Unexpected Uterine Sarcoma 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.

Impact on prognosis of unexpected uterine sarcoma with scalpel morcellation or enucleation

ObjectiveIt is well known that power morcellation of unexpected uterine sarcoma affects prognosis. There are few reports on the effects of scalpel morcellation or myomectomy of uterine sarcoma on prognosis, which is not well understood. This study investigated the effect on recurrence and prognosis when tumors of uterine sarcoma undergo scalpel morcellation or myomectomy. MethodsWe performed a retrospective, observational study by collecting data from the medical records of patients who were histologically diagnosed with uterine sarcoma at our hospital between 2005 and 2017. All patients with unexpected uterine sarcoma were diagnosed after laparoscopic hysterectomy with scalpel morcellation or myomectomy (abdominal and laparoscopic) for presumed myoma. We evaluated recurrence rate, recurrence site, progression-free survival (PFS), and overall survival (OS). ResultsA total of 15 patients were examined in this study. Twelve patients underwent myomectomy (7 patients with open surgery, 5 patients with laparoscopic surgery), and 3 patients underwent total laparoscopic hysterectomy with transvaginal scalpel morcellation. There were 11 cases of recurrence, and the recurrence rate was 78 %. The recurrence site was peritoneal dissemination in 10 cases (91 %) and lymph node metastasis in 1 case (9 %). The median PFS was 32 months [95 % confidence interval (CI) = 6.5-NA], and the median OS was 95.5 months [95 % CI = 55.8-NA]. ConclusionPower morcellation, scalpel morcellation, and myomectomy may affect recurrence and prognosis. Further studies are needed in the future.

Medicolegal Issues in Power Morcellation: Cautionary Rules for Gynecologists to Avoid Unfavorable Outcomes

Power morcellation in laparoscopic surgery enables specialists to carry out minimally invasive procedures such as hysterectomies and myomectomies by cutting specimens into smaller pieces using a rotating blade and removing pieces through a laparoscope. Unexpected uterine sarcoma treated by surgery involving tumor disruption could be associated with poor prognosis. The current study aims to shed light on power morcellation from a medicolegal perspective: the procedure has resulted in adverse outcomes and litigation, and compensation for plaintiffs, as published in various journals cited in PubMed and MEDLINE, Cochrane Library, EMBASE, and GyneWeb. Considering the claims after the US Food and Drug Administration warnings on morcellation, the current study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia, superior court of New Jersey, and US district court of Minnesota) between 1995 and 2019. Legal records show that courts determine professional responsibility regarding complications, making it essential to document adherence to safety protocols and specific guidelines, when available. Sound medical practices and clearly stated institute best practices result in better patient outcomes and are important when unfavorable clinical outcomes occur; adverse legal decisions can be avoided if there are grounds to prove professional conformity with specific guidelines and the unpredictability of an event.

A Case Report Of Uterine Leiomyosarcoma.

BackgroundUterine leiomyoma is the most common benign tumor in women. Uterine sarcoma, though with very low incidence, has a high malignant degree and poor prognosis. It has difficulties in preoperative diagnosis, frozen pathological examination and postoperative treatment.Case reportA 49-year-old woman presented with menstrual disorder. Magnetic resonance imaging showed a huge uterine mass. The patient underwent laparoscopic hysterectomy and part of the uterine tissue looked like fish. Specimens were sent to frozen pathological examination for four times, but none of the results showed malignancy certainly. Considering all abnormalities, we removed the uterine through vagina completely rather than morcellation and did pelvic lymph node biopsy. Postoperative pathological examination revealed uterine leiomyosarcoma and one pelvic lymph node had metastasized.ConclusionUterine sarcoma is difficult to be diagnosed even frozen pathological examination has been performed. Unexpected uterine sarcoma should always be considered, and precautions should be taken if we find anything suspicious. Fortunately, the patient has avoided second operation.

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.

No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy.

This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery. Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation. RECOMMENDATIONS.

