Cervical cancer Cervical cancer is the most common gynecological malignant tumor in China, with peak incidence age between 50 and 55 years old, and the incidence of young cervical cancer has gradually increased in recent years. The etiology has not been fully clarified, and is mostly thought to be related to early marriage, sexual disorders, multiple births, race and other factors. Recent studies have concluded that human papillomavirus (HPV) infection is the main risk factor for cervical cancer, with HPV 16, 18, 31, 33 and other high-risk types as the main ones. Pathologically, it can be divided into the following types: 1. precancerous lesions of cervical cancer: precancerous lesions of cervical cancer are cervical intraepithelial neoplasia (CIN), which is characterized by cell proliferation and disorderly arrangement of epithelial cells, and heterotypic changes such as large deep stained nuclei and uneven chromatin distribution. CIN grade I refers to heterotypic cells limited to the lower 1/3 of the epithelial layer, CIN grade II refers to heterotypic cells limited to the lower 1/3 to 2/3 of the epithelial layer, and CIN grade III refers to heterotypic cells involving almost all or all of the epithelial layer (carcinoma in situ). If it invades the glandular epithelium of the cervical gland, it is called cervical carcinoma in situ involving the gland. 2.Infiltrative carcinoma of cervix uteri: Heterotypic cells break through the epithelial basement membrane and invade the mesenchyme, which is called invasive carcinoma of cervix uteri. (1) Squamous cell carcinoma: It accounts for 80-85% of cervical cancer. (1) Macroscopic examination: early stage only shows cervical erosion-like changes, but the disease development can show exophytic, endophytic, ulcerative and cervical canal type. (2) Microscopic examination Microscopic early infiltrating carcinoma: on the basis of carcinoma in situ, it breaks through the epithelial basement membrane and infiltrates the interstitium with depth ≤ 5mm and width ≤ 7mm. Infiltrating carcinoma: infiltrating the interstitium beyond microscopic early infiltrating carcinoma, which is histologically classified into grade I, II and III (i.e. highly differentiated, moderately differentiated and poorly differentiated). (2) Adenocarcinoma: accounting for 15-20%. (1) Macroscopic examination: Most of them come from inside the cervical canal and show infiltrative growth, which can make the cervical canal show barrel-like changes. (2) Microscopic examination: including mucinous adenocarcinoma, malignant adenoma and adenosquamous carcinoma of the cervix. Clinical manifestations mainly include the following symptoms: 1. Vaginal bleeding: early stage is mostly contact bleeding (small amount of bleeding after sex or gynecological examination), and later stage is irregular vaginal bleeding, which is due to tumor rupture. The bleeding is caused by tumor rupture. The bleeding of exophytic type is earlier and more abundant, while the bleeding of endophytic type is later. 2.Vaginal fluid discharge: it is caused by tumor surface exudation and can be white or bloody. If there is necrotic infection, the discharge may be slop-like or purulent, with bad odor. 3.Late symptoms: When adjacent organs or tissues are involved in late stage, corresponding symptoms may appear, such as urinary frequency and urgency, constipation, swelling and pain of lower limbs, etc. Systemic exhaustion such as hyperemesis may appear. Preliminary diagnosis can be made based on clinical manifestations and gynecological examination (including triple examination). For cases with atypical cervical lesions, iodine test of cervical epithelium, nitrogen laser tumor intrinsic fluorescence test and colposcopy can be used to help determine the scope of possible lesions, and the diagnosis can be confirmed by pathological histological examination of biopsies. 1.Cervical scraping cytology: The cells in the migratory zone of the cervix are scraped for cytological examination by Pap smear and TBS, which is gradually replacing Pap smear. In TBS classification, abnormal epithelial cells or Pap smear grade III and above are required for cervical biopsy. Colposcopy: If the cervical scraping cytology is above Pap grade III, squamous intraepithelial lesions by TBS and positive intrinsic fluorescence of tumor, suspicious tissues on the surface of the cervix should be searched for through the magnifying effect of colposcopy to improve the accuracy of biopsy. 3, cervical biopsy: for obvious lesions of the cervix can be directly clamped, paying attention to avoiding necrotic tissue clamped fresh tissue. For atypical cervical lesions, iodine test, nitrogen laser tumor intrinsic fluorescence test and colposcopy can be used to assist in determining the extent of possible lesions for biopsy. Biopsies can be taken at points 3, 6, 9 and 12 of the squamocolumnar junction when no adjunct is available. If the cervical smear is positive and the surface of the cervix is smooth or the biopsy is negative, the endocervical canal should be scraped and sent for examination. 