Occult Leiomyosarcoma Research Articles

Preoperative identification from occult leiomyosarcomas in laparoscopic hysterectomy and laparoscopic myomectomy: accuracy of the ultrasound scoring system (PRESS-US).

To assess the diagnostic performance and inter-observer agreement of a PREoperative sarcoma scoring based on ultrasound (PRESS-US) in differentiating uterine leiomyosarcoma (uLMS) from leiomyoma (LM). We conducted a retrospective evaluation of patients who underwent surgery and received standardized ultrasound examinations due to the presence of uterine myoma-like masses. Histological diagnosis was used as the reference standard. The masses were analyzed using morphological uterus sonographic assessment criteria, and the diagnostic accuracy of PRESS-US was evaluated using ROC curve analysis. Kappa (κ) statistics were used to assess the inter-observer agreement between a less experienced and an expert radiologist. Among the 646 patients, 632 (97.8%) were diagnosed with LM, and 14 (2.2%) had uLMS. The malignancy rates for low-risk and high-risk patients were 0.35% and 13.48%, respectively. The optimal PRESS-US cutoff was 17.5, resulting in an AUC of 89.7% (95% CI, 0.79-1.00), with a sensitivity of 85.7% and a specificity of 87.8%. The inter-observer agreement between a less experienced and an expert radiologist was excellent (κ = 0.811, P < 0.001). PRESS-US provides effective risk stratification for uLMS for radiologists with different levels of experience, with high reliability. Subgrouping high-risk patients helps in better risk stratification.

An occult leiomyosarcoma in a hysterectomy specimen presumed to be uterine fibroid preoperatively: A case report

An occult leiomyosarcoma in a hysterectomy specimen presumed to be uterine fibroid preoperatively: A case report

Fibroid Removal after Myomectomy: An Overview on the Problems of Power Morcellation.

The authors reviewed uterine fibroid (UF) morcellation and its potential consequences, notably a hypothetical spread and dissemination of occult uterine leiomyosarcoma (LMS) tissue, evaluating the effect of laparoscopic versus open myomectomies with and without morcellation on patients’ outcomes, as well as related medical-legal issues. MEDLINE and PubMed search was performed for the years 1990–2021, using a combination of keywords on this topic. Relevant articles were identified and included in this narrative review. There is an individual risk, for all patients, for LMS diagnosis after myomectomy. However, the risk for occult LMS diagnosis during a laparoscopic myomectomy is generally reduced when the guidelines of scientific societies are followed, with an overall benefit from the laparoscopic approach with morcellation in appropriate cases. Gynecological societies do not ban morcellation and laparoscopic hysterectomy/myomectomy per se, but recommend their use on the basis of the patients’ clinical characteristics. It is suggested for gynecologists to provide detailed information to patients when obtaining an informed consent for open or laparoscopic hysterectomy/myomectomy. A detailed preoperative assessment of patients and the risk benefit ratio of laparoscopic morcellation of uterine mass could overcome the “a priori” banning of the morcellation technique.

Occult leiomyosarcomas during myomectomy: what should be considered?—a narrative review

Occult leiomyosarcomas during myomectomy: what should be considered?—a narrative review

A national survey: Evaluating current practice and risk assessment in morcellation amongst gynaecologists in the United Kingdom

