Treatment options in stage I endometrial stromal sarcoma: A retrospective analysis of 53 cases

Clinicopathological characteristics and prognosis of uterine sarcoma: a 10-year retrospective single-center study in China

BACKGROUND

Uterine sarcoma is a rare and heterogeneous gynecological malignancy characterized by aggressive progression and poor prognosis. The current study aimed to investigate the relationship between clinicopathological characteristics and the prognosis of uterine sarcoma in Chinese patients.

METHODS

In this single-center retrospective study, we reviewed the medical records of 75 patients with histologically verified uterine sarcoma treated at the First Affiliated Hospital of Xi'an Jiaotong University between 2011 and 2020. Information on clinical characteristics, treatments, pathology and survival was collected. Progression-free survival (PFS) and overall survival (OS) were visualized in Kaplan-Meier curves. Prognostic factors were identified using the log-rank test for univariate analysis and Cox-proportional hazards regression models for multivariate analysis.

RESULTS

The histopathological types included 36 endometrial stromal sarcomas (ESS,48%), 33 leiomyosarcomas (LMS,44%) and 6 adenosarcomas (8%). The mean age at diagnosis was 50.2 ± 10.7 years. Stage I and low-grade accounted for the majority. There were 26 recurrences and 25 deaths at the last follow-up. The mean PFS and OS were 89.41 (95% CI: 76.07-102.75) and 94.03 (95% CI: 81.67-106.38) months, respectively. Univariate analysis showed that > 50 years, post-menopause, advanced stage, ≥ 1/2 myometrial invasion, lymphovascular space invasion and high grade were associated with shorter survival (P < 0.05). Color Doppler flow imaging positive signals were associated with shorter PFS in the LMS group (P = 0.046). The ESS group had longer PFS than that of the LMS group (99.56 vs. 76.05 months, P = 0.043). The multivariate analysis showed that post-menopause and advanced stage were independent risk factors of both PFS and OS in the total cohort and LMS group. In the ESS group, diagnosis age > 50 years and high-grade were independent risk factors of PFS, while high-grade and lymphovascular space invasion were independent risk factors of OS.

CONCLUSION

In Chinese patients with uterine sarcoma, post-menopause and advanced stage were associated with a significantly poorer prognosis. The prognosis of ESS was better than that of LMS. Color Doppler flow imaging positive signals of the tumor helped to identify LMS, which needs to be further tested in a larger sample in the future.

A Case Report of Uterine Müllerian Adenosarcoma With Sarcomatous Overgrowth

Uterine adenosarcoma remains a highly aggressive tumor and is less described in the literature, with an unfavorable prognosis and an increased risk of local and distant recurrence. However, surgery, chemotherapy, and radiotherapy offer local control of the disease, and overall survival remains reduced. We report the case of a 79-year-old patient with stage IIIB uterine adenosarcoma, confirmed by immunohistochemistry and initially diagnosed with postmenopausal metrorrhagia. The patient was managed through a multimodal treatment by conducting a multidisciplinary consultation.

Is Adnexectomy Mandatory at the Time of Hysterectomy for Uterine Sarcomas? A Systematic Review and Meta-Analysis

Background and Objectives: Uterine sarcomas represents only 3% of all the female genital tract ones. The tumoral stage is the most significant prognostic factor. The role of the bilateral salpingo-oophorectomy (BSO) in the surgical management of FIGO stage IA and IB appears still controversial. This review aims to investigate the impact of bilateral adnexectomy in the treatment of uterine sarcoma. Methods: Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed, Scopus, Cochrane, Medline, and Medscape databases in February 2022. We applied no language or geographical restrictions, but we considered only English studies. We included the studies containing data about Recurrence Rate (RR), Disease-free Survival (DFS), and Overall Survival (OS). We used comparative studies for meta-analysis. Results: Seventeen studies fulfilled the inclusion criteria; 2 retrospective observational studies, and 15 retrospective comparative studies, And 14 out of the 15 comparative studies were enrolled in meta-analysis. A total of 3743 patients were analyzed concerning the use of adnexectomy with hysterectomy in patients with uterine sarcoma and compared with those who did not. Meta-analysis highlighted a non-significant worsening of the OS in the BSO group compared to the OP group and showed that adnexectomy does not improve the DFS (BSO OR 1.23 (95% CI 0.81–1.85) p = 0.34; I2 = 24% p = 0.22). Conclusions: Most studies selected for our review showed that adnexectomy does not significantly affect the RR, OS, and PFS in treating FIGO stage I uterine sarcomas. Therefore, even if there is a unanimous consensus about bilateral adnexectomy in menopausal patients, preservation of ovarian tissue may be considered in premenopausal women. Nonetheless, there are not enough cases in the literature to recommend this procedure.

Prognostic Value of Ki-67 Index in Patients With Endometrial Stromal Sarcoma

Objective

The Ki-67 index is used to evaluate cell proliferation activity, which is related to tumor progression, metastasis, and prognosis. We aimed to explore the prognostic value of Ki-67 index in endometrial stromal sarcoma and to explore the optimal cut-off value of Ki-67 index for predicting recurrent endometrial stromal sarcoma.

Methods

A total of 82 patients with endometrial stromal sarcoma who were treated in our hospital were collected. Clinicopathological data of these patients were retrospectively analyzed. Ki-67 index was detected by the immunohistochemical method. Receiver operating characteristic curve and the Youden index were performed to determine the optimal cut-off value of Ki-67 index for predicting recurrent endometrial stromal sarcoma. The Cox regression was performed to analyze risk factors affecting prognosis of endometrial stromal sarcoma. The Kaplan–Meier method and Log-rank test were performed to analyze the survival of patients.

Results

The optimal cut-off value of Ki-67 index for predicting recurrent endometrial stromal sarcoma was 35%. The results of univariate analysis showed that high Ki-67 index (≥35%) was statistically significantly bound up with shorter progress free survival and overall survival. The results of multivariate analysis showed that Ki-67 index (P = 0.001) and ovarian preservation (P = 0.040) were independent prognostic factors of progress free survival.

Conclusions

A Ki-67 index cut-off of 35% was optimal for predicting recurrent endometrial stromal sarcoma. Ki-67 index may be a useful prognostic marker in endometrial stromal sarcoma.

