Prognostic factors and treatment outcomes in uterine leiomyosarcoma: a 24-year experience from a single center

Uterine leiomyosarcoma (uLMS) is a rare but highly aggressive malignancy. This study aimed to identify prognostic factors, evaluate the outcomes of different surgical approaches and systemic treatments to improve clinical management and guide future research in uLMS patients. We retrospectively analyzed the clinical, pathological, treatment, and survival data of patients with uLMS treated from 2000 to 2024 at Zhejiang Cancer Hospital. In this study of 159 uLMS patients, the 5-year progression-free survival (PFS) and overall survival (OS) was 20.1% and 60.1%, with a median PFS of 18 months and a median OS of 89 months. High lactate dehydrogenase (LDH) (> 250 U/L), grade 3, and stage IV were identified as risk factors for poor outcomes. In stage I patients, oophorectomy, retroperitoneal lymph node dissection, and adjuvant chemotherapy did not affect survival. For first-line treatment in metastatic uLMS, gemcitabine plus docetaxel showed a favorable survival trend compared to anthracycline monotherapy. Efficacy was similar between gemcitabine plus docetaxel and anthracycline-based regimens, while anthracycline plus dacarbazine showed the highest response rates and a better survival trend among the anthracycline-based treatments. Limited evidence suggests that most patients have PD-L1 negative expression, low tumor mutation burden, and microsatellite stability. Immunotherapy had minimal effect and eribulin showed promising results in later treatment lines. High LDH, grade 3, and advanced stage were associated with poor survival. In stage I patients, our findings suggest that de-escalation of oophorectomy, retroperitoneal lymph node dissection, and adjuvant chemotherapy may be considered in selected patients. For metastatic disease, gemcitabine plus docetaxel and anthracycline plus dacarbazine showed favorable outcomes as first-line chemotherapy and warrant further prospective validation.