Six, Clinical Case Examples by Professor Pei Zhengxue

Clearing Phlegm and Unblocking Collaterals to Treat the Symptom. It is used for Yin Abscesses, just like when the bright sun shines in the sky, the gloom naturally dissipates; hence it is named "Yanghe." Basic Formula: Chai Shan Mixture: Bupleurum 10g, Pangolin Scale 6g, Akebia Vine 6g, Luffa 6g, Trichosanthes Root Powder 10g, Sparganium 10g, Curcuma 10g, Seaweed 10g, Kelp 10g, Angelica Sinensis 10g, Prunella Vulgaris 15g, Curcuma Wenyujin 6g, Frankincense 6g, Myrrh 6g, Fritillaria Thunbergii 10g, Cistanche Deserticola 15g. The Chai Shan Mixture is mainly formulated by modifying and adapting formulas such as Bupleurum Liver-Soothing Powder, Seaweed and Jade Pot Decoction, Kelp Pills, and Sparganium Decoction. Among them, Bupleurum and Curcuma Wenyujin both belong to the Liver and Gallbladder meridians, promoting blood circulation, relieving pain, regulating qi, and resolving depression; Akebia Vine paired with Pangolin Scale "mainly treats hard masses in the heart and abdomen"; Sparganium and Curcuma both belong to the Liver and Spleen meridians, breaking up blood stasis, regulating qi, eliminating accumulation, and relieving pain; Frankincense and Myrrh are both pungent and bitter, entering the Liver, Heart, and Spleen meridians, serving as essential medicines for unblocking the zang-fu organs and smoothing the collaterals; Seaweed and Kelp are both salty and cold in nature, entering the Liver and Kidney meridians, with the effects of eliminating phlegm and softening hard masses; Prunella Vulgaris and Fritillaria Thunbergii are both bitter and cold, working together to disperse nodules and eliminate six types of stagnation. Six, Clinical Case Examples by Professor Pei Zhengxue Case 1: Patient, female, 44 years old, first visit on March 28, 2012, chief complaint: One year after radical mastectomy for breast cancer, and more than half a year after radiotherapy and chemotherapy. Present illness: In March 2011, the patient accidentally discovered a hard lump in her left breast and went to a local hospital for examination, where she was diagnosed with breast cancer and underwent radical mastectomy. Postoperatively, she received radiotherapy and chemotherapy. Now she has distending pain in the right breast and both flanks, chest tightness and discomfort, irritability, bitter taste and dry throat, red tongue with little coating, and wiry pulse. Auxiliary examinations: On March 20, 2011, postoperative pathology at Wuwei Tumor Hospital in Gansu Province showed: (left breast) invasive ductal carcinoma. [Western Medical Diagnosis] Breast cancer postoperative radiotherapy and chemotherapy, mammary hyperplasia. [Traditional Chinese Medicine Diagnosis] Breast cancer. Syndrome type: Liver-Qi Stagnation syndrome. [Treatment] Soothe the liver and resolve depression, soften hard masses and disperse nodules. [Prescription] Modified Chai Shan Mixture: Bupleurum 12g, Angelica Sinensis 10g, White Peony 10g, White Atractylodes 10g, Poria 12g, Rehmannia 12g, Ligusticum 6g, Prunella Vulgaris 15g, Vitex 15g, Millettia 15g, Processed Frankincense 6g, Processed Myrrh 6g, Soapberry Thorn 10g, Turtle Shell 15g, Astragalus 20g, Akebia Vine 6g, Luffa 10g, Curcuma Wenyujin 6g, White Cistanche 10g, Fritillaria Thunbergii 10g, Seaweed 10g, Kelp 10g, Sparganium 10g, Curcuma 10g. Five doses, decocted in water and taken twice every three days. April 9, 2012, second visit: The patient reported that symptoms had improved compared with before, and continued with the previous formula for another 15 doses. May 2, 2012, third visit: The patient stated that most symptoms had basically disappeared and her condition was stable. The above formula was then supplemented with the core of the Lanzhou prescription (North Sand Ginseng 15g, Lu Dangshen 15g, Ginseng Hair 15g, Prince Ginseng 15g, Rehmannia 12g, Cornus Fruit 30g, Chinese Yam 10g, Ophiopogon 10g, Schisandra 6g), ground into powder ten times larger, sieved, and taken orally three times a day, six grams each time, mixed with warm boiled water, because the patient was still adhering to the medication, her physical condition was good, the hyperplasia