A Retrospective Analysis of the Impact of Myomectomy on Survival in Uterine Sarcoma

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Abstract

Laparoscopic myomectomy is a minimally invasive, conservative surgical approach commonly used for the treatment of uterine fibroids. However, there is a lack of effective means to distinguish the nature of uterine tumors prior to surgery. The impact of fibroid morcellation during laparoscopic surgery on the dissemination of cancerous uterine fibroids and long-term survival of patients has gained increasing attention. A retrospective cohort study was conducted to analyze the impact of different surgical approaches on recurrence-free survival (RFS) and overall survival (OS) in patients with a postoperative pathological diagnosis of uterine sarcoma at a single medical center. Patients who underwent the first surgery for uterine fibroids (confined to the uterus) and had a postoperative pathological diagnosis of uterine sarcoma were selected in the Chinese PLA General Hospital from January 2005 to January 2014. Based on the use of fibroid morcellation, the subjects were divided into fibroid morcellation (FM) and total hysterectomy (TH, non-morcellation) groups. Follow-up outcomes, including RFS and OS times, were observed. In total, 59 patients were included, with 30 cases in the FM group and 29 cases in the TH group. There were no significant differences in RFS and OS time between the two groups (RFS: P = 0.16, OS: P = 0.09). Multivariate correlation analysis showed that the impact of a higher grade level on RFS and OS was nearly 2-fold the impact of a lower grade level (RFS: P = 0.04, odds ratio (OR) = 1.97; OS: P = 0.03, OR = 2.29). Intraoperative morcellation, postoperative adjuvant therapy, age, tumor size, FIGO stage, and surgical approach were not risk factors affecting RFS and OS. Fibroid morcellation during laparoscopic surgery (including laparoscopic, transvaginal and transabdominal approaches) had no significant impact on RFS and OS time in patients. However, the 5-year RFS and OS rates were both lower in the FM group than in the TH group. Grade level was a significant risk factor for the prognosis of patients with uterine sarcoma.

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Most cited references 20

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The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma.

Jeong-Yeol Park, Sun-Kyung Park, Dae-Yeon Kim … (2011)

Uterine leiomyosarcoma (LMS) is usually diagnosed after surgery for leiomyoma; thus tumor morcellation frequently occurs. We evaluated the impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine LMS. Outcomes were retrospectively compared between patients who underwent total abdominal hysterectomy without tumor morcellation and those who underwent surgery that included abdominal, vaginal or laparoscopic tumor morcellation. We assessed 56 consecutive patients with stage I and II uterine LMS between 1989 and 2010, 25 with and 31 without tumor morcellation. There were no significant between group differences in age, parity, menopausal status, body mass index, stage, mitotic count, tumor grade, lymph node dissection, adjuvant therapy, and follow-up duration. However, tumor size was significantly smaller (9.8 cm vs. 7.3 cm, P=0.022) and ovarian tissue was more frequently preserved (38.7% vs. 72%, P=0.013) in patients with tumor morcellation. In univariate analysis, only tumor morcellation was significantly associated with poorer disease-free survival (DFS) (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.03-6.50; P=0.043), and higher stage (I vs. II; (OR, 19.12; 95% CI, 1.19-307.11; P=0.037)) and tumor morcellation (OR, 3.07; 95% CI, 1.05-8.93; P=0.040) were significantly associated with poorer overall survival (OS). In multivariate analysis, higher stage (OR, 20.34; 95% CI, 1.27-325.58; P=0.033) and tumor morcellation (OR, 3.11; 95% CI, 1.07-9.06; P=0.038) were significantly associated with poorer OS. The percentage of patients with abdomino-pelvic dissemination, as shown by peritoneal sarcomatosis or vaginal apex recurrence, was significantly greater in patients with than without tumor morcellation (44% vs. 12.9%, P=0.032). Tumor morcellation during surgery increased the rate of abdomino-pelvic dissemination and adversely affected DFS and OS in patients with apparently early uterine LMS. Copyright © 2011 Elsevier Inc. All rights reserved.

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Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma.

