Incidental gynecologic neoplasms in morcellated uterine specimens: a case series with follow-up

Uterine Tumors Resembling Ovarian Sex Cord Tumors (UTROSCTs): A Scoping Review of 511 Cases, Including 2 New Cases

Uterine Tumors Resembling Ovarian Sex Cord Tumors (UTROSCTs) are rare uterine mesenchymal neoplasms with uncertain biological potential. These tumors, which affect both premenopausal and postmenopausal women, usually have a benign clinical course. Nevertheless, local recurrences and distant metastases have been described. By analyzing 511 cases retrieved from individual reports and cases series, we provide here the most comprehensive overview of UTROSCT cases available in the literature, supplemented by two new cases of UTROSCTs. Case 1 was an asymptomatic 31-year-old woman who underwent a laparoscopic resection of a presumed leiomyoma. Case 2 was a 58-year-old postmenopausal woman with abnormal vaginal bleeding who underwent an outpatient hysteroscopic biopsy of a suspicious endometrial area. In both cases, immunohistochemical positivity for Calretinin and Inhibin was noted, typical for a sex cord differentiation. In both cases, total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was performed. In light of the available literature, no pathognomonic clinical or imaging finding can be attributed to UTROSCT. Patients usually present with abnormal uterine bleeding or pelvic discomfort, but 20% of them are asymptomatic. In most cases, a simple hysterectomy appears to be the appropriate treatment, but for women who wish to become pregnant, uterus-preserving approaches should be discussed after excluding risk factors. Age, tumor size, lymphovascular space invasion, nuclear atypia, and cervical involvement are not reliable prognostic factors in UTROSCT. The current research suggests that aggressive cases (with extrauterine spread or recurrence) can be identified based on a distinct genetic and immunohistochemical phenotype. For instance, UTROSCTs characterized by GREB1::NCOA1-3 fusions and PD-L1 molecule expression appear to be predisposed to more aggressive behaviors and recurrence, with GREB1::NCOA2 being the most common gene fusion in recurrent tumors. Hence, redefining the criteria for UTROSCTs may allow a better selection of women suitable for fertility-sparing treatments or requiring more aggressive treatments in the future.

Uterine Tumours Resembling Ovarian Sex-Cord Tumors: A Case Report and Review of the Literature

Uterine tumors resembling ovarian sex-cord tumors (UTROSCT) are thought to develop from pluripotent uterine mesenchymal cells or endometrial stromal cells with secondary sex-cord differentiation. The patient was a 73-year-old postmenopausal woman who had abnormal vaginal bleeding, and she underwent a laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The diagnosis was a case of UTROSCT. A scoping review of the UTROSCT case report present in the literature has been conducted, and 63 articles were found, of which 45 were considered for the 66 clinical cases examined. At the time of diagnosis, six metastatic localizations were found in 59 patients undergoing demolitive surgery (10.2%). Recurrences were diagnosed in 13/59 (22%) patients with multiple locations. A molecular study was performed in 18/66 cases (27.3%) and genetic alterations were found in 10/18 (55.6%) patients. UTROSCTs are considered rare uterine tumors, typically with a favorable prognosis, and are generally considered to have a good prognosis. But, from the review done, they may already manifest themselves at advanced stages, with the possibility of recurrences even at a distance. It would, therefore, be important to be able to define the most aggressive forms and, perhaps, molecular investigation with sequencing could help identify patients most at risk.

