Abstract
Objective
This project of the International Society for Gynecologic Endoscopy (ISGE) had the
objective to review the literature and provide recommendations on the occult sarcoma
risk assessment in patients who are candidates for minimally invasive gynecological
surgery involving intra-abdominal electromechanical tissue morcellation.
Study design
The ISGE Task Force for Estimation of the Risk in Endoscopic Morcellation initially
defined key topics and clinical questions which may guide a comprehensive preoperative
patient assessment. A literature search within the Medline/PubMed and Cochrane Database
was carried out using keywords “morcellation”, “uterine fibroids”, “uterine sarcoma”,
“myomectomy” and “hysterectomy”. Relevant publications (original studies, meta-analyses
and previous reviews), written in English and published until May 30th, 2017, were
selected and analyzed. Previously emitted statements of 12 recognized professional
societies or government institutions and their supporting literature were also studied.
For each topic/clinical question, the available information was graded by the level
of evidence. The ISGE recommendations were established in accordance with the evidence
quality.
Results
In the light of available information, 9 recommendations on preoperative clinical,
laboratorial and imaging evaluation of the candidates for intracorporeal uterus/leiomyoma
morcellation were formulated, mainly based on consensus and expert opinions. There
is a lack of high-quality evidence, which does not allow the establishment of strong
recommendations.
Conclusion
Electromechanical tissue morcellation may be used in gynecological patients who are
considered “low risk” upon appropriate preoperative evaluation; however, further studies
and prospective data collection are greatly needed to improve sarcoma risk assessment
in women with presumed uterine leiomyomas.
Keywords
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References
- Clinical management of uterine sarcomas.Lancet Oncol. 2009; 10: 1188-1198
- Laparoscopic versus open hysterectomy for benign disease in women with giant uteri (≥1500 g): feasibility and outcomes.J Minim Invasive Gynecol. 2016; 23: 922-927
- Surgical approach to hysterectomy for benign gynaecological disease.Cochrane Database Syst Rev. 2015; : CD003677
- Risk of venous thromboembolism in abdominal versus minimally invasive hysterectomy for benign conditions.Am J Obstet Gynecol. 2015; 212 (609.e1-7)
- Routes of hysterectomy in women with benign uterine disease in the Vancouver Coastal Health and Providence Health Care regions: a retrospective cohort analysis.CMAJ Open. 2014; 2: E273-E280
- Mini-laparotomy versus laparoscopy for gynecologic conditions.J Minim Invasive Gynecol. 2014; 21: 109-114
- Hysterectomy for benign uterine pathology: comparison between robotic assisted laparoscopy, classic laparoscopy and laparotomy.Chirurgia (Bucur). 2013; 108: 346-350
- Laparoscopic hysterectomy versus total abdominal hysterectomy: a retrospective comparative study.J Med Assoc Thai. 2011; 94: 8-16
- Surgical approach to hysterectomy for benign gynaecological disease.Cochrane Database Syst Rev. 2015; 8: CD003677
- Surgical approach to hysterectomy for benign gynaecological disease.Cochrane Database Syst Rev. 2009; 3: CD003677
- Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis.Eur J Obstet Gynecol Reprod Biol. 2009; 144: 3-7
- Abdominal versus laparoscopic hysterectomies for benigno dissesses: evaluation of morbidity and mortality among 465,798 cases.Gynecol Surg. 2013; 10: 117-122
- Evaluating the risks of electric uterine morcellation.JAMA. 2014; 311: 905-906
- The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma.Gynecol Oncol. 2011; 122: 255-259
- Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients.Eur J Gynaecol Oncol. 2003; 24: 237-240
- Uterine leiomyosarcoma: does the primary surgical procedure matter?.Int J Gynecol Cancer. 2009; 19: 257-260
- Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma.Cancer. 2014; 120: 3154-3158
- Outcome of occult uterine leiomyosarcoma after surgery for presumed uterine fibroids: a systematic review.J Minim Invasive Gynecol. 2015; 22: 26-33
- Incidental power morcellation of malignancy: a retrospective cohort study.Gynecol Oncol. 2015; 136: 274-277
