Uterine Cancer Rare in Hysterectomy With Morcellation, Study Shows

Veronica Hackethal, MD

July 22, 2014

(Updated) Uterine cancer is estimated to be present in 27 of 10,000 women undergoing minimally invasive hysterectomy with morcellation, according to a study by researchers at Columbia University Medical Center, published online July 22 in JAMA.

"This is one of the first nationwide studies examining the prevalence of cancer and precancerous changes specifically in women who underwent hysterectomy with electric power morcellation," lead author Jason D. Wright, MD, associate professor of obstetrics and gynecology at Columbia University College of Physicians and Surgeons in New York City, told Medscape Medical News. "Many prior studies included women who underwent hysterectomy alone."

The prevalence of uterine cancer found in this study was similar to that reported by the US Food and Drug Administration, and older age was a "strong risk" for cancer, Dr. Wright added.

Morcellation is the fragmentation of tissue into smaller pieces for easier removal during minimally invasive surgery. Recently, a controversy has spread about the potential for morcellation to spread undetected cancer during minimally invasive gynecologic surgery.

Women who have uterine cancer should not undergo morcellation, according to recent recommendations from the AAGL, formerly known as the American Association of Gynecologic Laparoscopists, and the American College of Obstetricians and Gynecologists. However, estimating the risk of spreading undetected cancer during morcellation is problematic. Accurate estimates of uterine cancer prevalence at the time of surgery are incomplete. Limited research, mostly from single-center studies, has suggested widely ranging prevalences of between 9 and 100 per 10,000 women, according to background information in the research letter.

"Prevalence information is the first step in determining the risk of spreading cancer with morcellation," the authors point out.

Using the Perspective insurance claims database, the researchers identified women who had minimally invasive surgery for hysterectomy from 2006 to 2012. The database covers more than 500 hospitals, mostly urban teaching centers in the southern United States. The researchers used International Classification of Diseases, Ninth Revision, diagnostic codes to identify gynecologic cancers and charge codes to identify procedures that used morcellators.

During the study time frame, 232,882 women had minimally invasive hysterectomy, of whom 36,470 (15.7%) underwent morcellation. Among those who had morcellation performed, 99 cases of uterine cancer were found, for a prevalence of 27 cases per 10,000 women (95% confidence interval, 22 - 32 per 10,000 women). The researchers also identified cancers of unclear malignancy, other types of gynecologic cancers (including cervical cancer), and endometrial hyperplasia.

Older age was linked to underlying cancer and endometrial hyperplasia.

The authors note that the study could have been limited by a design that precluded checking pathological findings, and that it held the potential for misclassification of pathology, as well as underestimation of morcellation. In addition, the authors lacked information on long-term follow-up and could not look at outcomes in women with uterine pathology found at the time of morcellation.

An Informed Patient is Key

"I think this study further validates that there are pre-existing uterine conditions that need to be taken into account prior to doing a morcellation," Sanaz Memarzadeh, MD, PhD, associate professor of OB/GYN and director of the Gynecology Oncology Discovery Lab at UCLA, told Medscape Medical News when contacted for an independent opinion.

The study identified the presence of three clinical conditions that could be contraindications to morcellation in a subset of women who had the procedure, Dr. Memarzadeh clarified. These conditions included uterine cancer, uterine growths of uncertain malignant potential, and endometrial hyperplasia, a precursor to cancer.

Minimally invasive surgery has many advantages, Dr. Memarzadeh pointed out, and more patients have benefited from it than have been harmed. On the other hand, morcellation during minimally invasive gynecologic surgery carries risks, such as spread and upstaging of a uterine tumor.

"My personal bias is that I'm not a fan of morcellation. To some extent it can be a risky procedure," Dr. Mermarzadeh commented. "Prior to surgery there's no real way of distinguishing between a benign condition, like a uterine fibroid, or a leiomyosarcoma, which is a very aggressive form of uterine cancer.

"The biggest take home point from this study and the recent discussions about morcellation is that there has to be a conversation with the patient about the approach that may be taken," Dr.Memarzadeh emphasized. "The patient should always discuss risks and benefits with their doctor. Depending on the risks and benefits for her, the patient should make an informed decision."

The study authors concur with that statement, concluding, "Patients considering morcellation should be adequately counselled about the prevalence of cancerous and precancerous conditions prior to undergoing the procedure."

Dr. Wright and a coauthor are both recipients of grants from the National Cancer Institute. Another coauthor is the recipient of a fellowship from the National Cancer Institute. The authors have disclosed no other relevant financial relationships. Dr. Memarzadeh reports no conflicts of interest.

JAMA. Published online July 22, 2014. Full text

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