Gynecologic Cancer Found During Hysterectomy and Myomectomy

Megan Brooks

March 15, 2018

The risk for occult gynecologic cancer in women who undergo hysterectomy or myomectomy for benign indications is low but not trivial, particularly in women older than 55 years, a new study suggests.

The findings were published online March 12 in Obstetrics and Gynecology.

The study also suggests that power morcellation may have potential utility in select patient populations, say the authors, led by Vrunda B. Desai, MD, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut.

The investigators were prompted to study the issue by the recent US Food and Drug Administration (FDA) decision discouraging morcellator use, Desai noted in a journal podcast. "When we started this project, there was some debate about risk of having an occult cancer during a benign hysterectomy, but there really wasn't that much data out there."

The researchers analyzed data for 2014-2015 from the American College of Surgeons National Surgical Quality Improvement Program (NISQIP) for 24,076 women who had undergone hysterectomies and for 2368 who had undergone myomectomies with no known or suspected cancer at the time of surgery.

Cancer In Women Undergoing Hysterectomy

In the women who underwent hysterectomy, malignancy of the corpus uteri was found in 1.44%. The prevalence varied "considerably" by surgical route; the rate was 0.23% in patients who underwent laparoscopic supracervical hysterectomy, 1.89% in those who underwent total laparoscopic or laparoscopic-assisted vaginal hysterectomy, and 1.86% in those who undersent total abdominal hysterectomy.

Additionally, in the women who underwent hysterectomy for benign conditions, 0.60% were found to have malignancy of the cervix uteri, and 0.19% were found to have ovarian cancer.

The occult corpus uteri and ovarian cancers tended to be in early stages; 80% of corpus uteri cancers and 60.9% of the ovarian malignancies were stage I-IC neoplasms. Among women with occult cancer of the cervix uteri, 44.1% had cancers of stage I-IB2; 40.7% had cancers of stage NOS.

Age was a factor, with older women significantly more likely to have preoperatively undetected malignancy of the corpus uteri. The adjusted odds ratio was 6.46 for women aged 55 years and older vs women aged 40 to 54 years. For women who underwent total abdominal hysterectomy, 9.72% of those aged 55 years and older had occult corpus uteri cancer, compared with only 1.06% of women aged 40 to 54 years.

The higher risk for occult cancer in older women and in women undergoing total hysterectomy "calls for more careful preoperative evaluation and counseling for these patients," Desai and colleagues write.

Among women who underwent myomectomy, only five were found to have occult cancer of the corpus uteri. One cancer was of stage I, and the other four were of stage NOS. None of these women underwent laparoscopic myomectomy (three had abdominal myomectomy, and two had vaginal myomectomy). None of the women who underwent myomectomy were found to have occult cervical or ovarian malignancy.

Use of Morcellation

The findings from this study, Desai and her colleagues say, suggest that power morcellation may have potential utility in select patient populations.

"For instance, no occult corpus uteri cancer was identified in women undergoing laparoscopic myomectomy. With careful screening, benefits of minimally invasive procedures enabled by power morcellation (eg, smaller incisions, lower complication rates, and more rapid recovery) may outweigh the risk of occult malignancy in these patients," they explain in their article. "Rather than completely dismissing its use, there may be a role for selective use of power morcellation, especially with advancement in techniques such as contained power morcellation inside an isolation bag, which offers additional protection."

John R. Fischer, MD, from the University of Minnesota, Minneapolis, who is also consultant Web editor for Obstetrics and Gynecology and podcast host, said this is a "timely and interesting paper. A lot of people think that the possibility of ever morcellating again is dead and gone, but [the authors] really did a great job of looking at the NISQIP data from American College of Surgeons to get a better handle on what maybe is the truer incidence of occult uterine malignancies in patients undergoing hysterectomy and myomectomy," said Fischer

"This is great work," added Nancy C. Chescheir, MD, editor-in-chief, Obstetrics and Gynecology. This article is "of interest" not just to the subspecialists but also to the general obstetrician/gynecologist, said Chescheir, of the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill.

One of the "brilliant" things the researchers did, Chescheir explained in the podcast, was to exclude surgeries performed by gynecologic oncologists specifically to "eliminate the chance that patients had complex or high-risk surgeries that may have then had a higher chance of having a malignancy."

Desai and colleagues say the lack of data on surgical indications is a limitation of their study. Also, because cervical and ovarian tissue was not always included in pathology assessment at the time of hysterectomy or myomectomy, the analysis might have underestimated the prevalence of occult cervical and ovarian cancer.

Additionally, owing to the 2014 FDA safety warning about power morcellation, there might have been more rigorous preoperative screening and more restrictive selection of patients with supracervical hysterectomy. For these reasons, this 2014-2015 data analysis may "reflect conservative estimates of occult cancer risk," the investigators write.

Despite these limitations, the authors say their findings have "important implications for clinical care.

"Currently, screening methods for uterine sarcoma or ovarian cancer are limited, whereas preoperative screening for cervical (cervical cytology) and endometrial cancer (endometrial sampling or imaging) is available but not sufficiently sensitive. Given the nontrivial risk of occult gynecologic cancer, it is imperative to further advance gynecologic cancer screening techniques," they note.

The study was supported by a grant from the Yale School of Medicine Discovery to Cure Translational Research Program. Dr Desai has disclosed no relevant financial relationships.

Obstet Gynecol. Published online March 12, 2018. Abstract

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