Could leiomyosarcoma be a real concern for the gynecologist performing minimally-invasive surgery for uterine myoma?

Abstract

Uterine leiomyosarcoma is a rare malignant tumor with a poor prognosis. The diagnosis of uterine sarcoma is often made after myomectomy or hysterectomy at the histologic examination. The differential diagnosis between leiomyosarcoma and uterine fibroids is difficult to establish preoperatively. Most cases of uterine fibroids can be treated minimally invasively, but extracting lar­ger specimens is an impediment to choosing this surgical method. The risks of morcellation (vascular or bowel injury, intraabdominal tissue dissemination) must be balanced against comorbidities related to laparatomy. In 2014, FDA warned that the prevalence of occult leiomyosarcoma in patients undergoing hysterectomy or myomectomy for presumed benign leiomyoma is 1 in 498 and discouraged the morcellation of uterine fibroids during laparoscopy. In order not to give up minimally-invasive surgery and to reduce the risks of morcellation, the use of endoscopic bags has been considered to avoid the spread of potentially malignant tissue. However, it is advisable not to use morcellator, even with the endoscopic bag, if there is a high suspicion of malignancy. We need to take into account the disadvantages of the method. In conclusion, uterine leiomyosarcoma continues to be a concern for gynecologists, given that until now there are no investigations to detect it preoperatively. The selection of patients with uterine fibroids for laparoscopy using the morcellation of the specimens should be rigorous.