Presumed Leiomyoma Research Articles

Risk Factors for Occult Uterine Sarcoma Among Women Undergoing Minimally Invasive Gynecologic Surgery

Study ObjectiveTo determine factors that can identify a population at increased risk for uterine leiomyosarcoma. DesignRetrospective case-control study (Canadian Task Force classification II-2). SettingUniversity teaching hospitals. PatientsSeventy-two women who underwent minimally invasive gynecologic surgery for presumed leiomyoma. Patients diagnosed with leiomyosarcoma (cases) were matched with up to 4 controls on age, year of surgery, and surgeon specialty. InterventionCases were identified through the pathology database, and the diagnosis of leiomyosarcoma or leiomyoma was confirmed by gynecologic pathologists. The cumulative risk of leiomyosarcoma was calculated, and factors predictive of elevated risk for leiomyosarcoma were investigated using conditional logistic regression. Measurements and Main ResultsFifteen patients with the diagnosis of inadvertently morcellated leiomyosarcoma were identified and matched with 57 controls. The cumulative risk of diagnosing uterine leiomyosarcoma on pathology after performing minimally invasive gynecologic surgery with morcellation was 0.19% (95% confidence interval [CI], 0.06%–0.56%). The presence of a hematocrit value < 30% (adjusted odds ratio [aOR], 20; 95% CI, 1.08–100; p = .05) was independently associated with the diagnosis of uterine leiomyosarcoma on multivariate analysis. Increased myoma size (aOR, 9.73; 95% CI, 0.75–1.26; p = .08) and presence of a solitary myoma (aOR, 3.85; 95% CI, 0.65–25; p = .14) were associated with a greater risk of uterine leiomyosarcoma; however, the difference was not statistically significant. ConclusionAnemia and myoma size >7 cm may be associated with occult leiomyosarcoma; however, these criteria are not sufficiently discriminatory to allow for preoperative identification of patients with uterine sarcoma. Future large multicenter studies are needed to further investigate these findings and the discovery of innovative ways to detect uterine leiomyosarcoma are urgently needed.

Abstract 5589: Age-stratified risk of unexpected uterine sarcoma following surgery for presumed benign leiomyoma

Abstract Background: Estimates of unexpected uterine sarcoma following surgery for presumed benign leiomyoma that utilize age-stratification are lacking. Patients and Methods: A retrospective cohort of 2075 patients that had undergone myomectomy was evaluated to determine the case incidence of unexpected uterine sarcoma. An aggregate risk estimate was generated using a meta-analysis of similar studies plus our cohort. Database-derived age distributions of the incidence rates of uterine sarcoma and uterine leiomyoma surgery were used to stratify risk by age. Results: Of 2075 patients in our cohort, six were diagnosed with uterine sarcoma. Our meta-analysis revealed 8 studies from 1980-2014. Combined with our cohort, there are 18 cases of leiomyosarcoma reported in 10120 patients, for an aggregate risk of 1.78 per 1000 [95% CI: 1.1-2.8], or 1 in 562. There are 8 cases of other uterine sarcomas reported in 6889 patients, for an aggregate risk of 1.16 per 1000 [95% CI: 0.5-4.9], or 1 in 861. The summation of these risks gives an overall risk of uterine sarcoma of 2.94 per 1000 [95% CI: 1.8-4.1], or 1 in 340. After stratification by age, we predict the risk of uterine sarcoma to range from a peak of 10.1 cases per 1000, or 1 in 98, for age 75-79 to less than 1 case per 500 for age &amp;lt;30. Conclusion: The risk of unexpected uterine sarcoma varies significantly across age groups. Our age-stratified predictive model should be incorporated to more accurately counsel patients and to assist in providing guidelines for surgical technique for leiomyoma. Age-stratified risk of unexpected uterine sarcoma at the time of surgery for presumed leiomyomaAgeEstimated(years)Risk of Uterine Sarcoma (per 1000 procedures)25-291.74(1 in 574)30-342.01(1 in 496)35-392.65(1 in 377)40-442.46(1 in 405)45-493.28(1 in 304)50-544.62(1 in 216)55-596.35(1 in 158)60-646.36(1 in 157)65-697.53(1 in 133)70-748.55(1 in 117)75-7910.1(1 in 98)80-845.57(1 in 179) Citation Format: Andrew S. Brohl, Li Li, Vaagn Andikyan, Angela Cioffi, Joel T. Dudley, Andrew Kasarskis, Robert G. Maki. Age-stratified risk of unexpected uterine sarcoma following surgery for presumed benign leiomyoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5589. doi:10.1158/1538-7445.AM2015-5589

