The risk of finding occult uterine sarcoma during hysterectomy for benign indications was lower than expected in a single-center retrospective cohort study, at 0.089%, or 1 in 1,124 hysterectomies, according to a recent analysis.
This is markedly lower than the estimated risks in previous studies, which ranged from 1 in 204 to 1 in 667 procedures for women with presumed myomas. The American College of Obstetricians and Gynecologists estimated the risk to be 1 in 500 hysterectomies, and the Food and Drug Administration pegged it at 1 in 352 based on a pooled analysis of nine studies of women undergoing hysterectomy or myomectomy for presumed myomas. The last estimate in particular has been criticized as inaccurate because of concerns about the quality of data and methodologic flaws of the nine studies, reported Dr. Kimberly A. Kho of the University of Texas Southwestern Medical Center, Dallas, and her associates (Obstet. Gynecol. 2016;127:468-73.).
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The investigators analyzed information in a database for all 10,119 hysterectomies performed for benign indications at their medical center during a 14-year period, and correlated it with data concerning all cases of uterine sarcoma in their center’s tumor registry. A total of 59.4% of these procedures used an abdominal approach, 21.6% were laparoscopic or robot assisted, and 18.9% used a vaginal approach. The most common indications were leiomyomata (37%), abnormal uterine bleeding (28%), and pelvic organ prolapse (11%).
Nine women were found to have an occult uterine sarcoma, including five leiomyosarcomas, two endometrial stromal sarcomas, and two uterine adenocarcinomas.
“All patients had received up-to-date cervical cancer screening and, in the majority of cases, women had received preoperative evaluation with either endometrial sampling or imaging, which did not suggest malignancy. Of the suggested risk factors for sarcoma, it is notable that none of the women we identified were postmenopausal, exposed to pelvic radiation or tamoxifen, nor had a family history of cancer,” the researchers wrote.
Only one patient underwent manual morcellation of a large, bulky uterus before her sarcoma was discovered during total abdominal hysterectomy. The abdominal cavity was then thoroughly explored, and no suspicious lesions were found. This patient later received chemotherapy and had no evidence of disease 3 years later.
The study findings may be helpful for surgical planning and for counseling patients about management options. “It is important to stress that although low, the risk of encountering an occult sarcoma exists. Hence, ongoing efforts to identify potentially safer methods for tissue extraction are essential, as are efforts to improve preoperative identification of malignancies,” the researchers noted.
The study was supported by the University of Texas Southwestern Medical Center. Dr. Kho reported ties to Actamax Surgical Materials and Applied Medical; one of her associates reported ties to AstraZeneca and Genentech.