Power Morcellation Associated With 0.6% Cancer Incidence

Lara C. Pullen, PhD

December 26, 2014

A retrospective review reveals that 0.6% of women who underwent laparoscopic hysterectomy with power morcellation were diagnosed with uterine sarcoma. Three of these women were diagnosed at the time of the hysterectomy on the basis of pathology evaluation of morcellated specimens, and three women were diagnosed later. All six cases of uterine sarcoma identified in the retrospective review occurred in women who underwent hysterectomy for apparent fibroids. Uterine sarcoma was not associated with any preoperative factors.

Jasmine Tan-Kim, MD, MAS, from Kaiser Permanente San Diego, California, and colleagues published the results of their medical record review of 3523 women online December 11 in the American Journal of Obstetrics and Gynecology. Their study included a large series of laparoscopic hysterectomies as well as long-term follow-up. Patients were treated within a captive health maintenance organization, and thus there was limited loss to follow-up.

Role of Power Morcellation

Power morcellation is performed to divide uterine tissue so that it can pass through the vaginal canal during laparoscopic supracervical hysterectomy, laparoscopic myomectomy, and laparoscopic total hysterectomy. Unfortunately, power morcellation destroys the gross appearance of the specimen, thereby compromising pathological examination.

Dr Tan-Kim and colleagues identified 941 women who underwent power morcellation at the time of hysterectomy. Three women were found to have uterine sarcoma during the initial pathology review of the morcellated specimen and three were diagnosed with uterine sarcomas 2 to 7 years later. The investigators found no cases of morcellated endometrial or cervical cancer.

Uterine Sarcomas and Parasitic Myomas

Uterine sarcomas are rare, malignant tumors of uterine connective tissue. They include leiomyosarcoma, endometrial stromal sarcoma, carcinosarcoma, and undifferentiated sarcoma. Very little is known about this relatively rare form of cancer and its underlying disease process. Approximately 30% of all uterine sarcomas are leiomyosarcomas.

Parasitic myomas are leiomyosarcomas that are not attached to the uterus, and that therefore receive their blood supply from surrounding organs. Previous studies have reported the incidence of parasitic myomas to range from 0.12% to 0.9%.

Dr Tan-Kim and colleagues calculated the incidence of parasitic leiomyomas to be 0.4%. They found that women who were younger than 40 years had a greater risk for parasitic myomas after power morcellation than older women.

Evaluation of Risk

This is the most recent of several studies to investigate the incidence of uterine sarcoma in patients who have a received a hysterectomy for what are presumed to be benign fibroids. Gynecologists are following the issue of power morcellation closely and exploring alternative means to perform minimally invasive hysterectomies. The benefits, however, of these alternative approaches have still not been quantified.

"We would like to be clear that we are not certain, based on these very small case reports, how morcellation affects the prognosis of occult sarcoma. We do not know for certain whether the alternative approaches listed above (minilaparotomy, vaginal morcellation, or in-bag morcellation, etc) would decrease morbidity of an unexpected sarcoma," Dr Tan-Kim emphasized  to Medscape Medical News.

Moreover, results from some studies have suggested that supracervical hysterectomy may be associated with decreased operative complications and decreased urinary and sexual issues relative to total hysterectomy. These risks must be weighed against the risks of power morcellation.

The authors conclude with the suggestion that patients be counseled about the possibility of complications before power morcellation.

The need for patient counseling has been brought into focus by a recent high-profile case of disseminated uterine sarcoma: In October 2013, anesthesiologist Amy Reed, MD, PhD, underwent a hysterectomy for uterine fibroids at Brigham and Women's Hospital in Boston, Massachusetts. She was subsequently diagnosed with stage IV cancer.

Morcellation may have spread a previously unidentified cancer throughout her abdomen. Her husband, cardiothoracic surgeon Hooman Noorchashm, MD, PhD, from Thomas Jefferson Medical College in Philadelphia, Pennsylvania, spoke with Medscape Medical News about the new study, emphasizing that, "This is a very important paper. It is a seminal paper, really.... The scope of the problem is pretty big."

The authors have disclosed no relevant financial relationships.

Am J Obstet Gynecol. Published online December 11, 2014. Abstract

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