| Background and Objective: Endometrial stromal sarcoma is a relativelyrare group of neoplasm. Nowadays, ESS is the second most common uterinesarcoma beside the LMS and the number of developing the disease isincreasing. ESS is difficult to diagnose before surgery because of lack ofspecial clinical features and detect method. LG-ESS is prone to invade inlocality and distant metastasis, so the recurrence rate is high. Surgery is themain treatment, but the choice of operation methods is controversial and thereis scope for dispute about whether the adjuvant treatments are need. Forty-sixcases of LG-ESS in the Forth Affiliated Hospital of Hebei Medical Universityfrom October2006to July2012were followed, and were analyzedretrospectively the clinical features, diagnosis, treatments, prognosis andrelapses. And the aim is to improve the level of diagnosis and treatment.Methods: A retrospective analysis and a follow-up of46patients withLG-ESS treated at the Fourth Affiliated Hospital of Hebei Medical Universityfrom October2006to July2012were conducted. The current study showedthe age was26~63years old, and the median age was45.5years old.According to the staging criteria of UICC-AJCCS（1994）, the staging of46cases: stageⅠ35cases, stageⅡ3cases, stageⅢ3cases, stageⅣ5cases, andamong them2cases of stage Ⅳ did not receive the surgery.SPSS18.0was used for statistical analysis. The measurement data used ttest, enumeration data usedχ2test, univariate analysis of prognosis usedKaplan-Meier survival analysis and Log rank test. The multivariate analysisof significant factors use the COX regression model, and the significancejudge standard was P＜0.05.Results: 1AgeAmong the46cases of LG-ESS, the median age was45.5years. Themean age of early stage (stageⅠ~Ⅱ) after surgery is45.9±7.8years, and latestage (stageⅢ~Ⅳ) is48.8±8.0years. There is no statistically different inmean age between the early and late stage (P＞0.05).2MenstruationThe number of premenopause females was35(76.1%), andpostmenopause was11(23.9%). This showed LG-ESS often occurs topremenopause females. Among44cases of receiving surgery, the number ofpremenopause females of early stage was30(78.9%), and postmenopause was8(21.1%); the number of premenopause females of late stage was4, andpostmenopause was2. The menstruation of the early and late stage had nosignificant difference(P＞0.05).3Clinical manifestation and SignsThe clinical manifestations of LG-ESS are not typical. The number ofpatients whose manifestation was abnormal vaginal bleeding was36(78.3%),and it showed abnormal vaginal bleeding was most-seen symptom.There were38(82.6%) patients whose urine size increased in differentdegrees and it indicated that larger size of urine was the most common sign.Among44cases of receiving surgery, the number of early stage of urine size≥3-month-pregnancy was17(44.7%),＜3-month-pregnancy was21(55.3%);the number of late stage of urine size≥3-month-pregnancy was5,＜3-month-pregnancy was1. The urine size of the early and late stage had no significantdifference (P＞0.05).4Preoperative diagnosisAmong44cases of receiving surgery,6cases were diagnosed beforesurgery and the definite diagnosis rate was13.6%.4cases among them diduterine curettage and the other two with vegetation of cervix uteri didpathological biopsy to confirmed diagnosis. There was23(52.3%) patientswho were misdiagnosed as urine fibroids before surgery,6(13.6%) cases weremisdiagnosed as adenomyosis of uterus,3（6.8%）cases were misdiagnosed asdysfunctional uterine bleeding,4(9.1%) cases were misdiagnosed as endometrial lesions,1(2.3%) cases was misdiagnosed as pelvic neoplasm,1(2.3%) cases was misdiagnosed as endometrial clear cell carcinoma, and themisdiagnose rate before surgery was86.4%. The data showed the misdiagnoserate of LG-ESS before surgery was high.There were15cases which can be refered to. The ultraphonic imaging:5(33.3%) cases were intrauterine placeholder,7(46.7%) cases were uterinemyometrium placeholder, and3(20%) cases were cervical placeholder.15cases all prompted the echo of uterine myometrium was not uniform,11(73.3%) cases which reported the lesion was low echo, and10(66.7%) casesreported obvious blood flow signal was seen in the lesions. The data showedthe majority of lesions of LG-ESS were low echo, and obvious blood flowsignal was seen in the lesions.There were33cases who did the CA125test.29cases were normal, and4cases were higher than normal(71.06~354.7U/ml, average150.643U/ml).Among the4cases whose pathology results after surgery withoutadenomyosis of uterus,3cases were stageⅠ, and1case was stage Ⅳ. Thatshowed high level of CA125was worth in prompting the LG-ESS.5Survival rate5.1The one-year overall survival rate was95.3%(41/43), three-year overallsurvival rate was91.3%(21/23), five-year overall survival rate was84.6%(11/13).5.2The survival rate of early stage and late stage after surgery had statisticallydifference (P<0.05), and that showed the prognosis survival of LG-ESS wasrelated to clinical stage, and the survival of early stage after surgery was high.5.3The survival rate after surgery of premenopause and postmenopausepatients had no statistically difference (P＞0.05). Among the patients of latestage, premenopause was4cases, postmenopause was2cases, and thedifference between the two had no statistically significance(P＞0.05).5.4The