Clinicopathological characteristics and treatment of patients with high-grade endometrial stromal sarcoma: A retrospective study of 40 cases

To investigate the clinicopathological characteristics of patients with high-grade endometrial stromal sarcoma (HG-ESS).The clinicopathological characteristics, treatments, and prognostic information of consecutive HG-ESS patients were collected from medical records and then evaluated.A total of 40 women were included in the analysis. The immunohistochemical profiles indicated that HG-ESS tumors tend to be locally or weakly positive for vimentin (100%) and CD10 (72.0%) but mostly negative for desmin (7.7%) and AE1/AE3 (9.1%). The progression-free survival intervals and the clinical benefit rates of patients receiving radiotherapy and/or chemotherapy were slightly longer and higher than those receiving simple observation (progression-free survival: 6 and 5 months vs 2 months; clinical benefit rate: 83.3% and 75.0% vs 28.6%). The 1-year disease-specific survival (DSS) rate was 62.7%. Tumor size, myometrial invasion, lymphovascular space invasion, cervical involvement, Federation International of Gynecology and Obstetrics (FIGO) stage, and residual disease all significantly affected the DSS rate (P < .001, =.002, <.001, =.004, <.001, and <.001, respectively). For patients with stage I disease, the 1-year DSS rate was as high as 91.7%, in contrast to 66.7%, 26.7%, and 0% for those with stage II, III, and IV disease, respectively.HG-ESS is associated with an adverse prognosis. FIGO stage could effectively predict the prognosis of patients with this lethal disease. Immunohistochemical markers, vimentin+/CD10+ (local or very weak), in combination with desmin-/AE1/AE3-, may be helpful for improving the diagnostic accuracy of this lethal condition. The therapeutic roles of adjuvant chemotherapy and radiotherapy warrant further investigation.

Low-grade endometrial stromal sarcoma in a young woman diagnosed after resection of endometrial polyp-like lesions: A case report

Low-grade endometrial stromal sarcoma (LG-ESS) is a rare tumor that mostly occurs in perimenopausal women. Treatment with total hysterectomy and bilateral salpingo-oophorectomy is recommended, although fertility preservation or ovarian preservation may be considered in younger patients. The present study reports a case of LG-ESS in a young woman diagnosed after resection of endometrial polyp-like lesions. A 26-year-old nulligravid woman was referred to our hospital after being diagnosed with endometrial polyps. Hysteroscopic endometrial polypectomy was performed twice, and LG-ESS was suspected on postoperative pathological examination. Magnetic resonance imaging revealed a tumor 5-cm in diameter on the right side of the uterus. In light of the young age of the patient, tumorectomy was first performed, and postoperative pathological diagnosis was LG-ESS with the positive resection margin. After thorough discussion with the patient about fertility preservation and recurrence risk, a total abdominal hysterectomy and ovarian preservation was performed. Medroxyprogesterone therapy was performed postoperatively and no recurrence was observed for 2 years.

The prognosis of recurrent low-grade endometrial stromal sarcoma: a retrospective cohort study

Background

The prognosis of recurrent low-grade endometrial stromal sarcoma (LGESS) is little known. This study was to investigate the survival outcomes of a cohort of patients with recurrent LGESS.

Methods

Patients with primary LGESS diagnosed and treated for first recurrence confirmed by histology in the study center from February 2012 to June 2019 were retrospectively included. The progression-free interval (PFI) after the last treatment for first recurrence and overall survival (OS) since the diagnosis of first recurrence, which were followed up to June 1, 2020, were compared between groups of various therapy modalities.

Results

Fifty-six patients were included, and 43 patients (76.8%) had definite follow-up outcomes. The 5-year PFI and OS rates were 30.0% (95% confidence interval [95% CI] 29.2–30.8) and 75.0% (68.0–82.0), respectively. In univariate analysis, only fertility-sparing treatment, ovarian preservation and surgical treatment had a significant impact on the PFI (hazard ratio [HR] 4.5, 3.1, and 0.2; 95% CI 1.5–13.1, 1.3–7.3, and 0.1–0.7; and p = 0.006, 0.009 and 0.006, respectively), but no factor was found to be associated with increased mortality risk. After adjusted with hormone treatment or chemotherapy, surgical treatment had significant effectiveness on OS (HR 0.3 and 0.3, 95% CI 0.1–1.0 and 0.1–1.0, p = 0.045 and 0.049, respectively). None of the patients with fertility-sparing treatment had successful conception, and all experienced repeated relapse.

Conclusion

For patients with recurrent LGESS, fertility-sparing treatment or ovarian preservation should not be provided. Surgery is the treatment of choice, and hormone treatment and/or chemotherapy was effective for the survival benefits of surgical treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-01802-8.

Low-grade Endometrial Stromal Sarcoma Presenting as a Sigmoid Mass

Low-grade endometrial stromal sarcoma (LG-ESS) is a very rare mesenchymal neoplasm of the uterus. LG-ESS can recur or metastasize to extrauterine sites, such as the pelvis, peritoneal cavity, and vagina, but rarely to the lung, liver, heart, bone, and colon. A 42-year-old female patient was transferred from an outside clinic for an evaluation of constipation. EUS revealed a 5 cm hypoechoic lesion with a regular margin, probably arising from the 4th layer (muscular propria) at the sigmoid colon level. CT revealed a 7-cm homogenous enhancing mass lesion at the pelvic cavity and multiple enlarged lymph nodes in the sigmoid mesocolon. The patient underwent an anterior resection, and the diagnosis based on the biopsy result was LG-ESS. After a multidisciplinary discussion, she underwent a bilateral salpingo-oophorectomy. Small nodules found in the endometrium were identified as LG-ESS by a biopsy. This paper reports a case of metastatic LG-ESS presenting as a solitary sigmoid tumor without intrauterine lesions through preoperative examinations and discusses the characteristics of this neoplasm with reference to the relevant literature.

Does ovarian preservation have an effect on recurrence of early stage low-grade endometrial stromal sarcoma?