in the right breast had healed, and no tumor recurrence was observed. Case 2: Patient, female, 53 years old, first visit on November 8, 2012, chief complaint: Ulceration and non-healing of the surgical site two months after radical mastectomy for right breast cancer. Present illness: In October 2012, the patient underwent examination due to a lump in her right breast and was diagnosed with breast cancer, subsequently undergoing radical mastectomy. Postoperatively, the surgical site ulcerated and did not heal. The ulcerated area was painful, oozing blood, with a foul odor, flushed face and red eyes, headache and insomnia, red tongue with no coating, and weak, rapid pulse. Auxiliary examinations: On October 20, 2012, postoperative pathology at the General Hospital of the Lanzhou Military Region showed: mucinous adenocarcinoma of the right breast. [Western Medical Diagnosis] Postoperative breast cancer. [Traditional Chinese Medicine Diagnosis] Breast cancer. Syndrome type: Heat-Toxin Accumulation. [Treatment] Clear heat and detoxify, nourish blood and generate muscle. [Prescription] Combination of Xianfang Huoming Drink, Yanghe Soup, and Tuoli Tou Nong San: Ephedra 10g, Rehmannia 12g, Cinnamon 3g, Deer Antler Glue 10g (processed), White Well Seed 10g, Honeysuckle 15g, Ledebouriella 10g, Angelica 6g, Frankincense 10g, Myrrh 10g, Angelica Sinensis 10g, Red Peony 10g, Fritillaria Thunbergii 15g, Citrus Peel 6g, Pangolin Scale 10g, Soapberry Thorn 15g, Astragalus 30g, Codonopsis 10g, Cimicifuga 5g, Green Peel 6g, Licorice 6g. Seven doses, decocted in water and taken once a day. November 15, 2012, second visit: The patient reported that the pain from the ulcerated surgical site had significantly improved after taking the medicine, and physical examination showed that new granulation tissue had formed in part of the ulcerated area, with partial healing. The previous formula, Yanghe Soup, was then supplemented with the core of the Lanzhou prescription for another 15 doses. November 30, 2012, third visit: The surgical site had healed, all symptoms had disappeared, and the condition was stable. She was advised to start chemotherapy, with the Lanzhou prescription: North Sand Ginseng 15g, Lu Dangshen 15g, Ginseng Hair 15g, Prince Ginseng 15g, Rehmannia 12g, Cornus Fruit 30g, Chinese Yam 10g, Ophiopogon 10g, Schisandra 6g, Cinnamon 12g, White Peony 15g, Floating Wheat 30g, Licorice 6g. Combined with chemotherapy. No further visits were scheduled during this period. Seven, A Collection of Ancient and Modern Theories "Discussions on the Causes and Symptoms of Various Diseases · Stone Symptoms": "The appearance of stones is slightly firm but not very large, not red, with mild pain and heat. When the heat subsides, it indicates the Foot-Yangming Meridian. If there is a downward flow to the breast, the meridian becomes deficient, allowing wind-cold pathogens to invade, resulting in blood stasis and the formation of lumps, with more cold than heat. In such cases, there is no significant heat, only nodules resembling stones, which are called 'stone epilepsy'." "Introduction to Medicine": "Breast cancer... ...nodules the size of turtle chess pieces, neither painful nor itchy. After five or seven years, the outer swelling turns purple-black, while the inside gradually ulcerates, known as breast cancer." "Surgical Orthodoxy": "Initially about the size of a bean, gradually growing to the size of a chess piece. Over half a year, a year, two years, three years, it remains neither painful nor itchy. Gradually it grows larger, starting to cause pain, which cannot be relieved. Later, the swelling becomes like a pile of millet or an overturned bowl, emitting a purple, foul-smelling gas, gradually ulcerating. Deep lesions resemble rock caves, while protruding ones look like blooming lotuses, with pain reaching the heart. Bleeding causes a foul odor." "Medical Compendium Today": "Breast cancer initially presents as hidden pain in the nodules... ...the nodules show no redness or heat, only cold and heat... ...if left untreated for a long time, the disease may worsen into breast cancer." Zou Yue pointed out: "Breast hyperplasia... ...if left untreated