Fibroid Morcellation Research Articles

Google searches and medical publication trends since the 2014 US Food and Drug Administration position on power morcellation: Do these translate into patient awareness?

ObjectivesOur primary objective was to assess patient awareness by observing Google Trends comparing search terms used in relation to morcellation rather than morcellation alone. Our secondary objective was to review trends and locations of publications on leiomyosarcoma and morcellation following the US Food and Drug Administration (FDA) position statement. Study designTo assess Internet trends, we obtained the relative search volume (RSV) for each month from 1 January 2004 to 1 March 2019 from Google Trends using the terms ‘fibroid’, ‘morcellation’, and ‘fibroid cancer’. RSV ranges from 0 to 100 with 100 being peak popularity for the term, and all other monthly search activity relative to the peak. To assess academic trends, we performed a systematic review of published literature discussing fibroid morcellation within the same time period. We used a two-way independent t-test to compare median RSV, and chi-squared test to compare academic output. P < 0.05 was considered statistically significant. ResultsSearch volume for ‘morcellation’ peaked during the FDA statement (RSV 0.5 to 2.9, t = 17.5, p < 0.05) but was not sustained. There is an increase in ‘fibroid’ activity post-FDA statement (RSV 68.8 to 76.3, t = 3.9, p < 0.05). ‘Fibroid cancer’ remained static throughout (t = 1.5, p = 0.1 and t=-0.5, p = 0.6). Afro-Caribbean countries had the highest RSV for ‘fibroid’, whereas ‘morcellation’ RSV was highest in predominantly Western countries. There was a significant increase in the rate of papers published on the subject following the FDA statement (6.8 vs 55.6 papers per year, 95% CI -53.96 to -43.64, p < 0.0001). No academic papers on morcellation were published from countries with the highest RSV for ‘fibroid’. ConclusionOur study suggests that interest in uterine fibroids has increased since the FDA statement, but the public are perhaps unaware or not concerned of the consequent potential risk of leiomyosarcoma following morcellation. Countries where fibroid interest is highest are not necessarily those that can offer power morcellation. Further studies are required to address how the Internet influences patient choice and informed consent, and how medical professionals can use it to further educate patients on the risks and benefits of laparoscopic myomectomy and power morcellation.

New approach to uterine fibroid morcellation with a focus on the risk of dissemination of previously undiagnosed uterine sarcoma

New approach to uterine fibroid morcellation with a focus on the risk of dissemination of previously undiagnosed uterine sarcoma

Update on Fibroid Morcellation

Purpose of Review The aim of this paper is to review the risks associated with morcellation of uterine and fibroid tissue during minimally invasive surgery, and provide updated suggestions for practice.

Fibroid Morcellation and Sarcoma Thread

In case of inadvertent morcellation of an unexpected uterine sarcoma the clinical outcomes, due to the rapid intraperitoneal dissemination of malignant tissue during the procedure can be negatively influenced.

Exabundanti cautela: From the tragedy of inadvertent sarcoma morcellation to inappropriate myoma screening.

The recent commotion about the risk of unexpected malignancy during myoma morcellation may have divergent consequences. Some are positive for future women’s health care, while others may be negative. On the positive side, the ‘sarcoma awareness’ will lead to improvements in the diagnosis of myometrial lesions including leiomyosarcoma and in the technical aspects of safer, ‘spill-free’ myoma removal. On the negative side, the fear of an unexpected sarcoma may lead to unnecessary, more invasive surgery and avoidance of minimal invasive surgery—out of an abundance of caution. The turmoil about the unexpected sarcoma, echoed and amplified in the press worldwide, may lead patients and doctors to have all too much faith in the adage that ‘any fibroid is a sarcoma, until proven otherwise’. Although this precautionary principle should be integrated in the decision making of any gynecologist before proceeding with a myomectomy, it could also have perverse effects. The latter may especially be true when confronted with the incidental finding of a well-defined myometrial lesion [1] on ultrasound examination. Some might even contemplate the introduction of a ‘screening program’ for sarcoma—‘because they care for their patients’. Indeed, the (public) perception of a fibroid being a ‘potential sarcoma’ could lead to following fallacious reasoning as illustrated in Fig. ​Fig.1.1. There is no doubt that a leiomyosarcoma is a very aggressive and often lethal disease. If the lesion is confined to the uterus, the 5-year survival is 50 % [2], but only 20 % in case of more extended disease [3]. The cumulative risk for developing a sarcoma is about 5/10,000 [4]. This means that in a cohort of 20,000 women, 10 will develop a sarcoma. Depending on the stage of the cancer at diagnosis, 5 to 8 of those 10 women will ultimately die of the disease. Figure ​Figure11 summarizes what would happen if, motivated by the high mortality rates and by the repetitive alarming press releases, a screening program for sarcoma was launched at age 50. Given the 50 % incidence of fibroids at age 50, and based on the adage that ‘any fibroid is a sarcoma, until proven otherwise’, half of the screened population would be ‘screen positive’. Because of the diagnostic unreliability to distinguish between a benign myoma and a malignant leiomyosarcoma (LMS), the safest way to perform a ‘spill-free tumor removal’ would be a total abdominal hysterectomy. One may hypothesize that at age 50, half of the sarcomas would be picked up and that this would be at an early stage, confined to the uterus. Half of these women would therefore be curable, while 2 to 3 women would still die from the sarcoma. However, an abdominal hysterectomy is not free of risk. A mortality rate for abdominal hysterectomy of 1.5/1000 has been reported [5]. This would mean that out of the 10,000 women undergoing a hysterectomy, 15 women would die due to the surgery. Finally, in the “screen negative” group of women at age 50, one may assume that 5 women would develop a sarcoma later in life. These would then be diagnosed in a later stage of the disease and 3 to 4 of these women would die of the disease. Based on this simulation, the mortality rate in the screened group would be between 10 and 11/10,000 versus 2.5 and 4/10,000 in the unscreened group. The ‘collateral damage’ of screening a group of 20,000 women would be 12 to 17 extra deaths. Fig. 1 Simulation: ‘screening for sarcoma’ I acknowledge that this simulation based on a few selected publications is simplistic and that the figures are prone to bias. However, I mean it to illustrate the real danger of generalizing partial knowledge in medicine. The risk of fibroid morcellation is an important women’s health issue and cannot be underestimated. However, it should be put in the right perspective as done by Brolmann et al. [6]. Both blunt denial of the problem and overreaction may have deleterious consequences. The incidental diagnosis of a fibroid in an asymptomatic woman is rarely an indication for surgery.