Surgical treatment of low-grade endometrial stromal sarcoma consists of hysterectomy. The role of oophorectomy is yet to be established. We aimed to examine the effect of preserving the ovaries on the pattern of recurrences in patients with stage I disease. Thirty-four patients with stage I low-grade endometrial stromal sarcoma were retrospectively analysed. Based on ovarian preservation the whole cohort was divided into two groups. Recurrence (liver, lung, groin and bone) was detected in 4 (11.8%) cases. No significant differences in overall survival or disease-free survival (DFS) were observed between the ovarian preservation and bilateral salpingo-oophorectomy (BSO) groups. Subset analysis revealed no significant difference in DFS between the ovarian preservation and BSO groups in the premenopausal arm. And also, the performance of pelvic (n = 2) or para-aortic lymphadenectomy (n = 6) or adjuvant hormonal therapy did not alter DFS significantly. The 5-year DFS rate for the group which received adjuvant radiotherapy was 62.5 and 94.4% for those which did not (p = .014). Preserving the ovaries had no adverse effect on the recurrence of stage I disease.IMPACT STATEMENTWhat is already known on this subject? Due to the rarity of the disease and the common postoperative diagnosis, only retrospective studies have been reported on low-grade endometrial stromal sarcoma. This disease is commonly diagnosed in premenopausal patients during the early stage. There is no consensus on preserving the ovaries, particularly in young patients, due to the tumour's hormonal characteristics and the risk of late recurrences.What do the results of this study add? Ovarian preservation had no effect on the recurrence of stage I low-grade endometrial stromal sarcoma. Lymphadenectomy and adjuvant hormonal treatment had no effect on DFS, and adjuvant radiotherapy decreased DFS in the current study.What are the implications of these findings for clinical practice and/or further research? Ovarian preservation should be considered, to prevent the negative effects of surgical menopause, particularly in young patients.

Endometrial stromal sarcoma: A review of rare mesenchymal uterine neoplasm

OBJECTIVE

This review aims to analyze the pathological aspects, diagnosis and treatment of rare mesenchymal uterine tumors.

METHODS

On August 2019, a systematic review of the literature was done on Pubmed, MEDLINE, Scopus, and Google Scholar search engines. The systematic review was carried out in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes statement (PRISMA). The following words and key phrases have been searched: "endometrial stromal sarcoma", "low-grade endometrial stromal sarcoma", "high-grade endometrial stromal sarcoma", "uterine sarcoma", "mesenchymal uterine tumors" and "uterine stromal sarcoma". Across these platforms and research studies, five main aspects were analyzed: the biological characteristics of the neoplasms, the number of cases, the different therapeutic approaches used, the follow-up and the oncological outcomes.

RESULTS

Of the 94 studies initially identified, 55 were chosen selecting articles focusing on endometrial stromal sarcoma. Of these fifty-five studies, 46 were retrospective in design, 7 were reviews and 2 randomized phases III trials.

CONCLUSION

Endometrial stromal sarcomas are rare mesenchymal uterine neoplasms and surgery represents the standard treatment. For uterus-limited disease, the remove en bloc with an intact resection of the tumor (without the use of morcellation) is strongly recommended. For advanced-stage disease, the standard surgical treatment is adequate cytoreduction with metastatectomy. Pelvic and para-aortic lymphadenectomy is not recommended in patients with Low-grade Endometrial Stromal Sarcoma (ESS), while is not clear whether cytoreduction of advanced tumors improves patient survival in High-grade ESS. Administration of adjuvant radiotherapy or chemotherapy is not routinely used and its role is still debated.

Recurrence of Endometrial Stromal Sarcoma, Two Decades Post-Treatment

Endometrial stromal cell sarcomas (ESS) are a unique subtype of uterine malignancy. Recurrent low grade endometrial stromal sarcomas (LESS) is identified in half of the patients. Here, we discuss a case of a 76-year-old Asian female with a past medical history of adenomyosis and hypertension who presented to the outpatient clinic with a chief complaint of painless hematuria for one day. Computed tomography scan of abdomen and pelvis with contrast showed a new right-sided mixed cystic and solid pelvic mass measuring up to 6 cm, obstructing and invading the distal right ureter, which was concerning for malignancy. Positron emission tomography (PET scan) demonstrated a right pelvic mass with increased radiotracer activity consistent with malignancy. She underwent laparotomy with excision of the right-sided pelvic mass with an abdominal washout and at the same time, also underwent cystoscopy with right ureteral stent placement. Tissue pathology was consistent with spindle cell neoplasm with staining and histologic features consistent with a recurrent stromal cell sarcoma. Uterine sarcomas tend to have an aggressive nature but there are key features about ESS that distinguish it from other uterine sarcomas. ESS has a more indolent clinical course and can reoccur years after initial diagnosis. They usually relapse locally, although relapses in extra-uterine sites have also been reported. Treatment of ESS depends on the grade and stage at the time of diagnosis. The main line of treatment for ESS consists of a total abdominal hysterectomy (TAH) and salpingo-oophorectomy (BSO). The significance of this case demonstrates that, although remission can be obtained after the initial diagnosis, recurrence can happen. Even when patients seem to be disease-free, clinicians should follow them closely; early diagnosis is important as treatment for this type of entity has a high survival rate.

Long-term impact of lymphadenectomies in patients with low-grade, early-stage uterine endometrial stroma sarcoma

AIM

The aim of our study was to investigate the lymph node metastasis (LNM) rate and effect of lymph node dissection (LND) in patients with stage I, low-grade endometrial stromal sarcoma (LGESS).

METHODS

Patients with stage I LGESS (n = 119) that underwent surgery from July 1969 to July 2017, following up over 48 years at the China National Cancer Center were retrospectively analyzed in this study.

RESULTS

Surgical records and consulting data for patients with LGESS were analyzed to find that 47 patients received systematic pelvic LND. The number of patients with menopause in the LND(+) group were significantly lower than those in LND(-) group (2.1% vs 22.2%, P = 0.005), meanwhile, patients received bilateral salpingo-oophorectomy procedure in LND(+) group were significantly higher than LND(-) (97.9% vs 58.3%, P < 0.001). Neither progression-free survival nor overall survival was significantly improved in the LND(+) group even after propensity score matching although the progression-free survival has a stronger trend in LND(+) population.

CONCLUSION

A systematic LND was not significantly associated with prognosis for patients with early-stage LGESS. There is no sufficient indication for a systematic LND for patients with early-stage LGESS. A systematic LND might be necessary if enlarged lymph nodes were detected by image graphology or observation during surgery.

