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Prevalence of Uterine Malignancy at Hysterectomy with Morcellation

Summary and Comment |
July 22, 2014

Prevalence of Uterine Malignancy at Hysterectomy with Morcellation

  1. Andrew M. Kaunitz MD

Large database allows estimate of preexisting cancer, but many questions remain.

  1. Andrew M. Kaunitz MD

Following a highly publicized case in which a uterine sarcoma was apparently upstaged as a consequence of fibroid removal performed with morcellation (NEJM JW Womens Health Feb 25 2014), this practice is receiving greater scrutiny. To assess the likelihood of preexisting malignancy at the time of morcellation, investigators analyzed an insurance database including 232,882 U.S. women who had minimally invasive hysterectomies between 2006 and 2012.

Among the 36,470 women (15.7%) who underwent morcellation, 99 cases of uterine cancer were observed (prevalence, 27/10,000). Other gynecologic neoplasia (including cervical, ovarian, and tubal malignancies as well as endometrial hyperplasia) were identified in an additional 26 women (7/10,000). Risk for uterine malignancy rose with age: Compared with women younger than 40, risk was 4.97 times higher in women aged 50 to 54 and 35.97 times higher in those 65 or older.

Comment

This study provides gynecologic surgeons and their patients with important new data facilitating the estimation of preexisting malignancy when morcellation is considered. However, as the authors point out, the analysis has major limitations (perhaps the most important of which arises from its lack of pathologic specificity and the inability to verify pathologic findings). The great majority of malignancies termed “uterine” are in fact endometrial cancers — and with appropriate evaluation, most endometrial cancers can be diagnosed preoperatively. In contrast, the malignancy generating the biggest concern with respect to morcellation is uterine sarcoma, a rare condition that typically cannot be diagnosed preoperatively. We await the recommendations of an FDA panel that is currently reviewing the practice of morcellation for minimally invasive hysterectomy. Meanwhile, in contemplating how these data will inform our decisions about approaches to hysterectomy, I find the marked association between age and risk for malignancy to be particularly relevant.

  • Disclosures for Andrew M. Kaunitz MD at time of publication Consultant / Advisory board Actavis plc; Bayer AG; Merck; Teva Pharmaceutical Industries Limited; UpToDate Royalties UpToDate Grant / Research support Trimel Pharmaceuticals Corp; TherapeuticsMD; NIH Editorial boards Contraception; Menopause; Contraceptive Technology Update; OBG Management; Medscape OB/GYN & Women’s Health Leadership positions in professional societies North American Menopause Society (Secretary)

Citation(s):

Reader Comments (4)

Katherine Ferguson Other

I agree with Dr. Kaunitz that the study has major limitations including as he states that it does break out of the types of uterine cancer. I would add a second limitation that it lacks information concerning the pre-op screening procedures. However, it has some very useful data regarding age. In addition, although it does not break out the types of uterine cancers, Dr. Wright who authored the study stated that between 10 and 20% of uterine cancers are uterine sarcomas (Outpatient Surgery (Aug edition). Other experts have estimated a lower rate, but assuming a rate of 15%, the study indicates that for women younger than 40, approximately 1 in 11,000 will have an undetected sarcoma compared to women over 65 who would have a rate of 1 in 219. And of course the rate would be even less if you agree with other experts that sarcomas make up significantly less than 15% of all uterine cancers.

In an FDA hearing concerning the use of power morcellators, Dr. Jubilee Brown presented a study that found that even if you assume an undetected sarcoma rate as high as approximately 1 in 500 women, a MIS procedure using a power morcellator will save lives compared to full open abdominal surgery. If you combine the results of the 2 studies, for women under 40, a MIS procedure would be far safer so if any procedure should be banned (and I am not advocating banning procedures), it is the full open abdominal surgeries. For added reference, the study predicts rates of undetected sarcomas for women between 50-54 at 1-1958 and 55-59 at 1 in 492. So at least through the 50-54 age group, the MIS procedure according to Brown’s study would be safer. Of course, hopefully doctors and scientists will continue to develop better procedures to identify cancers preoperatively.

Deepika Monga FRANZCOG Physician, Obstetrics/Gynecology, Australia

Fully agree it is really important to study outcome and cancer incidence from all hysterectomy/ myomectomy specimens done for non cancer diagnosis preoperatively. That may well be in excess of what is quoted.

Besides beneficence, ethical values also include non-maleficience. Must use every bit of information to make a decision that does no harm!

Ironically, it is the same group of specialists who are increasingly performing caesarean (laparotomy) to improve outcome for women and babies, who are recklessly pushing to decrease or eliminate laparotomy in those very women when they have fibroids/ bleeding!

Little, Joan Home

I'm perplexed by this study for a number of reasons. (Just a lay person looking at this who has been through minimally invasive fibroid surgery where a power morcellator was used both laparoscopically and hsyteroscopically.)

1) If only about 16% of the minimally invasive hysterectomies were done with power morcellation, then how were the other minimally invasive hysterectomies performed? Were the rest done vaginally or was some other non-power morcellation used and if so what?

2) Why didn't they also look at the pathology of the non-power morcellated hysterectomies? Why wouldn't it be important to also pull out that data?? I watched the FDA hearing and listened to the panelists discuss how any kind of morcellation, whether power, knife, scalpel, etc risks spreading cancer if it's there? Why didn't these researchers also look at the pathology of the non-morcellation group???

3) Why didn't they also do the same for minimally invasive myomectomies??

4) Why didn't they break out the different types of cancer??

5) From the claims data, its seems they might be able tell if and what kind of pre-surgical work up the patient did or didn't have -- e.g. pap smear, endometrial biopsy??? Wouldn't it be helpful to know whether those tests comported with what was found or not found after surgery??

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

I find it absolutely astonishing that even in the face of overwhelming evidence that many women have been killed through the practice of morcellation, the gynecological community continues to shed doubt and it attempting to defend the practice of morcellation. Dr. Kauntiz's "white-washed" commentary is yet another astonishing demonstration that this group of surgeons continues to assume that there may be a way to justify the continued mincing up of tissues with malignant potential inside of women's bodies - particularly using a power tool. The morcellation disaster is a historic example of failed self regulation in medicine. Sadly, gynecological surgeons must be restrained from harming (and killing) their patients using morcellation. This is not an academic issue. Many families have been devastated by this industry-wide act of carelessness on the part of this specialty - for nearly two decades.

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