Morcellation worsens survival outcomes in patients with undiagnosed uterine leiomyosarcomas: A retrospective MITO group study
Introduction
Uterine leiomyosarcoma represents a rare entity, constituting about 1.5% of all uterine malignancies, with an estimated annual incidence of 0.64/100,000 women [1]. Excluding carcinosarcomas which are actually classified as undifferentiated carcinomas, leiomyosarcomas (LMSs) and stromal sarcomas account for about 70% and 30% of all uterine sarcomas, respectively [2].
The survival of patients with LMS is strongly associated with the FIGO stage of disease at diagnosis: Stage I tumors have a 5-year survival rate of 84.3%, that decreases dramatically in stage II (43.6%), III (38.8%), and IV (19.8%) respectively [2]. Unfortunately, preoperatively it may be difficult to discriminate between benign uterine fibroids and uterine sarcomas. The true prevalence of uterine sarcomas in presumed fibroids is not exactly known, given the wide range (0.45–0.014%) reported in meta-analyses mainly based on retrospective data [3], [4]. Moreover, although some patients' characteristics (including older age and the presence of symptoms) and morphological features of the uterine lesions at imaging may be suggestive for the presence of uterine sarcoma, a reliable differential diagnosis is still difficult [5].
In November 2014, the U.S. Food and Drug Administration (FDA) issued a safety communication against power morcellation; morcellation was “discouraged” due to its detrimental potential effects in patients with undiagnosed uterine sarcoma [6]. In fact, if a presumed fibroid reveals to be a sarcoma (or other malignancy), any method of morcellation disrupts the integrity of the tumor, thus possibly upstaging the disease and affecting survival. In case of power morcellation, the centripetal forces of the cylindrical knife may add to the phenomenon of ‘seeding’ of tumor cells on the peritoneum [7].
Thereafter, representatives of many scientific societies published their opinions on this issue concluding about the lack of solid scientific evidence to reach strong recommendations on the use of power morcellation [8]. In this retrospective study we sought to determine the oncologic outcome of undiagnosed uterine sarcoma in a large group of women who underwent morcellation in comparison to a group of patients treated without morcellation at 8 referral institutions of MITO (Multicentre Italian Trialists in Ovarian Cancer and Gynecologic Malignancies) group.
Section snippets
Materials and methods
This is a retrospective study performed in eight high volume centers hospitals of MITO group. The medical records of consecutive women who underwent surgical treatment for apparent benign uterine myomas that revealed to be sarcomas at final diagnosis from January 1, 2004, to December 31, 2014 were reviewed and Institutional review board (IRB) was obtained for the study. All patients included in the study gave written consent to data collection and to the use of personal records for health
Results
Overall, 4.000 surgical interventions for benign fibroids were performed in 10 years in the 8 centers participating the study. Among those, 125 patients (3.1%) affected by unexpected FIGO stage I uterine sarcomas were identified: 52 (41.6%) patients had morcellation and 73 (58.4%) had not. Patients characteristics are reported in Table 1.
Median age was 55 years and the majority (72.8%) of women had uterine LMS. In most part of patients undergoing morcellation (n = 31; 59.6%) surgery was performed
Discussion
This retrospective, multi-institutional study confirms the detrimental impact of morcellation on oncologic outcomes of patients diagnosed with unexpected uterine leiomyosarcoma. Our data report a 3 times higher risk of death in patients who had morcellation of undiagnosed LMS in comparison to patients who had no morcellation.
Recently, the FDA claimed on the prognostic impact of morcellation of unexpected sarcomas. FDA warning was based on a pooled analysis of retrospective studies suggesting
Disclosure
The Authors declare no conflicts of interest. No funding sources supported this investigation.
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