for several years, one should pay attention to diet and avoid anger, so as to prevent the transformation into breast cancer." He believed that if breast hyperplasia is left untreated for a long time, combined with dietary indiscretion and emotional distress, it can lead to "breast hyperplasia" turning into "breast cancer." Gu Bohua believed that breast cancer lumps are not caused by cold leading to blood stasis, but rather by liver fire scorching and causing blood stasis and phlegm accumulation. Therefore, warming and dispersing cold formulas used for treating phlegm and yin abscesses should not be used; instead, clearing heat and detoxifying formulas must be employed. Treatment of breast cancer, especially advanced breast cancer, should always focus on supporting qi and blood and regulating the spleen and stomach. For advanced breast cancer, he strongly opposed solely attacking the disease, advocating prioritizing strengthening the body's foundation. Lu Deming advocated combining disease differentiation with syndrome differentiation, and strengthening with removing evil to treat breast cancer at all stages; For breast cancer recurrence and metastasis, emphasis should be placed on treating the root cause, stressing that "nourishing the righteous will naturally eliminate accumulation," advocating "strengthening the righteous as the primary approach, removing evil as the secondary approach;" paying close attention to tongue diagnosis in guiding treatment of metastatic breast cancer, with red tongue, no coating, or thin coating, or even peeling with cracks, indicating a need to increase yin-nourishing medications; pale and plump tongue, with tooth marks on the edges, often indicating qi deficiency and yang deficiency, suggesting the need to tonify qi and yang; thick and greasy tongue coating often results from gastrointestinal dysfunction caused by radiotherapy and chemotherapy, with particular importance attached to the dark purple discoloration on the tongue edge as an indicator of prognosis: if the dark purple discoloration fades, it indicates improvement in condition; if it further develops and worsens, it means the disease is progressing, with poor prognosis. He Ren believed that the fundamental cause of breast cancer is still "where evil gathers, the qi must be deficient," with "strengthening the righteous and removing evil" as the treatment principle. Traditional Chinese Medicine treatment should primarily focus on strengthening the righteous, maximizing the body's own immunity; Western medical surgery and radiotherapy/chemotherapy are methods for removing evil. Anatomy, Physiology, and Pathology The esophagus begins at the pharynx, passes through the thoracic cavity via the diaphragm to the gastric cardia. The esophagus stretches from the incisors to the ring-shaped pharyngeal muscle at the entrance of the esophagus, measuring 15 cm, and extends to the cardia for another 39–48 cm. The entrance of the esophagus starts from the lower edge of the cricoid cartilage, roughly at the level of the sixth thoracic vertebra, forming the first narrowing of the normal esophagus, right on the body's midline. At the third and fourth thoracic vertebrae, it occupies the far left side; at the fifth thoracic vertebra, due to the pressure of the aortic arch, the esophagus moves toward the midline, crossing over the aortic arch here, forming the second narrowing of the esophagus. Continuing downward, slightly to the right, at the eighth to tenth thoracic vertebrae, the esophagus lies in front of the aorta, shifting further to the right, passing through the esophageal hiatus in the diaphragm to enter the abdominal cavity. When passing through the diaphragmatic foot, it forms the third narrowing of the esophagus. Its main physiological functions are peristalsis and mucus secretion. Most esophageal cancers are squamous cell carcinomas, with moderate differentiation of cancer cells; a small number are adenocarcinomas, and undifferentiated cancers and other rare types are extremely uncommon. The main route of metastasis for esophageal cancer is direct spread, with lesions spreading along the lamina propria and submucosal