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European Journal of Gynaecological Oncology  2020, Vol. 41 Issue (3): 422-431    DOI: 10.31083/j.ejgo.2020.03.5107
Original Research Previous articles | Next articles
Ovarian conservation without postoperative radiation improved survival outcomes in patients with stage i uterine leiomyosarcoma
Ming Wang1, Shi-Hui Meng2, Yu-Mei Wu1()
1Department of Gynecologic Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100006, China
2Department of Obstetrics and Gynecology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100006, China
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Abstract  

Introduction: Little observational data exists regarding the efficacy of different treatment modalities on the survival outcome of patients with uterine leiomyosarcoma. Objective and Design: This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results database to identify surgery-based treated patients with uterine leiomyosarcoma diagnosed between 1982 to 2015 (N = 4289). The associations between survival outcomes and treatment modalities regarding postoperative radiation and ovarian conservation were assessed. Results: A total of 1104 patients were included in the study, 19.02% (210/1104) patients received postoperative radiation, 11.59% (128/110) patients received ovarian conservation. The median follow-up duration was 37.27 ± 34.69 months (95%CI: 35.39-39.38 months). After propensity score matching, there were no variable differences among compared groups. For FIGO stage I-II patients, postoperative radiation did not improve five-year-overall survival (49.1 vs. 47.1%, p = 0.818) and five-year-cause-specific survival (51.5 vs. 49.9%, p = 0.910). For International Federation of Gynecology and Obstetrics stage I patients who were younger than 50 years old, five-year-overall survival (75.4 vs. 60.3%, p = 0.053) and five-year-cause-specific survival (75.4 vs. 65.1%, p = 0.146) were similar between women underwent ovarian conservation and those who did not. However, after excluding patients who received radiotherapy, patients showed a better survival outcome than control group (five-year-overall survival: 76.3 vs. 54.0%, p = 0.031; five-year-cause-specific survival: 76.30 vs. 55.3%, p = 0.046). Conclusions: In women with stage I-II uterine leiomyosarcoma, postoperative radiation did not improve five-year-overall-survival and five-year-cause-specific survival. In young women with stage I uterine leiomyosarcoma who didn’t receive postoperative radiotherapy, ovarian conservation was associated with increased overall survival and cause-specific survival.

Key words:  Uterine leiomyosarcoma      Ovarian conservation      Postoperative radiation      Propensity score matching     
Submitted:  15 November 2019      Accepted:  05 June 2019      Published:  15 June 2020     
Fund: D1511000019150/Beijing Municipal Science and Technology Commission
*Corresponding Author(s):  Yu-Mei Wu     E-mail:  wym597118@163.com

Cite this article: 

Ming Wang, Shi-Hui Meng, Yu-Mei Wu. Ovarian conservation without postoperative radiation improved survival outcomes in patients with stage i uterine leiomyosarcoma. European Journal of Gynaecological Oncology, 2020, 41(3): 422-431.

URL: 

https://ejgo.imrpress.com/EN/10.31083/j.ejgo.2020.03.5107     OR     https://ejgo.imrpress.com/EN/Y2020/V41/I3/422

Figure 1.  - Flwchart of Retrospecrive Cohort to Assess Survival Outcomes. Three cohorts were extracted from the Surveillance, Epidemiology, and End Results (SEER) database, including postoperative radiation cohort, ovarian conservation cohort, ovarian conservation cohort without postoperative radiation. PSM: propensity score matching.