Incidence of sarcoma in patients undergoing hysterectomy for benign indications: a population-based study

Minimally invasive hysterectomy may require the use of morcellation to remove the uterus. In the presence of unexpected sarcoma, morcellation risks disseminating malignant cells and worsening survival outcomes. As a consequence, in 2014 the US Food and Drug Administration issued a black box warning against the use of power morcellator for the treatment of uterine fibroids. However, the proportion of unexpected sarcoma at the time of hysterectomy for presumed benign indication remains unclear. The objective of the study was to estimate the incidence of sarcoma among women undergoing hysterectomy for benign indication in Olmsted County, MN, between 1999 and2013. We conducted a population-based study including all hysterectomies performed for benign indication in Olmsted County women between Jan. 1, 1999, and Dec. 31, 2013. Cases were identified using the medical records-linkage system of the Rochester Epidemiology Project, and data were abstracted by a gynecologist who reviewed the complete medical records of eachwoman who underwent hysterectomy. An expert pathologist reviewed the pathologic slides of each sarcoma to ensure the accuracy of thediagnosis. Incidences of sarcoma (overall and by type of sarcoma) were estimated both overall and stratified by menopausal status, indication for surgery, and uterine weight as a rate per 100 persons. A total of 4232 hysterectomies were performed during the study period. Among them, we identified 16 sarcomas, of which 11 (69%) were suspected preoperatively and 5 (31%) were unexpected. Of the total number of hysterectomies, 3759 (88.8%) were performed for benign indication. Among those, the incidence of unexpected sarcoma was 0.13% (5 per 3759 [95% confidence interval, 0.04-0.31%]). Uterine fibroids comprised 27.3% of all hysterectomies for benign indication (n= 1025) and was the indication most commonly associated with diagnosis of unexpected sarcoma. The incidence of unexpected sarcoma among surgeries for uterine fibroids was 0.35% (3 of 851) for premenopausal women and 0.57% (1 of 174) for peri/postmenopausal, and all 4 unexpected sarcomas were leiomyosarcoma. The incidence of unexpected sarcoma progressively increased with higher uterine weight with an incidence of 0.03% (1 of 2993) among women with a uterine weight <250 g vs 15.4% (2 of 13) with a uterine weight ≥2000 g. Unexpected uterine sarcoma was low in all women undergoing hysterectomy for benign indication (0.13% or 1 in 752 surgeries) while it was increased in women with uterine fibroids (0.39% or 1 in 256 surgeries). Peri/postmenopausal women, women with large uteri, and age ≥45 years were risk factors for sarcoma.

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.

Outcomes of uterine sarcoma found incidentally after uterus-preserving surgery for presumed benign disease.

BackgroundThe aims of this study were to evaluate the impact of initial uterus-preserving surgery, such as myomectomy or subtotal hysterectomy, on the recurrence rates of patients with uterine sarcoma found incidentally and to investigate the role of surgical re-exploration in this disease subset.MethodsWe performed a retrospective chart review for patients who had previously undergone either total hysterectomy or subtotal hysterectomy or myomectomy at the time of initial surgery for presumed benign uterine leiomyoma and were found to have uterine sarcoma on final pathology. Survival analysis was performed comparing patients according to the type of initial surgery.ResultsBetween 2006 and 2014, 45 patients with uterine sarcoma were identified. Myomectomy or subtotal hysterectomy was performed in 15 patients, and 30 patients underwent total hysterectomy as the initial surgery. Of the patients who underwent myomectomy or subtotal hysterectomy as the initial surgery (n = 15), 14 were re-explored to complete staging. Of the patients who underwent re-exploration (n = 14), five (35.8 %) had remnant sarcoma on the remaining uterus and no patients had disseminated disease. A Kaplan–Meier curve and log-rank test showed no difference in progression-free survival (P = 0.941) between the two groups.ConclusionInitial uterus-preserving surgery does not appear to be associated with an adverse impact on survival outcomes for unexpected uterine sarcoma when surgical re-exploration was performed immediately. As such, surgical re-exploration may be useful for removing any remnant sarcoma.Electronic supplementary materialThe online version of this article (doi:10.1186/s12885-016-2727-x) contains supplementary material, which is available to authorized users.

Incidence and clinical characteristics of unexpected uterine sarcoma after hysterectomy and myomectomy for uterine fibroids: a retrospective study of 10,248 cases.