survival rate after surgery of patients whose uterine size≥3months ofpregnancy and patients whose uterine size＜3months had no statisticallydifference (P＞0.05). Among the patients of late stage, there were5patients whose urine size≥3months of pregnancy, and1case whose uterine size＜3months of pregnancy. Compared the survival rate after surgery between thetwo teams, the difference had no statistically significance(P＞0.05).5.5The survival rate after surgery of patients reserving ovaries and patientswithout ovaries reservation had no statistically difference (P＞0.05).5.6The comparison of survival rate between patients sweeping pelvic lymphnodes and patients without lymph sweeping had no statistically difference(P＞0.05). Among the patients of late stage, Compared the survival rate aftersurgery between the two, the difference had no statistically significance(P＞0.05).5.7The survival rate of surgery alone and surgery combined with adjuvanttreatments had no statistically difference (P＞0.05).5.8The survival rate of laparotomy and laparoscopic surgery had nostatistically difference (P＞0.05).6DFS after surgery6.1The DFS of early and late stage was78.5months and35.7months. Thedifference of DFS between the early stage and the late after surgery hadstatistically significant (P<0.05).6.2The DFS after surgery of premenopause and postmenopause patients hadno statistically difference (P＞0.05). Among the patients of early stage, theDFS after surgery of the premenopause and postmenopause had no statisticallydifference (P＞0.05). Among the patients of late stage, the difference betweenthe two had no statistically significant (P＞0.05).6.3The DFS after surgery of patients whose uterine size≥3months ofpregnancy and patients whose uterine size＜3months had statisticallydifference (P＜0.05).6.4The DFS after surgery of patients reserving ovaries and patients withoutovaries reservation had statistically difference (P＜0.05). Among the patientsof early stage, the DFS after surgery of patients reserving ovaries and patientswithout ovaries reservation had statistically difference (P＜0.05), and the DFSafter surgery of early stage without ovaries reservation was high. 6.5The comparison of DFS between patients sweeping pelvic lymph nodesand patients without lymph sweeping had no statistically difference(P＞0.05).Among the patients of early stage, the comparison of DFS between patientssweeping pelvic lymph nodes and patients without lymph sweeping had nostatistically difference(P＞0.05). Among the patients of late stage, thedifference between the two had no statistically significant (P＞0.05).6.6The DFS after surgery of surgery alone and surgery combined withadjuvant treatments had no statistically difference (P＞0.05). Among thepatients of early stage, the DFS of surgery alone and surgery combined withadjuvant chemotherapy had statistically significant (P<0.05), the DFS of earlystage patients of surgery combined with adjuvant treatments was higher.6.7The DFS of surgery alone and surgery combined with adjuvantchemotherapy had statistically difference (P<0.05), and the DFS of surgerycombined with adjuvant chemotherapy was higher than the surgery alone.6.8The DFS of laparotomy and laparoscopic surgery had no statisticallydifference (P＞0.05).7Multiple-factor analysisUse the COX regression model to analyze the effect of the stage, uterinesize, and the operation of ovaries preservation to recurrence, and the resultshowed the operation of ovaries preservation was statistically independentfactor(P<0.05). The relapse risk of patients with bilateralsalpingo-oophorectomy was lower than patients of ovaries preservation.Conclusion:1In this study,76.1%patients were premenopause,78.3%patients werevagina abnormal bleeding, and82.6%patients were urine enlargement; thestudy showed LG-ESS always happened on the premenopause female, andvagina abnormal bleeding and urine enlargement were most common clinicalsymptom and sign.2In this study, the preoperative misdiagnosis rate was86.4%, and52.3%patients were misdiagnosed as uterine fibroids. It prompted that thepreoperative misdiagnosis rate was high, and uterine curettage and pathological biopsy can help increasing the preoperative diagnosis rate.3The clinical stage influenced survival and relapse, and the later stage,the higher recurrence rate, the lower survival rate, and the worse prognosis.4The relapse rate of patients with uterine≥3months of pregnancy washigher than uterine size＜3months of pregnancy. The urine size influence therecurrence after surgery. But the urine size did not influence survival rate.5The relapse rate of operation of ovaries preservation was higher, andthe result of COX regression analysis was the operation of ovariespreservation was statistically independent factor. But it did not influence thesurvival rate. Therefore the early stage of the young should did bilateralsalpingo-oophorectomy to reduce the relapse.6The relapse rate of surgery alone was higher than operation combinedwith adjuvant treatments. Therefore the early stage of patients should receivethe adjuvant treatments after surgery to reduce the relapse.7The relapse rate of surgery alone was higher than operation combinedwith adjuvant chemotherapy. So the patients with LG-ESS should receiveadjuvant chemotherapy to reduce relapse. |
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