Myoma morcellation and leiomyosarcoma panic

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In a press release in April 2014, the US Food and Drug Administration [1] discourages doctors from using laparoscopic power morcellators in removing fibroids or myomatotic uteri in order to reduce the risk of sarcomatous cell escape. The USbased company Johnson & Johnson, the largest manufacturer of the devices, halted global sales and distribution of power morcellators, while many hospitals in USA ban the use of morcellation under these circumstances. Patients’ safety and wellbeing especially after surgery is a common and primary concern of surgeons and hospitals; however, there is no reliable way to determine if a uterine fibroid contains a sarcoma prior to removal. Patients should know that the use of laparoscopic power morcellation for hysterectomy or myomectomy may deteriorate their survival rate in case of a sarcoma, and they should discuss the risks and benefits of the available treatment options with their health care professionals. The incidence of uterine sarcomas is extremely low, 0.23% [2], or according to FDA analysis of currently available data (1:350), 0.29 %. They are classified according to histological subtypes in order of decreasing incidence: leiomyosarcomas, endometrial stromal sarcomas (ESS) and ‘other’ sarcomas. The ESS are lesions within the endometrial cavity and diagnosis can be established prior to surgery by endometrial biopsy [3]. The rarity of these tumours has prevented the performance of large epidemiological studies to identify risk factors. Assuming an incidence of uterine sarcomas of 0.23 % by applying the ‘inverse rule of 3’, a surgeonwill need to perform 1304 laparoscopic interventions to observe at least one case of uterine sarcoma with 95 % confidence. Imaging characteristics, tumour markers and other parameters indicating the risk of sarcoma are not available or not specific. In addition, the lack of uniform histologic criteria for diagnosing uterine leiomyosarcoma (ULMS) makes interpretation of the older studies difficult [4]. As the Stanford study [5] was the first to appreciate that the type of necrosis in a uterine smooth muscle tumour was of crucial importance, studies that preceded it did not evaluate the presence or absence of tumour cell necrosis. A leiomyosarcoma usually exhibits diffuse moderate-tosevere atypia, a mitotic count of >10 MFs/10 HPFs and tumour cell necrosis. A tumour with any two of these features V. Tanos :H. Brolmann : R. L. DeWilde : P. O’Donovan :R. Campo Head IVF and Reproductive Surgery, Aretaeio Hospital, Nicosia, Cyprus