[Interdisciplinary S2k guidelines on the diagnosis and treatment of uterine sarcomas-recommendations for surgical pathology]

Uterine sarcomas represent a heterogeneous group of rare malignancies, derived from the myometrium, the endometrial stroma, and very rarely from the nonspecialized uterine soft tissue. The actual incidence is about 1.5 for Caucasian and 3.0 for Afro-American women. There is no grading system for leimoysarcoma defined by the WHO classification; however, if clinicians request, the FNCLCC grading can be specified in analogy to soft tissue sarcomas. Adenosarcomas must be distinguished from adenofibromas (the existence of which is questionable)-with the vast majority of these tumors being uterine adenosarcomas. Within adenosarcomas, deep myometrial invasion (>50%), sarcomatous overgrowth, and a high-grade heterologous component are associated with a higher recurrence rate and poor survival. The immunohistochemical panel represents a very helpful tool for distinguishing low-grade from high grade endometrial stromal sarcomas (ESS) and may be supplemented by molecular analyses. Steroid hormone receptor analysis should be performed for all ESS due to the possible therapeutic relevance. Undifferentiated uterine sarcomas represent a diagnosis of exclusion and have a very poor prognosis. Carcinosarcomas represent a special subtype of endometrial carcinomas and are in fact not uterine sarcomas. Uterine sarcomas may present substantial intratumoral heterogeneity and adequate embedding is mandatory. Lesions ≤2 cm in the largest dimension should be processed completely and larger tumors should be processed with one block per centimeter for the largest tumor dimension.

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review

OBJECTIVE

This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas.

DATA SOURCES

Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020.

METHODS OF STUDY SELECTION

Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis.

TABULATION, INTEGRATION, AND RESULTS

The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen.

CONCLUSION

Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

Uterine leiomyomas: correlation between histologic composition and stiffness via magnetic resonance elastography - a Pilot Study

OBJECTIVES

To evaluate magnetic resonance elastography as a tool for characterizing uterine leimyomas.

MATERIAL AND METHODS

At total of 12 women with symptomatic leiomyomas diagnosed in physical and ultrasound examinations were enrolled in this pilot study. Before surgery, all patients underwent magnetic resonance elastography of the uterus using a 1.5 T MR whole-body scanner (Optima, GE Healthcare, Milwaukee, WI, USA). Surgical specimens were forwarded for histological examination. The findings were allocated into 3 categories depending on the percentage content of connective tissue: below 15%, from 15 to 30% and more than 30%. The median stiffness of leiomyomas for each of the group was calculated. The U-Mann Whitney test was used for statistical analysis.

RESULTS

The stiffness of the leiomyomas ranged between 3.7-6.9 kPa (median value 4.9 kPa). The concentration of extracellular components in the leiomyomas did not exceed 40%. An increasing trend of the stiffness with the growing percentage of extracellular component was observed. Stiffness of the leiomyomas obtained by MRE varies depending on microscopic composition.

CONCLUSIONS

The value of stiffness shows a trend of increasing with the percentage of extracellular component of the leiomyoma. Further studies are required to assess the usefulness of MRE in diagnostics of uterine leiomyomas.

Morcellation of the Uterus: Is There Any Place?

PURPOSE OF REVIEW

This paper aims to review recent findings related to uterine morcellation.

RECENT FINDINGS

In 2014, the US Food and Drug Administration (FDA) issued a safety communication warning against the use of laparoscopic power morcellators. A risk of occult uterine sarcoma in women is 1/770 to 1/10,000. Our goal is to minimize the risk of spillage due to morcellation and balance it with other risks due to different surgical approaches. In case of a presence of sarcoma risk factors, any form of morcellation should be contraindicated. Power morcellation should be limited to myomectomies. In peri- and postmenopausal age, an endometrial biopsy is highly recommended before surgery with expected morcellation. It is important to explain to the patient the risks of morcellation and the risks and benefits of different surgical approaches. Finally, women should be informed that the prognosis of leiomyosarcoma is poor regardless of the method of removal.