Unexpected Histopathological Diagnosis of Undifferentiated Uterine Sarcoma after Simple Hysterectomy: Extrapolating Limited Evidence

Uterine sarcomas are a rare malignancy, often retrospectively diagnosed after myomectomy or hysterectomy. Undifferentiated uterine sarcomas (UUS) are a particularly aggressive variant of this condition. Little evidence exists regarding the postoperative management of undifferentiated sarcomas diagnosed after hysterectomy performed for presumed benign conditions. We describe the case of a 33-year-old woman who presented with heavy bleeding and subsequently underwent hysterectomy on an emergency basis after failed medical management. Cut-section of the uterus revealed a grossly benign-looking sub-mucosal fibroid. However, the final histopathology report revealed undifferentiated uterine sarcoma. We worked up the patient postoperatively with MRI to rule out metastasis and performed bilateral salpingo-oophorectomy based on hormone receptivity status. We followed this with single-agent chemotherapy with adriamycin, which was followed by continuous therapy with oral letrozole (aromatase inhibitor). The patient was found doing well at the two-year follow-up, with no evidence of relapse. Postoperative diagnosis of UUS should include imaging to rule out metastasis, consideration for completion of surgery based on hormone receptivity of tumour, and lymphadenectomy based on the subtype of tumour.

Hormone therapy following surgery in low-grade endometrial stromal sarcoma: Is it related to a decrease in recurrence rate?

BACKGROUND

Low-grade endometrial stromal sarcoma (LGESS) is, in most cases, a slow-growing malignancy; however, it is related with high recurrence rates. The aim of this study is to determine which factors may be associated with the recurrence rate of LGESS.

METHODS

The clinicopathological features and treatment options in 37 patients with LGESS were evaluated.

RESULTS

All patients underwent the hysterectomy and bilateral salpingo-oophorectomy. Additionally, lymphadenectomy was performed in 56.8% (n = 21) of the patients. Among the patients who underwent lymphadenectomy, 14.3% (n = 3) had lymph node metastasis. The disease was limited to the uterus in 75.7% of patients. Treatment following surgery was radiotherapy in three patients, chemotherapy in seven patients, hormone therapy in 12 patients, and chemotherapy plus hormone therapy in one patient. Megestrol acetate was used in all patients who received hormone therapy. Median follow-up time was 96 months. The 5-year disease-free survival and disease-specific survival were 72% and 97%, respectively. The recurrence rate was 27%. Only hormone therapy following surgery was significantly associated with a lower recurrence rate, even in patients with stage 1 disease. None of the patients treated with hormone therapy following surgery had recurrence, whereas recurrence occurred in 38.5% of the patients who underwent surgery only (p = 0.039).

CONCLUSION

Hormone therapy after surgery should be considered a viable option for decreasing the LGESS recurrence rate, regardless of the disease stage.

Low-Grade Endometrial Stromal Sarcoma - a Review

Like other uterine sarcomas, low-grade endometrial stromal sarcomas (LG-ESS) are a very rare tumor entity. In the past, research studies therefore discussed the various different types of the disease in combination. In addition, the classification of endometrial stromal tumors presented difficulties for quite some time so that in earlier studies it was not always possible to precisely distinguish between LG-ESS, high-grade endometrial stromal sarcoma, and undifferentiated uterine sarcoma. For LG-ESS, surgery with hysterectomy and adnexectomy is the first-line treatment. The benefits of lymphadenectomy and tumor debulking are unclear. Endocrine therapy with gestagens and aromatase inhibitors is under discussion to provide adjuvant treatment for patients with advanced stages of the disease. As radiotherapy only provides locoregional control, and in view of the usually good prognosis of patients with LG-ESS, its benefits need to be weighed against its side effects. In the case of recurrence, repeat surgery is the first choice. Further research studies viewing LG-ESS as a distinct entity are needed in order to improve treatment options for patients with LG-ESS.

Safety of ovarian preservation in premenopausal women with stage I uterine sarcoma

Objective

To evaluate the oncologic safety of ovarian preservation (OP) in premenopausal women diagnosed with the International Federation of Gynecology and Obstetrics (FIGO) stage I uterine sarcoma.

Methods

The National Cancer Institute's Surveillance, Epidemiology, and End Results database was accessed and a cohort of women aged ≤50 diagnosed between 1988–2013 with a sarcoma limited to the uterus was drawn. Based on site-specific surgery codes, women who underwent hysterectomy with or without oophorectomy and did not receive radiation therapy were selected for further analysis. Overall (OS) and cancer-specific (CSS) survival were determined following generation of Kaplan-Meier curves; comparisons were made with the log-rank test. A Cox-proportional hazard model was constructed to control for possible confounders.

Results

A total of 1,482 women were included in the analysis; 800 (54.0%) were diagnosed with leiomyosarcoma (LMS), 520 (35.1%) with low-grade endometrial stromal sarcoma (LG-ESS), and 162 (10.9%) with adenosarcoma (AS). The OP group included 418 women (28.2%). Differences in the rate of OP were noted based on histology (p=0.014), year of diagnosis (p=0.001), patient age (p<0.001) and race (p=0.012). There was no difference in OS (p=0.220) or CSS (p=0.210) between women who had OP and those who did not. Multivariate analysis confirmed that OP was not associated with a worse mortality.

Conclusion

In this population-based cohort of women with sarcoma limited to the uterus, OP was not associated with worse oncologic outcomes. OP could be considered for women with LMS, sparing them from the morbidity associated with iatrogenic menopause. No conclusions could be made for those with LG-ESS or AS.

Clinicopathological characteristics and treatment strategies for patients with low-grade endometrial stromal sarcoma

To investigate and evaluate the clinicopathological characteristics and treatment strategies for patients with low-grade endometrial stromal sarcoma (LG-ESS).The medical records of LG-ESS patients who were treated at 2 cancer referral centers from January 2005 to December 2015 were retrospectively reviewed.Twenty patients with LG-ESS met the inclusion criteria and were included in this analysis. Hysterectomy with bilateral salpingo-oophorectomy was the mainstay of surgery. Lymphadenectomy was performed in 12 (60%) cases, and no positive nodes were identified. CD10 was the most commonly used immunohistochemistry marker, followed by smooth muscle actin (SMA), estrogen receptor (ER), desmin, progesterone receptor (PR), and S-100; the positivity rates of these markers were 88.2%, 66.7%, 75.0%, 16.7%, 88.9%, and 0, respectively. Postoperative chemotherapy, radiotherapy, and hormonal treatment were provided alone or in combination in 10 (50%) patients, 4 (20%) patients, and 1 (5%) patient, respectively. One patient developed lung metastasis at initial diagnosis, and 2 (10%) patients had recurrence with distant metastasis. They all underwent complete or incomplete resection followed by hormonal treatment. The overall survival time of these patients was 66, 89, and 109 months at last contact, respectively. The 5-year and 10-year disease-free survival rates for the entire cohort were 90% and 72%, respectively. No patients died of the disease.CD10/SMA/ER/PR in combination with desmin/S-100 might improve the diagnostic accuracy. Surgical resection is the foremost treatment for LG-ESS patients with recurrence or distant metastasis. Hormonal treatment may be beneficial for unresectable or residual tumors.