BackgroundUterine fibroids often require a hysterectomy or myomectomy via laparotomy or laparoscopy. Morcellation is often necessary to perform a laparoscopic surgery. The objective of this study is to determine the incidence of unexpected uterine sarcomas (UUSs) after hysterectomy and myomectomy for uterine fibroids and to reduce the occurrence and avoid the morcellation of UUSs by analyzing their characteristics.MethodsWomen who had a hysterectomy or myomectomy for uterine fibroids in Shengjing Hospital of China Medical University between November 2008 and November 2014 were selected for the study, and their clinical characteristics were analyzed.ResultsDuring the period, 48 UUSs were found in 10,248 cases, and the overall incidence was 0.47%. There was no statistical difference (P=0.449) regarding the incidence (0.50% vs 0.33%) between 42 UUSs in 8,456 cases undergoing laparotomy and six UUSs in 1,792 cases undergoing laparoscopy. Most of the UUSs were stage I (89.58%), which occurred more commonly (56.25%) in women aged 40–49. Abnormal uterine bleeding (39.58%) was the main clinical manifestation. Rapidly growing pelvic masses (12.5%), rich blood flow signals (18.75%), and degeneration of uterine fibroids (18.75%) prompted by ultrasonography may suggest the possibility of UUSs. The margins of most UUSs (93.75%) were regular, which may cause UUSs to be misdiagnosed as uterine fibroids. Fifteen cases underwent magnetic resonance imaging examinations. Approximately 73.33% showed heterogeneous and hypointense signal intensity on T1-weighted images, and 80% showed intermediate-to-high signal intensity on T2-weighted images, with necrosis and hemorrhage in 40% of cases. After contrast administration, 80% presented early heterogeneous enhancement.ConclusionThe incidence of UUSs after hysterectomy and myomectomy for uterine fibroids was low, and their clinical characteristics are atypical. It is necessary and very critical to make a complete and cautious preoperative evaluation to reduce the occurrence and avoid the morcellation of UUSs.

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.

Age-stratified risk of unexpected uterine sarcoma following surgery for presumed benign leiomyoma.

Estimates of unexpected uterine sarcoma following surgery for presumed benign leiomyoma that use age-stratification are lacking. A retrospective cohort of 2,075 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 data. Database-derived age distributions of the incidence rates of uterine sarcoma and uterine leiomyoma surgery were used to stratify risk by age. Of 2,075 patients in our retrospective cohort, 6 were diagnosed with uterine sarcoma. Our meta-analysis revealed 8 studies from 1980 to 2014. Combined with our study, 18 cases of leiomyosarcoma are reported in 10,120 patients, for an aggregate risk of 1.78 per 1,000 (95% confidence interval [CI]: 1.1-2.8) or 1 in 562. Eight cases of other uterine sarcomas were reported in 6,889 patients, for an aggregate risk of 1.16 per 1,000 (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 1,000 (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 1,000, or 1 in 98, for patients aged 75-79 years to <1 case per 500 for patients aged <30 years. 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 the surgical technique for leiomyoma.

Unexpected Uterine Sarcoma and Other Gynecologic Malignancies Diagnosed after Hysterectomy Performed for Benign Indications

Unexpected Uterine Sarcoma and Other Gynecologic Malignancies Diagnosed after Hysterectomy Performed for Benign Indications

Tissue Extraction and Morcellation: The Menace of Unexpected Malignancy

ABSTRACT Uterine fibroids are a common indication for hysterectomy or myomectomy. Even with optimal preoperative imaging, unexpected uterine sarcoma can be detected in histopathology after uterine fibroid surgery. 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. The purpose of this study was to determine the prevalence of uterine sarcoma in women undergoing hysterectomy or myomectomy for benign uterine fibroids. We performed retrospective study (2003-2014 years). The total number of women operated for uterine fibroids was 2297. Of this, 938 (42.5%) women had myomectomies and 1269 (57.5%) women had hysterectomies. In myomectomies the most frequently used surgical method was laparoscopic myomectomy in 591(63%) cases, followed by hysteroscopy myomectomy in 306 (32.62%) cases, and laparotomic myomectomy only in 41 (4.37%) cases. In hysterectomies, laparoscopic approaches significantly dominated in 1163 (61.1%) cases, showing laparotomic approaches in 491(25.82%) cases and vaginal approaches in 247 (12.99) cases. Only one patient with endometrial stromal sarcoma (ESS) was not preoperatively diagnosed and treated as symptomatic uterine fibroid; this patient underwent laparoscopic supracervical hysterectomy. In the post-operative histopathological examination ESS was detected. Thus, our incidence of sarcomas among women who underwent benign uterine fibroid surgery is 1/2297 (0,043%). Laparoscopic power morcellation should be performed only in cases with no suspicion of malignancy Patients, who undergo laparoscopic surgery with power morcellation should be informed about the possible risks of morcellation in cases of rare not suspected malignant disease. How to cite this article Mettler L, Abdusattarova K. Tissue Extraction and Morcellation: The Menace of Unexpected Malignancy. Int J Gynecol Endsc 2017;1(1):1-4.