A comparative study on the short-term clinical efficacy of the modified laparoscopic uterine comminution technique and traditional methods

To assess the value of the modified laparoscopic uterine comminution technique in laparoscopic uterine surgery, a total of 82 cases of laparoscopic myomectomy were divided into the traditional group and modified group, according to a random number table. During the same period, 92 patients who underwent laparoscopic hysterectomy were divided into the conventional group and the modified group, according to a random number table. The patients in the conventional group and modified group who underwent laparoscopic uterine fibroid removal showed no significant differences in the operation time, blood loss or average hospitalization (P>0.05). There was no significant difference in the operative time or average length of hospital stay between patients in the conventional group and modified group who underwent laparoscopic hysterectomy (P>0.05). In laparoscopic myomectomy, the fibroid specimens were placed in a self-made specimen bag for modified uterine comminution. In laparoscopic hysterectomy, the whole uterus specimen was placed in a self-made specimen bag and viewed from the vagina. The improved comminution technique is simple and feasible, does not increase the operation time or length of hospitalization, and has value for clinical use.

Iatrogenic parasitic myoma and iatrogenic adenomyoma after laparoscopic morcellation: A mini-review

Laparoscopy is widely recognized as a procedure of choice for gynaecological surgery. Myomectomy and hysterectomy are the most frequently performed surgical procedures in gynaecology. A morcellator is often used in myomectomies or subtotal hysterectomies, but morcellation may cause rare complications, such as parasitic iatrogenic myoma or adenomyoma. To improve patient counselling, proper risk estimation as well as risk factor identification should be acknowledged. This article aimed to review the literature on parasitic myoma and adenomyoma and to compare these diseases in terms of clinical, surgical, and prognostic factors. All published literature (case series and case reports) on iatrogenic myoma and adenomyoma was reviewed using PubMed/MEDLINE and ScienceDirect resources. Despite both conditions having an iatrogenic origin, iatrogenic parasitic myoma and adenomyoma are two different entities in terms of clinical manifestations as well as intraoperative particularities, with a common point: iatrogenic complication. A possible solution to avoid these iatrogenic complications is by using in-bag morcellation or switching to another surgical procedure (e.g., a vaginal or abdominal approach). It is concluded that parasitic myoma and iatrogenic adenomyoma are two different iatrogenic morcellator-related complications. In patients with a history of uterus or myoma morcellation who report pelvic symptoms, iatrogenic parasitic myoma or adenomyoma should be considered in the differential diagnosis.

Prevalence, characteristics, and risk factors of occult uterine cancer in presumed benign hysterectomy

BACKGROUND

Occult uterine cancer at the time of benign hysterectomy poses unique challenges in patient care. There is large variability and uncertainty in estimated risk of occult uterine cancer in the literature and prior research often did not differentiate/include all subtypes.

OBJECTIVES

To thoroughly examine the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications and to identify associated risk factors.

STUDY DESIGN

Using the New York Statewide Planning and Research Cooperative System database, we identified 229,536 adult women who underwent an inpatient or outpatient hysterectomy for benign indications during the period October 1, 2003 to December 31, 2013 at civilian hospitals and ambulatory surgery centers throughout the state. Diagnosis of corpus uteri cancer within 28 days after the index hysterectomy was determined using linked state cancer registry data. We estimated the prevalence of occult uterine cancer (overall and by subtype) and developed and validated risk prediction models using a random split sample approach.

RESULTS

Overall, 0.96% (95% confidence interval: 0.92-1.00%) of the women had occult uterine cancer, including 0.75% (95% confidence interval: 0.71-0.78%) with endometrial carcinoma and 0.22% (95% confidence interval: 0.20-0.23%) with uterine sarcoma. The prevalence of leiomyosarcoma was 0.15% (95% confidence interval: 0.13-0.17%). Seventy-one percent of the endometrial carcinomas and 58.0% of the uterine sarcomas were at localized stage. The risk for occult uterine cancer ranged from 0.10% in women aged 18-29 years to 4.40% in women aged ≥75 years; and varied from 0.14% in women undergoing hysterectomy for endometriosis to 0.62% for uterine fibroids and 8.43% for postmenopausal bleeding. The risk of occult uterine cancer was also significantly associated with race/ethnicity, obesity, comorbidity, and personal history of malignancy. Prediction models incorporating these risk factors had high negative predictive values (99.8% for endometrial carcinoma and 99.9% for uterine sarcoma) and good rule-out accuracy despite low positive predictive value.