A Retrospective Analysis of the Impact of Myomectomy on Survival in Uterine Sarcoma.

Laparoscopic myomectomy is a minimally invasive, conservative surgical approach commonly used for the treatment of uterine fibroids. However, there is a lack of effective means to distinguish the nature of uterine tumors prior to surgery. The impact of fibroid morcellation during laparoscopic surgery on the dissemination of cancerous uterine fibroids and long-term survival of patients has gained increasing attention. A retrospective cohort study was conducted to analyze the impact of different surgical approaches on recurrence-free survival (RFS) and overall survival (OS) in patients with a postoperative pathological diagnosis of uterine sarcoma at a single medical center. Patients who underwent the first surgery for uterine fibroids (confined to the uterus) and had a postoperative pathological diagnosis of uterine sarcoma were selected in the Chinese PLA General Hospital from January 2005 to January 2014. Based on the use of fibroid morcellation, the subjects were divided into fibroid morcellation (FM) and total hysterectomy (TH, non-morcellation) groups. Follow-up outcomes, including RFS and OS times, were observed. In total, 59 patients were included, with 30 cases in the FM group and 29 cases in the TH group. There were no significant differences in RFS and OS time between the two groups (RFS: P = 0.16, OS: P = 0.09). Multivariate correlation analysis showed that the impact of a higher grade level on RFS and OS was nearly 2-fold the impact of a lower grade level (RFS: P = 0.04, odds ratio (OR) = 1.97; OS: P = 0.03, OR = 2.29). Intraoperative morcellation, postoperative adjuvant therapy, age, tumor size, FIGO stage, and surgical approach were not risk factors affecting RFS and OS. Fibroid morcellation during laparoscopic surgery (including laparoscopic, transvaginal and transabdominal approaches) had no significant impact on RFS and OS time in patients. However, the 5-year RFS and OS rates were both lower in the FM group than in the TH group. Grade level was a significant risk factor for the prognosis of patients with uterine sarcoma.

Fibroid Morcellation: A Shared Clinical Decision Tool for Mode of Hysterectomy

Fibroid Morcellation: A Shared Clinical Decision Tool for Mode of Hysterectomy

Fibroid morcellation: a shared clinical decision tool for mode of hysterectomy

ObjectiveTo compare risks and benefits of laparoscopic hysterectomy with morcellation versus abdominal hysterectomy without morcellation for large fibroids. Study designWe developed a shared clinical decision tool to communicate risks and benefits of laparoscopic versus abdominal hysterectomy to patients with large fibroids as mandated by the FDA. The decision tool was designed to serve as a framework for providers to counsel patients about mode of hysterectomy to facilitate shared decision-making between patient and provider. Risks and benefits were estimated from the literature, including surgical complications (venous thromboembolism, small bowel obstruction, adhesions, hernia, surgical site infections, and transfusions), uterine sarcoma risks, and quality-of-life endpoints. The shared clinical decision tool was applied to a hypothetical population of 20,000 patients with large uterine fibroids, of which 10,000 underwent laparoscopic hysterectomies and 10,000 had abdominal hysterectomies. ResultsAbdominal hysterectomy would result in 50.1% more adhesions, 10.7% more hernias, 4.8% more surgical site infections, 2.8% more bowel obstructions, and 2% more venous thromboembolisms compared to laparoscopic hysterectomy. Abdominal hysterectomy would also result in longer hospital stays (2 days), slower return to work (13.6 days), greater postoperative day 3 narcotic requirements (48%), and lower SF-36 quality-of-life scores (50.4 points lower). 0.28% of fibroid hysterectomy patients would have unsuspected uterine sarcomas. Among these patients, laparoscopic hysterectomy with morcellation would have a 27% reduction in 5-year overall survival rates and a 28.8 month shorter recurrence-free survival period. ConclusionSome evidence suggests laparoscopic hysterectomy with morcellation may result in increased risk of cancer dissemination with worse survival outcomes among uterine sarcoma patients compared to abdominal hysterectomy without morcellation, however, the current data is limited and the exact risks associated specifically with electromechanical morcellation are not conclusive. Data also supports abdominal hysterectomy would lead to a net detriment in other outcomes, with greater risks of venous thromboembolism, obstruction, hernia, adhesions, infection, and blood loss compared to laparoscopic hysterectomy. This shared clinical decision tool may aid the patient and physician in determining an optimal mode of hysterectomy for large uterine fibroids while taking account of risks and benefits as mandated by the FDA.