Role of Lymphadenectomy for Uterine Sarcoma: A Meta-Analysis

Objective

Uterine sarcomas are rare, highly aggressive tumors with an unfavorable prognosis. The role of lymphadenectomy (LAD) remains controversial for this particular tumor type. To examine whether LAD can assist in prognosis or clinical benefits for uterine sarcoma patients, we performed a meta-analysis based on published studies.

Methods

We initially identified published studies by searching the PubMed database up to 30 November 2015. Study quality was evaluated systematically using the Newcastle-Ottawa Scale for assessing the quality of studies for inclusion in meta-analyses. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated using Stata software version 12.0.

Results

Our search retrieved 14 eligible studies, involving a total of 4867 patients, including 1356 (27.9%) patients who had LAD. The pooled RR for uterine leiomyosarcoma (uLMS) in patients with LAD in 5 trials was 0.90 (95% CI, 0.62–1.31) and for endometrial stromal sarcoma (ESS) in 11 trials was 0.96 (95% CI, 0.69–1.34), suggesting that there was no significant benefit of LAD in improving overall survival (P < 0.05). A random-effects model was chosen to estimate the RRs in view of the significant heterogeneity in the included studies (uLMS: Cochran Q test: P = 0.022, I2 = 64.9%; ESS: Cochran Q test: P = 0.005, I2 = 60.1%). No publication bias was detected by the Egger and Begg tests (uLMS: Begg: P = 0.221, Egger: P = 0.148; ESS: Begg: P = 1.000, Egger: P = 0.928).

Conclusions

Based on currently available evidence, the findings of this meta-analysis suggest that LAD bears little prognostic or therapeutic benefit in patients with uterine sarcoma. Systematic LAD may not be recommended in patients with uLMS or ESS unless the patient has obvious extrauterine involvement, clinically suspicious enlarged nodes, or advanced sarcomas.

A Case of Metastatic Low-Grade Endometrial Stromal Sarcoma Treated with Letrozole after Ovarian Ablation by Radiotherapy

A 50-year-old woman was admitted to our hospital due to multiple lung nodules detected incidentally on a chest X-ray. A video-assisted thoracoscopic lung biopsy revealed low-grade endometrial stromal sarcoma (LG-ESS). She had undergone a simple hysterectomy 1 year earlier owing to a diagnosis of adenomyosis. A review of her previous hysterectomy specimen showed not endometriosis but LG-ESS. According to the patient’s levels of serum follicle stimulating hormone and estradiol, she was in the premenopausal state with retained and normally functioning ovaries. She then underwent ovarian ablation by radiotherapy, after which she was administered 2.5 mg of letrozole once per day. Three months later, the size of the metastatic nodules in both lungs had decreased. The patient was followed up for 24 months while continuing on letrozole, and maintained a partial remission. We report herein on a case of metastatic LG-ESS treated with letrozole after ovarian ablation by radiotherapy.

Endometrial stromal tumours revisited: an update based on the 2014 WHO classification

Endometrial stromal tumours (EST) are rare tumours of endometrial stromal origin that account for less than 2% of all uterine tumours. Recent cytogenetic and molecular advances in this area have improved our understanding of ESTs and helped refine their classification into more meaningful categories. Accordingly, the newly released 2014 WHO classification system recognises four categories: endometrial stromal nodule (ESN), low-grade endometrial stromal sarcoma (LGESS), high-grade endometrial stromal sarcoma (HGESS) and undifferentiated uterine sarcoma (UUS). At the molecular level, these tumours may demonstrate a relatively simple karyotype with a defining chromosomal rearrangement (as in the majority of ESNs, LGESSs and YWHAE-rearranged HGESS) or demonstrate complex cytogenetic aberrations lacking specific rearrangements (as in UUSs). Herein we provide an update on this topic aimed at the practicing pathologist.

Current and future options in the management and treatment of uterine sarcoma

Uterine sarcomas are rare aggressive mesenchymal tumours with limited prognosis. They encompass various histological subtypes such leiomyosarcoma, endometrial stromal sarcoma and undifferentiated sarcomas with different surgical and medical strategies. Current evidence of surgery, adjuvant and palliative therapy is reported.

Successful pregnancy following conservative management of low-grade endometrial stromal sarcoma: A case report

It is uncommon that fertility is preserved in young nulliparous females with low-grade endometrial stromal sarcoma (ESS). Therefore, successful pregnancy following such conservative management has been rarely reported in previous literature. A 25-year-old female (gravida, 0; para, 0) underwent hysteroscopic surgery and was pathologically diagnosed with an endometrial stromal nodule. The patient underwent fertility-preserving local resection and uterine reconstruction, with a final pathological diagnosis of low-grade ESS. Endocrine therapy was then administered. Conservative management resulted in the complete remission of low-grade ESS. The patient naturally conceived and successfully delivered a healthy baby at 42 weeks' gestation by cesarean section, ~30 months following diagnosis with low-grade ESS. In conclusion, conservative management, including fertility-preserving local mass resection and endocrine therapy, can be effective for low-grade ESS and may yield a favorable outcome for young nulliparous females desiring fertility preservation.

Ovary and uterus-sparing procedures for low-grade endometrial stromal sarcoma: a retrospective study of 153 cases

OBJECTIVE

To discuss the optimal treatment options for low grade endometrial stromal sarcoma (LG-ESS).

METHODS

Medical records of consecutive patients with LG-ESS in our institute were collected. The pertinent data, including clinicopathological characteristics, treatment and prognostic information were evaluated.

RESULTS

A total of 153 cases of LG-ESS were included. The 5-year relapse free survival (RFS), overall survival (OS) and survival after relapse (SAR) rates were 66.1%, 95.8% and 82.9%, respectively. Ovary-sparing procedures, positive resection-margins, and myomectomy were the independent adverse factors for relapse (P<0.0001, =0.0041, and =0.0075, respectively). Post-menopause, cervical involvement, and positive lymphovascular space involvement were significantly associated with survival (P<0.0001, =0.0020, and =0.0163, respectively). Distance recurrence and macroscopically residual tumors negatively affected SAR (P=0.0137 and =0.0004, respectively). No benefit was found for lymphadenectomy in terms of both RFS and OS (P=0.1187 and =0.5138, respectively). Initial ovary-sparing procedures and myomectomy had no impact on OS (P=0.0810 and =0.8845, respectively). Adjuvant treatment had a slightly beneficial effect both on OS and SAR.

