Morcellation and myomas: Balancing decisions around minimally invasive treatments for fibroids

Getting square pegs out through round holes: A survey of Australian and New Zealand Gynaecologists regarding specimen retrieval

AIMS

To evaluate morcellation practices among Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).

MATERIALS AND METHODS

RANZCOG Fellows were invited to complete an online survey. This anonymous, cross-sectional survey consisted of 29 questions regarding demographics and morcellation practices.

RESULTS

Four hundred and thirty eight (19.04%) of 2300 RANZCOG Fellows responded, and of these 258 (11.22%) completed the entire survey; analysis was undertaken on data from the latter respondents. Respondents were broadly representative of all RANZCOG Fellows regarding gender, age, and location. Of the respondents, 53.10% considered themselves advanced laparoscopic surgeons. Of respondents who had worked as gynaecology consultants prior to 2014, 39.39% used uncontained power morcellation prior to 2014, compared to 17.58% since (a decrease of 44.63%). The most common reasons for utilising uncontained power morcellation less often were the 2014 Food and Drug Administration warnings (40.31%), risk of adverse outcomes (33.72%), and recommendations from colleges such as RANZCOG (27.13%). When undertaking an operation that required specimen extraction, the most common methods used were: employing an open approach from the get-go (utilised by respondents in 31.01% of such cases); contained manual morcellation (28.90%); and conversion to intra-operative laparotomy (10.10%).

CONCLUSIONS

There has been a strong trend away from uncontained power morcellation since 2014, with a 36.00% increase in clinicians who never use uncontained power morcellation, and an 80.65% decrease in clinicians who always use this method of specimen extraction. The most common reason cited for employing uncontained power morcellation less often was the 2014 Food and Drug Administration's warnings.

Preoperative MRI and LDH in women undergoing intra-abdominal surgery for fibroids: Effect on surgical route

INTRODUCTION

Our institution implemented a preoperative protocol to identify high-risk cases for which power morcellation should be avoided.

MATERIAL AND METHODS

In this retrospective cohort study, an institutional protocol requiring preoperative Magnetic Resonance Imaging with diffusion-weighted imaging and serum Lactate Dehydrogenase levels was implemented. Chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015.

RESULTS

A total of 1,085 women were included, 479 before and 606 after implementation of the Magnetic Resonance Imaging / Lactate Dehydrogenase protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p = 0.022) and women using tamoxifen (2% vs. 0%, p = 0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of open surgery for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (open hysterectomy rate was 19% vs. 16% in pre- and post-protocol groups, respectively, P = 0.463, and open myomectomy rate was 10% vs. 9% rates in pre- and post-protocol groups, respectively, P = 0.776). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p<0.001) and an increased use of containment bags (1% in pre- and 19% in post-protocol cohort). When analyzing the subset of women who had abnormal Magnetic Resonance Imaging / and Lactate Dehydrogenase results, abnormal Magnetic Resonance Imaging results alone resulted in higher rates of open approach (65% for abnormal vs. 35% for normal). Similarly, a combination of abnormal Magnetic Resonance Imaging and Lactate Dehydrogenase tests resulted in higher rates of open approach (70% for abnormal and 17% for normal). Abnormal Lactate Dehydrogenase results alone did not influence route.

CONCLUSIONS

Rates of MIS procedures were decreased for women with abnormal preoperative Magnetic Resonance Imaging results. False positive results appear to be one of the main drivers for the use of an open surgical route.

The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective

Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.

Oncologic and Reproductive Outcomes of Uterine Smooth Muscle Tumor of Uncertain Malignant Potential: A Single Center Retrospective Study of 67 Cases

Background: The term “uterine smooth muscle tumor of uncertain malignant potential” (STUMP) indicates a rare tumor that cannot be classified as a benign leiomyoma or malignant leiomyosarcoma. In this study, we assessed the clinical characteristics, fertility, and oncologic outcomes of patients diagnosed as STUMP in 14 years. In addition, we analyzed the risk factors for recurrence in patients with STUMP.

Methods: Medical records of STUMP patients at Peking Union Medical College Hospital (PUMCH) between January 2005 and June 2019 were reviewed and analyzed. Disease-free survival, age of diagnosis, tumor size, surgical procedure, pathology and immunohistochemistry, clinical characteristics, recurrence rate, and reproductive outcomes in the follow-up period were assessed. Univariate and multivariate analyses were performed to determine the prognostic factors.

Results: The median age was 42 years old (range: 21–63). Total hysterectomy with or without bilateral salpingo-oophorectomy was performed in 29/67 cases (43.3%), and myomectomy was performed in 38/67 cases (56.7%). Ten patients experienced recurrences, and all but two recurrences occurred within 5 years after the initial surgery. Only two of these recurrences were leiomyosarcoma. There were no deaths in the median follow-up period of 48.4 (range 2.6–170.2) months. There were no remarkable differences in location of tumor between the myomectomy and hysterectomy groups, but the patients in the myomectomy group were younger than those in the hysterectomy group. In univariate and multivariate analysis, mitosis on pathology was the only independent risk factor for recurrence. Expression of Ki-67, p53, and p16 was significantly higher in patients with recurrence. Seven of the 35 patients who attempted to conceive had successful pregnancies.