Table 1  - Clinicopathologic and Treatment Characteristics of Study Patients.
Values n = 1104 (%) OS-HR 95% CI P-value CSS-HR 95% CI p-value
Age at diagnosis (y)
Younger than 35 24 (2.17) 1 - 1 -
35-50 330 (29.89) 1.621 0.839-3.131 0.151 1.494 0.774-2.886 0.232
50-65 541 (49.00) 2.357 1.225-4.535 0.010 2.142 1.117-4.11 0.022
65+ 209 (18.93) 2.689 1.374-5.262 0.004 2.175 1.108-4.27 0.024
Ethnicity
White 790 (71.56) 1 - 1 -
Black 208 (18.84) 1.349 1.101-1.652 0.004 1.317 1.063-1.631 0.012
other 106 (9.60) 1.290 0.980-1.698 0.069 1.223 0.916-1.632 0.172
Marital status
Single 245 (22.19) 1 - - 1 -
Married 618 (55.98) 0.782 0.637-0.961 0.019 0.758 0.613-0.937 0.01
Separated,widowed,or divorced 241 (21.83) 0.977 0.763-1.249 0.850 0.93 0.718-1.204 0.582
Year at diagnosis
2001-2010 547 (49.55) 1 - 1 -
2011-2015 557 (50.45) 0.775 0.632-0.949 0.014 0.739 0.598-0.915 0.005
FIGO stage
I 663 (60.05) 1 - - 1
II 163 (14.76) 2.007 1.597-2.522 < 0.001 1.998 1.574-2.536 < 0.001
III 127 (11.50) 2.893 2.182-3.836 < 0.001 2.65 2.028-3.462 < 0.001
IV 151 (13.68) 3.581 2.688-4.771 < 0.001 3.519 2.616-4.733 < 0.001
Grade
Well differentiated 60 (5.43) 1 - - 1 - -
Moderately differentiated 157 (14.22) 0.847 0.499-1.440 0.541 0.93 0.518-1.668 0.807
Poorly differentiated 345 (31.25) 2.341 1.469-3.731 < 0.001 2.694 1.608-4.514 < 0.001
Undifferentiated 542 (49.09) 2.128 1.341-3.377 < 0.001 2.396 1.435-4.001 0.001
Tumor size (cm)
5.0 or less 109 (9.87) 1 - - 1 - -
5.0-10.0 440 (39.86) 1.118 0.803-1.556 0.509 1.224 0.856-1.749 0.269
10.0-15.0 336 (30.43) 1.459 1044-2.038 0.027 1.597 1.113-2.291 0.011
15.0 or more 219 (19.84) 1.499 1.051-2.136 0.025 1.636 1.117-2.396 0.012
Surgery modality
Hysterectomy and ovarian conservation 128 (11.59) 1 - - 1 - -
Hysterectomy and oophorectomy 842 (76.27) 1.362 0.998-1.857 0.051 1.298 0.947-1.779 0.105
Hysterectomy NOS 22 (2.00) 1.168 0.498-2.744 0.721 1.186 0.504-2.789 0.696
Radical hysterectomy or extension surgery 112 (10.14) 1.314 0.892-1.935 0.167 1.226 0.823-1.828 0.317
Radiation
No radiation 894 (80.98) 1 - - 1 - -
Beam radiation 178 (16.12) 0.857 0.693-1.059 0.153 0.886 0.711-1.104 0.28
Beam radiation and implants 32 (2.90) 0.756 0.455-1.256 0.280 0.774 0.459-1.307 0.338
Lymphadectomy
No 698 (4.80) 1 - - 1 -
Regional lymphadectomy 408 (95.20) 0.859 0.722-1.022 0.087 0.817 0.684-0.977 0.027
Lymph biopsy 1 (0.091) 0.001 2.52E-72-4.19E + 65 0.932 0.001 1.18E-74-8.218E + 67 0.934
Pariaortic lymphadectomy 2 (0.18) 2.507 0.346-18.170 0.363 2.589 0.357-18.793 0.347
Chemotherapy
No 561 (50.82) 1 - - 1 -
Yes 543 (49.18) 1.121 0.938-1.340 0.210 1.166 0.967-1.405 0.107
Table 2  - Baseline Characteristics of PSM Cohorts for Postoperative Radiation in Stage I-II Patients.
