Association of surgical approach with survival in clinically stage I uterine leiomyosarcoma: an National Cancer...

We aimed to compare oncologic and peri-operative outcomes after minimally invasive surgery versus open surgery among women with clinical stage I uterine leiomyosarcoma.

We performed a retrospective cohort study using the National Cancer Database (2010-2021). Eligible cases were clinical stage I leiomyosarcoma (cT1a/cT1b) treated with hysterectomy and bilateral salpingo-oophorectomy. Patients were grouped by surgical approach (minimally invasive surgery [laparoscopy/robotic] vs open); conversions were analyzed descriptively and excluded from outcome models. Primary outcome was overall survival; secondary outcomes were length of stay and 30-day readmission. Survival was assessed with Kaplan-Meier and log-rank tests; multi-variable Cox models adjusted for age, adjuvant therapy, margin status, and pathologic stage.

Among 683 patients, 208 (30.5%) underwent minimally invasive surgery, 447 (65.4%) open surgery, and 28 (4.1%) had conversions. Minimally invasive surgery patients more often were White (85.1% vs 70.0%) and privately insured (66.8% vs 54.4%), had higher neighborhood income, more clinical stage IA disease (30.3% vs 15.2%), and smaller tumors (median 7.2 cm vs 9.9 cm, all p <.001). Adjuvant chemotherapy and radiotherapy rates were similar between groups. Minimally invasive surgery was associated with a shorter hospital stay (median 1 vs 3 days, p <.001) and comparable 30-day readmission (both 3.8%). In clinical stage IA, unadjusted overall survival favored minimally invasive surgery (68.0% alive at 94 months vs 51.5% open, log-rank p =.028), whereas stage IB showed no difference (median overall survival 79 vs 79 months, p =.72). In multi-variable analysis, surgical approach was not independently associated with overall survival (adjusted hazard ratio 1.16, 95% confidence interval 0.91 to 1.49). Worse overall survival was associated with increasing age, higher stage, and positive margins.

The surgical approach was not independently associated with survival. Future prospective cohorts should capture specimen extraction and tumor disruption to better define which patients can safely undergo minimally invasive approaches.