Clinical Study Of The Fertility Or Ovarian Function-sparing Procedures Of Endometrial Stromal Sarcoma

Objectives.The purpose of this study was to to investigate the feasibility and risk factors of fertility or ovarian function-sparing procedures in endometrial stromal sarcoma(ESS)by retrospectively analyze the clinical data of endometrial stromal sarcoma in Qilu Hospital of Shandong University.Methods.The first part:The clinical data of ESS in Qilu Hospital of Shandong University from April 2000 to December 2016 were retrospectively analyzed,and the risk factors of recurrence and death were found to provide reference for fertility and physiological function preservation surgery for ESS.The second part:to evaluate the possibility of fertility-sparing surgery for ESS by searching the PubMed and CNKI database from April 2000 to July 2017,together with our present data,statistical analysis was made on reproductive outcomes,and prognosis;The third part,based on the conclusion of part one,a Meta-analysis was performed by searching the PubMed database from April 2000 to July 2017 together with our clinical data to evaluate the prognostic significance of ovarian sparing surgery of low grade endometrial stromal sarcoma(LGESS).ResultsThe first part:A total of 66 patients were eigible for the admission.The age range from 15 to 75 years,with an average age of 42.4 ± 13.1 years.8 cases(12.1%)were treated with myomectomy,58 cases(87.9%)had hysterectomy,45 cases(68.2%)had BSO and 21 cases(31.8%)had ovarian preservation surgery,of which 1 patient had RT after operation.The main clinical manifestation were abnormal vaginal bleeding(33.3%,22/66),followed by uterine fibroids or a rapid growth of uterine fibroids(25.7%,17/66).53 cases(80.3%)had stage I disease,13 cases(19.7%)had stage II-IV disease.There are 53 cases(80.3%)of LGESS and 13 cases(19.7%)of high grade endometrial stromal sarcoma(HGESS).Forty-four patients received adjuvant therapy,including 2 patients(3.03%)received radiotherapy,20 patients(30.3%)received chemotherapy,22 patients(33.3%)received hormone therapy,and 28(42.4%)received no treatment after surgery.The mean follow-up time was 53.2 months(range 6-167 months),22 cases recurred(33.3%),of which 68.1%patients performed radical surgery,the control rate after recurrence was 73.3%(11/15).9 patients(13.6%)are living with tumor,46(69.7%)cases are surviving without recurrence,and 11 cases(16.7%)died of the disease.Of the 8 patients who had preserved fertility function,3 patients had pregnancy intention and were all successfully delivered,the neonate have no dysplasia.The result of single factor analysis of recurrence shows that myomectomy,ovarian function preservation,cervical involvement,and HGESS are significantly associated with recurrence(P=0.014,0.014,0.039,0.006).Multivariate analysis of recurrence shows HGESS is an independent risk factors for recurrence(P=0.038);the single factor analysis of survival shows that cervical involvement and HGESS are the risk factors related with survival(P=0.029,0.005).Multivariate analysis of survival shows that HGESS was significantly associated with death(P=0.047).The second part:A total of 45 cases with fertility sparing-surgery were collected.Of the 45 patients 44 cases(97.8%)were in stage I and 1 case with stage III A.There were 43 cases of LGESS and 2 cases of HGESS.To explore the effect of fertility sparing-surgery on prognosis of ESS,we compared the 45 cases who preserved fertility function with the 46 cases who did radical surgery in our hospital,The relapse rate of stage I patients between the two groups didn't reach significantly level(P=0.147),and there is no difference in the mortality rate between the two groups(P=0.142);after eliminate the HGESS cases,the recurrence risk of stage I LGESS patients who preserved fertility function increased significantly(P =0.003),but no difference in the mortality rate(P = 0.197).we explore the effect of pregnancy on recurrence of the 45 cases,the result shows there is no significant correlation between pregnancy and the first postoperative recurrence(P =0.3).We explore the stage IA and stage IB on the prognosis of the 45 cases,the results show that The recurrence rate of IA and IB patients reach significant level(P =0.00)but there were no significant different in the mortality risk(P=0.39);and the relapse rate of IA and IB in LGESS patients of the 45 cases reach significant level(P =0.00),but there were no significant different in the mortality risk(P=0.861).The third part:A total of 10 studies and our data were included in the Meta analysis.There are 553 LGESS patients underwent bilateral salpingo-oophorectomy(BSO)and 244 LGESS patients underwent ovarian preservation operation(OP).The combined odds ratio of recurrence was 2.71(95%CI=1.85-3.97),(P=0.000,12=68.7%);the combined odds ratio for death was 0.88(95%CI=0.39-2.00),(P=0.531,I2=0.00%).the results suggesting that OP increase the recurrence rate for LGESS but have no effect on the death risk.Conclusions1.HGESS and LGESS have great differences in progression and prognosis.HGESS should be treated promptly and radically.LGESS is an indolent tumor characterized by late recurrence.Young patients with LGESS can be chosen for fertility or ovary preservation surgery.2.Patients with stage I low-grade endometrial stromal sarcoma who have conception of pregnancy are able to preserve their fertility by myomectomy surgery,and postoperative adjuvant progestin therapy prevents recurrence.The myomectomy surgery for low grade endometrial stroma increase the risk of recurrence.After relapse,the death risk could be reduced by radical surgery.Patients with stage IB are more likely to relapse than those with stage IA,but have no effect on death risk.3.OP improve the recurrence risk of LGESS patients,but have no effect on OS.4.LGESS is a hormone sensitive tumor.The use of hormone therapy in patients with ER and PR can significantly improve the RFS,reduce the recurrence rate and increase the disease control rate.