Diagnosis and surgical therapy of uterine sarkoma

• Published in: Acta chirurgica Iugoslavica Vol. 53; no. 3; pp. 67 - 72
• Main Authors: Vrzic-Petronijevic, S., Likic-Ladjevic, I., Petronijevic, M., Argirovic, R., Ladjevic, N.N.
• Format: Journal Article
• Language: English
• Published: 2006
• ISSN: 0354-950X; 2406-0887
• DOI: 10.2298/ACI0603067V

Introduction: Uterine sarcomas are rare gynecological neoplasms and their classification is complicated. Uterine sarcoma is usually diagnosed in postmenopausal women and the diagnosis is often accidental and postoperative. Aim of this study was to present clinical and pathological characteristics of uterine sarcomas, diagnostic procedures, treatment and two-, three- and five-years cumulative survival rates. Materials and methods: The retrospective study of 61 cases of uterine sarcomas was conducted. Cases were distributed into groups based on definitive diagnosis of uterine sarcoma: group of leiomyosarcomas (LMS), carcinosarcoma (CS), endometrial stromal sarcomas (ESS), adenosarcomas (AS) and other rare uterine sarcomas. We investigated patients with clinical and pathological characteristics of uterine sarcomas, diagnostic procedures and treatment. Survival rate was calculated by Kaplan-Meier method. Results: From 61 patients 43 patients (70.49%) were postmenopausal. Mean period from menopause until appearance of symptoms was 14,63 years. One or more risk factors were present in 46 (75.4%) patients. Diagnosis of uterine sarcoma were established averagely 7.38 months after appearance of symptoms. 50 patients (82.0%) underwent one or more diagnostic procedures. Preoperative diagnosis of uterine sarcoma was established in 42.5% of patients. 53 (86.9%) of patients were treated operatively. The most used operative procedure (60,7%) was total hysterectomy with bilateral salpingooophorectomy. Postoperative pathohistologic analysis showed that low grade (LG) leiomyosarcoma were present in 19 (35.9%) cases, high grade (HG) leiomyosarcoma in 1 (1.9%) case, carcinosarcoma in 14 (26.4%) cases, low grade (LG) endometrial stromal sarcoma in 5 (9.4%) cases, high grade (HG) endometrial stromal sarcoma in 9 (17.0%) cases, adenosarcoma in 2 (3.8%) cases, and 2 cases of rare uterine sarcomas: 1 (1.9%) MALT HG lymphoma and 1(1.9%) malignant hemangiopericytoma. In one case of ESS (1.9%) only adenomyosis was found postoperatively suggesting that the whole tumour was removed during diagnostic procedure. Eight patients were not treated operatively. Two-years cumulative survival rate was 74.3%, three-years cumulative survival rate was 71.1%, and five years survival rate was 64.3%. Discussion: Average age, percent of postmenopausal patients and the mean age at the time of menopause in our studied correlate with current data. Clinical presentation of uterine sarcoma is associated with obesity and hypertension in more than 30% of cases, which is approved in our study. For early diagnostics it is important to notice that risk factors are similar to those connected with far more frequent endometrial carcinoma. Postmenopausal abnormal bleeding was the main reason for medical examination, explaining relatively short period for establishing the diagnosis in this group of patients. The variety of clinical findings in our studied group showed that the diagnosis must be based on preoperative pathohistology. Conclusion: Adequate diagnosis and treatment of uterine sarcoma is possible with regular yearly or more frequent follow-up, especially in postmenopausal women with known risk factors present. We need special attention for unclear symptoms and postmenopausal bleeding and