CONCLUSION

Hysterectomy with bilateral salpingo-oophorectomy and complete resection of the macroscopic lesion should be treated as the initial and salvage mainstay treatments for LG-ESS patients. Ovary-sparing procedures could be considered for young women without cervical involvement; however, long-term follow-up should be mandatory. Myomectomy should only be conserved for young patients with a strong desire for future fertility, with fully informed consent; hysterectomy was recommended after the completion of pregnancy and delivery. However, the roles of lymphadenectomy and adjuvant treatment deserve further investigation.

Can proliferation biomarkers reliably predict recurrence in World Health Organization 2003 defined endometrial stromal sarcoma, low grade?

An estimated 1500–3000 invasive Endometrial Stromal Sarcomas (ESS) cases annually occur worldwide. Before 2003, ESS was divided as low and high grade ESS based on mitotic activity. In 2003 the WHO changed the names, excluded mitoses and made nuclear atypia and necrosis the essential diagnostic criteria to distinguish ESS, Low Grade (ESS-LG, recurrence-free survival >90%) and Undifferentiated Endometrial Sarcoma (UES, poor prognosis). We have evaluated in WHO2003 defined ESS-LG whether proliferation biomarkers predict recurrence. Using survival analysis, the prognostic value of classical mitosis counts (Mitotic Activity Index, MAI) in haematoxyllin-eosin (H&E) sections, and immunohistochemical proliferation biomarkers (Ki-67 and PhosphoHistone-3 (PPH3)) were examined in 24 invasive endometrial stromal sarcomas. Three of 24 (12.5%) ESS-LG recurred. The MAI, PPH3 and Ki-67 were all prognostic (P = 0.001, 0.002 and 0.03). MAI values were >3 in the recurrent cases, but never exceeded 10 (the classical threshold for low and high grade). Non-recurrent cases had 0≤MAI≤3. PPH3 and Ki67 counts can be easier to perform than MAI and therefore helpful in the diagnosis of ESS, Low Grade. In conclusion, in this small study of WHO2003 defined ESS-LG, high levels of proliferation as measured by MAI, PPH3 and Ki-67 are predictive of recurrence. Larger studies are required to confirm these results.

A very late recurrence of a formerly misdiagnosed low grade endometrial stromal sarcoma metastasized to the colon

INTRODUCTION

Endometrial stromal sarcomas are rare mesenchymal neoplasms of the uterus with an indolent clinical course but a high risk of recurrence.

PRESENTATION OF CASE

We report a case of a 78 year old woman who presented with rectal bleeding and recurrent urinary tract infections, caused by a very late recurrence of a formerly misdiagnosed low grade endometrial stromal sarcoma, metastasized to the colon.

DISCUSSION

Endometrial stromal sarcomas are difficult to diagnose, both due to the rarity of the tumor and because of the close resemblance of the tumor to normal stromal tissue. These tumors are known for a high tendency of recurrence, therefore long term follow up is required in patients with endometrial stromal sarcoma.

CONCLUSION

In patients with a history known for endometrial stromal sarcoma recurrence should always be considered.

Stages I to II WHO 2003-defined low-grade endometrial stromal sarcoma: how much primary therapy is needed and how little is enough?

OBJECTIVE

Before 2003, invasive endometrial stromal sarcomas (ESS) were classified into 2 categories, low-grade and high-grade ESS, according to the mitotic index. In 2003, the World Health Organization changed the definition and the diagnostic criteria. Before 2003, 20% to 35% low-grade ESS recurred, but WHO 2003-defined low-grade ESS has 10 years' recurrence rates of less than 10%. With so few recurrences, the balance between treatment guaranteeing cure and overtreatment ("not too little" or "too much") becomes increasingly important. However, primary treatment practices range from limited surgery only to extensive surgery combined with adjuvant chemotherapy and radiotherapy. We focused on the primary treatment of early-stage WHO 2003-defined low-grade ESS.

METHODS

We evaluated the effect of different therapeutic strategies in 57 patients with International Federation of Gynecology and Obstetrics 2009 stages I to II expert-reviewed WHO 2003-defined low-grade ESS treated at a single institution between 1992 and 2007.

RESULTS

The patients' median age was 43 years (range, 19-63 years). After 68 months' median follow-up (range, 17-140 months), recurrence and mortality rates were 9% and 2%, respectively. The patients with WHO 2003-defined low-grade ESS with ovary-preserving primary surgery had a much higher recurrence rate (75%) than those without (2%; P < 0.0001). Lymphadenectomy, radical abdominal hysterectomy, and omentectomy did not influence survival. Ten patients refused chemotherapy. With univariate analysis, multiple-agent chemotherapy improved the prognosis (P = 0.02) With multivariate analysis, only ovary preservation-or-not surgery had independent prognostic value.

CONCLUSIONS

In International Federation of Gynecology and Obstetrics 2009 stage I to stage II WHO 2003-defined low-grade ESS, total abdominal hysterectomy with bilateral salpingo-oophorectomy is sufficient surgery, but ovary-preserving primary surgery increases the risk of recurrence. More extensive surgical procedures than total abdominal hysterectomy with bilateral salpingo-oophorectomy do not improve prognosis in early-stage WHO 2003-defined low-grade ESS. Chemotherapy may improve progression-free survival in early-stage low-grade ESS, but a large sample size is needed to confirm this.

Prognostic factors and outcome of undifferentiated endometrial sarcoma treated by multimodal therapy

OBJECTIVE

To describe the natural history, prognostic factors, and optimal treatment modalities of undifferentiated endometrial sarcoma (UES).

METHODS

A retrospective review was conducted of 30 patients with UES treated at Institut Gustave-Roussy, France, between January 1978 and December 2008. Clinical and pathologic variables, treatment modalities, and outcomes were assessed.

