Parents who have girls at home must have concerned about the news last year that HPV vaccine has been available in Shanghai.

On July 31, 2017, GlaxoSmithKline's cervical cancer vaccine "Shrike" (bivalent HPV vaccine) was officially launched in the Mainland, which was the first cervical cancer vaccine approved in Mainland China. Shanghai Municipal Center for Disease Control and Prevention said that the vaccine had been available in 11 districts of Shanghai up to December.

Injection of HPV vaccine is an effective way to prevent cervical cancer in women. Before the vaccine entered the Mainland, many parents brought their children to Hong Kong for injection.

It is not surprising that HPV vaccines are so widely focused that aspiring female parents always want their children to stay away from the disease. But in addition to HPV vaccine, how much more do we know about the prevention of juvenile gynecological diseases? I am afraid people find the answer some embarrassment.

In China, various medical examinations organized by the schools do not include gynecological examinations. Parents also do not expect to have gynecological examinations with underage children even if they have abdominal pain and other symptoms. Gynecological diseases are generally not suspected. However, in fact, reproductive organs of the girl began to develop from birth until maturity, during which process gynecological diseases are also possible. More importantly, gynecological diseases can easily bring psychological burden to underage girls, and some malignant diseases can affect future fertility. Therefore, standardized treatment is extremely important.

As parents have little understanding of juvenile gynecological diseases and medical organizations have not clearly defined responsible departments for juvenile gynecological cancers in the past, the treatment of juvenile gynecological diseases in the country has been lacking in both doctors and norms for many years. Many patients have therefore lost their best time for diagnosis and treatment. Especially for juvenile gynecological cancers, early detection is very difficult due to lack of physical examinations. The treatment of juvenile tumors has always been a very difficult problem for doctors.

After the Spring Festival this year, Shanghai Renji Hospital will set up a juvenile gynecological clinic, which is the first juvenile gynecological clinic opened in large-scale 3A top hospitals in China after Peijing Union Medical College Hospital. In the past two years, Department of Obstetrics and Gynecology at Renji Hospital has admitted more than 20 juvenile patients with gynecological cancers aged 15 to 19 years, of which more are ovarian germ cell tumors and endometriosis.

Wen Di, Director of Department of Obstetrics and Gynecology at Renji Hospital said that Department of Obstetrics and Gynecology at Renji Hospital has accumulated rich experience in the diagnosis and treatment of juvenile gynecological diseases for many years. The hospital hopes to set up juvenile gynecological clinic, on the one hand to facilitate patient treatment, but also to arouse the attention of parents, so that young patients with gynecological diseases can be timely diagnosed and treated.

At present, the "Juvenile Gynecological Cancer Alliance" led by the Department of Gynecology and Obstetrics in Renji Hospital is also under preparation. The alliance will work together with the medical experts who have accumulated rich experience in the diagnosis and treatment of juvenile gynecological cancers in the country to work together and formulate guidelines on the diagnosis and treatment of juvenile gynecological cancers to promote standardization of treatment and progress of technology.

Juvenile gynecological cancers - long-neglected serious illnesses finally began to receive attention after so many "quiet" years

A girl who is undergoing the fourth surgery 

The situation of Shishi (alias) was already very dangerous when Director Wen Di from Department of Gynecology in Renji Hospital first met the 15-year-old girl in October 2017. "Her belly is as big as a full-term pregnant woman. Plus she is already a big girl; you would really think that she is pregnant, if you do not know her illness." In addition to a huge stomach caused by ascites, Shishi looked haggard, difficult to move, and her body was in a very weak state.

Director Wen Di introduced to the reporter that Shishi had been admitted to four hospitals and finally came to Renji Hospital.

About six months ago, Shishi was diagnosed with ovarian teratoma in other province, and the doctor made a minimally invasive laparoscopic surgery for her. However, during surgery, the cyst was damaged and the tumor cells spread to the abdominal cavity of Shishi as seeds. The terrible thing about the tumor cells is that they have extremely crazy growth ability. Not long time after the surgery, the abdominal cavity of Shishi was covered with tumor.

In order to clear these tumors, Shishi had undergone two surgeries and also chemotherapy. However, with little or no effect, Shishi's physical condition had been very poor.

Fate was somewhat unfair to Shishi, whose parents had been divorced when she was still very young. She was brought up by grandpa. She never thought that she would suffer from gynecological cancer at more than a dozen years old. Seeing that Shishi was growing worse, the grandpa who brought up the girl all by himself did not want to give up the last hope, but did not want to see Shishi so painful.

After referral from a hospital in other province, Shishi was admitted to Department of Obstetrics and Gynecology at Renji Hospital in October 2017.

Department of Obstetrics and Gynecology at Renji Hospital has the largest amount of outpatient and emergency visits as well as hospitalization among Department of Obstetrics and Gynecology in all the Shanghai General Hospitals. At the same time, Department of Obstetrics in Renji Hospital is the Clinical Key Specialist of Ministry of Health and the first batch of Shanghai Critical Maternal Consultation Center. Because the Eastern division of Renji Hospital is adjacent to the Shanghai Children's Medical Center, they often collaborate to deal with difficult juvenile gynecological diseases and have explored for years in juvenile gynecological diseases.

