Presumed Leiomyoma Research Articles

Clinical manifestations and prognosis of unexpected uterine sarcoma of uterine fibroids in Tianjin China

BackgroundUterine sarcoma is a rare malignancy of women and fewer uterine sarcomas are detected preoperatively. The reported incidence of preoperatively diagnosed uterine sarcoma (PDUS) was 0.07%. This study aims to identify the prevalence of unexpected uterine sarcoma (UUS) after operation for presumed leiomyoma and compare clinical outcomes after primary therapy.MethodsA retrospective study was performed evaluating all uterine sarcoma diagnosed in Tianjin Central Hospital of Gynecology and Obstetrics between May 2011 and July 2016.We used the χ2 and T tests to assess the incidence and clinical features of patients. The Kaplan–Meier method was used to calculate disease-related survival.ResultsThe study retrospectively analyzed 6625 patients with uterine fibroids and found 45 UUS patients and 21 patients of PDUS. The incidence of UUS is (45/6625) 0.67%. The incidence of UUS in patients undergoing total hysterectomy was higher undergoing tumor resection (P < 0.001); the age of UUS is younger than PDUS (P = 0.046); the differences in menopausal status and primary complaints between the two groups are not statistically significant. The PDUS group had more patients with Stage II and III sarcomas than the UUS group (P < 0.001); the duration of symptoms in the PDUS group was longer than in the UUS group (P = 0.033). The 5-year overall survival (OS) rate of the UUS group (77.7%) is higher than the PDUS group (46.3%) (P < 0.001).ConclusionsThe incidence of UUS is low. UUS has a younger age of onset, shorter history of the disease, earlier clinical stage, and better prognosis.

The incidence of neoplasm of uncertain behavior of uterus diagnosed after surgery for presumed leiomyoma: A national population-based study.

To investigate the incidence of neoplasm of uncertain behavior of uterus (NUBU) diagnosed after hysterectomy, myomectomy, or hysteroscopy for presumed leiomyomas. We performed this population-based retrospective cohort study using the Korean national health insurance database between January 2002 and December 2018. Women with or without NUBU diagnosed after surgery were extracted using diagnosis codes and procedure codes. The median age of patients who underwent surgery for presumed leiomyomas was 39 years (interquartile range [IQR] 31-47 years). The median age of women diagnosed with NUBU after surgery was 45 years (IQR 38-49 years). The incidence of NUBU diagnosed after surgery for presumed leiomyomas was 1.89%. The incidences of NUBU diagnosed after hysterectomy, myomectomy, or hysteroscopic myomectomy for presumed leiomyomas were 2.03%, 1.84%, or 1.64%, respectively. There was no difference in the incidence of NUBU according to these surgical methods. Regardless of the surgical procedure performed, the incidence of NUBU diagnosed after surgery was higher than that of unexpected uterine malignancy diagnosed after hysterectomy (0.19%), myomectomy (0.12%), or hysteroscopic myomectomy (0.86%) for presumed leiomyoma. Compared with unexpected uterine malignancy, NUBU seems to occur in relatively young women.

Uterine Leiomyoma in Postmenopausal Women: Possible Reasons for Growth and Differential Diagnosis

Background: Uterine leiomyomas appear after menarche, typically grow during the reproductive years, and then stabilize or regress after menopause. However, there have been several reports of a considerable number of patients who have undergone surgery for uterine leiomyomas during the postmenopausal period. In this paper, we discuss two issues: the possible reasons for the growth of uterine leiomyomas and the differential diagnoses of presumed leiomyomas in postmenopausal women. Methods: PubMed was searched for studies about uterine leiomyomas and sarcomas with a focus on postmenopausal women. Main findings: Several hypotheses exist for the growth of postmenopausal leiomyomas. Among these, we propose the following as an important candidate: estrogen and progesterone do not necessarily work in a positive way. In addition, in postmenopausal patients, the incidence of malignant tumors is very high, and it is generally difficult to diagnose uterine sarcoma prior to surgery. Conclusion: We propose that in cases in which uterine sarcomas cannot be ruled out, physicians should proactively consider surgery, particularly for postmenopausal patients.