ObjectiveTo evaluate current practice and adherence to AAGL and BSGE power morcellation guidelines. Study designCross-sectional survey. SettingUnited Kingdom. Patients/Population157 National Health Service (NHS) hospital trusts (organisation comprising of one or more hospitals) offering gynaecological services. InterventionA questionnaire was emailed between March–July 2018 and completed by Lead/ Directors of Gynaecology within each organisation. Descriptive statistics were used to present results from this study. Measurements/ResultsWe assessed power morcellation practice patterns, informed consent processes and outcomes over the last 12 months. We received 136 responses (87 % response rate). Power morcellation was performed by a third (59, 37.6 %) of all UK hospitals. The median number of gynecologists performing morcellation per organisation was 2 (Q1-Q3: 2–4). A median of 7 morcellators (Q1-Q3: 0–17) were purchased and 7 morcellators (Q1-Q3: 1.25–15.75) used per annum. A median of 10 (Q1-Q3: 2.0–15.0) laparoscopic hysterectomies and 5 (Q1-Q3: 0.5–9.0) myomectomies requiring morcellation were performed per annum. Almost, a third of hospitals did not perform an endometrial biopsy or MRI. 79.7 % (47) of trusts consented for power morcellation and 76 %, (46) explained risk of inadvertent leiomyosarcoma. 83.3 %, (50) had no patient literature and almost half had no audit process 45 %, (27). ConclusionCurrent UK practice does not reflect recommendations from the AAGL or BSGE. Deficiencies were identified in pre-operative evaluation, local governance procedures, and consenting practices regarding use of a power morcellator and risk of occult leiomyosarcoma.

1668 A National Survey: Evaluating Current Practice and Risk Assessment in Morcellation Amongst Gynecologists in the United Kingdom

Study Objective To evaluate current practice and adherence to AAGL and BSGE power morcellation guidelines. Design Multiple-choice questionnaire. Setting United Kingdom. Patients or Participants 157 NHS hospitals offering gynaecological services. Interventions n/a. Measurements and Main Results Power morcellation practice patterns, informed consent processes and outcomes over the last 12 months. We received 136 responses (87% response rate). Power morcellation was performed by a third (59, 37.6%) of all UK hospitals. The median number of gynecologists performing morcellation per organisation was 2 (Q1-Q3: 2-4). A median of 7 morcellators (Q1-Q3: 0-17) were purchased and 7 morcellators (Q1-Q3: 1.25-15.75) used per annum. A median of 10 (Q1-Q3: 2.0-15.0) laparoscopic hysterectomies and 5 (Q1-Q3: 0.5-9.0) myomectomies requiring morcellation were performed per annum. Almost, a third of trust did not perform an endometrial biopsy or MRI. 79.7% (47) of trusts consented for power morcellation and 76%, (46) explained risk of inadvertent leiomyosarcoma.83.3%, (50) had no patient literature and almost half had no audit process 45%, (27). Conclusion Current UK practice does not reflect recommendations from the AAGL or BSGE. Deficiencies were identified in pre-operative evaluation, local governance procedures, and consenting practices regarding use of a power morcellator and risk of occult leiomyosarcoma.

Incidence of Leiomyosarcoma at Surgery for Presumed Uterine Myomas in Different Age Groups

To evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups. A retrospective cohort study. A tertiary referral hospital. All women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016. Laparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy. A total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%). The incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe.

Occult uterine leiomyosarcoma in women undergoing abdominal and minimally invasive surgeries for myomas.

To estimate (i) the incidence of occult uterine leiomyosarcoma (LMS) in patients operated on for presumedmyomas, and (ii) the proportion of occult LMS to preoperatively diagnosed LMS in a tertiary center. An Institutional Review Board-approved retrospective cohort study was performed. The electronicdatabase of 30,476 patients was searched for women who had undergone surgery due to presumed myomas (N = 2675) as well as those with uterine LMS recognized via histology (N = 10) between January 2010 and December 2016. Six of the 2675 treated women had occult LMS (incidence 1:446; 0.002; CI 0.0-0.013), and one underwent power morcellation (incidence 1:951; 0.001; CI 0.0-0.006). Parallel searching revealed that 6 of the 10 cases (60%) with uterine LMS recognized via histology were diagnosed postoperatively, whereas 4 of the 10 (40%) were diagnosed preoperatively. The incidence of LMS morcellation during laparoscopy was 1:951 and, when all MIS cases were included, 1:1178. The patient who underwent LMS morcellation was operated in the general surgery ward 5 years after laparoscopy (omental recurrence). These results are similar to the first and recent conservative FDA estimations, but two-times lower for procedures with laparoscopic morcellation and all MIS procedures than for abdominal. Because above half of LMS may be recognized after surgery, the risk of occult LMS and the delay of targeted surgical treatment should be included in all informed consent forms for conservative management of presumed myomas without histology.

