Gynecology and Obstetrics, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Canarias, Spain
Gynecology and Obstetrics, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Canarias, Spain.
Int J Gynecol Cancer. 2020 Nov;30(11):1726-1732. doi: 10.1136/ijgc-2020-001745. Epub 2020 Sep 18.
Tumor rupture during surgery is a risk factor for recurrence of sarcomas in other locations. However, the independent impact of rupture on prognosis is uncertain in uterine sarcomas. The aim of this study was to evaluate whether uterine rupture impacts outcomes in patients with uterine sarcoma.
A retrospective analysis was carried out of all consecutive patients with uterine sarcoma managed at the Department of Gynecology and Obstetrics of the Complejo Hospitalario Universitario Insular-Materno Infantil of the Canary Islands, Spain between January 1990 and December 2016. Inclusion criteria included all patients with histologically proven uterine sarcoma. Exclusion criteria included patients with endometrial carcinoma (non-sarcomatous) and carcinosarcomas. During this period, 1981 patients were diagnosed with a uterine malignancy; 1799 were excluded because of a diagnosis of endometrial carcinoma and 85 patients were excluded for a diagnosis of carcinosarcoma. Thus, the final sample included 97 patients with uterine sarcoma (4.9%). These included leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, and liposarcoma. Surgical resection was the primary treatment, including open, laparoscopic and vaginal surgery. Survival rates were analyzed using the Kaplan-Meier method.
The median age was 52 years (range 25-90); 49.5% (48) were pre-menopausal. Distribution per histological type was: 46.4% (45) leiomyosarcoma, 23.7% (23) high-grade endometrial stromal sarcoma, 17.5% (17) low-grade endometrial stromal sarcoma, 11.3% (11) adenosarcoma, and 1% (1) liposarcoma. Uterine leiomyoma was the most frequent pre-operatively suspected diagnosis (49.5%). Iatrogenic rupture of the tumor during surgery occurred in 25.3% of cases (23). International Federation of Gynecology and Obstetrics stages I-II and III-IV were identified in 74.2% (72) and 25.8% (25) of patients, respectively. The median tumor size was 8 cm (range 2-40). The recurrence rate was 47.8% (11) for patients with intra-operative tumor rupture and 25% (17) for patients without uterine rupture (p=0.03). Disease-free survival rates at 1, 2, and 5 years for patients with uterine rupture were 72.7%, 55.4%, and 13.9%, respectively, with a median time of 39 months (95% CI 2.9 to 75). For those patients without uterine rupture, disease-free survival rates at 1, 2, and 5 years were 84.8%, 76.1%, and 71.3%, respectively, with a mean time of 208.6 months (95% CI 169 to 248.3) (p=0.01). Multivariate analysis showed that stage, histological type, and iatrogenic tumor rupture during surgery were all independent prognostic factors for overall survival (OR 7.9, 95% CI 1.6 to 38.2, p=0.01); OR 5.3, 95% CI 2.1 to 13, p<0.0001; and OR 2.6, 95% CI 1.1 to 6.5, respectively, p=0.03).
Considering that uterine sarcomas, especially leiomyosarcomas, often occur in pre-menopausal women as bulky tumors requiring laparotomy and that they are rarely diagnosed pre-operatively, efforts should be made to avoid iatrogenic uterine rupture during surgery as it impairs patient survival.
肿瘤破裂是肉瘤在其他部位复发的一个危险因素。然而，破裂对子宫肉瘤预后的独立影响尚不确定。本研究旨在评估子宫破裂是否影响子宫肉瘤患者的结局。
对西班牙加那利群岛综合医院妇产科 1990 年 1 月至 2016 年 12 月期间连续收治的所有经组织学证实为子宫肉瘤的患者进行回顾性分析。纳入标准包括所有组织学证实为子宫肉瘤的患者。排除标准包括子宫内膜癌（非肉瘤性）和癌肉瘤患者。在此期间，共诊断出 1981 例子宫恶性肿瘤患者；1799 例因诊断为子宫内膜癌而被排除；85 例因诊断为癌肉瘤而被排除。因此，最终样本包括 97 例子宫肉瘤患者（4.9%）。这些患者包括平滑肌肉瘤、子宫内膜间质肉瘤、腺肉瘤和脂肪肉瘤。手术切除是主要的治疗方法，包括开腹、腹腔镜和阴道手术。采用 Kaplan-Meier 法分析生存率。
中位年龄为 52 岁（范围 25-90）；49.5%（48 例）为绝经前患者。按组织学类型分布：46.4%（45 例）为平滑肌肉瘤，23.7%（23 例）为高级别子宫内膜间质肉瘤，17.5%（17 例）为低级别子宫内膜间质肉瘤，11.3%（11 例）为腺肉瘤，1%（1 例）为脂肪肉瘤。术前最常见的疑似诊断为子宫平滑肌瘤（49.5%）。术中肿瘤破裂的发生率为 25.3%（23 例）。国际妇产科联合会（FIGO）分期 I-II 期和 III-IV 期分别占 74.2%（72 例）和 25.8%（25 例）。肿瘤中位大小为 8cm（范围 2-40）。术中肿瘤破裂患者的复发率为 47.8%（11 例），无子宫破裂患者的复发率为 25%（17 例）（p=0.03）。有子宫破裂的患者 1、2 和 5 年无病生存率分别为 72.7%、55.4%和 13.9%，中位时间为 39 个月（95%CI 2.9-75）。无子宫破裂的患者 1、2 和 5 年无病生存率分别为 84.8%、76.1%和 71.3%，平均时间为 208.6 个月（95%CI 169-248.3）（p=0.01）。多因素分析显示，分期、组织学类型和术中肿瘤破裂是总生存的独立预后因素（OR 7.9，95%CI 1.6-38.2，p=0.01）；OR 5.3，95%CI 2.1-13，p<0.0001；OR 2.6，95%CI 1.1-6.5，p=0.03）。
考虑到子宫肉瘤，尤其是平滑肌肉瘤，常在绝经前妇女中作为需要剖腹手术的大肿瘤发生，且术前很少被诊断，应努力避免术中医源性子宫破裂，因为这会影响患者的生存。