Abstract 447: Circulating TP53 tumor DNA as a potential biomarker for pre-operative identification of uterine leiomyosarcoma

Abstract Uterine leiomyosarcoma (LMS) is a highly aggressive but rare malignancy with a dismal prognosis. In nearly all cases, LMS is unsuspected prior to resection for a presumed leiomyoma. The risk of occult uterine LMS is reported to be 0.2% (1 in 500) in the largest cohort study of women undergoing surgery for presumed fibroid disease. The major problem is that there is no reliable preoperative method to distinguish LMS from a leiomyoma (LM) or STUMP (smooth muscle tumor of uncertain malignant potential), and the patient's prognosis for LMS is even poorer if the tumor is transected, which occurs in procedures performed for LM. Effective therapy for LMS is lacking and most patients eventually succumb to the disease. Thus, there is a considerable need for a reliable preoperative test to triage patients into the proper surgical procedure for LMS. TP53 alterations are reportedly associated with uterine LMS in about 40% of cases. We screened plasma for TP53 variants in patients with pathologically confirmed LMS. We evaluated TP53 circulating tumor DNA (ctDNA) by deep next-generation sequencing in a cohort of 7 patients with LMS, 1 patient with STUMP, and 3 patients with LM. Clinical data were reviewed to assess disease burden. LMS patients' tumor burden ranged from no evidence to extensive metastatic disease. DNA extraction was performed using the QIAamp DNA Micro Kit, QIAamp DNA FFPE Tissue Kit, or QIAamp MinElute ccfDNA Mini Kit. DNA quality was assessed using the TapeStation Genomic DNA kit. NGS libraries targeting the entire exonic region of the p53 gene were prepared using the QIASeq Targeted DNA Custom Panel. Sequencing was performed on the MiSeq system using 150bp paired end sequencing with a minimum read depth of 2x0.5M reads for plasma and 2x1M reads for formalin-fixed paraffin embedded and fresh-frozen tissue samples. Raw sequencing data were demultiplexed by bcl2fastq to generate the FASTQ files. Then raw sequencing reads were aligned to the human reference genome GRCh38 by BWA-MEM 0.7.9a-r786. SmCounter2 was used for p53 variants calling and variants quality control. We discovered TP53 ctDNA variants in 5 of 7 (71.4%) LMS cases including p.E258V, p.R248Q, P.R337C, p.E221*, p.R174_R175delinsWC, but not in the control cases of LM or STUMP. In the 5 plasma samples with TP53 mutated LMS, the patients had extensive metastatic disease and in the 2 TP53 wild-type LMS and STUMP cases, the patients had no evidence of disease. To our knowledge, this is the first pilot study to demonstrate the comparative use of TP53 ctDNA in patients with LMS, LM, and STUMP. Further study of these rare LMS is needed to determine the preoperative utility of NGS TP53 ctDNA mutational status as a useful molecular biomarker to help guide surgery and avoid unwarranted manipulation and pelvic contamination of undetected LMS. Supported by the Gottlieb, Buss and Snyder Endowments in Surgical Oncology Citation Format: Jean R. Lopategui, Bonnie Balzer, Yizhou Wang, Chintda Santiskulvong, Carissa A. Hyunh, Chun Yat Ong, Manuel Arana, Matthew Gayhart, Farin Amersi, Allan W. Silberman. Circulating TP53 tumor DNA as a potential biomarker for pre-operative identification of uterine leiomyosarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 447.

Uterine Morcellation for Presumed Leiomyomas: ACOG Committee Opinion Summary, Number 822.

Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.

Uterine Morcellation for Presumed Leiomyomas: ACOG Committee Opinion, Number 822.

Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.