Safety and feasibility of contained uterine morcellation in women undergoing laparoscopic hysterectomy

BackgroundWidespread concerns have been raised regarding the safety of power morcellation of uterine specimens because of the potential to disseminate occult malignancy. We sought to assess the safety and feasibility of contained manual uterine morcellation within a plastic specimen bag among women with uterine neoplasms.MethodsA retrospective single-institution descriptive cohort study was conducted from 2003 to 2014. Patients with leiomyoma and/or uterine malignancy who underwent minimally invasive surgery with contained uterine manual morcellation were identified from surgical logs. Demographic data, pathology results, operative details and adjuvant treatments were abstracted.ResultsEighty-eight patients were identified; 35 with leiomyoma and 53 with endometrial cancer. The mean age was 48 and 60, respectively. Uterine size/weight was greater in women with leiomyoma compared to those with cancer (15.1 weeks/448 g vs. 10.7 weeks/322 g). Mean operative time was 206 min (range 115–391) for leiomyoma cases and 238 min (range 131–399) for cancer cases. Median length of stay was 1 day (range 0–3 days). There were no cases of occult leiomyosarcoma and all specimens were successfully manually morcellated within a bag. There were no intraoperative complications. Thirty-day postoperative complications occurred in 7 patients, including one readmission for grade (G) 1 vaginal cuff separation after intercourse, G1 port-site hematoma (1), G2 port-site cellulitis (1), G2 vaginal cuff cellulitis (2), G2 bladder infection (2), G2 pulmonary edema (1), and G1 musculoskeletal injury (1).ConclusionsContained uterine hand morcellation is a feasible procedure with low peri-operative complication rates that allows for minimally invasive surgical procedures for women with large uterine neoplasms. Further evaluation is needed to assess survival outcomes for uterine malignancies.

Occult Leiomyosarcomas in a Canadian Province: A Retrospective Cohort Study.

The risk of unexpected uterine leiomyosarcoma (LMS) following surgery for presumed benign leiomyoma is quoted to be between 1 in 498 and 1 in 5000. The objectives of the present study were to determine the prevalence of uterine LMS in a specific patient population and the rate of diagnosis of occult uterine LMS and to evaluate the risk of unintended morcellation of LMS in Saskatchewan. This study was a Canadian Task Force Classification II-2 multicentre retrospective cohort study in academic-affiliated tertiary care centres. All women with the histopathologic diagnosis of uterine LMS in Saskatchewan between January 2000 and December 2014 were included. Women with metastatic LMS at diagnosis or other types of uterine sarcomas were excluded. Data including patients' characteristics, clinical presentation, physical examination findings, imaging, pathology reports, surgical interventions, and survival outcomes were reviewed. A total of 28 patients had a confirmed histopathologic diagnosis of LMS over the 15-year study period. Approximately 26 212 hysterectomies were performed in Saskatchewan over the same time frame. The prevalence of uterine LMS in this patient population over the study time frame is estimated to be one in 853. Mean age at diagnosis was 53.8 ± 10.0. Medical records of 25 patients could be retrieved, and 15 cases (60%) had an occult diagnosis. There were five cases of unintended morcellation (one power, four mechanical). Survival outcomes were comparable in women with unintended morcellation of occult disease and in those without morcellation. This study contributes to the existing body of literature on morcellation of occult LMS, and it ascertains the rate of LMS in a patient population. The results of this study provide valuable information to health care professionals, policy makers, and women in Saskatchewan so that they may make more informed decisions concerning uterine masses.

Morcellation in gynecologic oncology.