4.Cervical conization: For cervical scrapings with multiple positive results and negative biopsies, or if the biopsy is in situ cancer and further examination of interstitial infiltration is needed, conization is feasible. Cervical conization includes conventional surgical excision, LEEP technique or condenser knife excision. Cervical cancer should be differentiated from other lesions of the cervix, such as cervical erosion, cervical polyp, cervical glandular epithelial ectasia, cervical tuberculosis and other benign cervical lesions; cervical papilloma, cervical duct myoma, cervical submucosal myoma and other benign cervical tumors; cervical sarcoma, lymphoma, malignant melanoma and other malignant tumors, and the differentiation is based on pathological histological examination. Treatment principle: Treatment measures should be decided according to clinical stage, patient’s age, general condition, equipment condition and medical technology level, and commonly used treatment methods include surgery, radiotherapy and chemotherapy. (A) Surgery 1. Principles of surgical treatment: Surgery is only applicable to early stage patients. The greatest advantage of surgery is that the function of ovaries and vagina can be preserved while completing the treatment, and currently surgery should be preferred for early stage middle-aged and young patients. Those with severe cardiovascular disease, severe diabetes mellitus, etc. who cannot tolerate surgery should be treated with radiation therapy instead. It is applicable to patients of all stages and is the main treatment for cervical cancer, mainly used for those with stage IIb or above and those whose physical conditions are not suitable for surgery. It includes intracavitary post-mounted radiation therapy and external irradiation therapy. The treatment principle is to maximize the killing of cancer cells, maximize the therapeutic effect and minimize the occurrence of complications while protecting normal tissues and important organs as much as possible. Intracavitary irradiation with external irradiation is the most commonly used method for radiation therapy of cervical cancer. Intracavitary treatment adopts post-mounted treatment machines with iridium 192 (192Ir) or cesium 137 (137Cs) as the radiation source for treating local primary foci of the cervix, while extracorporeal irradiation adopts linear gas pedal or cobalt 60 (60Co) for treating primary foci and metastases of the cervix. Chemotherapy is mainly used for the treatment of more advanced localized large lesions, recurrent patients and adjuvant treatment before surgery or radiotherapy. The prognosis of patients with cervical cancer is closely related to factors such as clinical stage, pathological type, pathological grading, lymph node metastasis and treatment methods. The effect of surgery and radiotherapy for early stage patients is similar. Patients with advanced stage, those with lymph node metastasis and cervical adenocarcinoma have poor prognosis. The 5-year survival rate of patients in each stage is: >85% in stage I; 50% in stage II; 25% in stage III; and 5% in stage IV. The main causes of death in advanced cases are 1. uremia: caused by tumor compression of bilateral ureters; 2. hemorrhage: caused by cancer foci invading large blood vessels; 3. infection: local or systemic infection; 4. cachexia: death due to metastasis or systemic failure of important organs throughout the body. The first follow-up is 1 month after discharge from hospital, and the first year after treatment is reviewed every 2-3 months. The second year was reviewed every 3 to 6 months, and the third to fifth year was reviewed every 6 months. In the 6th year, the follow-up was once a year. The follow-up mainly includes pelvic examination, vaginal biopsy of recurrent foci, chest X-ray, ultrasound of liver, spleen and kidney, pelvic CT and MRI, etc. Depending on the condition. Endometrial cancer Endometrial cancer, also known as uterine body cancer, is an epithelial malignant tumor of the endometrium, most of which are adenocarcinomas. It is one of the three common malignant tumors in female reproductive tract, with a high incidence age of 58-61 years old and an increasing trend in recent years. The exact etiology of endometrial cancer is still unclear, but it may be related to the following factors: 1. Long-term continuous stimulation of endometrium by estrogen: related to anovulatory uterine function, polycystic ovary syndrome, functional ovarian tumor (granulosa cell tumor, follicular membrane cell tumor), long-term use of estrogen without progesterone antagonism after menopause, long-term use of tamoxifen, etc. Endometrial hyperplasia: Some endometrial hyperplasia can develop into endometrial cancer, and about 30% of atypical hyperplasia develop into endometrial cancer. 3.Physical factors: The occurrence of endometrial cancer is related to obesity, hypertension, diabetes, unmarried, few births and postmenopausal delay. 