1. Diagnosis and treatment of ovarian cysts
With the popularization of imaging methods, the detection rate of ovarian cysts has increased significantly. For benign and malignant ovarian cysts, the differential diagnosis is very important, it determines the specific treatment and prognosis. The most common internationally is the risk of malignancy index (RMI) proposed by the Royal College of Obstetrics and Gynecology, which is composed of ultrasound score, menopausal status score and serum carbohydrate antigen (CA125) measurement value. The calculation formula RMI= U×M×CA125, U represents the ultrasound examination score, M represents the menopausal status score, and CA125 (U/ml) is the direct value. Ultrasound examination is five indicators: (1) whether there is separation; (2) whether there is nipple or solid area (maximum diameter ≥ 3 mm); (3) whether it is bilateral; (4) whether there is ascites; (5) yes No metastases. Each ultrasound result is positive for 1 point, and the sum of all indicators is the ultrasound score. The menopausal status score is specifically 1 point for premenopausal status and 3 points for postmenopausal status. CA125 uses the last inspection result before surgery. Through index analysis, adnexa mass can be divided into high risk of malignancy, medium risk and low risk. RMI>250 is considered high risk of malignancy. In the last 16 systematic retrospective analysis, it was found that the sensitivity of RMI was 78% (95% confidence interval 71). %～85%), the specificity is 87% (95% confidence interval 83%～91%) . In 2008, the International Ovarian Tumor Analysis Group also introduced a simpler evaluation index as the "simple rule" of ultrasound scanning , which analyzes and evaluates the benign and malignant tumors of the accessory tumors through 10 indicators, without the need for the determination of tumor markers.
The 5 (M-rule) indicators for predicting malignant tumors are (1) irregular solid tumors; (2) ascites; (3) at least 4 papillary structures; (4) irregular and multilocular solid tumors , The diameter of the largest chamber is at least 100 mm; (5) Doppler ultrasound shows abundant blood flow signals (color Doppler ultrasound score 4 points). The five (B-rule) indicators for predicting benign tumors are (1) unilocular cysts; (2) solid tumors with a maximum diameter of less than 7mm; (3) acoustic shadow; (4) solid tumors with smooth cyst wall The diameter of the largest mass was less than 100 mm; (5) Color Doppler ultrasound did not detect blood flow signals (color Doppler ultrasound score 1 point). It is considered analytically that if there are no indicators in the B-rule, if one or more indicators in the M-rule are met, the attached tumor is evaluated as malignant. If there are no indicators in the M-rule, if one or more indicators are met For indicators in the B-rule, the attached tumor is evaluated as benign. If none of the indicators of M-rule and B-rule are met, the attached tumor is evaluated as uncertain. This method is relatively simple, but it is easily affected by the level of ultrasound diagnosticians.
The treatment of benign ovarian cysts includes open ovarian cyst removal, laparoscopic ovarian cyst removal, puncture drainage and sclerotherapy. Laparotomy ovarian cystectomy has the disadvantages of large surgical trauma, many complications, and easy recurrence, which brings great pain to patients. Laparoscopic ovarian cyst removal is the most widely used in benign ovarian cysts . The effect of surgery is affected by the surgical experience and proficiency of the surgeon. For cysts with heavier adhesions, they may not be peeled cleanly and may recur and damage the intestines Ureter, etc., even lead to varying degrees of damage and loss of ovarian tissue, shrinkage of the remaining ovaries, and premature ovarian failure in severe cases [4, 5]. With the development of imaging technology and equipment, puncture and drainage under the guidance of ultrasound and CT provides a new minimally invasive treatment technology for ovarian cysts. The disadvantage is that it is prone to recurrence. With the development of sclerotherapy and the development and application of sclerosing agents, puncture and drainage combined with sclerotherapy have largely achieved the purpose of treating cysts. It has the advantages of minimal invasiveness and safety, and is especially suitable for patients who are unmarried or not pregnant, unwilling to undergo surgery, unable to tolerate surgery, or relapse and pelvic adhesions after multiple operations.