Values Before Matching p After Matching p
Postoperative Radiation
(n = 172)
No Postoperative Radiation
(n = 652)
Postoperative Radiation
(n = 172)
No Postoperative Radiation
(n = 167)
Age at diagnosis (y) Z = 1.728, p = 0.084 Z = 0.328, p = 0.743
Younger than 35 5 12 5 3
35-50 59 206 59 59
50-65 81 305 81 75
65+ 27 129 27 30
Ethnicity Z = 1.508, p = 0.132 Z = 0.572, p = 0.568
White 128 479 128 121
Black 29 107 29 25
Other 15 66 15 21
Marital Status Z = 0.120, p = 0.904 Z = 0.675, p = 0.500
Single 31 140 31 39
Married 106 362 106 93
Separated, Widowed, Divorced 35 150 35 35
Year at diagnosis Z = 0.808, p = 0.419 Z = 0.428, p = 0.668
2000-2010 121 348 121 121
2011-2015 51 304 51 46
FIGO stage Z = 0.637, p = 0.524 Z = 0.280, p = 0.779
IA 24 81 24 21
IB 102 454 102 111
IIA 7 15 7 2
IIB 24 44 24 20
II,NOS 15 58 15 13
Grade Z = 0.324, p = 0.746 Z = 0.508, p = 0.611
Well Differentiated 11 44 11 12
Moderately Differentiated 24 109 24 26
Poorly Differentiated 54 195 54 52
Undifferentiated 83 304 83 77
Tumor Size (cm) Z = 1.658, p = 0.092 Z = 0.836, p = 0.403
5.0 or less 28 89 28 24
5.0-10.0 78 261 78 72
10.0-15.0 44 205 44 46
15.0 or more 22 97 22 25
Surgery Modality Z = 1.267, p = 0.205 Z = 0.026, p = 0.980
Hysterectomy and Ovarian Conservation 17 89 17 20
Hysterectomy and Oophorectomy 139 491 139 128
Hysterectomy NOS 3 18 3 1
Radical Hysterectomy or Extension Surgery 13 54 13 18
Lymphadectomy Z = 4.800,p < 0.001 Z = 0.289,p = 0.773
Yes 82 221 82 77
No 90 431 90 90
Chemotherapy Z = 3.332, p < 0.001 Z = 1.009,p = 0.313
Yes 73 270 73 80
No 99 382 99 87
Table 3  - Baseline Characteristics of PSM Cohorts for Ovarian Conservation in Stage I Patients.
Values Before Matching p After Matching p
Ovarian conservation(n = = 68) No Ovarian Conservation
(n = 146)
Ovarian Conservation
(n = 68)
No Ovarian Conservation
(n = 59)
Age at daignosis (y) Z = 0.123, p = 0.902 Z = 0.294, p = 0.769
Younger than 35 3 7 3 2
35-50 65 139 65 57
Ethnicity Z = 0.355, p = 0.723 Z = 0.321, p = 0.748
White 49 102 49 44
Black 10 22 10 8
Other 9 22 9 7
Marital Status Z = 0.029, p = 0.977 Z = 0.370, p = 0.711
Single 17 36 17 11
Married 43 93 43 43
Separated, Widowed, Divorced 8 17 8 5
Year at diagnosis Z = 0.381, p = 0.704 Z = 0.111, p = 0.912
2000-2010 41 84 41 35
2011-2015 27 62 27 24
FIGO stage Z = 2.316, p = 0.021 Z = 1.643, p = 0.100
IA 20 23 20 10
IB 48 123 48 49
Grade Z = 1.799, p = 0.072 Z = 0.844, p = 0.398
Well Differentiated 6 10 6 3
Moderately Differentiated 24 27 24 15
Poorly Differentiated 11 41 11 18
Undifferentiated 27 68 27 23
Tumor size (cm) Z = 1.276, p = 0.202 Z = 1.029, p = 0.304
5.0 or less 20 24 20 11
5.0-10.0 26 71 26 22
10.0-15.0 16 39 16 21
15.0 or more 6 12 6 5