Laparoscopic Power Morcellation: Techniques to Avoid Tumoral Spread

To show 3 different techniques for achieving an endobag morcellation without adding extra time and cost to the surgery. Stepwise demonstration of the 3 techniques with narrated video footage. Morcellation is a useful procedure for fragmenting and extracting specimens during laparoscopic surgery without the need to perform a laparotomy. Patients who otherwise would not be eligible for minimally invasive surgery (i.e., those with a large uterus or myomas) could benefit from laparoscopic advantages. However, morcellation has a major limitation: the risk of dissemination of unsuspected malignancies. In 2017, the Food and Drug Administration released an updated assessment of the use of laparoscopic power morcellators for treatment of leiomyomas. A total of 23 studies were included in the analysis, and 20 studies (90 910 women) contributed to the estimated prevalence of leiomyosarcoma at the time of surgery for presumed leiomyomas. Depending on the modeling methodology used, the estimated prevalence of uterine sarcoma was 1 in 305 to 1 in 360 women, and for leiomyosarcoma, the estimated prevalence was 1 in 570 to 1 in 750 women [1]. Currently available evidence has suggested that if an undiagnosed uterine malignancy is intra-abdominally morcellated, there is a risk of intraperitoneal dissemination of the disease [2]. Therefore, the European Society of Gynecological Oncology emitted a statement in 2016 recommending avoiding morcellation if there is any suspicion of sarcoma and using endobag containers for morcellation of the surgically removed uterine myomas [3]. In addition, in the United States, the Food and Drug Administration recommends performing laparoscopic power morcellation for myomectomy or hysterectomy only with a tissue containment system, legally marketed in the United States [4]. There are several techniques described in the literature for contained uterine myomas morcellation [5]. In this video, we present 3 of them: First, an indirect-view morcellation is described. In this technique, we placed the myoma in the bag and exteriorize it through one of the trocars. Once outside the abdomen, we placed the morcellator through the bag opening and did the morcellation inside the bag while checking through the umbilicus camera. Special attention must be paid to avoid any damage to the bag because the visualization is limited in this technique. Second, a direct-view technique is described, in which we exteriorized the opening of a 15-mm bag through the suprapubic trocar and a closed end of the bag through the umbilicus. We made a hole in the umbilicus end of the bag and introduced the camera trocar through it. Once done, we introduced the morcellator through the opening and the camera in the umbilicus port. Third, a single-port-contained morcellation is explained. The bag was exteriorized through the umbilicus, and a skin retractor was placed. A glove was placed outside the retractor to isolate the bag. Once placed, 2 of the fingers were opened and used as trocars (one for the morcellator and the other for a 30° camera). After using this technique, the scope should be replaced to minimize the risk of contamination. The following are possible limitations of each technique: in the indirect-view technique, owing to the limited visualization, the surgeon must pay special attention to avoid tearing the bag while morcellating the specimen. In the direct-view technique method, the surgeon needs to ensure the proper closure of the bag before removing it from the abdomen to avoid possible dissemination risk. Finally, in the single-port technique, the surgeon must have previous experience in this type of approach, minimizing the risk of contamination by changing the scope after the morcellation process. Laparoscopic power morcellation may provide several benefits for our patients, when performing a hysterectomy or a multiple myomectomy. We presented 3 different and feasible techniques for laparoscopic power morcellation using an endobag container.

&lt;p&gt;Laparoscopic Myomectomy – Converting to Laparotomy for a Suspicious Intraoperative Appearance with Subsequent Benign Histology – a Pre- and Intra-Operative Dilemma&lt;/p&gt;

BackgroundAlthough the most common uterine tumour is leiomyoma, the differential diagnoses also include the rarer adenomyoma and leiomyosarcoma. A lack of clear reliable clinical and radiological features makes the triage of uterine masses to the appropriate surgical procedure difficult. In the case of suspicious appearance of a presumed leiomyoma, an open surgical approach is recommended and morcellation is avoided.CaseWe present a case of a woman undergoing an elective laparoscopic myomectomy for a fibroid that appeared benign on ultrasound but had suspicious features intraoperatively. The operation was converted to a laparotomy to avoid the risk of morcellation-related seeding in the event that the histology was malignant. The histology was subsequently a benign exophytic adenomyoma.ConclusionThe assessment of the nature of fibroids can be difficult both pre- and intraoperatively, and the need for difficult decision making to convert to open surgery during a laparoscopic myomectomy but with subsequent benign histology should be part of patient counselling.

ACOG Committee Opinion No. 770: Uterine Morcellation for Presumed Leiomyomas: Correction.

ACOG Committee Opinion No. 770: Uterine Morcellation for Presumed Leiomyomas: Correction.

Mass lesions of the myometrium: interpretation and management of unexpected pathology.

