Arnold Advincula's Surgical Techniques
What is the prognosis when a leiomyosarcoma is morcellated?
OBG Management: What do we know about outcomes when a leiomyosarcoma is inadvertently morcellated?
Dr. Fader: This is considered a “cut-through” procedure, in that a cancerous tumor that is potentially contained to an organ is not removed intact or with clean margins. The morcellation procedure effectively cuts through the occult cancer, which is not desirable. Intact surgical removal of uterine cancers or sarcomas is the mainstay of therapy for these malignancies, based on NCCN guidelines.22
OBG Management: Does a morcellated leiomyosarcoma carry a worse prognosis than an unmorcellated leiomyosarcoma?
Dr. Fader: When it comes to morcellated versus “intact” uterine leiomyosarcoma, we enter a largely data-free zone. We don’t know with certainty whether the outcome is worsened. If we’re being intellectually honest, we must admit the possibility that a morcellated cancer is more likely to be disseminated, rendering it potentially more difficult to treat. However, sarcomas primarily spread by hematogenous dissemination. It is quite possible that even the act of incising an intact fibroid in an open abdominal procedure or performing a supracervical or total hysterectomy without morcellation may still result in hematogenous cancer dissemination. So there is no indication yet that electromechanical morcellation poses a unique and higher risk of cancer upstaging or worse prognosis compared with techniques such as open myomectomy, supracervical hysterectomy, or hysteroscopic myomectomy.
In addition, the prognosis associated with even early-stage uterine leiomyosarcoma is uniformly poor. A published study from Hopkins that included 108 patients with uterine leiomyosarcoma suggests that the recurrence rate and survival of patients with early-stage, “intact” leiomyosarcoma are very poor and comparable to the survival rate documented in the literature for women with morcellated sarcomas.23
The few retrospective studies that exist suggesting worse outcomes with morcellation have limitations that preclude any definitive conclusions.2 These studies are marred by small numbers, heterogeneity in morcellation practices, poor follow-up times, and a lack of detail regarding how patients with morcellated versus unmorcellated sarcomas were treated. Nevertheless, a couple of these small retrospective reports indicate the possibility of worse outcomes in women with morcellated uterine sarcomas, compared with historical controls with intact sarcoma removal.
The bottom line is that we need more—and better quality—data before we can comment definitively on the prognosis for morcellated and unmorcellated uterine sarcoma in an informed manner.
Is the morcellator at fault—or the user?
OBG Management: Some would argue that even one case of a morcellated uterine sarcoma is too many. How would you respond?
Dr. Fader: There is no doubt that a handful of women each year have been harmed by morcellation practices. Those women deserve our dedication and best efforts to learn how to better treat morcellated sarcomas—and more importantly—how to mitigate the risks associated with morcellation practices and reduce the risk of preventable harm for all women undergoing minimally invasive fibroid procedures. I think the single best thing we can do to mitigate risk is to be more conscientious about selecting our patients for tissue-extraction procedures (ie, strict selection criteria, appropriate preoperative work-ups). If we did this, we likely would reduce the number of oncologic morcellator mishaps by 50% to 80% without changing anything else.
When we closely scrutinize the literature, and when I reflect on the women with morcellated cancers that we have cared for at Hopkins, we observe that some (but not all) “occult” uterine cancers were not that hidden after all and may have been detected preoperatively if an effort had been made.
We have noted a number of patients in this setting who experienced harm not because a specific device was used to cut up their uterus but because they were never appropriate candidates for the procedure in the first place. For instance, I recently cared for an elderly woman with a morcellated uterine cancer who underwent a laparoscopic supracervical hysterectomy without an appropriate preoperative work-up (ie, no endometrial biopsy or imaging) or informed consent about the possibility that she might have cancer. If an elderly woman presents with concerning symptoms related to her uterus (ie, enlargement, bleeding), she must be evaluated and counseled regarding the considerable risk of potential malignancy. Even in the setting of a normal work-up, I don’t believe it is a good idea to perform electromechanical morcellation in higher-risk women, including elderly women. That does not mean that select, well-screened women cannot be considered for alternative tissue-extraction techniques, but the risks and benefits must be carefully weighed in each patient, and informed consent must be obtained.
By continuing to refine the safety features of the electromechanical morcellator devices and choosing patients more carefully for minimally invasive procedures and tissue extraction, we likely will reduce the risk of preventable harm in women undergoing gynecologic surgery.
