To our knowledge, the FDA stated that tumor morcellation promoted an adverse effect on the prognosis of patients with LMS [12]. Jeong-Yeol Park et al confirmed that tumor morcellation facilitated recurrence in peritoneal cavity and adversely affected DFS(OR, 2.59; 95% CI, 1.03–6.50; P = 0.043)and OS༈OR, 3.07; 95% CI, 1.05–8.93; P = 0.040༉ in patients with uterine LMS [6]. They also found tumor morcellation was associated with a significantly higher rate of abdominopelvic recurrence and significantly poorer DFS (OR, 4.03; 95% CI, 1.06–15.30; P = 0.040) in patients with ESS, but OS was not significantly compromised [8]. Another research with 123 patients found the rate of pelvic recurrence 3 months after surgery was higher in the morcellation group than in the non-morcellation group, but the difference was not statistically significant (8.8% vs. 3.6%, P = 0.25) [7].
Our study found 47.8% of patients suffered sarcoma recurring. Patients with no remedial procedures seemed to experience recurrence probably and have worse prognosis. It was much frequently that the recurrence occurred in the pelvis where former primary lesion was located. The peritoneal and gastrointestinal implantation in upper abdomen were also common.
In our study, cytoreduction as remedial re-operation was very important for those patients to improve DFS (OR, 0.17; 95% CI, 0.03–0.85; P = 0.031), no matter how long between the initial surgery and re-operation (༜30 days vs. ≥30 days, P = 0.950). Cytoreduction after the initial incomplete surgery may be the optimal option, which could eliminate all iatrogenic implantation metastasis caused by morcellation, especially the metastasis on omentum, according to our study. Cytoreduction we mentioned should contain total hysterectomy and oophorectomy, and additional surgical resection for intraoperative discovery of extrauterine disease should be individualized.
None of 7 patients undergoing cytoreduction suffered recurrence while 6 of 12 patients undergoing simple hysterectomy ± oophorectomy suffered recurrence. Simple hysterectomy ± oophorectomy (P = 0.194) and adjuvant therapy (P = 0.159) seemed not to impact the DFS. A previous retrospective study showed that 2 of 13 patients with uterine malignancy underwent paracervical hysterectomy during the initial surgery was upstaged by re-exploration; both had LMS originally resected with morcellation. Patients who underwent completion surgery with restaging appeared to have a good prognosis [15]. Moreover, re-operation long after the initial surgery (≥ 30 days) with morcellation can still be valuable. Cao H et al also confirmed that the time interval between initial treatment and secondary definitive surgery was not shown to impact prognosis[16].
The limitation of our study included the retrospective design and the relatively small number of patients.