Uterine leiomyomas are the most common benign uterine smooth muscle tumors. On the basis of imaging, these masses are often presumed to be benign conventional leiomyomas and surgical excision is a common treatment choice. After myomectomy or hysterectomy for presumed leiomyomas, the surgical pathology report may reveal an unexpected diagnosis of another type of mesenchymal tumor. These can range from a variant of benign smooth muscle tumors to smooth muscle tumors of uncertain malignant potential to malignant sarcomas. This review describes these variant pathologies and reviews data on recurrence risk and postoperative management. The majority of benign smooth muscle tumors will be classified as leiomyomas. Cellular, bizarre nuclei, mitotically active, epitheliod, myxoid, and dissecting are all terms that describe pathologic variants of benign leiomyomas. Smooth muscle tumors of uncertain malignant potential contain both benign and malignant features and should be referred to Gynecologic Oncology for follow-up. Leiomyosarcomas and low-grade endometrial stromal sarcomas may present preoperatively as benign tumors but are malignant with a high risk of recurrence and should be referred to Gynecologic Oncology. We advocate for the continued benefits of minimally invasive procedures in appropriately selected patients. Despite these measures, unexpected pathologic diagnoses can occur and should be managed appropriately.

Unexpected uterine sarcomas after hysterectomy and myomectomy for presumed leiomyoma: a retrospective study of 26,643 patients.

ObjectivesWe conducted this study to explore the clinical characteristics, prognosis, and prevalence of unexpected uterine sarcoma (UUS) after hysterectomy and myomectomy for presumed leiomyoma.Study designThe records of women who underwent hysterectomy or myomectomy through laparoscopy or laparotomy for preoperatively presumed uterine leiomyomas from January 2009 to December 2016 were reviewed and data were retrospectively analyzed.ResultsEleven patients had morcellation of uterine sarcoma. Eighty-eight patients were diagnosed with uterine sarcomas (total prevalence: 0.33%) including 29 leiomyosarcomas (LMS), 48 endometrial stromal sarcomas (ESS), and 11 adenosarcomas. ESS patients with advanced stage were significantly associated with worse overall survival (p<0.01).ConclusionOnly 0.33% of patients who underwent surgery for presumed leiomyoma experienced UUS, and advanced stage seemed to be the single prognostic factor for sarcoma. However, the time interval between initial treatment and secondary definitive surgery was not shown to impact prognosis. In addition, the small number of UUS patients having morcellation (4 LMS and 7 ESS) may be underpowered to detect differences in survival.

Uterine leiomyosarcoma: A 10-year review in a referral hospital in Peru, 2005 - 2014

Background. Uterine leiomyosarcoma (LMS) accounts for more than 50% of uterine sarcomas, representing 1.3% of all uterine malignancies. The presenting symptoms of uterine LMS are the same as those of leiomyoma. This characteristic hinders a prompt diagnosis, or suspicion, before a surgical intervention. Patients diagnosed with uterine LMS are often in an early stage of the disease. Nonetheless, the overall prognosis is poor. Objective. To describe the general characteristics, clinical features, diagnosis and treatment of patients with LMS. Methods. From 2005 to 2014, clinical files of patients diagnosed with a uterine LMS at Hospital Nacional Edgardo Rebagliati Martins in Peru were reviewed. Results. Eleven cases with complete information were identified. The mean age at diagnosis was 45.36 years (range 27 - 61 years); the most frequent symptom reported was pelvic pain in 54% ( n =6/11) patients; 72% ( n =8/11) patients were diagnosed after surgical intervention. The most frequent clinical stage was IB in 90% ( n =10/11) cases. Initial treatment was total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) in 62% ( n =7/11) cases. The prevalence of undiagnosed uterine LMS in hysterectomies and myomectomies performed for presumed leiomyomas was 0.24% and 0.22%, respectively. Conclusion. The clinical presentation of uterine LMS does not differ from usual leiomyomas. Most of the cases were diagnosed incidentally after surgical specimen analysis. The most accepted initial management to date is still en bloc TAH and BSO. Follow-up strategies should be implemented and be the goal of any long-term programme.

ACOG Committee Opinion No. 770 Summary: Uterine Morcellation for Presumed Leiomyomas.

Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering open morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated, and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.

ACOG Committee Opinion No. 770: Uterine Morcellation for Presumed Leiomyomas.

Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering open morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated, and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.

