Survival Outcomes of Different Treatment Modalities in Patients with Low-Grade Endometrial Stromal Sarcoma
Low-grade endometrial stromal sarcoma (LGESS) is a rare histologic subtype of uterine sarcoma, accounting for approximately 38% of all uterine sarcomas. Early and complete surgical resection is the cornerstone of treatment for LGESS. However, the roles of ovarian conservation, lymphadenectomy, and postoperative radiation in the management of LGESS remain unclear. This study aimed to evaluate the impact of these treatment modalities on survival outcomes in patients with LGESS, using data from the Surveillance, Epidemiology, and End Results (SEER) database.
The International Federation of Gynecology and Obstetrics (FIGO) 2009 staging system classifies LGESS patients with lymph node metastasis as stage IIIC, indicating a significant adverse effect of lymph node status on prognosis. According to the National Comprehensive Cancer Network (NCCN), bilateral salpingo-oophorectomy is preferred in LGESS, but there is no strong evidence supporting the routine use of lymphadenectomy. The management of ovaries may be individualized in patients of reproductive age, especially since over 80% of LGESS cases are estrogen receptor-positive. Postoperative estrogen blockade is recommended for stages II to IV LGESS, and adjuvant radiotherapy is suggested for stage II disease to reduce local recurrence rates. However, the benefits of lymph node resection and postoperative radiation in nonmetastatic LGESS remain controversial.
This retrospective study analyzed data from the SEER 18 registry database (1973–2015) to evaluate the impact of lymphadenectomy, postoperative radiation, and ovarian conservation on 5-year overall survival (OS) and 5-year cause-specific survival (CSS) in LGESS patients. The study included 517 patients with LGESS who underwent surgical treatment. Patients were screened based on diagnosis, primary disease of the uterus, active follow-up, and surgical treatment. Cancer stages were reclassified according to the FIGO 2009 staging system based on tumor size, tumor extension, and lymph node status recorded in the database.
The mean age at diagnosis was 49.2 years, with 63.2% of patients younger than 50 years. The mean follow-up duration was 67.9 months. Most patients were white women (74.7%), followed by black women (12.0%) and those of other ethnicities (13.4%). The majority of patients had stage I disease (77.2%), while 13.2%, 5.6%, and 4.1% had stages II, III, and IV, respectively. Moderately differentiated carcinoma was present in 67.9% of patients, and well-differentiated carcinoma was found in 31.5%. Ovarian conservation was performed in 17.8% of patients, lymphadenectomy in 35.6%, and postoperative radiotherapy in 13.9%.
Cox regression analysis revealed that patients aged over 65 years were more likely to have advanced-stage disease (stage IV). Black ethnicity, radical hysterectomy or extension surgery, and chemotherapy were associated with a higher hazard ratio for death. Propensity score matching (PSM) was used to control for variables such as age, stage, ethnicity, chemotherapy, and surgery. After PSM, there were no statistically significant differences in baseline characteristics between the groups.
Kaplan-Meier survival curves were constructed to compare 5-year OS and CSS among the treatment groups. In the lymphadenectomy group, the 5-year OS was 94.7% for patients who underwent lymphadenectomy and 93.5% for those who did not. The 5-year CSS was 96.0% and 96.8%, respectively. In the ovarian conservation group, the 5-year OS was 92.4% for patients with ovarian conservation and 100% for those without. The 5-year CSS was 95.0% and 100%, respectively. In the postoperative radiation group, the 5-year OS was 90.9% for patients who received radiation and 95.2% for those who did not. The 5-year CSS was 92.3% and 95.2%, respectively.
Multivariable logistic regression analysis showed that lymphadenectomy did not improve 5-year OS or CSS in LGESS patients. However, lymphadenectomy may still be important for accurate FIGO staging, which can influence decisions regarding adjuvant therapy. Ovarian conservation had no significant impact on OS or CSS in stage I LGESS patients, suggesting that ovaries can be preserved in selected patients who wish to retain hormonal function. Postoperative radiation was not associated with improved OS or CSS in LGESS patients, indicating that its use should be carefully considered, particularly in patients with high-risk lesions for local recurrence.
The study had some limitations, including the lack of information on tumor recurrence and exact details that could help investigate differences in progression-free survival. Additionally, not all patients underwent lymphadenectomy, which may have led to stage migration. Due to the rarity of LGESS, data from large-scale trials and multiple centers are needed to provide more robust evidence.
In conclusion, total hysterectomy remains the main treatment modality for early-stage LGESS. Lymphadenectomy and postoperative radiation do not appear to improve survival outcomes, and the ovaries can be preserved in selected patients with stage I LGESS. Further research is needed to refine treatment strategies and improve outcomes for patients with this rare disease.
doi.org/10.1097/CM9.0000000000000259
Was this helpful?
0 / 0