Characterization and Preoperative Risk Analysis of Leiomyosarcomas at a High-Volume Tertiary Care Center

Advances in the Preoperative Identification of Uterine Sarcoma

Simple Summary

As a lethal malignant tumor, uterine sarcomas lack specific diagnostic criteria due to their similar presentation with uterine fibroids, clinicians are prone to make the wrong diagnosis or adopt incorrect treatment methods, which leads to rapid tumor progression and increased metastatic propensity. In recent years, with the improvement of medical level and awareness of uterine sarcoma, more and more studies have proposed new methods for preoperative differentiation of uterine sarcoma and uterine fibroids. This review outlines the up-to-date knowledge about preoperative differentiation of uterine sarcoma and uterine fibroids, including laboratory tests, imaging examinations, radiomics and machine learning-related methods, preoperative biopsy, integrated model and other relevant emerging technologies, and provides recommendations for future research.

Abstract

Uterine sarcomas are rare malignant tumors of the uterus with a high degree of malignancy. Their clinical manifestations, imaging examination findings, and laboratory test results overlap with those of uterine fibroids. No reliable diagnostic criteria can distinguish uterine sarcomas from other uterine tumors, and the final diagnosis is usually only made after surgery based on histopathological evaluation. Conservative or minimally invasive treatment of patients with uterine sarcomas misdiagnosed preoperatively as uterine fibroids will shorten patient survival. Herein, we will summarize recent advances in the preoperative diagnosis of uterine sarcomas, including epidemiology and clinical manifestations, laboratory tests, imaging examinations, radiomics and machine learning-related methods, preoperative biopsy, integrated model and other relevant emerging technologies.

Differentiating uterine sarcoma from leiomyoma: BET1T2ER Check!

Although rare, uterine sarcoma is a diagnosis that no one wants to miss. Often benign leiomyomas (fibroids) and uterine sarcomas can be differentiated due to the typical low T2 signal intensity contents and well-defined appearances of benign leiomyomas compared to the suspicious appearances of sarcomas presenting as large uterine masses with irregular outlines and intermediate T2 signal intensity together with possible features of secondary spread. The problem is when these benign lesions are atypical causing suspicious imaging features. This article provides a review of the current literature on imaging features of atypical fibroids and uterine sarcomas with an aide-memoire BET¹T²ER Check! to help identify key features more suggestive of a uterine sarcoma.

Molecular Bio-Imaging Probe for Non-Invasive Differentiation Between Human Leiomyoma Versus Leiomyosarcoma

Leiomyosarcoma is the most frequent subtype of the deadly uterine sarcoma and shares many common clinical grounds with leiomyoma, which is in turn the most common solid benign uterine neoplasm. With the recent progress in minimally invasive techniques for managing leiomyomas, accurate preoperative diagnosis of uterine masses has become the most important selection criterion for the safest therapeutic option. Therefore, different imaging modalities would be playing a key role in management of uterine masses. Testing for a sarcoma-specific promoter that expresses its downstream reporter gene only in leiomyosarcoma and not in leiomyoma or healthy uterine tissue. Adenoviral vectors were utilized both in vitro and in vivo to test the specificity of the promoters. Quantitative studies of downstream gene expression of these promoters was carried out both in vitro and in vivo. Our data indicated that human leiomyosarcoma cells highly expressed the reporter gene downstream to survivin promoter (Ad-SUR-LUC) when compared with benign leiomyoma or normal cells (p value of 0.05). Our study suggested that survivin is the unique promoter capable of distinguishing between the deadly sarcoma and the benign counterparts.

The impact of recent power morcellator risk information on inpatient surgery and patient outcomes

Aim: We examine the impact of the new risk information about a surgical device on surgery and patient outcomes for hysterectomy in the inpatient setting. Methods: We utilize a difference-in-differences approach to assess the impact of new risk information on patient outcomes in the inpatient setting between 2009 and 2014. The inpatient data come from a nationally representative sample of hospitalizations in the USA. We use the likelihood of laparoscopic surgery, measures of resource use and surgical complications as outcome variables. Results: We estimate a three-percentage point decrease in the likelihood of receiving laparoscopic hysterectomy, a one-percentage point increase in the likelihood of experiencing a surgical complication and no impact on resource use, relative to pre-existing means. Conclusion: Our findings show that there was movement away from laparoscopic surgery in the months following the dissemination of new risk information. These changes had limited effect on patient outcomes.

Occult Leiomyosarcomas in a Canadian Province: A Retrospective Cohort Study

OBJECTIVE

The risk of unexpected uterine leiomyosarcoma (LMS) following surgery for presumed benign leiomyoma is quoted to be between 1 in 498 and 1 in 5000. The objectives of the present study were to determine the prevalence of uterine LMS in a specific patient population and the rate of diagnosis of occult uterine LMS and to evaluate the risk of unintended morcellation of LMS in Saskatchewan.

METHODS

This study was a Canadian Task Force Classification II-2 multicentre retrospective cohort study in academic-affiliated tertiary care centres. All women with the histopathologic diagnosis of uterine LMS in Saskatchewan between January 2000 and December 2014 were included. Women with metastatic LMS at diagnosis or other types of uterine sarcomas were excluded. Data including patients' characteristics, clinical presentation, physical examination findings, imaging, pathology reports, surgical interventions, and survival outcomes were reviewed.

RESULTS

A total of 28 patients had a confirmed histopathologic diagnosis of LMS over the 15-year study period. Approximately 26 212 hysterectomies were performed in Saskatchewan over the same time frame. The prevalence of uterine LMS in this patient population over the study time frame is estimated to be one in 853. Mean age at diagnosis was 53.8 ± 10.0. Medical records of 25 patients could be retrieved, and 15 cases (60%) had an occult diagnosis. There were five cases of unintended morcellation (one power, four mechanical). Survival outcomes were comparable in women with unintended morcellation of occult disease and in those without morcellation.

CONCLUSION

This study contributes to the existing body of literature on morcellation of occult LMS, and it ascertains the rate of LMS in a patient population. The results of this study provide valuable information to health care professionals, policy makers, and women in Saskatchewan so that they may make more informed decisions concerning uterine masses.

Outcome and Management of Uterine Leiomyosarcoma Treated Following Surgery for Presumed Benign Disease: Review of Literature

Uterine leiomyosarcoma (uLMS) is a rare and aggressive cancer, usually diagnosed incidentally at the time of myomectomy or hysterectomy. There have been concerns for several years about the fact that the inadvertent disruption of occult uLMS may have a negative impact on patient outcome. This study reviews the outcome and management of patients with a diagnosis of uLMS after surgery for presumed benign disease. We conducted a literature search in which 47 published English-language articles were obtained for evaluation. A total of 23 studies with outcomes data were included. It is evidenced that patients who underwent surgery with tumor disruption resulted in poorer outcomes compared with en bloc tumor, especially by power morcellation. The power morcellation was associated with an increased risk of recurrence, shorten time to recurrence, and upstage after re-exploration. Early re-exploration and surgical staging are appreciated for better prognosis and may alter postoperative treatment. We also updated on the incidence and preoperative evaluation to assess the risk of patient and give an effective counseling.