Unexpected uterine sarcomas in 4478 patients with electric power morcellation for leiomyomas

ObjectivesOur objective is to investigate the prevalence, pathology and prognosis of uterine sarcomas in laparoscopic hysterectomy/myomectomy with electric power morcellation for presumed leiomyomas. Study DesignWe retrospectively reviewed patients with laparoscopic power morcellation (LPM) for presumed leiomyomas in a Chinese tertiary institution by chart review from September 1, 2013 to December 31, 2016. ResultsTwenty-four in 4478 patients (0.54%) with LPM for presumed leiomyomas had unexpected cancers. The patients showed the highest frequency of occult cancers (10/375, 2.6%) at 51–60 years and lowest (0/255) before 30 years. The pathology included 14 endometrial stromal sarcomas (ESS) (low-grade 12 and high-grade 2), 9 leiomyosarcomas, and 1 malignant mixed mesodermal tumor. The patients underwent abdominal re-exploration including total hysterectomy with bilateral salpingo-oophorectomy and staging surgery. Three patients were at advanced FIGO stage (IIIb-IVb) and 21 at stage I. Seven patients recurred within 1–25 (mean 6.29) months including 5 leiomyosarcomas, 1 high-grade and 1 low-grade ESS. Four recurrent patients with leiomyosarcomas and one with high-grade ESS died of disease in 1–3 months. Seventeen patients had no relapse and were alive for 6–41 (mean 24) months. ConclusionsOur study suggests that patients with LPM for presumed leiomyomas appear to have a considerable risk of unexpected cancers. Moreover, morcellation is potentially associated with adverse prognosis in patients with high-grade sarcomas. Informed consent on unexpected cancers that should be discussed before morcellation.

Üreme çağındaki kadınlarda leiomiyosarkoma

Purpose: Uterine leiomyosarcomas are exytremely rare tumors. Increased age and postmenopausal status are the potential risk factors of leiomyosarcomas. We aimed to determine the incidence of uterine leiomyosarcoma in women during reproductive period who undergoing hysterectomy or myomectomy for presumed benign leiomyomas. Materials and Methods: This retrospective study was carried out on women in reproductive age who had undergone myomectomy or hysterectomy due to presumed leiomyoma from January 1, 2013 to January 1, 2015. The incidence of leiomyosarcoma was calculated. Patient ages, admitting symptoms, and operative and pathologic findings were analyzed. Results: A total of 919 women in reproductive age underwent surgeries in the period of the study. We found four cases (0.40%) of rare primary sarcomas of uterus. Case-1 and Case-3 were a 40-year old women, Case-2 was a 36-year-old women, and Case-4 was a 39-year-old woman. Abnormal uterine bleeding and pelvic pain were the two symptoms in our malignant cases. 3 of the women underwent myomectomy procedure while one patient had hysterectomy.Conclusion: All women should be informed about quite minimal but potential possibility of malignancy that is present for their presumed leiomyomas during the counseling about the treatment options of leiomyomas.

Undiagnosed Uterine Sarcomas Identified During Surgery for Presumed Leiomyoma at a National Tertiary Hospital in Thailand: A 10-Year Review.

The aim of this study was to evaluate the rate, clinical characteristics, and survival outcomes of an undiagnosed uterine malignancy in patients who underwent surgical treatment for presumed leiomyomas. Medical records of patients who underwent surgical treatment for presumed leiomyomas, from January 2004 to September 2013, were retrospectively reviewed, and the data were followed until September 2016. Demographic data, tumor characteristics, oncologic treatment, and response rate were analyzed by descriptive statistics. Kaplan-Meier method was used for survival analysis. This study includes follow-up data through December 31, 2016. A total of 11,258 medical records of presumed leiomyoma patients undergoing hysterectomy during the studied period were reviewed. Pathology of uterine sarcoma was found in 22 patients (0.2%), all of whom were included. Nineteen patients had leiomyosarcoma, and 3 had endometrial stromal sarcoma. Mean age of patients was 48.3 ± 6.9 years. All patients underwent total abdominal hysterectomy, with 20 patients undergoing concurrent bilateral salpingo-oophorectomy. Uterine sarcoma was classified as stage IB in 21 patients and stage IIIC in 1 patient. Fifteen patients were prescribed the following adjuvant treatment: chemotherapy in 13 patients and megestrol acetate in 2 patients. Thirteen patients had recurrent disease, and 3 patients died of their disease. The mean progression-free survival was 50.1 ± 41.3 months, and overall survival was 59.3 ± 43.0 months. One in 512 patients who underwent hysterectomy because of presumed uterine leiomyomas had inadvertent uterine sarcomas. Even with adjuvant therapy, treatment outcome was rather poor, with almost 60% recurrence rate and median progression-free survival and overall survival of less than 5 years.