Clinical characteristics and management experience of unexpected uterine sarcoma after myomectomy

ObjectiveTo identify the prevalence of unexpected uterine sarcoma after myomectomy for presumed leiomyoma and compare clinical outcomes after primary myomectomy with and without power morcellation. MethodsIn a retrospective study, a review was undertaken of the medical records of patients who had unexpected uterine sarcoma after myomectomy with and without power morcellation at Peking Union Medical College Hospital, Beijing, China, between January 2009 and December 2013. ResultsAmong 4248 patients who underwent myomectomy for presumed leiomyoma, 9 (0.2%) had unexpected uterine sarcoma (1 [<0.1%] had leiomyosarcoma; 8 [0.2%] endometrial stromal sarcoma). The malignancy was identified in 5 (0.2%) of 3068 women who were treated by laparoscopy with power morcellation and 4 (0.3%) of 1180 who underwent laparotomy (P=0.274). All nine patients were alive after a mean follow-up of 31.2months in the laparoscopy group and 40.5months in the laparotomy group. ConclusionThe overall incidence of unexpected uterine sarcoma after myomectomy was low. Incidental power morcellation of unexpected uterine sarcoma seemed to cause no increase in sarcoma dissemination.

Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma.

Uterine leiomyosarcoma (ULMS) is identified in 0.1% to 0.2% of hysterectomy specimens of presumed leiomyoma. To date, there is no preoperative technique that reliably differentiates ULMS from uterine leiomyoma. Increasing use of minimally invasive approaches for the management of leiomyomas may result in inadvertently morcellated ULMS with resultant intraperitoneal dissemination of tumor. The objective of this study was to assess the impact of intraperitoneal morcellation on the outcomes of patients with ULMS. In this retrospective cohort study, all patients with ULMS who attended the authors' institutions from 2007 to 2012 were reviewed. Demographics and outcomes were compared between those who underwent morcellation or total abdominal hysterectomy (TAH) as their first surgery for uterus-limited ULMS. In total, 58 patients were identified, including 39 who underwent TAH and 19 who underwent intraperitoneal morcellation. Intraperitoneal morcellation was associated with a significantly increased risk of abdominal/pelvic recurrences (P = .001) and with significantly shorter median recurrence-free survival (10.8 months vs 39.6 months; P = .002). A multivariate adjusted model demonstrated a > 3 times increased risk of recurrence associated with morcellation (hazard ratio, 3.18; 95% confidence interval, 1.5-6.8; P = .003). Intraperitoneal morcellation of presumed leiomyoma worsens the outcomes of women with ULMS. Because there are no reliable preoperative techniques to distinguish ULMS from benign leiomyoma, all efforts to minimize intraperitoneal uterine morcellation should be considered. [See editorial on pages 000-000, this issue.]

