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Is There Negative Impact from Morcellation in Unsuspected Leiomyosarcoma?
Abstract & Commentary
By Robert L. Coleman, MD, Professor, University of Texas; M.D. Anderson Cancer Center, Houston, is Associate Editor for OB/GYN Clinical Alert.
Dr. Coleman reports no financial relationship to this field of study.
Synopsis: Uterine morcellation procedures are common in the management of uterine leiomyomata, but may adversely impact outcomes and patterns of recurrence when performed in the setting of leiomyosarcoma.
Source: Park JY, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 2011, doi:10.1016/j.ygynon.2011.04.021.
Uterine leiomyosarcomas (LMS) rarely are suspected preoperatively unless there has been documented rapid growth of the uterus or evidence of extrauterine disease. Thus, it is not surprising that the antecedent procedures performed for a number of these cases are uterine sparing, such as myomectomy, or uterine morcellation at the time of vaginal hysterectomy or under endoscopic guidance. The impact of these procedures on patterns of recurrence and survival was addressed in a retrospective evaluation of a referral population over an 11-year period. In all, researchers identified 77 patients, from which 56 were considered "early stage," that is, corpus-confined or suspected stage I or II. In this cohort, 31 had undergone abdominal hysterectomy as their antecedent procedure before diagnosis of LMS; 25 had undergone morcellation procedures for vaginal hysterectomy (n = 19) or myomectomy (n = 6). Once the diagnosis of LMS was made, all patients who had not undergone hysterectomy had completion procedures, as well as some undergoing additional staging procedures. However, no patient at initial surgery or at the time of reoperation was upstaged based on the pathological assessment of extrauterine tissues. Of interest, the populations were surprisingly well-balanced with regard to age, parity, proportion menopausal, symptoms, and uterine LMS characteristics such as mitotic count and grade. Patients in the morcellation group were less likely to have had a history of prior abdominal surgery, had smaller uterine tumors, and were more likely to have had ovarian preservation. Nevertheless, patients who had undergone morcellation were significantly more likely to recur (52% vs 23%), have abdomino-pelvic sarcomatosis at recurrence (44% vs 13%), and have a shorter disease-free survival (DFS) and overall survival (OS). In the multivariate analysis, only stage (odds ratio [OR] 20.34, 95% confidence interval [CI] 1.27-325.6) and morcellation (OR 3.11, 95% CI 1.07-9.1) were significantly associated with OS. The authors conclude that tumor morcellation at the time of surgery increases the rate of abdomino-pelvic dissemination and adversely affects DFS and OS.
This manuscript raises a hypothesis that conforms to a concern many oncologists who treat sarcoma share tumor disruption adversely affects outcome. As such, the practice of intact tumor removal is prevalently recommended in essentially all soft tissue sarcomas, regardless of type or location. However, the prevalence of benign uterine pathology and the lack of discriminating features on preoperative evaluation and imaging for the diagnosis of LMS make a clear recommendation regarding morcellation difficult. Morcellation offers uterine sparing options for very large masses and preservation of minimally invasive surgical options for extirpation. Since uterine LMS is so rare in the general population, it would be inappropriate to alter management in concern for the diagnosis. However, it is clear that if LMS is suspected, morcellation or even percutaneous biopsy should be avoided.1,2 Ultimately, the finding becomes another in a long list of adverse prognostic factors, that heretofore, we have had little to offer. In the current series, despite fairly equal postoperative management practices (chemotherapy and radiation), outcomes were still disparate. The lack of upstaging or identified residual disease at restaging was surprising, although the sample was small and the interval between morcellation and reoperation was not stated. Most oncologists are already quite concerned about the recurrence risk of LMS in patients with intact removal; however, the concern is heightened (and for good reason) for women with LMS who have undergone morcellation. Because of this, most oncologists recommend adjuvant therapy usually chemotherapy in this situation. A decision to restage usually is based on postoperative imaging, but as seen in this series, is generally of low yield in the absence of measurable disease. Fortunately, a cooperative group effort to study adjuvant therapy in these cases has been organized and is exploring new avenues of therapy, including novel hormones, biologically targeted agents, and new cytotoxics.3