2. Clinical application of sclerotherapy in ovarian cysts
2.1 Principles of sclerotherapy and application scope of sclerosing agents
The sclerotherapy technology is to inject sclerosing agent into the local area of the lesion through various ways, through its physical, chemical and biological properties to destroy the target tissue and cause a controllable inflammatory response, cell damage, fibroblast proliferation, and tissue structure hardening. A medical technology to achieve the purpose of treatment. In 1853, Cassaigue first used carbolic acid for the treatment of varicose veins. Because carbolic acid is highly corrosive, it can cause skin necrosis, purulent infection, and ectopic thrombosis, leading to slow development of clinical applications .With the use of tumor drugs and the research on some chemical reagents, it has been found that certain drugs and chemical reagents have a sclerosing effect with less toxic and side effects, so that sclerotherapy has developed rapidly. At present, the commonly used sclerosing agents are carbolic acid, pingyangmycin, absolute ethanol, 5% sodium morrhuate, cyclophosphamide, nitrogen mustard, 1% ethoxy sclerosing alcohol, sodium tetradecyl sulfate, hypertonic solution, ethanolamine, OK432 et al.  are widely used in lower extremity varices, internal hemorrhoids, esophageal and gastric varices, hemangioma and other diseases. In addition to the above-mentioned sclerosing agents for cysts, there are tetracycline, minocycline, doxycycline, povidone, iodophenyl ester, acetic acid, etc. [7-9], and domestic use of Xiaozhiling, CO2, golden grape Fluid for cyst treatment.
2.2 Absolute alcohol sclerotherapy
In 1981, Bean first reported 29 cases of sclerotherapy with absolute ethanol for the treatment of renal cysts. It was found to be a very effective sclerosing method. It is also a classic sclerosing agent at home and abroad. It is often used as a comparative research object for other sclerosing agents. Prove which drug has a more effective and safer hardening effect than absolute ethanol . Its mechanism of action includes cytotoxicity, thrombosis, protein denaturation, intracellular dehydration, protein coagulation, etc. In the treatment of cysts, it can successfully destroy the epithelial cells, capillary beds, and lymphatic structures of true cysts to reduce or block The effect of the severing fluid. Compared with the traditional ovarian cystectomy, Wang Jian  believes that absolute ethanol sclerotherapy can reduce postoperative pelvic adhesions and cause infertility and ovarian deficiency syndrome caused by ovarian resection, and it is also suitable for ovaries Infertile patients with cysts after marriage. Xie Jingyan et al.  also observed the changes in hormone levels before and after the operation on the basis of the above, and concluded that the absolute alcohol group has short operation time, less intraoperative blood loss, low postoperative analgesic use rate, and short hospitalization period. , The operation cost is significantly lower than that of the caesarean group, the short-term operation does not affect the ovarian function, and it can be carried out in the primary hospital. In terms of the specific curative effect of sclerotherapy, Wang Wenge et al.  believed that the curing effect of ovarian cysts is related to the concentration of absolute ethanol, the thoroughness of cyst fluid suction, the nature of the cyst, and the shape of the cyst. For the sclerotherapy of chocolate cysts caused by endometriosis, the recurrence rate is higher than that of simple cysts, and oral administration of mifepristone can further atrophy and necrosis of the remaining ectopic endometrium and reduce the recurrence of chocolate cysts . In summary, absolute ethanol has a significant effect on curing ovarian cysts. Although anhydrous ethanol is widely used, there are still some problems in specific operations, including the total amount of anhydrous ethanol, retention time, and the number of treatments that have not yet reached a consensus. At present, it is believed that the hardening effect of absolute ethanol depends on its concentration in the cyst, residence time, and contact surface with tissues. It is generally believed that the maximum amount of ethanol used is 1ml/kg, 20%-40% of the cyst volume is injected for lavage, at least 20min is reserved, 5-10ml after the operation, and the change of position fully contacts the cyst wall and other factors can achieve the effect of hardening [7 ]. The most common side effect of anhydrous ethanol is ethanol poisoning, so a single intraoperative dose often does not exceed 1ml/kg. For patients with large or multilocular cysts, due to the limited dose, the absolute ethanol stays in the capsule for insufficient time and cannot fully contact the capsule wall, which becomes the main cause of recurrence. During the injection of anhydrous ethanol, there may also be increased pressure in the capsule, leakage of the needle tract, and peritoneal irritation, which may cause severe pain, causing the patient to be unable to tolerate and complete the operation. In terms of the impact on ovarian function, the osmotic function of absolute ethanol , the large amount of injection, the escape of the puncture channel, the incomplete withdrawal and other factors may cause the necrosis of the ipsilateral ovary and surrounding tissues, and even affect the ovary Features. Domestic scholars have performed ovarian hormone measurement and ovarian blood flow and follicular ultrasound monitoring before and after the treatment of chocolate cysts with absolute ethanol, showing that it can improve the blood supply of the patient’s ovaries in the short term, and adjust the level of ovarian sex hormones to maintain a normal range , But lack of long-term follow-up and observation . The currently used anhydrous ethanol is a non-medicinal chemical preparation, which failed to enter the clinic in the name of a drug. Although the effect is obvious, there are potential medical disputes and legal risks in clinical application, which have become obstacles to the treatment of anhydrous ethanol sclerotherapy. The core reason.