Myometrial Myxoidosis: A Report of 2 Cases of a Distinctive Type of Secondary Myometrial Hypertrophy in Patients With Lupus Erythematosus

Myxoid mesenchymal lesions of the uterus are generally restricted to tumors, but non-neoplastic myxoid mesenchymal lesions of the uterus have not received much attention in the literature. We analyzed the clinicopathologic features of 2 patients with lupus erythematosus (ages 43 and 52 yr, respectively) in whom myometrial myxoidosis produced a markedly enlarged uterus with myometrial thickening ("secondary myometrial hypertrophy"). Both patients underwent a hysterectomy for presumed leiomyomas, and intraoperatively an enlarged uterus was noted. On gross examination, the uteri measured 13.5 x 13.5 x 11.5 cm and 14.5 x 11.5 x 9.5 cm, respectively. The significantly thickened myometrium was due to marked expansion of the interstitial compartment of the myometrium, in which non-neoplastic smooth muscle fascicles were widely separated by abundant extracellular mucin producing a striking myxoid appearance ("myxoidosis"). These histologic findings are akin to the pattern of dermal mucin deposition seen in lupus erythematosus. The lesion in each case diffusely involved the entire myometrium. Histochemical stains were performed and showed the following results: mucicarmine-diffusely but weakly positive; periodic acid-schiff (PAS)-negative; colloidal iron-diffuse positive; alcian blue, pH 2.5 (without hyaluronidase digestion)-diffuse positive, and alcian blue, pH 2.5 (with hyaluronidase digestion)-negative. These histochemical findings are consistent with hyaluronic acid. Follow-up in 1 case was not available. In the other case, the patient presented to clinical attention 5 weeks after surgery because of ascites, which after an extensive clinical evaluation was interpreted as being of unknown etiology. To the best of our knowledge, this rare and unusual non-neoplastic myometrial lesion has not been previously described. Pathologists should be aware of its existence because of the distinctive appearance and as it may prompt consideration of various myxoid neoplasms of the uterus in the differential diagnosis. Patients with myometrial myxoidosis should be evaluated for lupus erythematosus.

Hystérectomies pour léiomyomes présumés : la crainte du léiomyosarcome doit-elle faire appréhender la voie d’abord chirurgicale autre que laparotomique ?

Objectives The presenting symptoms of leiomyosarcoma (LMS) are the same as those of leiomyoma. The diagnosis of LMS is usually achieved retrospectively after pathological analysis of hysterectomy specimens. The aim of surgery in uterine sarcomas being resection without tumor morcellation, LMS poses the problem of the choice of surgical route because it is more likely to occur in relatively young women. This study was undertaken to determine, firstly, the frequency of LMS in a series of hysterectomies performed for presumed leiomyomas, secondly, if there exist any particular context in which LMS should be considered and how this may modify the choice of surgical route, thirdly, to discuss about the therapeutical aspects of those cases of LMS diagnosed incidentally after uterine morcellation. Patients and methods A retrospective review, from 1996 to 2005, of cases of LMS diagnosed retrospectively in patients having benefited from hysterectomy for presumed leiomyomas, at the department of Obstetrics-Gynaecology, Belfort Hospital. Results From 1996 to 2005, 1297 hysterectomies have been performed for presumed leiomyomas in our department. Patients’ mean age was 48 years (34 to 77 years). Menometrorraghia was the most common symptom having motivated surgery (57%), followed by pelvic pain (31%) and the notion of a rapidly growing uterine mass (12%). The distribution of surgical route was as follows: laparotomic route, n = 393 (30%); vaginal route, n = 855 (66%) and laparoscopic assisted vaginal route, n = 49 (4%). Pathological analysis had revealed LMS in three patients (0.23%). Discussion and conclusion LMS is usually diagnosed incidentally on hysterectomy specimen analysis. Indeed, the surgeon may find himself in a therapeutic dilemma in cases where vaginal extraction has required tumour morcellation with an increased risk of peritoneal and/or vaginal dissemination. However, given the extremely low incidence of LMS in series of hysterectomies performed for presumed leiomyomas and the lack of specific preoperative context to clearly evoke this diagnosis, the fear of leiomyosarcoma should not make us apprehend nonlaparotomic surgical routes.