Fate of laparoscopic morcellation post-FDA warning: a literature review

In laparoscopy, tissue extraction might require morcellation for larger intra-abdominal specimens, especially in gynecological patients. specimen, the specimen needs to be reduced. The Food and Drug Administration (FDA) issued a press release in April 2014 that discouraged the use of devices used for morcellation - power morcellators. This article has the objective to review the literature related to complications by power morcellation of uterine fibroids in laparoscopy and offer recommendations to laparoscopic surgeons in gynaecology. Respecting women who have leiomyosarcoma, it can be concluded that the FDA directive was based on a mis­leading analysis due to inherent flaws in the trials analysed by it. Hence, the need of the hour are more accurate esti­mates regarding the prevalence of leiomyosarcoma among women having surgery for presumed leiomyomas. Modification of the FDA’s current restriction regarding power morcellation would empower each woman to allow surgeons and hospitals to make the most appropriate, informed choices regarding utilization of tissue extraction in individual patients undergoing uterine surgery without undermining the freedom of the woman to choose the best-suited procedure.

Uterine Sarcomas in Patients Undergoing Surgery for Presumed Leiomyomas: 10 Years' Experience

Study ObjectiveTo find the incidence of sarcomas in patients undergoing surgery for presumed leiomyomas. DesignRetrospective study (Canadian Task Force classification II-3). SettingPaul's Hospital, Centre for Advanced Laparoscopy and Infertility, Kochi, India. PatientsAll women who underwent total laparoscopic hysterectomy (TLH), laparoscopic myomectomy (LM), and hysteroscopic myomectomy (HM) at Paul's Hospital for presumed leiomyomas from January 1, 2004 to December 31, 2014 that were then diagnosed as sarcomas on histopathologic examination. InterventionsTLH, LM, and HM. Measurements and Main ResultsA total of 2678 patients underwent TLH, LM, and HM at Paul's Hospital for presumed leiomyomas from January 1, 2004 to December 31, 2014. Five patients were diagnosed as leiomyosarcoma and 3 patients as endometrial stromal sarcoma on histopathologic examination. Women's ages ranged from 12 to 53 years. Histopathologic diagnosis of leiomyosarcoma was made in 3 patients from the TLH group and 2 patients from the myomectomy group. Two patients from the TLH group and 1 patient from the myomectomy group were diagnosed as endometrial stromal sarcoma on histopathologic examination. The incidence of uterine sarcomas (leiomyosarcoma and endometrial stromal sarcoma) in patients undergoing surgery for presumed leiomyomas was found to be .29% (1 in 335 patients) in our study. ConclusionOver a period of 10 years (2004–2014), the incidence of uterine sarcomas in patients undergoing surgery for presumed leiomyomas was found to be .29% in our study.

Laparoscopic Morcellation of Fibroid and Uterus In-Bag

Uterine morcellation of presumed leiomyomas inadvertently results in an increase in morcellated uterine leiomyosarcoma (ULMS). Morcellation alters the natural course of ULMS, leading to an increased incidence and earlier recurrences. Recurrences following tumor morcellation are significantly more likely to occur in the peritoneum. Since there is no reliable method for predicting whether a woman with fibroids may have a uterine sarcoma, the US FDA (Food and Drug Administration) discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy (US Food and Drug Administration, http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm in 2014). In the wake of recent ban on usage of power morcellation by US FDA, we introduce a technique of in-bag morcellation, thus avoiding spillage of tissues in the peritoneal cavity and spread of an undiagnosed disease or cancer or sarcoma. We present a study of twenty-one cases of laparoscopic in-bag morcellation of fibroid and uteri done by Total Health Care method. The in-bag morcellation technique handles the issue of ULMS and makes laparoscopic myomectomy and hysterectomy possible with fair safety. Further studies should be directed toward identifying patients at high risk of ULMS prior to presumed leiomyoma resection in order to reduce the risk of inadvertent tumor morcellation.