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Cancer Risks from Uterine Morcellation Examined — Physician’s First Watch

Medical News |
February 7, 2014

Cancer Risks from Uterine Morcellation Examined

By Amy Orciari Herman

The potential risk for cancer dissemination associated with uterine morcellation has again come under scrutiny, this time in two articles in JAMA.

A news perspective piece describes the issue: When fibroids or uterine tissue is cut into small pieces during morcellation, there's a risk that undetected malignant cells could spread into the abdominal cavity. In one study, two of seven patients with undiagnosed stage I uterine leiomyosarcoma and one of four with undiagnosed stage I smooth muscle tumors had disseminated intraperitoneal disease after morcellation.

"The problem is that, in most cases, we don't have a perfectly reliable way to identify patients with uterine sarcoma in the preoperative setting," said one expert.

The authors of a separate article contend that the limited experience with morcellation doesn't allow estimates of "whether the benefit-to-harm balance is any different from other accepted medical procedures."

Both articles note that lower-risk, experimental morcellation techniques are promising.

Reader Comments (10)

Robert Gore M.D. Physician, Obstetrics/Gynecology, Retired
Competing Interests: I am associated with a law firm representing claims for product liability related to morcellation.

Would anyone fly if they were told that there was a 1 in 300 chance they would be killed by choosing to fly? The dissemination of malignancy as an unintended consequence of morcellation is inexcusable. Unfortunately, there are "experts" testifying that the patient would have had the same outcome with traditional procedures.
I am working to help injured patients receive compensation from the manufacturers who are able to introduce new technology with minimal oversight.

edith hamel

I had a supra-cervical hysterectomy at Brigham and Womens in 2008. Now I hear the reports of possible cancer risk after this surgery. I am concerned because my aunt died of uterine cancer. Should I be worried even though it's been 6 years since I had the procedure? Before hearing this report I have been feeling extremely tired over the past year and have noticed I have visibly aged dramatically in one year. Are these signs of cancer? Should I see my doctor? what kinds of tests can they do if I have no other symptoms?

GAEL DEPPERT Other, Other, Juvenile Court

I wish my surgeon had not morcellated adenocarcinoma through my body cavity last month during a laparoscopic supracervical hysterectomy, and I wish he had informed me prior that pre-op tests could be false negatives, as they were. Psychologically, I struggle against feeling like Dead Woman Walking, and continue to try to sort through what treatment options make sense in light of a growing belief that the end result will be the same.

Hugo D. Ribot Jr. , M.D. Physician, Obstetrics/Gynecology, Georgia Advanced Surgery Center for Women, Cartersville, GA

In the vast majority of cases even with enlarged fibroid uteri, a skilled laparoscopic surgeon can - by carefully creating a colpotomy using non-thermal surgical cutting techniques - obtain an elastic vaginal portal for extracting even larger specimens WITHOUT resorting to intra-abdominal piecemeal morcellation and uncontrolled fragmentation of uterine tissue. In cases where the specimen is too big to fit intact, one can place the uterus in a strong endoscopic bag and bring the mouth of the bag out through the vagina to perform a contained transvaginal coring type morcellation avoiding intra-abdominal spill.
Unfortunately, in my 24 years since completing my ob/gyn residency, the quality of residency surgical instruction has declined due to resident work hour restrictions, lower case volume in teaching hospitals, and poor mentoring in private practice, and thus we are graduating large numbers of docs who have poor minimally invasive skills. This has progressed to the point where a discredited procedure such as subtotal hysterectomy has come back into vogue because allows gyn docs to misinform their patients that they are offering a good minimally option with LSH. They are trading a meaningless short term advantage of avoiding a colpotomy - measured literally in just days, not weeks of recovery reduction compared to removing the cervix and having available the colpotomy to remove intact specimens. I can tell you the vast majority of patients, whether they have a subtotal hysterectomy OR a total one where the cervix is removed, will resume intercourse around the same time postoperatively. Done properly, a total hysterectomy has no significant greater morbidity.