2.3 Ethoxysclerol treatment
1% ethoxysclerodiol is internationally recognized and currently the most widely used sclerotherapy drug. It was first used as a local anesthetic in 1931 . After its hardening effect was discovered in 1960, it was used as a foam hardener, and it became popular in the mid-1990s . Clinically, it is mainly used for emergency hemostasis of esophagus-gastric varices and sclerotherapy of varicose veins, and a small part of it is used for sclerotherapy of vascular malformations, hemangioma, hydrocele, internal hemorrhoids and cysts.The mechanism of the treatment of cysts is that the chemical action of the drug stimulates the cyst wall, causes the epithelial cell of the cyst wall to degenerate, dehydration, and necrosis, and produces aseptic inflammation and fibrous tissue proliferation, thereby causing the cyst cavity to adhere and shrink, gradually absorb and disappear. Foreign applications are relatively mature and have been approved in many countries. In China, it was developed by Shaanxi Tianyu Pharmaceutical Co., Ltd. and was officially launched in 2008 with the approval number of the State Food and Drug Administration (SFDA). The domestic common name is "polycinnamyl alcohol". Due to the short time to market, reports in the domestic literature are mostly focused on the treatment of varicose veins of the lower extremities, liver and kidney cysts, and endoscopic esophageal and gastric varices. There is no relevant report on the treatment of benign ovarian cysts. There are two ways to use it: (1) injection of the original liquid in the cyst cavity after puncture and drainage; (2) injection of foam hardener after mixing with air. Domestic related reports have the same efficacy in treating liver and kidney cysts with lauric alcohol and absolute ethanol. In contrast, lauric alcohol has a local anesthetic effect, retains the sclerosing effect of ethanol, no irritating pain, and no drunken symptoms when left in the body. The advantages of simple operation, no need for multiple washings, less adverse reactions, and good patient tolerance are expected to become an alternative to absolute ethanol in the treatment of cysts . In terms of contraindications for use, whether it is the use of the original liquid or the foam method, it is well tolerated. Absolute contraindications include allergies, acute superficial and deep vein thrombosis, peripheral arteriosclerosis obliterans, 3 months and 36 weeks of pregnancy, hydrocephalus, etc. Relative contraindications are long-term edema, advanced diabetes comorbidities, etc. Complications are common but short-lived such as urticaria, pigmentation, and local telangiectasia, rare but self-limiting are short-term chest tightness and visual disturbance, and rare but more serious are skin necrosis and deep vein thrombosis. , Systemic allergic reactions.
3. Problems and prospects in the use of hardeners
As a classic sclerosing drug, absolute ethanol has a good effect in the treatment of benign cyst diseases, but it also has the above-mentioned prone to recurrence, multiple treatments, potential ovarian function effects, peripheral organ necrosis and perforation, and no drug approval number Wait for more questions. With the research and development of polycinnamyl alcohol and the approval number of drugs in China, it is gradually used in the clinical treatment of varicose veins, internal hemorrhoids, liver and kidney cysts, and the initial use of liver and kidney cysts is the same as absolute ethanol. The curative effect, and the complications are minor. It will also have clinical application value in the treatment of ovarian cysts. Especially in terms of side effects and dose limitation, since lauroram can be mixed with air to form foam for intracavitary injection, theoretically the volume of foam increases the diffusion area of the drug and reduces the dose of the original solution, which may achieve sufficient hardening and concurrent The multiple effects of fewer symptoms and economy. On the whole, polycinnamyl alcohol has a good application prospect and development value in the treatment of ovarian cyst sclerosis.