we need to use all diagnostic procedures soon as possible including preoperative histology because early metastases are characteristic for uterine sarcomas. Factor of the most important predictive value is histologic grade. . Uvod: Sarkomi uterusa obuhvataju samo 5% od svih maligniteta u ginekologiji. Njihova klasifikacija je komplikovana zbog male ucestalosti i velikih histoloskih razlicitosti. Sarkom uterusa se obicno dijagnostifikuje kod postmenopauzalnih zena i to najcesce slucajno postoperativno. Cilj ove studije je: da prikaze klinicke i patohistoloske karakteristike sarkoma uterusa, dijagnosticke procedure, terapiju i dvogodisnju, trogodisnju i petogodisnju kumulativnu stopu prezivljavanja. Materijal i metode: Nasa sudija predstavlja retrospektivnu studiju 61 bolesnice sa sarkomom uterusa. Bolesnice su podeljene u grupe zavisno od definitivne dijagnoze sarkoma uterusa: 1. grupa sa lejomiosarkomom (LMS), 2. grupa sa karcinosarkomom (CS), 3. grupa sa sarkomom strome endometrijuma (ESS), 4. grupa sa adenosarkomom (AS) i 5. ostale retke vrste sarkoma. Kod bolesnica su ispitane klinicka slika i patohistoloske karakteristike sarkoma uterusa, dijagnosticke procedure i terapija. Stepen prezivljavanja je izracunavan pomocu Kaplan-Meier metode. Rezultati: Od 61 bolesnice 43 (70,47%) je bilo postmenopauzalnih. Prosecno vreme od menopauze pa do pojave simptoma je bilo 14,63 godine. Kod 46 bolesnica je bio prisutan jedan ili vise faktora rizika. Dijagnoza sarkoma uterusa je postavljena prosecno 7,38 meseci posle pojave simptoma. Jedna ili vise dijagnostickih procedura je izvedena kod 50 bolesnica (82%). Preoperativna dijagnoza sarkoma uterusa je postavljena kod 42,5% bolesnica. Operativno su lecene 53 bolesnice (86,9%). Najcesce koriscena operativna metoda je bila totalna histerektomija sa bilateralnom salpingooforektomijom (60,7%). Postoperativna patohistoloska analiza je pokazala da smo imali 19 bolesnica (35,9%) sa lejomiosarkomom niskog stadijuma, jednu bolesnicu sa lejomiosarkomom visokog stadijuma, 14 bolesnica (26,4%) sa karcinosarkomom, 5 bolesnica (98,4%) sa sarkomom strome endometrijuma niskog stadijuma, 9 bolesnica (17%) sa sarkomom strome endometrijuma visokog stadijuma, 2 bolesnice (3,8%) sa adenosarkomom i 2 bolesnice sa retkim sarkomima uterusa: jedan (1,9%) MALT limfom visokog stadijuma i jedan (1,9%) maligni hemangiopericitom. Osam bolesnica nije leceno operativno. Dvogodisnje kumulativno prezivljavanje je bilo 74,3%, trogodisnje 71,1% a petogodisnje 64,3%. Diskusija: Procenat postmenopauzalnih bolesnica, prosecna starost i srednje godine pojave menopauze u nasem istrazivanju se slazu sa nalazima u literaturi. Sarkome uterusa klinicki vidimo udruzene sa gojaznosti i hipertenzijom u vise od 30% slucajeva a to je pokazano u nasem istrazivanju. Za ranu dijagnozu veoma je bitno primetiti da su rizik faktori slicni onima kod endometrijalnog karcinoma. Postmenopauzalno abnormalno krvarenje je bio glavni razlog za medicinski pregled i to objasnjava relativno kratak period do uspostavljanja dijagnoze. Velika razlicitost i broj klinickih znakova u nasoj studiji ukazuje da dijagnoza mora biti zasnovana na preoperativnoj patohistologiji. Zakljucak: Adekvatna dijagnoza i lecenje sarkoma uterusa je moguce ukoliko se sprovode godisnji ili cesci pregledi zena a posebno postmenopauzalnih zena sa faktorima rizika. Posebno treba obratiti paznju na nespecificne simptome i postmenopauzalno krvarenje i sto pre sprovesti dijagnosticke procedure i preoperativnu histologiju jer su rane metastaze karakteristicne za sarkome uterusa. Najvazniji faktor predvidjanja je histoloski nalaz i stadijum. .