VM Resident, Obstetrics/Gynecology

I could not DISAGREE more. As a current resident in OB/GYN I do more laparoscopic cases than open procedures hands down. Decreased work hours has nothing to do with this trend in doing undesirable procedures. I had a change of specialty and have been on both sides of road (no restrictions vs restrictions) as far as that goes and I can say, at least at my institution, the only part of the statement that rings true are yes, lower case numbers (because more and more management is trending toward non-operative intervention) and time-saving, but on the side of private physicians. Attendings at my institution would be called out and admonished for performing an LSH without a really good reason. I believe most of the issue is lack of education more than lack of skill. Performing the colpotomy is not very difficult, and you don't have to do 500 to figure that out.

Colleen Daley MSW Other, Other, Native American Community Service

My sister died 8 months after laporascopic surgery on a rapidly growing uterus and fibroids. She was postmenepausal. She received no informed consent, during the surgery the needed to use three morcellators on the huge hard mass. The cancer spread and when these tumors were removed they were found to be LMS the previous benign patholgy was retested and also found LMS.

Mahsheed Khajavi, M.D. Physician, Internal Medicine, Emory University

I can not agree more with Dr. Noorchashm. There is indeed a significant deficit in those who have been trained more recently, and this extends to all of the medical sub-specialties. A well trained GYN surgeon can perform hysterectomy laparoscopically but those who do not have this training would opt for morcellation, as it requires less skill and expertise. I think the last paragraph is spot on. Many of my GYN colleagues have said just this: They would NEVER perform this procedure as the alternative is, in fact, standard of care for competent srgeons. However, because of corporate interest, namely, those who produce the equipment for morcellation, this procedure is likely to continue. What ever happened to "doctor do no harm?". I feel ashamed to be part of a profession where lack of skill coupled with fragile egos and corporate wealth, has led to such an horrid and horrendous procedure. This practice is antithetical to all which we should hold dear. Shame on those physicians who would continue this practice and shame on Ethicon, Olympus and Storz and Company.

Lisa Nielsen Other

As a patient who had her fibroids morcellated and 2 years later was diagnosed with Uterine Leiomyosarcoma. I would have perferred being told there was a risk that if my fibriods had any unstable or malignant cells they could spread because of the procedure. I almost died suffering through two different chemo therapies and an 8 hour surgery to remove 7 tumors all uterine in origin. The largest weighted 25 pounds. Women must be informed!!!

Robin Yiaski N/A

I would like to thank everyone personally. My sister had a procedure done in 2011. She now has cancer thru out her body. I really think Obgyn's need to rethink these procedures and do a whole uterine hysterectomy. Had this been done maybe my sister would not be suffering a death sentence.

Hooman Noorchashm MD, PhD Physician, Surgery, Specialized, Brigham and Women's Hospital

Systematic and routine Intracorporeal morcellation of tissues in order to extract the dissected specimen from "minimally invasive", small port incisions is a current "standard of practice" in gynecological surgery in the US and globally. No other subspecialty of surgery accepts this practice as safe. In fact, in general and thoracic surgery, we would consider intracorporeal morcellation of any tissue an error than can lead to serious complications, such as upstaging and locoregional spread of occult malignancies or ectopic spread of "benign" tissues. Morcellator devices are specifically marketed to gynecological surgeons and until recently most general and thoracic surgeons did not clearly grasp that our gynecological counterparts are engaged in this practice widely. Moreover, until November of 2013, the gynecological specialty believed the risk of an occult uterine malignancy to be 1 in 10,000-20,000 and had accepted that level of hazard for their patients as being intrinsic to a minor technical detail of a commonly performed procedure. This risk is now shown to be closer to 1 in 400-1000. The response of gynecological bodies such as the SGO and the Brigham and Women's Hospital has been to claim that the procedure can be rendered safe and ethical if the patient is informed of this deadly possibility. This response on the part of an entire specialty is quite alarming, because "informed consent" in this scenario does nothing to protect the 1 in 400-1000 women with, preoperatively undiagnosable, occult uterine malignancies from a locoregionally spread stage 4 cancer using an avoidable technique. However, informed consent does protect the hospital, lawyers and corporate interests quite well in this case. And that, unfortunately, is not ethical medicine oriented at keeping our patients safe in the year 2014 in the United States of America.

Morcellating a tumor with malignant potential inside a woman's abdominal cavity is a flawed and hazardous practice that has exposed 1 in 400-1000 women to deadly stage cancers for over a decade now. This practice should never have been accepted as a "standard of care" by gynecological surgeons. It was adopted because of a severe deficit in the surgical training structure of Gynecological residency programs and potentiated by corporate interests on the part of device manufacturers.

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