CONCLUSIONS

In women undergoing hysterectomy for presumed benign indications, 0.96% had unexpected uterine cancer. Patient characteristics such as age, surgical indication, and medical history may help guide risk stratification.

Endometrial Carcinoma, Grossing and Processing Issues: Recommendations of the International Society of Gynecologic Pathologists

Endometrial cancer is the most common gynecologic neoplasm in developed countries; however, updated universal guidelines are currently not available to handle specimens obtained during the surgical treatment of patients affected by this disease. This article presents recommendations on how to gross and submit sections for microscopic examination of hysterectomy specimens and other tissues removed during the surgical management of endometrial cancer such as salpingo-oophorectomy, omentectomy, and lymph node dissection—including sentinel lymph nodes. In addition, the intraoperative assessment of some of these specimens is addressed. These recommendations are based on a review of the literature, grossing manuals from various institutions, and a collaborative effort by a subgroup of the Endometrial Cancer Task Force of the International Society of Gynecological Pathologists. The aim of these recommendations is to standardize the processing of endometrial cancer specimens which is vital for adequate pathological reporting and will ultimately improve our understanding of this disease.

Laparoscopic management of uncommon benign uterine tumors: a systematic review

The objective of the study was to review the reported cases of uncommon benign uterine tumors managed by laparoscopy. Medline database was searched using predefined search terms linked to atypical leiomyomas, leiomyoma variants, laparoscopy and morcellation. Quality of articles was assessed using Joanna Briggs Institute (JBI) critical appraisal tool. Due to heterogeneity in reporting characteristics of the patients, radiological findings, macroscopic findings, histological characteristics and follow-up, we performed a narrative synthesis. We included 109 cases of leiomyoma variants managed by laparoscopy. This stands for an incidence of 2.5% out of all the included laparoscopic management of leiomyomas. These cases were approached as classic leiomyoma. Only after the final histological results that their uncommon aspect was diagnosed. Intra-operatively, the management was similar to that of leiomyoma, with either myomectomy or hysterectomy performed depending on each individual case. Follow-up of these cases was variable: one case (0.9%) recurred as peritoneal sarcoma after 5 years of follow-up. It is important for the gynecologist, radiologist and pathologist to be aware about leiomyoma variants trying to diagnose them preoperatively. Strict follow-up of these cases is mandatory, because of the risk of recurrence and the very low but possible risk of future sarcomas.

Uterine morcellation and survival in uterine sarcomas

BACKGROUND

There is concern but no solid evidence that morcellation during laparoscopic or vaginal hysterectomy may cause abdominal spread and thereby impaired prognosis of incidental uterine sarcomas.

OBJECTIVE

Our purpose was to compare survival among patients with uterine sarcomas who underwent hysterectomy with or without morcellation to test the hypothesis that morcellation impairs prognosis.

STUDY DESIGN

We identified all women in Norway diagnosed with uterine sarcoma between 1953 and 2012 through national registries and retrieved data on surgical technique and morcellation by evaluation of patient files. Patients were categorised into abdominal, laparoscopic or vaginal hysterectomy with or without morcellation. Vaginal and laparoscopic hysterectomies were introduced in 1991; our main comparison is from 1991 to 2012. We compared age-adjusted disease-specific survival of sarcoma patients treated with or without morcellation and calculated age-adjusted hazard ratios (HRs) and subdistribution HR (accounting for competing risk) with 95% confidence intervals (CIs).

