Introduction
Endometrial cancer is a group of endometrial epithelial cancers and is most commonly found in perimenopausal and postmenopausal women. In China, with the improvement of social and economic conditions the incidence of endometrial cancer is also increasing year after year and is now second only to cervical cancer, ranking second in malignancy of the female reproductive system.
The clinical manifestations are mainly vaginal bleeding, vaginal discharge, lower abdominal pain, and abdominal mass. Advanced cancer patients with cancer infiltration oppressing iliac vessels can experience ipsilateral lower limb edema and pain. The lesion infiltration oppressing the ureter causes ipsilateral hydronephrosis and hydroureter and even leads to renal atrophy. Continuous bleeding can lead to secondary anemia. Cancer long-term consumption can lead to weight loss, fever, cachexia, and other symptoms of systemic failure.
Treatments
1.Surgery
Surgery is the main treatment for endometrial cancer. Surgical procedures for early-stage patients are surgical–pathological staging, accurately determining the extent of disease and prognosis, resecting uterus with lesions and possible metastatic lesions, and determining the choice of postoperative adjuvant therapy. For stages I and II, radical surgery is focused. For stage III or IV, reduction of cancer should be tried as much as possible to create the conditions for postoperative chemoradiotherapy. A considerable number of early endometrial cancer patients can be cured through standard surgery. But for patients with high risk factors of recurrence through surgical–pathological staging, or for advanced patients, certain adjuvant therapies are required. Because endometrial cancer patients are often older and have more complications, such as hypertension, diabetes, obesity, and other cardiovascular and cerebrovascular diseases, we need to assess body tolerance of specific patients in detail and give individualized treatment.
2.Radiotherapy
Radiotherapy is one of the effective methods for the treatment of endometrial cancers. Radiotherapy alone is only suitable for patients who are frail, patients with serious medical complications who cannot tolerate surgery or have contraindications for surgery, as well as patients above stage III who are unfit for surgery, including intracavitary and external irradiation. Postoperative adjuvant radiotherapy is often used in clinical applications. Indications for postoperative radiotherapy are as follows: lymph node metastasis or suspicious lymph node metastasis as shown by surgical detection; uterine myometrial invasion greater than 1/2 or G2, G3; special histological types, such as serous carcinoma and clear cell carcinoma; and cancer residual at the vaginal cutting edge. For the first three cases, whole pelvic irradiation is given; for the last case, brachytherapy needs to be added.
3.Chemotherapy
Chemotherapy alone is rarely used for the treatment of endometrial cancers; but it is commonly used for special types of endometrial cancer, such as serous and clear cell carcinoma recurrent cases, and for patients with high risk factors for recurrence after surgery, such as patients with G3 and those who are ER/PR negative.
4.Hormone Therapy
Indications: advanced or recurrent patients, endometrial cancer patients who want to retain fertility, conservative surgery combined with high-dose progesterone for preserving ovarian function, and postoperative adjuvant therapy for patients with risk factors.
5.Hyperthermia
High-intensity focused ultrasound and local hyperthermia by microwave or radio-frequency heating is commonly applied clinically. Extensive clinical practice has proved that the efficacy of radiotherapy combined with hyperthermia is significantly higher than that of radiotherapy alone in patients.
6.Chelation Detoxification Therapy
The therapeutic effects of chelation detoxification therapy for treatment of uterine cancers include direct cancer cell killing, induced apoptosis of cancer cells, improvement of immune function, as well as a synergistic effect with radiotherapy; the effects include, in particular, reduction of side effects of radiotherapy-induced leukopenia and others. Chelation detoxification and local hyperthermia can be performed simultaneously once every other day, with 20 times as a course of treatment for three courses. When patients are in stable condition, the frequency of treatment can be gradually reduced, and it can be taken for long-term maintenance therapy.
7.Medical Ozone Therapy
Use EBOO once every other day, with 20 times as a course of treatment for a total of three courses. For patients in poor physical condition or who are unable to tolerate it, medical ozone saline infusion is given once every other day, with 10–14 days as a course of treatment, or medical ozone major autohemotherapy is given once every other day, with12 times as a course of treatment. According to the specific circumstances of patients, vaginal medical ozone insufflation or medical ozone saline rinse can also be chosen after radio- therapy, once a day, which has a clear effect in alleviating the vaginal injury after radiotherapy.
8.Traditional Chinese Medicine
The syndrome of stagnation of qi due to depression of the liver is common at the early stage. The prescription recommended is modified Xiaoyao Powder; for the syndrome of blood stasis obstruction in the interior, the prescription recommended is a modified Shaofu Zhuyu Decoction. The syndrome of yin deficiency of liver and kidney is commonly seen in the medium-advanced stage, and the prescription recommended is a modified Zhibai Dihuang Pill. For the syndrome of deficiency of vital qi as well as interior invasion by heat toxicity, the prescription recommended is a modified Fuzheng Jiedu Decoction.