- Risk of occult uterine sarcoma in women undergoing hysterectomy for benign indications.Obstet Gynecol. 2016; 127: 468-473
- Impact of morcellation on survival outcomes of patients with unexpected uterine leiomyosarcoma: a systematic review and meta-analysis.Gynecol Oncol. 2015; 137: 167-172
- Occult uterine sarcoma and leiomyosarcoma: incidence of and survival associated with morcellation.Obstet Gynecol. 2016; 127: 29-39
- A retrospective analysis of the impact of myomectomy on survival in uterine sarcoma.PLOS ONE. 2016; 11: e0148050
- Laparoscopic morcellator-related complications.J Minim Invasive Gynecol. 2014; 21: 486-491
- Iatrogenic parasitic leiomyoma and leiomyomatosis peritonealis disseminata following uterine morcellation.J Obstet Gynaecol Res. 2016; 42: 990-999
- Disseminated peritoneal leiomyomatosis after laparoscopic supracervical hysterectomy with characteristic molecular cytogenetic findings of uterine leiomyoma.Genes Chromosomes Cancer. 2010; 49: 1152-1160
- Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA safety communication.2014 (Available at: https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm)
- Laparoscopic electric morcellators – risk of spread of unsuspected uterine sarcoma – notice to hospitals.2014 (Available at: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2014/39409a-eng.php)
- SGO position statement: morcellation.2013 (Available at: https://www.sgo.org/newsroom/position-statements-2/morcellation)
- ACOG statement on power morcellation.2014 (Available at: http://www.acog.org/About-ACOG/News-Room/Statements/2014/ACOG-Statement-on-Power-Morcellation)
- AAGL practice report: morcellation during uterine tissue extraction.J Minim Invasive Gynecol. 2014; 21: 517-530
- Options on fibroid morcellation: a literature review.Gynecol Surg. 2015; 12: 3-15
- European Society of Gynecological Oncology Statement on fibroid and uterine morcellation.Int J Gynecol Cancer. 2017; 27: 189-192
- APAGE statement on laparoscopic morcellation of uterine fibroids.2015 (Available at: http://www.apagemit.com/about/news_content.asp?news_id=72)
- Tissue extraction at minimally invasive procedures.2014 (Available at: https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Tissue-Extraction-at-Minimally-Invasive-Procedures-(C-Gyn-33)-Review-November-2014.pdf?.ext=.pdf)
- BSGE statement on power morcellation.2015 (Available at: http://bsge.org.uk/news/bsge-statement-power-morcellation [accessed 20.05.17])
- Hysterectomy for benign disease: clinical practice guidelines from the French College of Obstetrics and Gynecology.Eur J Obstet Gynecol Reprod Biol. 2016; 202: 83-91
- Surgical methods for the treatment of uterine fibroids – risk of uterine sarcoma and problems of morcellation: position paper of the DGGG.Geburtshilfe Frauenheilkd. 2015; 75: 148-164
- Statement of the Society of Gynecologic Oncology to the Food and Drug Administration's Obstetrics and Gynecology Medical Devices Advisory Committee concerning safety of laparoscopic power morcellation.2014 (Available at: https://www.sgo.org/wp-content/uploads/2014/04/SGO-Testimony-to-FDA-on-Power-Morcellation-FINAL.pdf)
- Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms.PLoS ONE. 2012; 7: e50058
- Italian multicenter study on complications of laparoscopic myomectomy.J Minim Invasive Gynecol. 2007; 14: 453-462
- Safety of manual morcellation after vaginal or laparoscopic-assisted vaginal hysterectomy.J Minim Invasive Gynecol. 2016; 23: 542-547
- Clinical characteristics and prognosis of unexpected uterine sarcoma after hysterectomy for presumed myoma with and without transvaginal scalpel morcellation.Int J Gynecol Cancer. 2016; 26: 456-463
- Uterine sarcomas: clinical features and management.in: Coppleson X. Monagham J. Morrow P. Tattersall M. Gynecologic oncology. Chruchill Livingstone, London1992: 827-840
- Endometrial stromal tumors: the new WHO classification.Adv Anat Pathol. 2014; 21: 383-393
- Retroperitoneal leiomyosarcoma associated with an elevated beta-HCG serum level mimicking extragonadal germ cell tumor.Sarcoma. 2000; 4: 179-181
- High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence.Am J Obstet Gynecol. 2003; 188: 100-107
- Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989–1999.Gynecol Oncol. 2004; 93: 204-208
- Uterine sarcoma: analysis of 13,089 cases based on surveillance, epidemiology, and end results database.Int J Gynecol Cancer. 2016; 26: 1098-1104
- Mesenchymal tumors of the uterus. I. A clinical and pathological study of 53 endometrial stromal tumors.Cancer. 1966; 19: 755-766
- Retrospective review of 208 patients with leiomyosarcoma of the uterus: prognostic indicators, surgical management, and adjuvant therapy.Gynecol Oncol. 2003; 89: 460-469
- Leiomyosarcomas: clinical presentation.Am J Obstet Gynecol. 1993; 168: 180-183
- The treatment of uterine leiomyosarcoma. Results from a 10-year experience (1990–1999) at the Massachusetts General Hospital.Gynecol Oncol. 2004; 92: 648-652
- Uterine sarcoma: a report of 57 cases over a 16-year period analysis.Eur J Gynaecol Oncol. 2008; 29: 129-134
- Clinicopathologic study of 28 uterine leiomyosarcomas with metastasis.Int J Gynecol Pathol. 1995; 14: 243-249
- Abdominal myomectomy in women with very large uterine size.Fertil Steril. 2006; 85: 36-39
- Natural history of uterine polyps and leiomyomata.Obstet Gynecol. 2002; 100: 3-7
- Sarcoma arising in a leiomyoma of the uterus: factors influencing prognosis.Am J Obstet Gynecol. 1965; 92: 421-427
- Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma.Obstet Gynecol. 1994; 83: 414-418
- Short-term change in growth of uterine leiomyoma: tumor growth spurts.Fertil Steril. 2011; 95: 242-246
- Growth of uterine leiomyomata among premenopausal black and white women.Proc Natl Acad Sci U S A. 2008; 105: 19887-19892
- Transient rapid growth of uterine leiomyoma in a postmenopausal woman.Oncol Rep. 1999; 6: 1289-1292
- Unsuspected leiomyosarcoma: treatment with a gonadotropin-releasing hormone analogue.Obstet Gynecol. 1990; 75: 529-532
- Leiomyosarcoma after uterine artery embolization. A case report.J Reprod Med. 2001; 46: 278-280
- Literature review of outcomes and prevalence and case report of leiomyosarcomas and non-typical uterine smooth muscle leiomyoma tumors treated with uterine artery embolization.Eur J Obstet Gynecol Reprod Biol. 2015; 191: 130-137
- Uterine sarcoma occurring in a premenopausal patient after uterine artery embolization: a case report and review of the literature.Gynecol Oncol. 2007; 104: 260-263
- Metastatic leiomyosarcoma diagnosed after uterine artery embolization.Eur J Gynaecol Oncol. 2009; 30: 199-202
- Uterine leiomyosarcoma diagnosed during treatment with agonist of luteinizing hormone-releasing hormone for presumed uterine fibroid.Fertil Steril. 1990; 54: 530-531
- Avoiding treatment of leiomyosarcomas: the role of magnetic resonance in focused ultrasound surgery.Fertil Steril. 2008; 90 (850.e9-12)
- Benign metastasizing leiomyoma of the lung.World J Surg Oncol. 2013; 11: 279
- Cost-effectiveness of endometrial evaluation prior to morcellation in surgical procedures for prolapse.Am J Obstet Gynecol. 2013; 209 (22.e1-9)
- FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age.Int J Gynaecol Obstet. 2011; 113: 3-13
- Incidence of unanticipated uterine pathology at the time of minimally invasive abdominal sacrocolpopexy.J Minim Invasive Gynecol. 2014; 21: 97-100
- The role of endometrial biopsy in the preoperative detection of uterine leiomyosarcoma.J Minim Invasive Gynecol. 2016; 23: 567-572
- The utility of preoperative endometrial sampling for the detection of uterine sarcomas.Gynecol Oncol. 2008; 110: 43-48
- Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas.Am J Obstet Gynecol. 1990; 162 (discussion 74-6): 968-974
- Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus.Int J Gynecol Cancer. 2002; 12: 354-361
- Leiomyosarcoma of the uterus: ultrasonography and serum lactate dehydrogenase level.Gynecol Obstet Invest. 1992; 33: 114-118
- Potential role of preoperative serum CA125 for the differential diagnosis between uterine leiomyoma and uterine leiomyosarcoma.Eur J Gynaecol Oncol. 2006; 27: 370-374
- A rare case of uterine leiomyosarcoma: a case report.J Med Case Rep. 2010; 4: 222
- CA125 expression in the tissue of uterine leiomyosarcoma.Isr Med Assoc J. 2014; 16: 697-699
- Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group.Ultrasound Obstet Gynecol. 2015; 46: 284-298
- Leiomyomas in pregnancy: sonographic study.Radiology. 1987; 164: 375-380
- Fibroids in pregnancy – common but poorly understood.Obstet Gynecol Surv. 2005; 60: 132-138
- Characterising acute gynaecological pathology with ultrasound: an overview and case examples.Best Pract Res Clin Obstet Gynaecol. 2009; 23: 577-593