RESULTS

Among 1367 patients with uterine sarcoma between 1953 and 2012 in Norway, 653 were diagnosed after 1991, and 23 of these patients (3.5%) underwent morcellation. Uterine sarcoma prevalence was 3.6 per 1000 laparoscopic hysterectomies. Mean follow-up was 6.0 years in the morcellated group and 6.9 years in the non-morcellated group. The risk of dying from uterine sarcoma after morcellation was 1.5 per 1000 procedures. Sarcoma mortality was higher in the morcellated group than in the non-morcellated group (age-adjusted HR 1.90, CI 1.05-3.44; multivariate HR, 2.50, 95% CI 0.57-10.9). Age-adjusted 10-year uterine sarcoma survival was 32.2% for women treated with morcellation compared with 57.2% for non-morcellated group (difference 25.5%; CI -55.7 to 18.1). All-cause 10-year survival was 32.2% in the morcellated group and 44.1% in the non-morcellated group (difference 11.9%; CI -40.9 to 32.7).

CONCLUSION

Our results strengthen the evidence that morcellation during hysterectomy in patients with incidental uterine sarcoma may cause impaired survival. These results can guide shared decision-making in clinical practice.

Risk of Occult Uterine Sarcoma in Presumed Uterine Fibroids

Symptomatic fibroids are a common indication for hysterectomy or myomectomy. Although rare, unexpected gynecologic malignancies in presumed fibroids have been documented. In cases where tissue retrieval is performed through morcellation, there is increasing concern that intra-abdominal dispersion of occult uterine malignancies may lead to peritoneal dissemination and worse outcomes. We examined the available literature to determine the prevalence of all uterine cancers in women undergoing hysterectomy or myomectomy for benign uterine disease, with attention to the risk of morcellating occult uterine sarcomas. We also reviewed the available tools for preoperative discrimination between benign and malignant uterine disease.

Effects of morcellation on long-term outcomes in patients with uterine leiomyosarcoma

OBJECTIVES

Clinical long-term outcomes of women with uterine leiomyosarcoma (ULMS) with different types of hysterectomy (open abdominal, vaginal, laparoscopic and switch from laparoscopic to open abdominal) were compared according to morcellation and other factors.

MATERIALS

The clinical cancer registry Regensburg (Germany) registered 64 patients between 2004 and 2013 with ULMS. A retrospective cohort analysis was performed using the Kaplan-Meier method to estimate 5-year overall survival (OAS), recurrence-free survival (RFS) and recurrence rates. To compare surgery with or without morcellation log rank test was used. To adjust for age, FIGO stage, grading and other factors multivariable Cox regression models were applied to estimate hazard ratios (HR).

RESULTS

In the cohort of 64 patients 15 underwent morcellation, preferably during laparoscopic surgery. Although numbers were small we performed analysis for OAS and RFS. Median OAS for morcellation was 10.6 vs. 6.4 years for non morcellation. 5y-OAS was 76.0 % for morcellation compared to 54.8 % in patients without morcellation (p = 0.115). Cox regression models rendered an unadjusted (univariable) HR 0.428 for morcellation vs. non-morcellation (p = 0.125) and an adjusted (multivariable) HR 0.644 (p = 0.406). 5y-RFR was 64.0 % compared to 42.8 % in patients without morcellation (p = 0.104; unadjusted HR 0.484, p = 0.111; adjusted HR 0.607, p = 0.306).

CONCLUSION

In general, the prognosis of patients with ULMS is poor. In our cohort, women who underwent hysterectomy with morcellation had a better cumulative OAS and RFS than women without morcellation. Although we adjusted for differences between women with and without morcellation regarding age, grading and stage, there were no statistically significant differences between the groups.

Extracorporeal Manual Morcellation of Very Large Uteri Within an Enclosed Endoscopic Bag: Our 5-Year Experience

STUDY OBJECTIVES

To describe a technique to manually morcellate large uteri within a polyurethane endoscopic bag at the time of laparoscopic hysterectomy, and report perioperative outcomes from our 5 years of experience.

STUDY DESIGN

Retrospective review of all consecutive hysterectomies with uterine weight >500 g performed between January 2010 and December 2014 in which the uterus was manually morcellated within an endoscopic bag by either an abdominal or vaginal approach (Canadian Task Force Classification Level III).