Morcellation of uteri with unsuspected malignancies has been the focus of reports for decades. More intensive evaluation of clinical outcomes and evaluation of impact of changes in practice has occurred since the release of FDA statement advising against the use of power morcellators. The review summarizes some of the most relevant publications on this topic. The Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists concur that symptomatic women should undergo appropriate evaluation, morcellation should not be performed whenever malignancy is suspected or diagnosed, and acknowledge the limitations of diagnostic testing currently available to detect leiomyosarcoma. Accurate incidence of occult leiomyosarcoma in women undergoing hysterectomy for symptomatic myomas is not known because of poor quality of data. Increased complication rates, including death, with abdominal procedures and increased societal costs have been reported. The FDA safety communication has resulted in decreased laparoscopic hysterectomy rates. Clinical judgement and practice in accordance to clinical guidelines, based on best current scientific evidence, is recommended. Women should be aware of the limitation of current data regarding the incidence of occult leiomyosarcoma or other malignancies whenever consenting to any form of therapy for symptomatic myomas, including surgical, medical and expectant management. If surgical treatment is selected, morcellation should not be performed if a malignancy diagnosis is known or suspected. A minimally invasive surgical approach is associated with a decreased complication rate and an increased quality of life years. Research efforts should focus on improving diagnostic accuracy and efficacy of therapeutic interventions.

The prevalence of occult leiomyosarcoma in women undergoing presumed fibroid surgery and outcomes after morcellation.

To review the data-derived prevalence rates for occult leiomyosarcoma (LMS), and outcomes for women who have these tumors inadvertently morcellated. In 2014, the Food and Drug Administration presented data showing the prevalence rates of occult LMS at 2.02/1000 surgeries for presumed benign fibroids. They also attributed poorer outcomes for women undergoing power morcellation of these tumors. Two more recent meta-analyses have shown much lower rates, as low as one in 8300 surgeries when including only prospective studies, and one in 1428 surgeries when including both prospective and retrospective studies. When looking at outcomes, both studies show no difference in outcomes when comparing power or any other type of morcellation. The most recent data suggest that even intact removal has no advantage when looking at mortality rates. Prevalence of occult LMS remains quite rare, but outcomes after intact removal or any type of morcellation appear to be no different.

Prevalence of Occult Leiomyosarcomas and Atypical Leiomyomas After Laparoscopic Morcellation of Leiomyomas in Reproductive-Age Women

(Abstracted from Hum Reprod 2017;32(10):2036–2041) Uterine tumors are a public health issue because of their prevalence in women and their connection to menstrual disorders, anemia, pelvis pain, pregnancy loss, and infertility. Treatment of symptomatic fibroids includes open myomectomy or hysterectomy, which have higher morbidity rates, longer hospital stays, and more disruption of daily life.

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

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.

511 - Incidence of Occult Leiomyosarcomas in a Canadian Province: a Retrospective Cohort Study

511 - Incidence of Occult Leiomyosarcomas in a Canadian Province: a Retrospective Cohort Study

Prevalence of occult leiomyosarcomas and atypical leiomyomas after laparoscopic morcellation of leiomyomas in reproductive-age women.

What is the prevalence of leiomyosarcomas and atypical leiomyomas after laparoscopic morcellation of fibroids in reproductive age women? No case of leiomyosarcomas but seven atypical leiomyomas were found in 1216 subjects. Although uterine sarcoma is a rare entity affecting usually older peri- or post-menopausal women, the Food and Drug Administration discourages use of laparoscopic power morcellation of uterine fibroids. Retrospective review of data extracted from a single center database of 1216 consecutive women who underwent laparoscopic morcellation of 2582 unsuspicious leiomyomas between June 2003 and December 2015 and were followed-up until December 2016. A total of 1216 women, aged 18-45 years, underwent laparoscopic morcellation of 2582 apparently benign leiomyomas by the same surgeon and all specimen slides were examined by the same experienced pathologist. The prevalence of leiomyosarcomas and atypical leiomyomas was 0% (95% CI: 0-0.3%) and 0.6% (95% CI: 0.23-1.18%) (six atypical-bizarre and one mitotically active leiomyoma) respectively. In addition, there were identified 34 cases of adenomyomas, 45 leiomyomas with infarcts, 81 cellular leiomyomas and 133 degenerated leiomyomas. No morcellator-associated complication was recorded and none of the patients included in this study required conversion to laparotomy. Retrospective and single referral center study design. Laparoscopic morcellation of unsuspicious leiomyomas after careful preoperative work up seems to be safe in women of reproductive age. None.