- Leiomyomas beyond the uterus: unusual locations, rare manifestations.Radiographics. 2008; 28: 1931-1948
- Uterine smooth-muscle tumors with unusual growth patterns: imaging with pathologic correlation.AJR Am J Roentgenol. 2007; 188: 246-255
- Uterine smooth-muscle tumors with unusual growth patterns.J Minim Invasive Gynecol. 2009; 16: 263-268
- Conservative treatment of diffuse uterine leiomyomatosis.Fertil Steril. 2004; 82: 450-453
- Uterine smooth muscle tumors other than the ordinary leiomyomas and leiomyosarcomas: a review of selected variants with emphasis on recent advances and unusual morphology that may cause concern for malignancy.Adv Anat Pathol. 2010; 17: 91-112
- Pathology of uterine leiomyosarcomas and smooth muscle tumours of uncertain malignant potential.Best Pract Res Clin Obstet Gynaecol. 2011; 25: 691-704
- Uterine sarcoma: can it be differentiated from uterine leiomyoma with Doppler ultrasonography? A preliminary report.Ultrasound Obstet Gynecol. 1997; 9: 101-104
- Uterine sarcoma: a report of 10 cases studied by transvaginal color and pulsed Doppler sonography.Gynecol Oncol. 1995; 59: 342-346
- The characterization of uterine tumors by transvaginal color Doppler.Ultrasound Obstet Gynecol. 1991; 1: 50-52
- Color Doppler ultrasonography in the differentiation of uterine sarcomas from uterine leiomyomas.Eur J Gynaecol Oncol. 2002; 23: 29-34
- Value of ultrasonography and magnetic resonance imaging for the characterization of uterine mesenchymal tumors.Acta Obstet Gynecol Scand. 2014; 93: 261-268
- Endometrial stromal sarcoma mimicking a myoma.Fertil Steril. 2009; 92: 1744-1746
- Can gray-scale and color Doppler sonography differentiate between uterine leiomyosarcoma and leiomyoma?.J Clin Ultrasound. 2007; 35: 449-457
- Uterine sarcomas versus leiomyomas: gray-scale and Doppler sonographic findings.J Clin Ultrasound. 2005; 33: 10-13
- Does pelvic magnetic resonance imaging differentiate among the histologic subtypes of uterine leiomyomata?.Fertil Steril. 1998; 70: 580-587
- Smooth muscle tumors of uncertain malignant potential and leiomyosarcomas of the uterus: MR findings.J Magn Reson Imaging. 2004; 20: 998-1007
- MR imaging of uterine sarcomas.AJR Am J Roentgenol. 2001; 177: 1307-1311
- Clinical application of diffusion-weighted imaging for preoperative differentiation between uterine leiomyoma and leiomyosarcoma.Am J Obstet Gynecol. 2014; 210 (368.e1-8)
- The utility of diffusion-weighted MR imaging for differentiating uterine sarcomas from benign leiomyomas.Eur Radiol. 2008; 18: 723-730
- Diagnostic accuracy of the apparent diffusion coefficient in differentiating benign from malignant uterine endometrial cavity lesions: initial results.Eur Radiol. 2008; 18: 384-389
- Combined use of T2-weighted and diffusion-weighted 3-T MR imaging for differentiating uterine sarcomas from benign leiomyomas.Eur Radiol. 2009; 19: 2756-2764
- Advanced MRI in malignant neoplasms of the uterus.J Magn Reson Imaging. 2013; 37: 249-264
- Differentiation of benign and malignant uterine corpus tumors by using proton MR spectroscopy at 3T: preliminary study.Eur Radiol. 2011; 21: 850-856
- Variations of dynamic contrast-enhanced magnetic resonance imaging in evaluation of breast cancer therapy response: a multicenter data analysis challenge.Transl Oncol. 2014; 7: 153-166
- Quantitative dynamic contrast-enhanced MR imaging analysis of complex adnexal masses: a preliminary study.Eur Radiol. 2012; 22: 738-745
- CT and MRI of uterine sarcomas and their mimickers.AJR Am J Roentgenol. 2003; 181: 1369-1374
- Spectrum of FDG PET/CT findings of uterine tumors.AJR Am J Roentgenol. 2010; 195: 737-743
- Transcervical needle biopsy for the differential diagnosis between uterine sarcoma and leiomyoma.Cancer. 2002; 94: 1713-1720
- Contained morcellation: review of current methods and future directions.Front Surg. 2017; 4: 15
- Supracervical hysterectomy.J Obstet Gynaecol Can. 2010; 32: 62-68
- AAGL position statement: route of hysterectomy to treat benign uterine disease.J Minim Invasive Gynecol. 2011; 18: 1-3
Article info
Publication history
Published online: November 06, 2017
Accepted:
October 30,
2017
Received in revised form:
October 16,
2017
Received:
June 10,
2017
Identification
Copyright
© 2017 Elsevier B.V. All rights reserved.