RESULTS

Disease was advanced in most cases: FIGO stage III-IV in 70% of patients. Overall, 29 patients (96.7%) underwent hysterectomy as part of the initial surgical treatment; however, only 18 (60.0%) attained complete macroscopic resection. The incidence of pelvic and/or para-aortic lymph-node involvement at primary surgery or first recurrence was 44.4%. Median postoperative follow-up was 5 years; progression-free survival (PFS) and overall survival (OS) were 9.7 and 23 months, respectively. No differences in OS and PFS were observed by staging subgroup (FIGO vs the American Joint Committee on Cancer). Only postoperative pelvic radiotherapy with or without brachytherapy correlated with improved PFS (19.1 vs 6.5 months; P=0.04) and OS (54.5 vs 16.7 months; P=0.01) in a univariate analysis.

CONCLUSION

Neither staging system was optimal for risk stratification. Multimodal therapy was recommended after surgery.

Endometrial stromal tumors: immunohistochemical and molecular analysis of potential targets of tyrosine kinase inhibitors

BACKGROUND

The systemic treatment of malignant endometrial stromal tumors (EST) is not well established. A few reports describe objective responses to imatinib, which suggest a novel therapeutic strategy for these tumors. Due to these facts, we aimed to perform a retrospective analysis of possible molecular targets of tyrosine kinase inhibitors (TKI) in EST: KIT, PDGFRA and EGFR.

METHODS

52 endometrial stromal sarcomas and 13 undifferentiated endometrial sarcomas were examined and reviewed. Mutational analysis were performed for exons 9, 11, 13, and 17 of the KIT gene, exons 12 and 18 of the PDGFRA gene and exons 18, 19, 20 and 21 of the EGFR gene. The incidence and distribution of the KIT, PDGFRA, and EGFR expression were examined by immunohistochemistry, and EGFR amplification was assessed by fluorescence in situ hybridization.

RESULTS

No mutations in KIT, PDGFRA and EGFR genes were detected. Overexpression of KIT, PDGFRA, EGFR, was detected in 2 (3%), 23 (35.4%), 7 (10.8%) cases respectively, whereas amplification of EGFR gene was not found.

CONCLUSIONS

Absence of significant expression, amplification and activating mutations on these tyrosine kinase receptors suggest that it is unlikely that EST can benefit from therapies such as TKI on the systemic setting.

Cerebral metastases of an endometrial stromal sarcoma: report of the first case

BACKGROUND

Endometrial stromal sarcomas (ESSs) of the uterus are rare gynecological malignancies. Common locations of distant metastases are vagina, vulva, lung, mediastinum, abdomen, bones and ovaries.

CASE REPORT

We present the case of a 69-year-old woman with a Federation of Gynecology and Obstetrics (FIGO) IIb (classification 2009) ESS of the uterus of high-grade malignancy. Initially, a hysterectomy Piver II and total colpectomy were performed, followed by pelvic field irradiation. 8 months later, the patient suffered seizures and hemiparesis. A computed tomography (CT) scan revealed cerebral metastases, and irradiation of the brain was initiated. After completion of the staging examinations, additional metastases of lung, abdomen, mediastinum, vulva and inguinal lymph nodes were found. This is the first reported case of brain metastases of an ESS.

CONCLUSION

Appropriate treatment options like surgery, chemotherapy or endocrine therapy should be discussed on an individual basis since large-scale clinical trials have not yet been conducted in this rare entity.

Endometrial stromal sarcoma: prognostic factors and impact of adjuvant therapy in early stages

BACKGROUND AND OBJECTIVES

Endometrial stromal sarcomas (ESS) are rare uterine neoplasms. surgery remains the cornerstone of treatment for early stages and consists of an abdominal hysterectomy with bilateral salpingo-oopherectomy. Despite appropriate surgical treatment, relapse rates are high (18% to 45%) and the value of adjuvant therapies is not clear. We evaluated prognostic factors and the impact of adjuvant treatment on localized ESS (stages I and II).

DESIGN AND SETTING

Retrospective, case-control study conducted at the National Institute Of Oncology in Rabat, Morocco over 10 years from 2000 to 2009.

PATIENTS AND METHODS

twenty-one cases of localized ESS were included in the analysis.

RESULTS

standard surgery was performed in 71.4% of our patients. Myometrial invasion was noted in 57.1% of cases. Mitotic activity was considered high in five patients. Adjuvant treatment was given to 52.3% of patients: endocrine therapy in five patients and radiotherapy in six. Survival was significantly longer in the group of patients who underwent standard surgical treatment (P=.0007), in the absence of deep myometrial invasion (P=.0248) in cases with a low mitotic index (P<.0001) and in patients who received adjuvant therapy (hormone or radiotherapy) (P=.0048). In a multivariate analysis independent risk factors for monitoring were inadequate surgical treatment and absence of adjuvant treatment.

CONCLUSIONS

Myometrial invasion and mitotic index appear to be important prognostic factors. the reference surgery is hysterectomy with bilateral salpingo-oopherectomy. Lymph node dissection does not appear to provide a benefit. finally adjuvant treatment may carry a significant survival benefit.

High grade undifferentiated uterine sarcoma: surgery, treatment, and survival outcomes

OBJECTIVES

High grade undifferentiated uterine sarcomas (HGUS) are rare, aggressive malignancies. Data regarding management are limited. We aimed to describe disease stage, response to treatment, and survival outcomes among patients with HGUS at our institution.

METHODS

We identified all patients with HGUS who received treatment at our institution from 1/2000 to 3/2011. Demographics, surgical procedures, disease stage, treatment response, and survival outcomes were abstracted from the medical records.

RESULTS

Twenty-one patients were identified. FIGO 2008 stage distribution was: I-7 (33%), II-1 (5%), III-2 (10%), IV-11 (52%). Eighteen of 21 patients (86%) undergoing primary surgical resection achieved a complete gross resection; however, progression within the abdominal cavity was identified in 11 patients (61%) by the time they underwent postoperative imaging. Of 13 patients who received first-line chemotherapy for measurable disease, the overall response rate was 62%. Responses were observed in patients treated with gemcitabine/docetaxel (6 of 8) and doxorubicin-based regimens (2 of 5). Progression-free and overall survivals for the entire cohort were 7.3 months and 11.8 months, respectively. In 14 patients with measurable disease at the time of treatment, 1-year survival was 35.7% versus 80% in 5 patients without measurable disease at time of treatment (P=0.112). Nine patients received second- or additional chemotherapy for progressive disease, with response rate of 19%. Time to progression was short among responders.

CONCLUSIONS

HGUS represents a distinct histologic subtype of uterine sarcoma with poor outcomes regardless of stage at diagnosis. A majority rapidly develops distant metastases despite surgical resection. Gemcitabine-docetaxel and doxorubicin-based treatment achieved objective, but short-lived, responses in patients with measurable disease.