But even in Renji Hospital, such conditions as Shishi are still very rare. After admission, Department of Gynecology and Obstetrics organized a MDT (Multidisciplinary Joint) discussion on gynecological cancers. Experts in anesthesiology, imaging, general surgery, urology and other gynecologists discussed in depth about the condition of Shishi. The expert groups diagnosed that the current disease of Shishi was peritoneal glioma.

Glioma is a malignant tumor that usually occurs in the brain. The situation appears in the abdominal cavity relatively occasionally, while the probability of appearing in young people is even much smaller. There are only a few dozens of similar cases reported worldwide, and the case of Shishi which progressed so rapidly was rare.

Multidisciplinary team of experts agreed that Shishi's condition can only be improved by complete re-destruction of the cancer by surgery. After a thorough preparation, Director Wen Di conducted surgery for Shishi together with Department of General Surgery. When Shishi’s abdominal cavity was opened, the doctors were shocked. Widespread dissemination of tumor tissue closely adhered to the surrounding organs, and no boundary could be found. The surgeons carefully and patiently separated, so that the surgery can not damage the child's organ function, but also clean the tumor as much as possible. The successful surgery was concluded, and according to the results of genetic testing after surgery, Shishi began to take targeted drugs to control the disease.

The 16-year-old Shishi, still has a strong vitality. More than a month after surgery she was able to eat and read books and her basic life returned to normal. Looking at the Shishi’s improvement day by day, Shishi’s grandfather was the most gratifying. His only desire was: even if Shishi’s disease could not be cured, at least not to make Shishi as painful as before. 

The experience of Shishi is a good example. The domestic diagnosis and treatment of juvenile gynecological diseases is still lack of talents and standards. When a girl like Shishi becomes ill, she often has to go to many places so that delay the best treatment time and can not get the proper treatment plan.

Chinese medical standards take 16 years as a boundary that patients under the age of 16 are pediatric; meanwhile patients over the age of 16 should go to the adult hospital. Department of Gynecology is not available in pediatric hospitals, and adult gynecologists lack experience in juvenile gynecology, so that children and juveniles with gynecological diseases are practically seeking medical help. So far, only large-scale top 3A hospitals like Peijing Union Medical College Hospital and Shanghai Renji Hospital, which have strong comprehensive strength in Department of Gynecology and Obstetrics conducted a lot of exploration in juvenile gynecological diseases, and especially juvenile gynecological cancers.

Parents are seldom aware of juvenile gynecological cancers, also easily delay treatment. Professor Wen Di reminded that although the incidence of children and juvenile ovarian cancers is low, the higher the degree of malignancy is, the younger the patient is and the higher the proportion of malignancy is. Abdominal pain and abdominal mass are common symptoms and parents should consider the possibility of gynecological diseases if they develop these symptoms. In addition, precocious puberty and increasing abdominal circumference may also reflect the existence of gynecologic cancer diseases.

Cancers can not be "cut" without anymore

"Gynecological diseases can easily bring far-reaching psychological effects for women. Especially for those suffering from juvenile gynecological diseases, doctors need to think more about their treatment," Professor Wen Di said.

Last year, a 19-year-old girl was also admitted to Renji Hospital. She was suffering from endometrial stromal sarcoma, which is a malignant tumor, but also a very rare tumor in juveniles. Such conditions determine that the doctor must cut off the uterus and ovaries for the girl; otherwise the tumor will endanger the life and safety. However, it is conceivable that the future life of girls will be severely affected by the loss of the uterus and ovaries.

Faced with such a young life, doctors use the current medical technology to improve the quality of life of girls in the future as much as possible.

Ovary is an important female reproductive organ. It is not only the basis of fertility, but also the source of female estrogen. If the ovary is loss, patients may have a variety of symptoms due to lack of estrogen. The current method is to improve the symptoms of ovariectomized patients by estrogen replacement.

Nowadays, doctors are trying another better way - ovarian cortical transplantation. This method is to freeze the patient's ovary cortex until the right time to transplant the frozen ovarian cortex back to the abdominal cavity after the treatment of cancer. Ovarian cortex has a strong ability to regenerate, it is possible to develop into a new ovary, so that the new ovary will continue to play ovarian function, maintain the balance of the hormone in the female body.

This plan is not a fantasy

Last year, the authoritative medical journal "New England Journal of Medicine" reported a successful attempt. The report said that Winthrop Hospital of New York University achieved a dream of having a baby after transplanting the ovary cortex for a patient.

The patient was diagnosed with lymphoma at 15 years of age and subsequently underwent bone marrow transplantation. As cancer patients often require high doses of chemotherapy and radiation, the side effects of these treatments can completely eliminate the eggs. Dr. Kutluk Oktay, a reproductive specialist at Winthrop Hospital of New York University, removed the ovaries for her and then sliced ovarian tissue and stored them frozen in DMSO. Recently, the patient contacted the doctor and asked for ovarian transplantation. "She is married and she wants to start a new family, so we want to help her."