layer, potentially extending beyond 5 centimeters. Lesions can also spread along blood vessels and lymphatic vessels to invade the muscular layer of the esophageal wall; once they enter the muscular layer, they quickly invade neighboring organs such as the lungs, pleura, pericardium, trachea, and spine. Another route of metastasis is lymphatic and hematogenous spread, with the former most commonly manifesting as enlarged supraclavicular lymph nodes, and the latter often involving distant organ metastasis, such as the liver, usually the lungs, bones, brain, and kidneys. Two, Western Medical Diagnosis and Treatment (---) Clinical Diagnosis Anyone aged 50 or above who experiences difficulty swallowing or retrosternal pain that persists for several days without relief should undergo further examination; generally, diagnosis is not difficult. For patients with achalasia of the esophageal cardia, regular check-ups should be conducted to determine whether esophageal cancer has developed concurrently. The main clinical manifestation of esophageal cancer is progressive difficulty swallowing, because the esophageal wall has good elasticity and expansibility. Only when two-thirds of the esophagus is invaded by cancer in the late stage does difficulty swallowing become obvious. Ulcerative esophageal cancer may not have obvious obstruction symptoms, but patients often experience retrosternal pain when swallowing. Cancer tumors can secrete large amounts of mucus, and as swallowing becomes more difficult, mucus and food may reflux. Some tumors invade the adjacent mediastinum, causing persistent chest and back pain. Sometimes tumors invade the recurrent laryngeal nerve, leading to hoarseness; when they invade the bronchi, esophagotracheal fistulas may form, potentially causing severe lung infections. Tumors can also metastasize to supraclavicular lymph nodes, lungs, liver, bones, and other areas, presenting corresponding symptoms. In the late stage of esophageal cancer, due to prolonged inability to drink and eat, patients may experience obvious dehydration, emaciation, exhaustion, and cachexia. Barium swallow X-ray: In the early stages, localized stiffness may appear, with barium remaining in that area, and the esophageal mucosa becoming thicker; small niche shadows or filling defects may also be seen. In the middle and late stages, esophageal narrowing, barium retention, and irregular large niche shadows and filling defects can be observed. Esophageal cell collectors gather shed cells, which have certain significance for early diagnosis of esophageal cancer, but are currently rarely used. Esophagoscopy can provide further information on the location, nature, and extent of the lesion; other examination methods—CT, MRI, intraluminal ultrasound of the esophagus, mediastinoscopy, etc.—help further stage esophageal cancer, in order to formulate surgical plans and radiation therapy regimens. (2) Western Medical Treatment

1. Surgical Treatment Surgical resection of lower esophageal cancer yields relatively good results, with a 5-year survival rate of 30%. Stage I to IIa are the best periods for surgical treatment. For Stage IIb and some Stage III cases, appropriate radiotherapy and chemotherapy should be administered before and after surgery.
2. Radiation Therapy Mainly used for upper esophageal cancer that is difficult to operate on, as well as for middle and lower esophageal cancer that cannot be removed. Radiation therapy for upper esophageal cancer is as effective as surgery; combining radiotherapy before and after surgery can increase the 5-year survival rate.
3. Chemotherapy Mainly used as adjuvant therapy after surgery for Stage IIb and some Stage III cases, as well as palliative treatment for some Stage V cases. Squamous cell carcinomas often choose DDP, BLM, CTX, while adenocarcinomas frequently use 5-FU. Common regimens mostly feature platinum-based drugs and fluorouracil; efficacy ranges from 40% to 58%, with options such as docetaxel, paclitaxel, gemcitabine, and vinorelbine available.
4. Targeted Therapy Cetuximab, Nivolumab, Gefitinib, Bevacizumab, and others have shown certain efficacy in the treatment of esophageal cancer.