Laparoscopic Hysterectomy With Morcellation Versus Abdominal Hysterectomy for Presumed Fibroids: An Updated Decision Analysis Following the 2014 FDA Safety Communications

(Abstracted from Am J Obstet Gynecol 2017;216:259.e1–259.e6) Increasing concern that use of electric power morcellation during hysterectomy for benign conditions may result in the spread of an occult leiomyosarcoma (LMS) led the US Food and Drug Administration (FDA) to issue safety communications in April 2014 and November 2014, recommending that this procedure should not be used in perimenopausal and postmenopausal women. These communications significantly changed practice patterns of many gynecologic surgeons, increasing rates of abdominal hysterectomy (AH), and possibly resulting in more complications for patients.

Clinical Application of Morcellation: Provider Perceptions Survey (the CAMPPS Study)

Abstract Objective: The goal of this research was to explore physicians' perceptions of uterine morcellation and minimally invasive hysterectomy in the setting of new hospital regulations, comparing gynecologists and internal medicine providers, geographic locations, and levels of training. Design: This was a multicenter cross-sectional study. Materials and Methods: A 17-question, anonymous, electronic survey was administered to resident, fellow, and attending gynecologists, and internal medicine physicians at three institutions. Results: Two hundred and twenty-two gynecologists responded for a response rate of 46%. Most gynecologists believe morcellation is safe and acceptable, and the benefits of minimally invasive surgery outweigh the potential risk of cancer dissemination as a result of morcellation. The majority reported that the incidence of occult leiomyosarcoma is rarer than 1 in 350. Physicians from Boston, MA, responded less favorably toward morcellation than providers in Pittsburgh, PA, and Cha...

Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroids: an updated decision analysis following the 2014 Food and Drug Administration safety communications

Previous decision analyses demonstrate the safety of minimally invasive hysterectomy for presumed benign fibroids, accounting for the risk of occult leiomyosarcoma and the differential mortality risk associated with laparotomy. Studies published since the 2014 Food and Drug Administration safety communications offer updated leiomyosarcoma incidence estimates. Incorporating these studies suggests that mortality rates are low following hysterectomy for presumed benign fibroids overall, and a minimally invasive approach remains a safe option. Risk associated with morcellation, however, increases in women age >50 years due toincreased leiomyosarcoma rates, an important finding for patient-centered discussions of treatment options for fibroids.

Updates in uterine fibroid tissue extraction.

Safety concerns regarding morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in surgical technique. The prevalence of occult leiomyosarcoma is debated; however, estimates from a robust meta-analysis suggest it may be in the range of 1 case per 1960-8300 fibroid surgeries. Advancing age is an important clinical risk factor for occult malignancy. The impact of tumor morcellation may vary by mode of tissue removal, though tissue fragmentation is consistently associated with poorer outcomes. Decision and cost analyses continue to support laparoscopic hysterectomy as a low-morbidity and cost-effective approach. The increased scrutiny on fibroid procedures in the past few years may lead to changes in surgical approach; however, alternative tissue extraction options are evolving, including incorporation of contained morcellation. Although the incidence of occult leiomyosarcoma is low, outcomes are poor and may be worsened by morcellation. By addressing risk factors for malignancy and incorporating evolving surgical techniques into practice, gynecologists can continue to offer patients a minimally invasive approach for fibroid management.