In addition to the woman, Dr. Kutluk Oktay also had an ovarian transplantation for a 39-year-old woman named Rosaria Ruttenber, who had Hodgkin's lymphoma before. After ovarian transplantation surgery a baby girl was successfully born in 2014.

Director Wen Di introduced that more than 70 cases of cryogenic ovarian cortical cell transplantation has been reported in the world. The team of Department of Obstetrics and Gynecology at Renji Hospital is also doing this attempt. They have frozen ovarian cortical cells from a 19-year-old girl who may be able to undergo a transplant in the future. At least, the technology leaves a desired seed for the girl.

In fact, with advances in medical technology, the survival time of gynecologic cancer patients can be very long, which requires doctors to consider more about the future life of female patients when choosing treatment options. In particular, the protection of reproductive function has become a new topic in the treatment of gynecologic cancers in recent years.

Director Wen Di said that, Department of Obstetrics and Gynecology at Renji Hospital has helped many patients, who are postoperative patients with gynecological cancers, kidney transplant patients, postoperative patients with gastric cancer, postoperative patients with bowel cancer, to achieve their dream of having a baby over the years. In the face of gynecologic cancers, doctors will also protect the patient's reproductive function in the premise of effective treatment of the disease. Renji Hospital is currently one of the hospitals in the country that carries out the most numbers of fertility preserving laparoscopic cervical cancer surgery.

Treatment needs to reflect the humanness

The treatment of gynecological diseases requires doctors to give more humane consideration for the patient to choose the appropriate treatment.

Speaking of treatment options for the choice of surgical approach, Director Wen Di believes that the "Wave of minimally invasive" for obstetrics and gynecology surgeries in recent years, needs to be treated calmly. Minimally invasive surgery in the country mainly refers to laparoscopic surgery. The emergence of laparoscopic surgery is an important advance in modern medicine, providing a new surgical choice. For some diseases, laparoscopic surgery is less traumatic while more clear doctor's vision than conventional laparotomy, which will contribute better therapeutic results.

However, any technology has its limitations. Laparoscopic surgery and subsequent "upgrade" - Da Vinci surgery and other techniques are not suitable for all diseases. Director Wen Di believes that doctors and patients should rationally choose the surgery mode. The most famous export of obstetrics and gynecology, Academician Jinghe Lang from Peijing Union Medical College Hospital said that: "Minimally invasive surgery is not a panacea. Improper use can cause a huge hit!"

"Whether 'minimally invasive' or not, need to be judged when integrated with the entire surgical procedure. If the appearance of wound is small, but internal trauma is huge, it is not a 'minimally invasive' at all. We advocate the appropriate choice of surgical approach. When it’s needed to open an abdomen, it should be opened." Wen Di stressed that "minimally invasive" should be a concept. Whether to use open surgery or laparoscopic surgery, doctors should pursue the best results under the smallest trauma. For some medical institutions, blind pursuit of minimally invasive, and gradually abandon the traditional practice of open surgery, Wen Di considered it undesirable. He stressed that the traditional technique of open surgery is the most important basic skills as a surgeon.

Director Di said that there are some tumor resection surgeries that are not suitable for minimally invasive surgery. The size of the wound would limit the doctor's operation to affect the treatment effects, so the traditional laparotomy should be chosen in this situation. "No matter what kind of surgical technique you choose, the only standard is for the treatment."

In the recent decade, the superb surgical techniques of surgeons in China have become extremely popular in the international arena, attracting overseas doctors to pursue advanced studies in China. The rapid development of medical technology in China has provided better and better medical services to the public. At the same time, patients also place higher demands on medical services. "Now the gap between domestic medical treatment and that of developed countries may not be in medical technology but in humane care. Our Chinese doctors should consider the overall treatment effects for the patients and think more about the quality of life afterwards so that the medical treatment can reflect the due temperature. "

Director Wen Di has so many fans after more than thirty years of medical treatment. The patients are very moved that the doctor Di not only cure their diseases, but also take care of their psychological experience. When Director Wen Di is in the clinic, he always tries to fully communicate with each patient, for which, the morning clinic is often ended up to 15:00. "The attitude is very important for patients with cancers, who need mental support. Mental factors would play a key role in cancer treatment, and doctors should pay more attention to this aspect." Director Wen Di’s advocacy of humanistic care and the idea that technology should serve people, deeply affected the entire department culture. In the Department of Obstetrics and Gynecology at Renji Hospital, when deciding on the patient's treatment plan, doctors will take as much as possible into consideration, including the medical technology, the treatment effects, the quality of life, the psychological endurance, the patient's own expectations of the treatment effects and others. All of these could help the doctors’ appropriate plans for the patients.

Medical treatment is not just pure medicine, but also humanities and social psychology, has gradually been accepted by more doctors.

"Xinmin Weekly" Reporter: Qi Huang