9.Acupuncture
The main syndrome of early uterine cancer is stagnation of qi due to depression of the liver. The therapeutic principle should focus on relieving the depressed liver, as well as regulating Chong-Ren.
10.Medicated Diet, Nutrition, and so on
Nutritional supportive treatment focuses on medicated diet and food therapy for adjustment. For medium- advanced patients who can eat, focus on medicated diet conditioning by oral administration. Total parenteral nutrition is given to patients with serious nutritional imbalances, to which fat-soluble vitamins, water-soluble vitamins, and essential minerals and trace elements should be added.
11.Others
Combine with qigong, tai chi, music, and mental therapy of TCM to maintain calmness, positivity, and optimism in patients and to improve their self-healing ability and delay tumor progression. Through adjustment of body, breathing, and heart, qigong can stimulate the meridian qi of the human body, restore vital energy, and adjust qi and blood, which are conducive to reinforcing the vital energy and consolidating the constitution, as well as enhancing body immunity, and can jointly have an anticancer effect by combining with other nontoxic integrative treatments. Psychological therapy and music therapy can make patients feel happy and refreshed and have good regulative effects for improving sleep and relieving anxiety, fear, depression, and other negative moods, hence enhancing the quality of life of cancer patients.
Typical Case
A 59 year old female patient was admitted on Jan 27, 2010 to Clifford Hospital for “postoperative endometrial cancer for 15 months, abdominal distension and abdominal pain with weight loss for 4 months, aggravating for two days.” In October 2008, patient underwent hysterectomy + adnexectomy + partial vaginectomy + lymphadenotomy of para-aortic lymph nodes for endometrial cancer. She received 24 treatment of radiotherapy within 1 month after surgery and experienced stool irregularity and constipation alternated with diarrhea after radiotherapy. In September 2009, patient showed recurrent abdominal distension and abdominal pain radiating to the back, which was aggravated after liquid and food intake. Abdominal distension was felt throughout the entire abdomen. Sour regurgitation was felt, with loud bowel sounds. Vomiting of the stomach contents occurred. Abdominal distension and abdominal pain could be alleviated after vomiting or bowel movement. Patient had poor appetite and ate less. On Dec 8, 2009, x-ray taken at another hospital showed possible intestinal obstruction. Abdominal CT scan + enhancement showed a small amount of ascites, small bowel expansion, effusion, and likely intestinal obstruction was considered; colonoscopy showed: proctitis and schistosome eggs. Diagnosis was “proctitis, schistosomiasis, chronic gastritis, and intestinal obstruction. After antischistosome, regulation of intestinal function and anti-inflammatory treatment were given. Patient was discharged after the symptoms were alleviated. On Jan 6, 2010, mesenteric contrast examination revealed intestinal obstruction, likely caused by adhesions. Patient suffered persistent symptoms and could only have a liquid diet, resulting in weight loss, malaise and palpitation. Patient had abdominal distension and abdominal pain intensified accompanied by frequent vomiting 2 days prior to her transfer to Clifford Hospital. Patient was admitted as outpatient for “postoperative incomplete intestinal obstruction of endometrial cancer”.
Physical examination: Body weight of 45 kg, poor nutrition, marasmus, and clear lung breathing sounds. Wet and dry rales were not heard. The heart rate was 85 beats/min, with regular rhythm. Pathological murmurs were not heard at the auscultation area of the heart valve. The abdomen was soft, with visible intestinal shape at intervals, which could be relieved by itself after about a few minutes. There was lower abdominal tenderness (+) and no rebound tenderness. High-profile sounds of air over water could be heard.
Auxiliary examinations: blood routine: WBC 3.91×109/L, RBC 2.8×1012/L, HGB 67 g/L, and PLT 120×109/L. Biochemistry: ALT 55U/L and AST 95U/L. Bilirubin and protein were normal. CHOL 2.04mmol/L and LDL 0.72mmol/L. Determination of blood trace elements: Ca 2.03mmol/L and Fe 8.8μmol/L. Tumor marker: CA12-5 148.60U/ml. On January 22, 2010, PET/CT results reported the following: (1) postoperative endometrial adenocarcinoma after radiotherapy, and retroperitoneum multiple high metabolic enlarged lymph nodes, considered to be lymph nodes metastases; (2) no residual tumor and no signs of recurrence in the local pelvic surgery area; (3) incomplete small bowel obstruction and pelvic fluid; (4) fatty liver; (5) left and right coronary artery calcification; and (6) PET / CT imaging showed no abnormalities in other parts of the body.
