytiotrophoblastic cells. Diagnosis requires the presence of both types of trophoblastic cells due to the presence of varying amounts of syncytiotrophoblastic cells in other germ cell tumors, especially embryonal carcinomas.

　　2. The typical tumor volume of绒癌 is large, unilateral, solid, soft, with obvious hemorrhage and necrosis.The morphology is the same as that of uterine绒癌. If it is mixed, it can appear in the morphological characteristics of other germ cell tumors.

　　3. Metastasis:Mainly blood-borne metastasis to various organs in the body, the most common site of metastasis is the lung. The next is the liver, brain, kidney, gastrointestinal tract, and pelvic organs. The lymphatic metastasis of non-gestational绒癌 is more common than that of gestational绒癌.

　　Due to the rapid growth of the tumor, the patient may become extremely weak and develop cachexia early. The term 'cachexia' comes from the Greek words 'kakos' and 'hexis', which literally means 'a bad condition'. It can be seen in various diseases, including tumors, AIDS, severe trauma, postoperative conditions, malabsorption, and severe sepsis, among which cachexia associated with tumors is the most common, known as tumor cachexia. It is caused by the tumor causing changes in metabolism through various pathways, preventing the body from absorbing nutrients from the outside world. The tumor夺取 nutrients from the body's inherent fat and protein to build itself, so the body loses a large amount of nutrients, especially essential amino acids and vitamins (formed by the decomposition of fat and protein). The oxidation process in the body is weakened, incomplete oxidation products accumulate, and nutrients cannot be fully utilized, leading to a state dominated by wasteful metabolism. Heat is insufficient, leading to anorexia, being able to eat only a small amount of food or not being able to eat at all, extreme emaciation, bones showing through the skin, resembling a skeleton, anemia, weakness, complete bedridden, unable to take care of oneself, extreme suffering, and systemic failure, and other syndromes.

　　1. Abdominal manifestations:Abdominal pain and mass are the most common symptoms. Abdominal pain may be due to tumor bleeding or necrosis, and acute abdominal pain may be due to tumor rupture.

　　2. Irregular vaginal bleeding:Irregular vaginal bleeding is caused by the secretion of HCG (chorionic gonadotropin) by ovarian绒癌, often accompanied by functional stroma, also known as stromal luteinization, and the endometrium may have decidual reaction.

　　3. Fever:The body temperature can reach 38-39°C, and fever may be due to tumor bleeding, necrosis, or infection.

　　4. Precocious puberty:Those occurring before puberty may manifest as precocious puberty.

　　5. Pelvic examination:Pelvic or abdominal masses of varying sizes can be detected, often accompanied by blood-filled ascites.

　　I. Prevention

　　If you are careful and pay close attention to your body, you can discover the 'yellow card' issued by ovarian cancer in a timely manner.

　　1. Oligomenorrhea or amenorrhea

　　The menstrual cycle of most ovarian cancer patients remains unchanged. If the ovary undergoes malignant changes or both ovaries are destroyed by cancer tissue, the patient's overall condition may worsen, leading to oligomenorrhea or amenorrhea.

　　2. Abdominal distension

　　Abdominal distension can be considered as a red 'signal' of ovarian cancer, often occurring before palpation of the lower abdominal mass. The cause is the compression of the tumor itself and the traction of surrounding ligaments in the abdominal cavity. In addition, a few patients may have varying degrees of ascites, causing patients to have a feeling of abdominal distension. Therefore, women with unexplained abdominal distension (especially during menopause) should receive gynecological examination in a timely manner.

　　3. Abdominal and lumbar pain

　　Ovarian cancer invasion of surrounding tissues or adhesion with adjacent tissues can compress nerves, causing abdominal pain, pain, ranging from slight pain to dull pain, even severe pain.

　　4. Lower limb and vulvar edema

　　Ovarian cancer grows in the pelvis, becomes fixed, and can compress pelvic veins or affect lymphatic return, causing lower limb and vulvar edema over time. At this time, one should consider the possibility of ovarian cancer 'haunting'.