radiation Z = 1.102, p = 0.270 Z = 0.705, p = 0.481
Observation 58 116 58 53
Beam Radiation 9 22 9 4
Beam Radiation and Implants 1 8 1 2
Lymphadectomy Z = 2.304,p = 0.021 Z = 0.145,p = 0.885
Yes 12 48 12 11
No 56 98 56 48
Chemotherapy Z = 0.163, p = 0.871 Z = 0.731,p = 0.465
Yes 29 64 29 29
No 39 82 39 30
Table 4  - Baseline Characteristics of PSM cohorts or Ovarian Conservation without Radiation in Stage I Patients.
Values Before Matching p After Matching p
Ovarian conservation (n = 58) No Ovarian Conservation
(n = 116)
Match-Ovarian conservation
(n = 58)
No Ovarian Conservation
(n = 50)
Age at diagnosis (y) Z = 0.255, p = 0.799 Z = 1.623, p = 0.105
Younger than 35 3 5 3 0
35-50 55 111 55 50
Ethnicity Z = 1.016, p = 0.309 Z = 0.605, p = 0.545
White 43 77 43 34
Black 8 21 8 10
other 7 18 7 6
Marital status Z = 0.190, p = 0.849 Z = 0.018, p = 0.986
Single 15 28 15 13
Married 36 74 36 31
Separated, Widowed, Divorced 7 14 7 6
Year at diagnosis Z = 0.429, p = 0.688 Z = 0.536, p = 0.592
2000-2010 33 62 33 31
2011-2015 25 54 25 19
FIGO stage Z = 1.956, p = 0.051 Z = 1.807, p = 0.071
IA 15 16 15 6
IB 43 100 43 44
Grade Z = 1.322, p = 0.186 Z = 0.249, p = 0.804
Well Differentiated 6 8 6 6
Moderately Differentiated 20 25 20 11
Poorly Differentiated 9 33 9 15
Undifferentiated 23 50 23 18
Tumor size (cm) Z = 0.990, p = 0.322 Z = 1.782, p = 0.075
5.0 or less 15 17 15 6
5.0-10.0 23 55 23 20
10.0-15.0 14 35 14 17
15.0 or more 6 9 6 7
Lymphadectomy Z = 1.741,p = 0.082 Z = 0.620,p = 0.535
Yes 10 33 10 11
No 48 83 48 39
Chemotherapy Z = 0.431, p = 0.666 Z = 0.893,p = 0.372
Yes 24 52 24 25
No 34 64 34 25
Table 5  - Survival Outcomes of Different Local Modalities in Patients of Uterine Leiomyosarcoma.
Values 5-y, OS (%) 95% CI (%) p-value, Log-rank test
5-y, CSS (%)
95% CI (%) p-value, Log-rank test
Postoperative radiation
No 47.1 47.06,47.12 p = 0.818 49.9 49.86,49.94 p = 0.910
Yes 49.1 49.06,49.14 51.5 51.47,51.53
Ovary conservation
Yes 75.4 75.29,75.51 p = 0.053 75.4 75.29,75.51 p = 0.146
No 60.3 60.16,60.44 65.1 64.96,65.24
Ovary conservation without postoperative radiation
Yes 76.30 76.18,76.42 p = 0.031 76.30 76.18,76.42 p = 0.046
No 54.0 53.84,54.16 55.3 55.14,55.46
Figure 2.  - Overall survival Cause-specific survival of patients with different local treatment modalities in the marched data. A. Overall survival of postoperative radiation group B. Cause-specific survival of postoperative radiation group C. Overall survival of ovarian conservation group D. Cause-specific survival of overian conservation group E. Overall servival of ovarian conservation without radiation group F. Cause specific survival of ovarian conservation without radiation group

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