J Berek, Anthony W Parker, Amy Fu (1994)

To determine the incidence of uterine sarcoma in patients operated on for symptomatic uterine leiomyomas or "rapidly growing" leiomyomas. We reviewed the medical records of 1332 women admitted to either of two community hospitals between 1988-1992 for hysterectomy or myomectomy for uterine leiomyomas. The incidence of leiomyosarcoma, endometrial stromal sarcoma, and mixed mesodermal tumor was calculated. Patient ages, admitting symptoms, and operative and pathologic findings were analyzed. The study included 371 women (28%) operated on for rapidly growing leiomyomas. All patients operated on during the same interval and found to have a uterine sarcoma were reviewed. One of the 1332 patients operated on for presumed leiomyoma was found to have a leiomyosarcoma. This women was the only patient found to have a sarcoma among 371 women operated on for rapid growth of the uterus. None of 198 patients who met a published definition of rapid growth had a uterine sarcoma. Two women (0.15%) had endometrial stromal sarcoma, but none had a mixed mesodermal tumor. During the same interval, nine additional patients were found to have uterine sarcomas, and for these women, the preoperative diagnosis was sarcoma in four, endometrial cancer in three, ovarian cancer in one, and prolapsed uterus in one. The total incidence of uterine sarcoma (leiomyosarcoma, endometrial stromal sarcoma, and mixed mesodermal tumor) among patients operated on for uterine leiomyoma is extremely low (0.23%). The incidence of sarcoma among patients having surgery for "rapidly growing" leiomyoma (0.27%) or among those who met published criteria for rapid growth (0%) does not substantiate the concept of increased risk of sarcoma in these women.

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Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas.

J B Schlaerth, Daniel R. Mishell, G d'Ablaing … (1990)

The incidence of leiomyosarcoma in uterine leiomyomas is estimated to be between 0.13 to 0.29%. However, the exact incidence of leiomyosarcoma in uteri removed with a preoperative diagnosis of benign uterine leiomyomas has not been previously reported. Between 1983 and 1988, a total of 1432 patients in Women's Hospital, a self-referred indigent population, had a hysterectomy planned because of abnormal uterine bleeding or abdominal pain associated with the presence of uterine leiomyomas, or because of a pelvic mass thought to be uterine leiomyoma of sufficient size or character to warrant surgical exploration. The ages of these women ranged from 36 to 62 years and the presence of leiomyosarcoma in the hysterectomy specimens increased steadily from the fourth to seventh decades of age (0.2%, 0.9%, 1.4%, and 1.7%, respectively). Preoperative histologic examination of the endometrium was performed in eight patients. Three of the eight patients had a preoperative tissue diagnosis of leiomyosarcoma that was clinically confined to the uterus. After the hysterectomy in the 1429 patients with presumed benign disease, histologic diagnosis of leiomyosarcoma was made in seven (0.49%). There was no evidence of malignancy in the endometrial sampling of any of these seven patients and the diagnosis was suspected intraoperatively in only three. Preoperative uterine size ranged from 8 to 20 weeks' gestational size and postoperative uterine weight ranged from 120 to 1100 gm. Seven of the 10 patients had symptoms of abnormal uterine bleeding. Between the ages of 40 and 60 years, 1% (8 of 817) of women with presumed uterine leiomyomas producing symptoms that necessitated hysterectomy in this series had leiomyosarcoma diagnosis postoperatively. Such treatments as gonadotropin-releasing hormone agonists, endometrial ablation, myomectomy by hysteroscopy or laparotomy instead of hysterectomy in such women could delay the diagnosis and definitive treatment of leiomyosarcoma.

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Author and article information

Contributors

Stanley J. Robboy: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 1 February 2016

Publication date Collection: 2016

Volume: 11

Issue: 2

Electronic Location Identifier: e0148050

Affiliations

[1 ]Department of Obstetrics and Gynecology, General Hospital of Armed Police Forces, Beijing, China

[2 ]Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, China

Duke University Medical Center, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: ZZG LAL YGM. Performed the experiments: ZZG LAL. Analyzed the data: ZZG LAL. Contributed reagents/materials/analysis tools: ZZG LAL. Wrote the paper: ZZG. Patients follow-up: ZZG.

* E-mail: llapla@ 123456163.com (LAL); meng6512@ 123456vip.sina.com (YGM)

Article

Publisher ID: PONE-D-15-28111

DOI: 10.1371/journal.pone.0148050

PMC ID: 4735478

PubMed ID: 26828206

SO-VID: 2889c227-a76b-4e47-a783-8372cddd9435

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 16 July 2015

Date accepted : 12 January 2016

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Figures: 2, Tables: 3, Pages: 9

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The authors have no support or funding to report.

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Data Availability All relevant data are within the paper and its Supporting Information files.

A Retrospective Analysis of the Impact of Myomectomy on Survival in Uterine Sarcoma

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Most cited references 20

The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma.

Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma.

Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas.

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