　　5. Endocrine disorders

　　The pathological type of ovarian cancer is complex and variable. Some tumors can secrete estrogen, and excessive estrogen production can cause premature puberty, menstrual disorders, or vaginal bleeding after menopause (commonly known as 'reversing the flowers'). If it is testicular teratoma, it can produce excessive androgens, causing feminization signs in women. People should 'follow the thread and find the root cause' of these strange phenomena.

　　6. Unexplained weight loss

　　The gradual growth of ovarian cancer can mechanically compress the gastrointestinal tract, causing a decrease in appetite and indigestion in patients. In addition, cancer cells greedily consume human nutrients, causing patients to become increasingly emaciated, anemic, and lack of energy. The complexion becomes pale.

　　II. Prognosis

　　The malignancy of ovarian choriocarcinoma is extremely high, and the prognosis is extremely poor. Among the 8 patients at Peking Union Medical College Hospital, 3 were referred from other hospitals after surgery. Among the 6 patients who underwent unilateral adnexectomy, 1 received 17 chemotherapy courses after surgery. Two and a half years later, due to recurrent lung metastasis, the patient underwent reoperation, with right lower lung resection and hysterectomy with the opposite adnexa. Pathology showed no lesions in the uterus and bilateral adnexa, and the right lower lung was choriocarcinoma.

　　1. Tumor marker examination.

　　2. Hormone level examination:The titer of blood or urine human chorionic gonadotropin (HCG) is elevated. Among the 6 cases reported by Axe, 5 were HCG (+), and another 6 cases had blood HCG levels of 2500 to 81400 mU/ml. HCG is produced by syncytiotrophoblasts. Elevated AFP (alpha-fetoprotein) is only positive when mixed with yolk sac tumor.

　　3. B-ultrasound:It can show the metastatic tumors of solid liver lesions, and B-ultrasound shows renal积水.

　　4. X-ray examination:When there is lung metastasis, chest X-rays can show shadows. Among the 8 cases at Peking Union Medical College Hospital, 5 had lung metastasis.

　　5. CT examination:Head CT can show the presence of brain metastases, and abdominal CT can show solid liver lesions.

　　6. Laparoscopic examination.

　　7. Histopathological examination.

　　1. Chew ginger slices after chemotherapy. Suitable for those with nausea and vomiting after chemotherapy.

　　Use fresh Foshou slices to make tea. Suitable for those with nausea and indigestion after chemotherapy.

　　3 grams of Huoxiang and 3 grams of Peilan, boiled together for tea. Suitable for those with indigestion, nausea, dizziness, and chest tightness after chemotherapy.

　　11, 5 grams of dried ginger decocted into a decoction, add brown sugar, drink 3 times a day. Suitable for patients with nausea, abdominal pain, and diarrhea after chemotherapy.

　　10, Boil 200 grams of soybeans in soup, add a little salt, often eat. Suitable for patients with weakened physical strength and anemia after chemotherapy.

　　9, Fried leek, or fried leek with eggs. Often eat. Suitable for patients with绒癌 after treatment who are weak in physical strength.

　　8, Crab shell incinerated powder, take 3 times a day, 1 gram each time. Suitable for the initial stage of绒癌 that has not been treated.

　　7, 9 grams of Dendrobium officinale, 20 grams of purple herb, 30 grams of coix seed, 30 grams of Smilax glabra, decocted into a decoction as tea, take 1 to 2 times a day. Suitable for any type of绒癌, regardless of before or after treatment.

　　First, surgical treatment:Like other malignant germ cell tumors, ovarian primary绒癌should also be treated with a combination of surgery and chemotherapy. Because ovarian绒癌 often occurs in young girls or young women before puberty and is mostly unilateral, in recent years, the efficacy of PVB (vincristine, bleomycin, cisplatin) and other combination chemotherapy regimens has been significantly improved, and the prognosis of ovarian绒癌 has undergone a fundamental change, so in most cases, for unmarried patients, if there is no metastasis to the uterus and the opposite ovary, conservative fertility surgery can be performed to remove the affected adnexa and lesions, resect the omentum and para-aortic lymph nodes.