SETTING

Tertiary care academic medical center.

PATIENTS

A total of 104 women with a uterine weight >500 g who underwent laparoscopic hysterectomy using a manual morcellation technique.

INTERVENTION

Manual morcellation was done extracorporeally, within a partially exteriorized specimen bag, using a scalpel under direct visualization by the operating surgeon.

MEASUREMENTS AND MAIN RESULTS

A total of 104 laparoscopic hysterectomies were performed in women with a uterus weighing >500 g using a manual morcellation technique for specimen extraction. The median patient age was 48.1 years (range, 34-69 years), and the median body mass index was 31.0 kg/m(2) (range, 19.1-56.7 kg/m(2)). The median blood loss and specimen weight were 200 mL (range, 20-1200 mL) and 741.5 g (range, 500-1930 g), respectively. Morcellation was performed through an abdominal approach in 58.7% of the patients and through a vaginal approach in 41.3%. The median duration of morcellation was 14.8 minutes (range, 4.5-21.6 minutes) for the abdominal route and 11.7 minutes (range, 5.2-16.8 minutes) for the vaginal route. Occult malignancy was identified in 2 patients. There were no complications related to the morcellation technique or gross bag rupture.

CONCLUSION

Manual morcellation within an endoscopic bag allows for the extraction of large uteri without the use of a power morcellator. In our 5 years of experience, we have not experienced any incidence of gross spillage, visually noted bag rupture, or complications associated with our morcellation technique.

Laparoscopic Hysterectomy for Uterine Fibroids: Is it Safe?

As more complex cases and larger uterine specimens are able to be managed with minimally invasive surgery, the limitations of tissue retrieval with these methods are of increasing concern. Risks of morcellator-related injury, tissue dissemination, or fragmentation must be weighed against increased morbidity of abdominal approach to hysterectomy. In an effort to mitigate the risks of tissue morcellation, containment system use must be considered when fragmenting a specimen, either with power morcellation or a manual technique via the vagina or minilaparotomy.

Sarcoma of the Uterus. Guideline of the DGGG (S2k-Level, AWMF Registry No. 015/074, August 2015)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Due to their rarity and their heterogeneous histopathology uterine sarcomas remain challenging tumors to manage and need a multidisciplinary approach. To our knowledge so far there is no evidence-based guideline on the appropiate management of these heterogeneous tumors. Methods: This S2k-guideline is the work of an representative committee of experts from a variety of different professions who were commissioned by the DGGG to carry out a systematic literature review of uterine sarcoma. Members of the participating scientific societies developed a structured consensus in a formal procedure. Recommendations: 1. The incidence and histopathologic classification of uterine sarcoma. 2. The clinical manifestations, diagnosis and staging of uterine sarcoma. 3. The management of leiomyosarcoma. 4. The management of endometrial stromal sarcoma and undifferentiated uterine sarcoma. 5. The management of adenosarcoma as well as carcinosarcomas. 6. The management of morcellated uterine sarcoma.

A critical assessment of morcellation and its impact on gynecologic surgery and the limitations of the existing literature

Uterine sarcomas are rare uterine malignancies that are difficult to diagnose preoperatively. Because of cases of disseminated sarcoma after laparoscopic hysterectomy, the role of power morcellators in gynecologic surgery has been questioned. Morcellation is an integral part of making laparoscopic surgery possible for the removal of large uterine leiomyomata, and the development of power morcellation has increased efficiency during these procedures. Minimally invasive surgery has demonstrated benefits that include improved pain control, decreased infection risk, and faster surgical recovery and return to work. In this review, we examine the risk of incidental sarcoma at the time of surgery, the quality of the data, the accuracy of clinical and radiologic predictors of uterine sarcoma, and the impact of morcellation on the prognosis of uterine sarcoma.