5. Immunotherapy Pembrolizumab, Opdivo, Sintilimab, Carrelizumab, combined with chemotherapy, have demonstrated good efficacy. 6. Interventional Therapy (1) Intravascular Intervention: Selective intravascular intervention for esophageal cancer is a new technique that has been developed in recent years. By directly infusing anti-cancer drugs into the arteries supplying the tumor, the drug concentration within the tumor tissue can be significantly increased. According to the dose-effect relationship of anti-cancer drugs, this can greatly enhance their cytotoxic effect, thereby improving therapeutic efficacy and achieving treatment goals. (2) Non-intravascular Intervention: Esophageal stent placement. Esophageal stent implantation has become another option for patients who cannot undergo surgery or do not wish to receive radiotherapy, helping to relieve esophageal stenosis, obstruction, and difficulty swallowing. With the development of science and technology, stent types have gradually increased, including bare stents, coated stents, particle stents, etc., allowing for comprehensive consideration based on various patient factors to place the most suitable stent, improving quality of life and prolonging survival. Three, Professor Pei Zhengxue’s Thinking Method Professor Pei Zhengxue believes that the cause of esophageal cancer is worry and grief damaging the stomach and spleen’s ability to transform and transport; excessive alcohol and sexual indulgence leading to fatigue and heat accumulation. Heat accumulates in the Three Yangs, depleting body fluids; when the spleen cannot circulate body fluids, the fluids become depleted, resulting in insufficient fluid transmission for digestion. Water and grain are the source of qi and blood production; if water and grain cannot enter the stomach, qi and blood are depleted, leading to long-term qi stagnation and blood stasis, disruption of Ying-Wei balance, or transformation into fire, or generation of phlegm, or accumulation of toxins, or qi stagnation and blood stasis resulting in symptom clusters. The main pathogenesis is depletion of body fluids, caused by long-term dietary indiscretion, emotional imbalance, internal injury from overwork, and damage to the spleen and stomach, leading to dysfunction of the zang-fu organs, resulting in qi stagnation and blood stasis, phlegm and blood stasis intermingling, and qi and blood depletion—symptoms that persist for a long time, damaging yin and drying out the body, ultimately leading to qi deficiency and yang weakness, making it difficult to eat and drink—critical conditions. Regarding the treatment of esophageal cancer, Professor Pei Zhengxue believes that strengthening the body’s foundation should run throughout the entire course of treatment, with clinical practice guided by principles of tonifying the liver and kidneys, detoxifying externally, opening up qi and regulating emotions, and nourishing yin and moistening dryness. Chinese medicine treatment must be carried out in conjunction with Western medical supportive therapies, especially for patients with obvious obstruction, who require various nutritional solutions. Early-stage esophageal cancer should primarily rely on surgical treatment, with pre- and post-operative radiotherapy and chemotherapy being standard procedures; the application of Chinese medicine can alleviate symptoms to some extent and reduce side effects of radiotherapy and chemotherapy. For patients in the middle and late stages who have lost the opportunity for surgery, combining Chinese medicine with radiotherapy and chemotherapy often produces better results. Xiangsha Liujunzi Tang, San Dui Da Dan Shen, Liu Wei Di Huang Tang, Tuoli Tou Nong San, Qige San, Xuanfu Dai Zhe Tang, Sheng Zhe Bei Qi Tang, Lanzhou Fang, Banxia Xiexin Tang are commonly used formulas by Professor Pei Zhengxue; Banxia Houpu Tang, Si Qi Tang, Si Ni San, Banxia Xiexin Tang can also be modified and applied. In addition, Professor Pei Zhengxue places great emphasis on regulating qi and opening up depression, dissolving phlegm and dispersing nodules in the treatment of esophageal cancer, frequently using Qige San and Xuanfu Dai Zhe Tang, while simultaneously employing detoxifying and muscle-generating, blood-circulating and blood-stasis-dissolving drugs, with a strong emphasis on using Astragalus to detoxify and generate muscle, and Turtle Shell, Soapberry Thorn, and Seaweed to disperse and penetrate while also having blood-circulating and blood-stasis-dissolving effects, particularly effective for those with difficulty swallowing. Furthermore, based on the core of the Lanzhou prescription, he strengthens the body’s foundation, targeting the root cause of tumor occurrence and development. Four, TCM Syndrome Differentiation and Formulas 1. Phlegm-Qi Obstruction Symptoms: Most early-stage esophageal cancers fall into this category, with patients experiencing only mild food blockage or feeling that food flows freely without obstruction. There is hidden chest pain, fullness in the chest and diaphragm, and discomfort in the stomach area. Facial pallor, loss of appetite, fatigue, and lack of energy are also observed. Pulse is deep, fine, and wiry, with a pale, thin tongue coating. Treatment involves strengthening the spleen and benefiting qi, as well as transforming phlegm and eliminating accumulation. Formulas: Xiangsha Liujunzi Tang, San Dui Da Dan Shen flavored. Formulas: Codonopsis 10g, White Atractylodes 10g, Poria 12g, Pinellia 6g, Citrus Peel 6g, Fructus Aurantii 10g, Wood