　　Second, chemotherapy:Primary绒癌is a highly malignant tumor with a high degree of hematogenous metastasis, which was considered to have a very poor prognosis in the past. However, in recent years, surgery combined with active and strong chemotherapy is the key to improving efficacy. Chemotherapy regimens can be single-agent or combination chemotherapy, and currently most use combination chemotherapy. Axe reported 6 cases, of which 4 received chemotherapy after surgery, 2 were treated with surgery alone without chemotherapy, and 4 were treated with chemotherapy: methotrexate (MTX) single chemotherapy, and 2 cases used combination chemotherapy: methotrexate (MTX), vinblastine sulfate (VLB), actinomycin D (KSM, actinomycin D), bleomycin (BLE), cisplatin (DDP), cyclophosphamide (CTX, cytoxan). According to the FIGO staging method, all 6 cases were early stage I and II cases, of which 5 cases had been followed up for more than 5 years with only 1 death (case of stage II without chemotherapy after surgery), 4 cases survived without tumor for 8 to 19 years, and another 1 case survived without tumor for 9 months, with a survival rate of 83%. Among the 8 cases at Peking Union Medical College Hospital, 5 were initial treatment cases, 2 were transferred from other hospitals after recurrence, and 1 was transferred to this hospital after unilateral adnexectomy in another hospital; 5 were simplex, and 3 were mixed, with immature teratoma, embryonal carcinoma, and dysgerminoma; 6 were stage IV cases, 1 case of stage II tumor resection received PVB chemotherapy for 4 courses within 3 months, with blood HCG receptor decreasing from 81140 mU/ml to normal, and has survived without tumor for 5 years; 1 case of stage I patient received unilateral adnexectomy and EMA-CO treatment for 11 courses in more than a year, the HCG decreased to normal after the first course and has survived without tumor for 3 years. Another case of recurrence received PVB for 3 courses but the condition still progressed and could not be controlled, and the other 4 cases of stage IV 3 cases were short-term (

　　Commonly used chemotherapy drugs include methotrexate (MTX), vincristine (VCR), actinomycin D (KSM), bleomycin (BLE), fluorouracil (5-FU), nitrocaphate (AT1258), cisplatin (CDDP), etoposide (VP-16). There are many types of combined chemotherapy, such as fluorouracil (5-FU) + actinomycin D (KSM), actinomycin D (KSM) + nitrocaphate (AT1258), fluorouracil (5-FU) + nitrocaphate (AT1258) or the above three combined with vincristine (VCR). In recent years, the PVB regimen has shown significant efficacy. In 1987, Williams modified the PVB regimen, replacing VCP with etoposide (VP-16) and changing it to the PEB combined chemotherapy regimen.

　　1, EMA/CO regimen:It is a regimen used for the treatment of high-risk choriocarcinoma, using EMA, i.e., etoposide (VP-16), methotrexate (MTX), actinomycin D (KSM). CO is cyclophosphamide (CTX), vincristine (VCR).

　　2, PVB regimen:Attention should be paid to toxic reactions during use. The use of pingyangmycin can cause fever, which reaches its peak 2-3 hours after administration and then decreases to normal. If the body temperature exceeds 39℃, indomethacin (anti-inflammatory pain) 1 tablet can be taken orally, and attention should be paid to fluid replacement. And pay attention to interstitial pneumonia and pulmonary fibrosis, regular lung function tests should be performed during chemotherapy. The application of cisplatin (DDP) should pay attention to the urine volume should be >100ml/h, and a large amount of hydration before administration of cisplatin (DDP) to reduce nephrotoxicity.

　　3, PVE regimen:Namely cisplatin (DDP), vincristine (VCR), etoposide (VP-16). Dosage: cisplatin (DDP) 20mg/m2 intravenous infusion, once daily, for a total of 5 days; vincristine (VCR) 1-1.5mg/? intravenous infusion, on the 1st and 2nd days; etoposide (VP-16) 100mg/? intravenous infusion, once daily, for a total of 5 days.

　　Precautions:Record the intake and output of fluids, the urine volume during chemotherapy should be >1500ml/d; review blood and urine routine during chemotherapy, and pay attention to blood count.