Conclusions: The prognosis of STUMP was favorable and tumors with more than 10 mitoses per 10 high power field should be monitored closely. The surgical procedure was not an independent risk factor of recurrence, and myomectomy may be an acceptable option for patients wishing to preserve fertility.

Two-port myomectomy using bag-contained manual morcellation: A comparison with three-port myomectomy using power morcellation

OBJECTIVES

To evaluate the feasibility and safety of two-port myomectomy using bag-contained manual morcellation compared to three-port myomectomy using power morcellation.

MATERIAL AND METHODS

A retrospective chart review was conducted for 428 cases of either two-port or three-port laparoscopic myomectomy performed by single operator in the university hospital between January 2011 and December 2016.

RESULTS

The cohorts of three-port myomectomy with power morcellation was consisted of two hundred and forty-eight patients. One hundred and eighty patients underwent two-port myomectomy with manual morcellation in contained bag. Two-port group showed shorter hospital stay (5.16 ± 1.39 d vs. 4.83 ± 1.19 d, p = 0.001), less estimated blood loss (61.8 ± 58.2 mL vs. 50.2 ± 52.4 mL, p = 0.001), and higher hemoglobin level at postoperative day 1 (10.7 ± 1.17 g/dL vs. 11.0 ± 1.14 g/dL, p = 0.028) with statistical significance. Morcellation time (25.8 ± 9.30 min vs. 18.9 ± 10.11 min, p = 0.001) and total operative time (82.4 ± 30.19 min vs. 76.4 ± 25.47 min, p = 0.047) were also significantly shorter in two-port group. There were no identified spillages of fibroids, ruptures of specimen bag during manual morcellation in two-port myomectomy. In both groups, there were no cases of leiomyosarcoma diagnosed postoperatively.

CONCLUSION

Two-port laparoscopic myomectomy with bag-contained manual morcellation is a feasible and safe alternative for three-port with power morcellation. Its surgical outcomes were shown to be superior to conventional laparoscopic myomectomy according to our study but further evaluation in near future is needed.

Magnetic resonance imaging features of uterine sarcoma and mimickers

Uterine myometrial tumors are predominantly benign conditions that affect one-third of women and represent the main indication for hysterectomy. Preoperative imaging is of utmost importance for characterization and for precise mapping of myometrial tumors to best guide therapeutic strategy. New minimally invasive therapeutic strategies including morcellation, myolysis, uterine artery embolization and image-guided radiofrequency or focused ultrasound ablation have been developed for the treatment of uterine leiomyoma. However, preoperative differentiation between atypical leiomyomas and leiomyosarcomas is critical on imaging as uterine sarcoma requires a specific surgical technique to prevent dissemination. A single, rapidly growing uterine tumor, associated with endometrial thickening and ascites, in post-menopausal women is suspicious of uterine endometrial stromal sarcoma and carcinosarcoma. Suggestive magnetic resonance imaging features have been described, but overlap in imaging appearance between uterine leiomyosarcomas and cellular leiomyomas makes it challenging to ascertain the diagnosis. This review aims to illustrate the imaging features of uterine sarcomas and potential mimickers to make the reader more familiar with this serious condition which needs special consideration.

Prognostic significance of preoperative ¹⁸F-FDG PET/CT in uterine leiomyosarcoma

Objective

Uterine leiomyosarcoma (LMS) is a rare and aggressive disease with poor outcome. Due to its rarity and conflict of data, investigation on finding prognostic factor is challenging. The aim of the study was to investigate the prognostic significance of preoperative ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) in uterine LMS.

Methods

This was a retrospective observational cohort study in 3 tertiary referral hospitals. We retrospectively evaluated data from patients with pathologically proven uterine LMS who underwent preoperative ¹⁸F-FDG PET/CT scans at 3 institutions. The prognostic implication of PET/CT parameters and other clinico-pathological parameters on disease-free survival (DFS) and overall survival (OS) was evaluated.

Results

Clinico-patholgical data were reviewed for 19 eligible patients. In the group overall, median DFS and OS were 12 and 20 months, respectively. As for the recurrence, large tumor size, and high tumor maximum standardized uptake value (SUV_max) were demonstrated as risk factors of recurrence. As for the OS, high tumor SUV_max was demonstrated as the unique risk factor. There were significant differences in tumor size, mitotic count, SUV_max, and DFS between patients with and without recurrence. Also, there were significant differences in tumor size, SUV_max, DFS, and OS between 2 subgroups stratified by cut-off SUV_max.

Conclusion

SUV_max at preoperative ¹⁸F-FDG PET/CT was associated with worse outcome in patients with uterine LMS. In the preoperative setting, SUV_max can be a valuable non-invasive prognostic marker. Additionally, SUV_max can help identify highly aggressive uterine LMS and may help in adjusting standard treatment toward an individualized, risk-adapted treatment.