4.Hereditary factors: about 20% of endometrial cancer patients have family history. The main symptoms of endometrial cancer include abnormal vaginal bleeding and vaginal discharge, which may not have obvious symptoms in early stage. 1.Vaginal bleeding: non-menopausal patients show increased menstrual flow, prolonged menstrual period or intermenstrual bleeding. In menopausal patients, vaginal bleeding may be more or less, but it is rare to see a lot of bleeding. 2. Vaginal discharge: Some patients complain of increased vaginal discharge, mostly plasma or plasma-blood discharge in the early stage, and pus-blood discharge and bad odor in the late stage of combined infection. 3.Pain: Pain appears in late stage. It is caused by cancer infiltrating surrounding tissues or compressing nerves, and may radiate to the lower limbs and feet. When the cancer invades the cervix and blocks the cervical canal, resulting in pus accumulation in the official cavity, lower abdominal distension and cramp-like pain will appear. 4. Systemic symptoms: Advanced patients often have systemic symptoms, such as anemia, emaciation, cachexia, fever and systemic failure. In the early stage, there is no obvious abnormality in gynecological examination, and the uterus is of normal size and good activity. In the process of disease development, the uterus gradually increases in size and softness; in advanced stage, cancerous tissues can be seen to prolapse from the uterine orifice, with brittle texture and easy bleeding when touched. If the uterine cavity is combined with pus accumulation, the uterus is obviously enlarged, soft and cystic in nature. If the cancer infiltrates into the surrounding area, a mass can be found in the parametrium or pelvis. Segmental curettage is the most common and reliable biopsy method to confirm the diagnosis of endometrial cancer. Other auxiliary diagnostic methods, such as B-type ultrasonography, hysteroscopy, MRI, CT, lymphography, cytology, etc., are commonly used for endometrial cancer examination and diagnosis. The treatment of endometrial cancer should be based on the size of uterus, whether the muscular layer is infiltrated by cancer, whether the cervical canal is involved, the degree of differentiation of cancer cells and the patient’s general condition. The main treatments are surgery, radiotherapy and drug therapy, which can be applied alone or in combination. Surgery is the preferred treatment method, especially for early stage cases. Radiotherapy and chemotherapy are mainly used for patients who are not suitable for surgery, and also for preoperative and postoperative adjuvant treatment. Other treatments include hormone therapy, Chinese herbal medicine, etc. The prognostic factors affecting endometrial cancer are mainly the pathological type of tumor, differentiation degree, depth of muscle layer infiltration, lymph node metastasis and distant metastasis, etc. In addition, the patient’s physical condition and the effect of treatment can also affect the patient’s prognosis. 5-year survival rate is 94% for stage IaIb, 84% for stage II and 40-60% for stage III respectively. Ovarian cancer is one of the three most common malignant tumors of female genitalia. Because of its insidious onset and lack of obvious manifestations in early stages, it is mostly diagnosed in late stages. Its mortality rate is the highest among gynecological malignant tumors, with a 5-year survival rate of 20-30%. Ovarian tissues have complex components and are the organ with the most types of primary tumors in all organs of the body, and in addition to a wide range of types, there are also benign, junctional (low malignant potential) and malignant. Ovary is also a common site for gastrointestinal malignancy, breast cancer and endometrial cancer metastasis. Because it is located deep in the pelvic cavity, it is difficult to detect abnormalities during the examination, and once symptoms appear, it is mostly advanced and should be highly alerted. The cause of the disease is still unknown and may be related to fertility status, genetics or genetic changes. Histopathologically, ovarian cancer is divided into the following types: 1. Ovarian epithelial tumor: it accounts for 50% to 70% of ovarian tumors, and its malignant type accounts for 85% to 90% of ovarian malignant tumors. The age of onset is mostly 30 to 60 years old. Histologically, they can be divided into benign, junctional and malignant types. Junctional tumors are those with active epithelial cell proliferation and nuclear heterotypes, manifesting as increased epithelial cell layers but without mesenchymal infiltration, and are low grade potentially malignant tumors with slow growth, low metastasis rate and late recurrence. Malignant ovarian epithelial tumors include plasmacytoid cystic adenocarcinoma, mucinous cystic adenocarcinoma, ovarian endometrioid carcinoma, clear cell carcinoma, etc. 2. Ovarian germ cell tumor: It is a group of ovarian tumors derived from germ cells, and its incidence is second only to epithelial tumors, accounting for 20%-30% of ovarian tumors. They are more common in children and adolescents. Ovarian mesenchymal tumors originate from the gonadal cords and mesenchymal tissues of the primitive gonads, accounting for 5% to 8% of ovarian malignant tumors. Ovarian malignant tumors are mostly asymptomatic in the early stage and can be detected during gynecological examination. Patients are often seen when they have abdominal distension, abdominal mass and ascites. On gynecologic examination, the masses are mostly bilateral, solid or cystic, uneven and inactive, often accompanied by ascites, and if there is intrapelvic dissemination, a nodule can be palpated in the rectal fossa of the uterus. If there is intra-pelvic spread, implantation nodes in the rectal fossa of the uterus may be palpable. If the tumor infiltrates into the surrounding tissues or compresses the nerves, it may cause abdominal pain, lumbago or lower limb pain; if it compresses the pelvic veins, lower limb swelling may occur; if it is a functional tumor, it may produce corresponding symptoms of estrogen or androgen excess. In late stage, it may show signs of cachexia such as emaciation and severe anemia. According to the patient’s age, medical history and physical signs, it can be initially identified as ovarian tumor, attention should be paid to differentiate benign and malignant tumors, and the following auxiliary examinations can be performed when the diagnosis is difficult. 1.Cytological examination: if there is ascites, it is feasible to perform ascitic fluid tumor cell examination by abdominal puncture, and if there is pleural effusion, cytological examination should also be performed to determine whether there is thoracic metastasis. 2.B-type ultrasonography: It can detect the site, size and shape of the mass, suggest the nature of the tumor (cystic or solid, with or without papillae in the capsule) and initially identify ovarian tumor, ascites and tuberculous encapsulated effusion. 3.CT and MRI examinations: benign tumors have thin, smooth walls and uniform intracapsular echogenicity; malignant tumors have irregular contours and may have intracapsular papillae or infiltrate into the surrounding area or be accompanied by ascites. It can show the condition of intra-abdominal organs and retroperitoneal lymph node metastasis. 4.Laparoscopic examination: for tumors of medium size or less, the mass and its relationship with the surrounding can be directly observed, and biopsy can be performed at the primary and metastatic parts of the lesion. However, if the preoperative examination is suspected to be malignant tumor, it is not advisable to puncture the tumor with intact envelope to prevent the implantation and metastasis of tumor cells. 5.The common laboratory tests are CA125, AFP, HCG, etc., which can be used for auxiliary diagnosis and disease monitoring. (1)CA125: CAl25 level is higher than normal in 80% of ovarian epithelial cancer patients; the level of CAl25 is consistent with remission or deterioration in more than 90% of patients, so it can be used for disease monitoring and follow-up with high sensitivity. (2) AFP: significantly increased in ovarian endodermal sinus tumor, and also increased in immature teratoma and mixed anaplastic tumor with yolk sac component. (3) HCG: specific for primary ovarian choriocarcinoma and also elevated in some malignant germ cell tumors. (4) CEA: may be elevated in mucinous ovarian cancer and metastatic ovarian cancer of the gastrointestinal tract. (5) Sex hormones: granulosa cell tumors and follicular membrane cell tumors produce higher levels of estrogen. The principle of treatment is surgery, supplemented by chemotherapy, radiotherapy and other comprehensive treatments. The stage of the tumor and the scope of surgery will be decided according to the results of the exploration and intraoperative frozen pathology examination. In advanced cases, the tumor should be removed as much as possible to reduce the tumor cell load. Chemotherapy is the main adjuvant treatment. Preoperative chemotherapy is available for patients with advanced disease who are temporarily unable to undergo surgery. Radiation therapy is an adjuvant therapy to surgery and chemotherapy. The prognosis is related to the stage, histological classification and grading, patient’s age and treatment modality. The overall 5-year survival rate of ovarian cancer is 20-30%. The 5-year survival rate can be 90% for stage Ia and Ib cancer confined to the envelope and 68% for stage Ic. Early stage is better than late stage, highly differentiated tissues are better than those with low differentiation, those sensitive to chemotherapy drugs are better than those resistant to them, and postoperative residual foci <1cm in diameter are better than those >1cm. Ovarian cancer is prone to recurrence and should be followed up and monitored for a long time, and if there is recurrence, surgery and chemotherapy should be repeated.