Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms
Background: Power morcellation has become a common technique for the minimally invasive resection of uterine leiomyomas. This technique is associated with dissemination of cellular material throughout the peritoneum. When morcellated uterine tumors are unexpectedly found to be leiomyosarcomas or tumors with atypical features (atypical leiomyoma, smooth muscle tumor of uncertain malignant potential), there may be significant clinical consequences. This study was undertaken to determine the frequency and clinical consequence of intraperitoneal dissemination of these neoplasms.
Methodology/Principal Findings: From 2005-2010, 1091 instances of uterine morcellation were identified at BWH. Unexpected diagnoses of leiomyoma variants or atypical and malignant smooth muscle tumors occurred in 1.2% of cases using power morcellation for uterine masses clinically presumed to be “fibroids” over this period, including one endometrial stromal sarcoma (ESS), one cellular leiomyoma (CL), six atypical leiomyomas (AL), three smooth muscle tumor of uncertain malignant potential (STUMPs), and one leiomyosarcoma (LMS). The rate of unexpected sarcoma after the laparoscopic morcellation procedure was 0.09%, 9-fold higher than the rate currently quoted to patients during pre-procedure briefing, and this rate may increase over time as diagnostically challenging or under-sampled tumors manifest their biological potential. Furthermore, when examining follow-up laparoscopies, both from in-house and consultation cases, disseminated disease occurred in 64.3% of all tumors (zero of one ESS, one of one CL, zero of one AL, four of four STUMPs, and four of seven LMS). Only disseminated leiomyosarcoma, however, was associated with mortality. Procedures are proposed for pathologic evaluation of morcellation specimens and associated follow-up specimens.
Conclusions/Significance: While additional study is warranted, these data suggest uterine morcellation carries a risk of disseminating unexpected malignancy with apparent associated increase in mortality much higher than appreciated currently.
Some professional groups and medical institutions are stressing the importance of counseling patients about both the potential risks and benefits of morcellation of a fibroid or uterus
Evaluating the Risks of Electric Uterine Morcellation
Gynecologic surgeons, like many other surgical specialists, have embraced laparoscopic surgical techniques because they offer quicker recovery, less postoperative pain, and fewer wound complications than open procedures. The removal of large pieces of tissue through the small incisions of laparoscopy is difficult. However, this problem can be overcome by tissue morcellation, a technique of fragmenting tissue into smaller pieces that often prevents the need to enlarge established incisions. Surgeons have long used manual morcellation with a scalpel or scissors to remove masses abdominally and vaginally, but use of the technique has increased with wide adoption of laparoscopic approaches and with the introduction of laparoscopic electric morcellators in 1993.
Critics of Fibroid Removal Procedure Question Risks It May Pose for Women With Undetected Uterine Cancer
Use of a surgical technique that involves cutting fibroid or uterine tissue into small pieces for extraction during minimally invasive surgery has come under scrutiny recently—scrutiny prompted by concerns that the process may disperse fragments of undetected malignant tumors throughout the abdominal cavity and upstage otherwise contained cancers.
Because it’s not possible to reliably detect the presence of uterine sarcomas before surgery, some experts say that use of the technique—known as intracorporeal uterine morcellation, which can be performed with an electric morcellator or by hand with a knife—may be too risky under any circumstance. Others say more research on risks associated with the procedure is needed before banning it outright. In the meantime, some professional groups and medical institutions are stressing the importance of counseling patients about both the potential risks and benefits of morcellation of a fibroid or uterus.
Sources and Full Text
Evaluating the Risks of Electric Uterine Morcellation, The Journal of the American Medical Association, 1828692, 2014;311(9):905-906. doi:10.1001/jama.2014.1093.
Critics of Fibroid Removal Procedure Question Risks It May Pose for Women With Undetected Uterine Cancer, JAMA Network, 1828691, 2014;311(9):891-893. doi:10.1001/jama.2014.27.
Hysterectomy and procedures to remove uterine fibroids should avoid use of laparoscopic power morcellation, according to a safety advisory from the Food and Drug Administration
DES Action USA communication:
DES Daughters, with their increased risk for uterine fibroids – pay attention! Find out what your doctor plans to do when surgically treating them. A tool called a power morcellator, that looks and works like the immersion blender found in your kitchen, may inadvertently spread cancer cells while breaking up the fibroid. You may want to be firm with your doctor about options. Sources: here.
Uterine fibroids are noncancerous growths that develop from the muscular tissue of the uterus. Most women will develop uterine fibroids (also called leiomyomas) at some point in their lives, although most cause no symptoms1. In some cases, however, fibroids can cause symptoms, including heavy or prolonged menstrual bleeding, pelvic pressure or pain, and/or frequent urination, requiring medical or surgical therapy.
Many women choose to undergo laparoscopic hysterectomy or myomectomy because these procedures are associated with benefits such as a shorter post-operative recovery time and a reduced risk of infection compared to abdominal hysterectomy and myomectomy2. Many of these laparoscopic procedures are performed using a power morcellator.
A number of additional treatment options are available for women with symptomatic uterine fibroids including traditional surgical hysterectomy (performed either vaginally or abdominally) and myomectomy, laparoscopic hysterectomy and myomectomy without morcellation, laparotomy using a smaller incision (minilaparotomy), deliberate blocking of the uterine artery (catheter-based uterine artery embolization), high-intensity focused ultrasound, and drug therapy. Evidence demonstrates that, when feasible, vaginal hysterectomy is associated with comparable or better results and fewer complications than laparoscopic or abdominal hysterectomy3.
Importantly, based on an FDA analysis of currently available data, it is estimated that 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s likelihood of long-term survival. For this reason, and because there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma, the FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for uterine fibroids.
FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids, FDA, Press Announcements, ucm393689, April 17, 2014
Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication, FDA, Safety Communications, ucm393576, April 17, 2014
Uterine Fibroids, NIH Fact Sheets, csid=50, March 29, 2013
FDA Warns of Cancer Risk With Laparoscopic Device, MedPage Today, 45309, Apr 17, 2014
Vitamin D may reduce risk of uterine fibroids, according to NIH study
Fibroids, also known as uterine leiomyomata, are noncancerous tumors of the uterus. Fibroids often result in pain and bleeding in premenopausal women, and are the leading cause of hysterectomy in the United States.