Diagnosis: (1) postoperative endometrial cancer, (2) incomplete intestinal obstruction, (3) radiation enteritis, and (4) schistosomiasis.
Integrative treatment prescription: patient was unable to ingest food when she was admitted. Gastrointestinal decompression and intravenous nutritional support were given immediately after admission. Patient underwent nontoxic integrative treatments, which included chelation and detoxification therapy, medical ozone, herbal medicines, acupuncture, systemic biofeedback therapy, and other integrative treatments were given. Patient exhibited dark tongue, petechia, and a deep and unsmooth pulse. The syndrome belonged to toxin and blood stasis stagnating in the body. The treatment focused on promoting blood circulation and removing blood stasis, as well as removing lumps and relieving pain.
Medications: The prescription recommended was a modified Shaofu Zhuyu Decoction. Specific medication: Angelica Sinensis 15g, Radix Paeoniae Rubra 15g, Foeniculum Vulgare Mill 15g, Ginger 10g, Rhizoma Corydalis 9g, Myrrha 12g, Ligusticum chuanxiong Hort. 9g, Cinnamomum Cassia Presl 6g, Faeces Trogopterpri 12g, Cattail Pollen 9g, Rhizoma Sparganii 10g, and Rhizoma Curcumae 10g, one dose a day, decocted with water for oral administration.
Acupuncture on acupoints: Neiguan, Sanyinjiao, Zusanli, Shangjuxu, Yinlingquan, Tianshu, Qihai, Shenshu, Taichong, Taixi and Waisanguan. Methods: Even reinforcing-reducing methods were used. Retained the needles for 20 minutes once a day. Took 2 days off after five sessions of acupuncture.
Moxibustion on acupoints: Guanyuan, Zhongji, Shenque, Zusanli, Guanyuanshu and Baihuanshu. Methods: Took 2 points each time with a moxa stick for moxibustion. Conducted moxibustion for 10 minutes above each point, once per day. Took 2 days off after five times of moxibustion.
Auricular acupoints: Zigong, Penqiang, Yaodizhui, Kidney, Pizhixia, Adrenal Gland, Neifenmi, Jiaogan, Liver and Erjian; stuck auricular points with cowherb seed. The patient was asked to press each point for 3-5 minutes, 3-5 times every day, twice a week, alternating ears.
After patient underwent 9 days of aggressive treatment, intestinal obstruction was reduced and hemoglobin was raised to 85g/L from 67g/L. Patient took a small amount of porridge and water, and had bowel movement once every 2 days. Chelation and detoxification therapy was given once every other day, synchronized with local hyperthermia. Systemic biofeedback treatment was conducted 3 times a week, EBOO twice a week; medical ozone rectal infusion once a day; intraperitoneal hyperthermic perfusion of cisplatin 40 mg once every 2 weeks, with four sessions in total.
Patient was discharged after 2.5 months of treatment. She continued to receive outpatient local hyperthermia, systemic biofeedback therapy, chelation and detoxification therapy, and medical ozone therapy. During hospitalization, patient persisted on practicing medical Qigong and had been taking megestrol.
Treatment outcome: after more than 70 days of hospitalization, the symptoms from intestinal obstruction were relieved and her mental state significantly improved, appetite was acceptable, urine and stool normal. Skin and mucous membranes were in blush, and weight was increased to 52 kg. The KPS was 90. Recheck: CA12-5 38.50 U/ml. Blood routine showed: WBC 4.8×109/L, RBC 4.2×1012/L, HGB 90 /L, and PLT 150×109/L. In May, 2010, the review of PET/CT results was reported: (1) postoperative endometrial adenocarcinoma after radiotherapy and retroperitoneum multiple high metabolic enlarged lymph nodes, considered to be lymph node metastasis. Compared with PET-CT of January 22, metabolism was significantly lower and metabolic lesions were significantly reduced. (2) No residual tumor and signs of recurrence in the local pelvic surgery area. (3) Small bowel obstruction was basically relieved; fluid in pelvic cavity was detected. (4) Fatty liver. (5) Left and right coronary artery calcification. (6) PET/CT imaging showed no abnormalities in other parts of the body.
Patient continued to have local hyperthermia, systemic biofeedback therapy, chelation and detoxification therapy, medical ozone, TCM, herbal medicine, and other integrative treatment after hospital discharge. Review showed that CA125 gradually returned to normal. To date, intestinal obstruction was not detected by follow-up examinations. To date, tumor indexes are normal and multiple review of abdomen have been conducted, and no swelling lymph nodes evident by CT.