Long-term medroxyprogesterone acetate therapy for low-grade endometrial stromal sarcoma

BACKGROUND

Low-grade endometrial stromal sarcoma (ESS) is a rare tumor. Endocrine treatment is frequently necessary, but treatment details have not been established.

PATIENTS AND METHODS

Thirteen consecutive patients with low-grade ESS were examined clinicopathologically. All patients underwent surgery, and six were treated with a uniform regimen of medroxyprogesterone acetate (MPA) against residual or recurrent disease.

RESULTS

Of the 13 patients, 9 were in stage I, whereas the others were in advanced stages. The median follow-up period was 117 months (range 43-170 months). Six patients, including three with residual peritoneal dissemination and three with recurrent tumors, were treated with MPA. Six months after the initiation of treatment, 3 patients demonstrated a partial response, and 3 patients demonstrated stable disease. The median dosing period was 64 months (range 28-92 months). Five of the patients, including 2 patients who are alive with no evidence of disease and 3 patients who are alive with disease, continue with MPA therapy.

CONCLUSION

The clinicopathological characteristics of the low-grade ESS in this study are consistent with those reported in previous studies. MPA therapy with residual or recurrent disease achieved excellent disease control over a period of 5 years. These results indicate that MPA therapy might be considered as a therapeutic option for residual or recurrent low-grade ESS and perhaps chosen as a first-line therapy.

Treatment of recurrent or metastatic low-grade endometrial stromal sarcoma: three case reports

BACKGROUND

The treatment of recurrent or metastatic low-grade endometrial stromal sarcoma (LG-ESS) is still controversial. Recurrent disease mainly develops in the lung or in the pelvis. When the evidence of extrauterine tumor extension exists, debulking is recommended. Responses to hormonal therapy have been reported, because of the presence of estrogen and progestin receptors. Also chemotherapy has been used, but the percentage of response is low.

CASES

Three patients with lung and pelvic localization of LG-ESS are reported. The first patient showed lung relapse 22 months after pelvic surgery. The second patient developed pelvic and abdominal recurrences, managed by surgery, 33 months after primary treatment and a subsequent lung recurrence 11 years later. The third patient had lung metastases at the primary diagnosis. All these patients underwent hysterectomy, bilateral salpingo-oophorectomy, and exeresis of lung recurrences. Our 3 patients were all treated with medroxyprogesterone acetate for long periods. They all presented regression or stabilization of metastatic lesions. At present, they are alive and without any evidence of disease (39, 70, and 28 months).

CONCLUSIONS

In LG-ESS, the combined treatment of surgery and progestin therapy is effective in achieving both local and distant disease control. Metastatic lesions, especially pulmonary lesions, seem to benefit from surgical removal, followed by progestin therapy. Hormonal therapy should be maintained for an indefinite period. On account of the long period existing between primary tumor and recurrent disease, a long-term follow-up is always recommended after the primary treatment.

Staging of uterine sarcomas

Uterine sarcomas comprise leiomyosarcoma, endometrial stromal sarcoma, adenosarcoma, undifferentiated endometrial sarcoma, and their variants. Carcinosarcoma is historically classified as sarcoma, but it is now regarded as a metaplastic carcinoma. Uterine sarcomas are rare, and are traditionally staged in the same way as endometrial carcinoma. Because of their different clinical and biological behaviours, the International Federation of Gynecology and Obstetrics introduced a new staging system in 2009 for leiomyosarcoma, endometrial stromal sarcoma and adenosarcoma, and carcinosarcoma, respectively. Following an extensive literature review no good evidence was found to support the modification of the staging system. This is mainly because of the rarity of the sarcomas and the heterogeneity of the reports, the different diagnostic criteria and treatments changing over the decades the retrospective nature and small sample size in most studies, and the lack of uniform pathological review even in large studies. Currently, evidence is still lacking about the use of preoperative imaging for staging purpose, and uterine sarcomas remain to be surgically staged. Total hysterectomy is the cornerstone for both staging and treatment. Newer evidence shows that routine lymphadenectomy and bilateral salpingo-oophorectomy may not be necessary, unless in the presence of extra-uterine spread, suspicious ovaries or lymph nodes, and certain poor histological types, such as undifferentiated endometrial sarcoma and adenosarcoma with sarcomatous overgrowth. More research and data collection are definitely needed in order to verify and further revise the current staging systems.

Recurrent endometrial stromal sarcoma in the cecum causing intussusception

INTRODUCTION

Most endometrial stromal sarcomas (ESS) develop recurrent disease at pelvis and lung. Recurrent ESS in the cecum causing intussusception is a rare but emergent phenomenon.

CASE REPORT

After initial surgical treatment in 1997, a 41-year-old female developed recurrent ESS in the cecum causing ileo-colic intussusception in 2008, which were operated with right hemicolectomy. The patient was then treated with progestin for 2 years to date. She has since been disease-free.

CONCLUSION

This case report emphasizes the importance of long-term follow-up and initial surgical treatment of ESS and suggests systemic hormonal therapy in case of recurrence.

Impact of adjuvant treatment modalities on the management of patients with stages I-II endometrial stromal sarcoma

PURPOSE

To explore whether adjuvant treatment options may impact on the prognosis in localized endometrial stromal sarcomas (ESSs; stages I and II). The historical options usually discussed in addition to hysterectomy and bilateral salpingoophorectomy (BSO) are active surveillance, pelvic radiotherapy, chemotherapy and hormonal therapy, alone or in combination.

PATIENTS AND METHODS

Among 84 consecutive patients treated for ESS at a single referral center, 54 with localized stage disease were identified. Recurrence-free survival and overall survival were estimated and patterns of recurrences described. Univariate and multivariate analyses were carried out.

RESULTS

With a median follow-up of 58 months, only one patient had died. None of the 23 patients who had received adjuvant therapy relapsed compared with 13 of 31 patients who had not received any adjuvant therapy. Adjuvant treatments were hormonal therapy (n = 10) and brachytherapy with/without pelvic radiotherapy (n = 13). Almost the majority of relapses were local (92%) and extra-pelvic metastasis was observed in nearly half of the patients (46%). In the multivariate analysis, the major determinants of relapse-free survival were adjuvant treatment, myometrial invasion (P = 0.005) and no BSO (P = 0.005).

CONCLUSIONS

In this series, adjuvant treatment of localized ESSs was associated with the absence of recurrence.