Clinicopathologic factors and treatment strategies of LEGSS patients
Of 153 ESS during the study period, 135 (88.2%) patients were identified as LGESS while 15 (9.8%) HGESS and 3 (2.0%) UUS patients were excluded in the analysis.
Clinicopathological characteristics were presented in Table 1. Median age at diagnosis was 41.2 years (19-65 years). One hundred and eighteen patients (87.4%) were premenopausal. Most (62.2%) patients had no symptoms and the second symptom was abnormal vaginal bleeding in 37 (27.4%) patients. Leiomyoma was the common clinical diagnosis before we got the pathology. So 30 (22.2%) patients had the history of laparoscopic myomectomy and 56 (41.5%) patients received a secondary operation after the first surgery was hysteromyoma or subtotal hysterectomy.
Large tumor size (≥5 cm) was found in 96 (71.1%) cases. Deep muscle infiltration was observed in 103 (76.3%) patients. Positive lymphovascular invasion was in 33 (24.4%) patients. Lymph node metastasis was shown in 9 (6.7%) patients. FIGO staging indicated that 108 patients (80.0%) had stage I, 13 (9.6%) had stage II, 12 (8.9%) had stage III, and 2 (1.5%) had stage IV.
Table 2 summarized the different treatments and outcomes in 135 LGESS patients. Two patients received fertility-sparing surgery and 133 patients received hysterectomy. One hundred and nine (80.7%) patients received ovariectomy and 73 (54.1%) patients had lymphadenectomy. Fifty-two (38.5%) patients had no adjuvant treatment, 38 (28.1%) patients received hornome therapy, 22 (16.3%) patients had radiotherapy and hornome therapy, and 23 (17.0%) patients received chemotherapy and hornome therapy. Ten (7.4%) patients had residual disease after the operations.
Survival and recurrence
The patients were followed up for a median duration of 52 months (3-342 months). The 5-year and 10-year disease free survival rates were 72.0% and 61.0%, respectively (Fig. 1A). The 5-year and 10-year overall survival rates were 88.0% and 79.8%, respectively (Fig. 1B). Thirty-nine (28.9%) patients had disease recurrence, with a median time to recurrence of 24 months (1-321 months). The distribution of recurrences according to the stage of disease was as follows: 29 out of 108 (26.9%) patients were stage I, 5 out of 13 (38.5%) stage II and 5 out of 12 (41.7%) stage III. Pelvis was the main recurrent site in 76.9% (30 of 39) patients. The other recurrent sites included intestine (n=4), omentum (n=1), liver (n=2), and lung (n=2).
The median survival after recurrence was 17 months (1-177 months) and 29 patients received cytoreductive surgery for recurrences. It was associated with improved mean survival of 47.5 months as compared to mean survival of 14.8 months in 10 patients without it. It was also related to improved overall survival (p<0.05, Fig. 2). The main surgical complications for recurrent diseases were as follows: hemorrhage (n=2), infection (n=3), intestinal fistula (n=2), and urinary fistula (n=1). The complication rate was 27.6%. At the time of last follow up, 17 patients had died of cancer-related diseases.
Treatment modalities and clinicopathologic factors associated with disease free survival or overall survival
In univariate analyses for disease free survival, menopausal status was associated with disease free survival (p<0.05). So were deep muscle infiltration (p<0.05) and lymphovascular invasion (p<0.01). However, upon multivariate analyses, only lymphovascular invasion remained as an independent predictor of disease free survival (hazard ratio, 2.062; 95 % confidence interval, 1.040-4.086; p=0.038) (Fig. 3A).
In univariate analyses for overall survival, menopausal status was associated with overall survival (p<0.01). So were FIGO stage (p<0.05), lymphovascular invasion (p<0.05), lymph node metastasis (p<0.05), residual disease (p<0.05), and recurrence (p<0.01). However, upon multivariate analyses, only menopausal status remained as an independent predictor of overall survival (hazard ratio, 3.691; 95 % confidence interval, 1.012–13.457; p=0.048) (Fig. 3B).
When we further assessed different treatment methods and prognotic factors in 108 LGESS patients with stage I, we still found the similar results (data not shown).