When the initial diagnosis of stage I uterine leiomyosarcoma is made via a non-intact resection such as a myomectomy or supracervical hysterectomy, what factors, if any, might push you to consider adjuvant chemotherapy after completion surgery?

Great question. Delivering a non-intact uterus has been investigated and reported over the past several years. Specifically, it has been reported in the context of uterine morcellation and the prognosis of those surgeries that morcellated sarcomas compared to those that the uterus was delivered intact. The evidence is clear and non-controversial. Morcellation worsens the prognosis for those patients diagnosed with a uterine leiomyosarcoma.

Adjuvant chemotherapy and radiation therapy have been investigated in this disease. No studies to date have demonstrated a survival benefit of either modality. In fact, the last trial done (GOG 278) was not statistically significant but suggested that chemotherapy may portend a worse prognosis in the adjuvant setting.

If a patient is referred to me with a diagnosis of a leiomyosarcoma from non-intact uterus, I work up the patient with full-body imaging. If there is no evidence of disease, I will observe these patients with imaging every 3 months for the first year and then twice a year for 4 more years. If there is evidence of disease, I will consider surgical debulking and chemotherapy.