| Background and Objective Uterine sarcomas are rare malignant neoplasms of stromal and mesenchymalorigin with poor prognosis and a tendency for early distant metastases.It has been estimated that about 1%of malignant tumors in female reproductive duct are uterine sarcomas.According to the NCCN guidelines,the initial treatment for uterine sarcomas is total abdominal hysterectomy with or without bilateral salpingo-oophorectomy(TAH/BSO).However,the status of lymphadenectomy(LAD)in the prognosis of uterine sarcomas remains controversial.Thus,we performed a retrospective analysis of the clinical pathological characteristics and prognostic factors of 105 uterine sarcoma patients admitted to Qilu hospital.Combined with the relevant research searched from the PubMed database,we performed a meta-analysis of investigating the role of LAD for the prognosis of patients with uterine leiomyosarcoma(uLMS)and endometrial stromal sarcoma(ESS).Methods Retrospectively analyze 105 cases with uterine sarcoma admitted to Qiluhospital from January 2005 to March 2016.SPSS 20.0 statistical software was used for statistical analysis of the clinical pathological characteristics and prognostic factors with uterine sarcoma.To discuss the role of LAD for the prognosis of uterine sarcomas,in addition to the 88 cases(32 cases of uLMS and 56 cases of ESS)admitted to our hospital,we searched the entire PubMed database up to March 2016 for studies evaluating the effects of LAD on uterine sarcoma patients.Only 14 studies met all inclusion and exclusion criteria eventually.We computed a pooled relative rate(RR)and 95%confidence intervals(95%CI)using Stata software version 12.0.For all tests,the standard of statistical difference was a P value less than 0.05.Results1.Clinical characteristics1.1 Age of onsetAmong the 105 cases of uterine sarcoma,the mean age of onset was 45.07+11.76 years,median onset age was 45 years.The mean ages of uLMS,ESS,undifferentiated uterine sarcoma(UUS)and other types of sarcomas were 45.97+8.07 years,42.59± 12.15 years,58.75±9.25 years and 49.31 ± 14.82 years respectively.The onset age of uLMS and ESS was relatively younger,while UUS was older.The differences of the age of onset among different histological types were statistically significant(P=0.017).1.2 Pregnancy-labor historyAmong the 105 cases of uterine sarcoma patients,95 cases were multipara.Themean number of pregnancy was 2.83± 1.53 times,and the mean number of parturition was 1.48±0.94 times.The differences of pregnancy and parturition among different histological types were not statistically significant(P=0.967,P=0.546).1.3 Menopausal status and family history of malignancyAmong the 105 cases of uterine sarcoma patients,the number of menopause females was 42(40%),and the mean age of menopause was 48.15±4.85 years,median age was 49 years.The differences among different histological types were statistically significant(P=0.014).Thirteen of uterine sarcoma patients had a family history of malignancy,accounting for 12.38%(13/105).1.4 Clinical manifestation and signsThe major clinical manifestation of uterine sarcoma was abnormal vaginal bleeding,accounting for about 40.95%,followed by abdominal pain(33.33%),abdominal distension(16.2%),lower abdominal mass(15.24%),vaginal drainage(9.52%),and other symptoms,etc(13.33%).The differences of vaginal drainage and abdominal distension among different histological types were statistically significant(P=0.017,P= 0.013).1.5 Preoperative diagnosisThe preoperative diagnosis rate was merely 46.67%(49/105).49 cases of patients were diagnosed uterine sarcoma before the operation,among which 11 cases(22.45%)were confirmed by diagnostic curettage surgery.The misdiagnosis rate of uterine fibroids was 58.10%(61/105).47 cases of patients were diagnosed by intraoperative rapid pathology,which accounted for 71.21%(47/66).1.6 Tumor markersAmong 105 cases with uterine sarcoma,64 cases did the CA125 testpreoperatively.Only 18 cases were higher than normal(ranged from 35.2 U/ml to370.4 U/ml).The differences among different histological types were not statistically significant(P=0.102).1.7 Clinical stagesAccording to the 2009 FIGO system of uterine sarcoma,surgical stages were I in 75 patients(71.43%),II in 8 patients(7.62%),III in 12 patients(11.43%)and IV in 10 patients(9.52%).The differences among different histological types were not statistically significant(P=0.292).1.8 Immunohistochemistry stainSMA was highly expressed in uLMS patients(91.67%).While in ESS patients,ER(90%)and PR(95%)were over-expressed.CD10 had different degree of positive expression in different histological types.2.TreatmentAll the uterine sarcoma patients underwent surgery,among which 56 cases with postoperative adjuvant chemotherapy,1 case with postoperative adjuvant radiotherapy and 20 cases with adjuvant hormonotherapy.Chemotherapy courses were 4 to 6 months.The average time was 3.45± 1.86 months.The treatment of adjuvant hormonotherapy was medroxyprogesterone(250 mg-500mg)on a daily basis over 3 to 6 months.3.Prognostic factorsKaplan-Meier survival analysis and Log rank test were used for univariate analysis of prognosis,which showed that the age of onset(P=0.000),clinical staging(P=0.001),histologic types(P=0.000),and differentiated degree(P=0.000)affected the prognosis of uterine sarcoma significantly.The multivariate analysis of significant factors used the COX regression model,and the result showed the age of onset and the clinical staging were statistically independent factors(P<0.05).4.The role of LAD for the prognosis of uLMS and ESS patientsCombined the 88 cases admitted to our hospital with the data searched from PubMed database,a total of 4,955 patients were pooled;1,408(28.42%)had the LAD procedure.The pooled RR for uLMS in patients with LAD was 0.89(95%CI=0.63-1.25)and for ESS was 0.95(95%CI=0.69-1.31),suggesting that LAD has no significant benefit in improving overall survival of uLMS and ESS patients(P<0.05).Conclusions1.The onset age of uLMS and ESS was relatively younger.The major clinical manifestation of uterine sarcoma was abnormal vaginal bleeding,followed by abdominal pain,abdominal distension,lower abdominal mass,vaginal drainage,etc.2.Uterine sarcoma was lack of specific tumor markers and check methods with low preoperative diagnosis rate,and many cases were misdiagnosed as uterine fibroids.Diagnostic curettage surgery bears a larger diagnostic value to ESS.3.The initial treatment of uterine sarcomas is TAH/BSO.The ovaries may be preserved in selected patients with early-stage uLMS in young women.Postoperative adjuvant chemotherapy and(or)radiotherapy had therapeutic effect to a certain extent.Postoperative hormone therapy was recommended for LGESS patients.4.The prognosis of uterine sarcoma was poor.There were many factors that affect the prognosis,including the age of onset,clinical staging,histologic types,differentiation degree,etc.The age of onset and the clinical staging were statistically independent factors.5.As shown in our study,lymph node metastases in patients with uLMS and ESS were too low,LAD and the number of resected lymph nodes do not improve overall survival rate.Hence,LAD may not be recommended unless these patients had obvious extrauterine involvement,enlarged lymph nodes showing by preoperative imageological examination,clinically suspicious enlarged lymph nodes or advanced uterine sarcomas. |
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