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

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