The risk of finding occult gynecological malignancy in women undergoing hysterectomy or myomectomy is not negligible, especially in women more than 55 years in age reports the results of a large population-based study published ahead of print in Journal of Obstetrics and Gynecology.
This timely and interesting study not only looked at the prevalence of gynecological malignancy in women undergoing hysterectomy and myomectomy for benign conditions but also looked at the utility of power morcellators in selected patient populations.
In 2014 US-FDA issued a warning against the use of power morcellators in hysterectomy or myomectomy in women with uterine fibroids because of the risk of spreading and upstaging the cancerous tissue beyond the uterus. The researchers of this study started on the project because, besides few studies, there was no real data to support FDA’s decision to ban the use of power morcellator.
FDA has issued the warning following advocacy by Amy Reed, MD, Ph.D., an anesthesiologist who died following a laparoscopic hysterectomy in October 2013. The use of power morcellator to remove the specimen dispersed and upstaged her undiagnosed uterine sarcoma inside her abdomen.
The study led by Vrunda B. Desai, MD, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut looked at data from the American College of Surgeons National Surgical Quality Improvement Program (NISQIP) for the year 2014-2015.
The sample included 24,076 women who underwent the hysterectomy and 2,368 women who had myomectomy for benign indication at the time of surgery. The researchers did not include data from surgeries performed by gynecologic oncosurgeon to eliminate the possibility of including cases of suspected malignancy before surgery.
After regression analysis, it was seen that the incidence of corpus uteri was found in 1.44%, with variation according to the route of hysterectomy. The highest incidence of 1.89% was found in specimens from total laparoscopic or laparoscopic-assisted vaginal hysterectomy followed by 1.86% in samples from the total abdominal hysterectomy. The lowest incidence of 0.23% was noted in patients who underwent the laparoscopic supracervical hysterectomy.
Other gynecological malignancies identified in the study were cervical cancer in .60% of patient and ovarian cancer in .19% of patients.
The older the women, the greater the risk of detecting malignancy with an adjusted odds ratio of 6.46 for women aged 55 years and older vs women aged 40 to 54 years. Occult cancer of uterine corpus was seen in 9.72% of those aged 55 years and older as compared to only 1.06% of women aged 40 to 54 years.
Prevalence of cancer in patients undergoing myomectomy was very rare with only five women testing positive for cancer of uterine corpus. Out of 5, two underwent vaginal myomectomy while three patients had undergone the abdominal hysterectomy. No cancer was detected in women undergoing laparoscopic myomectomy.
Hence, Desai and colleagues suggested that power morcellators can be of use in selected patients with careful preop evaluation and shared decision making. In these selected group of patients, the benefits of minimally invasive surgery may outweigh the potential risk of cancer dissemination, especially with the recent advancement in techniques such as contained power morcellation inside anisolation bag, which offers additional protection.
Despite few limitations, the authors say that the study has important clinical implications. The study emphasizes the need of advancing research in screening methods for gynecological malignancies especially cancers of uterine corpus and ovaries. The study also calls for improvement in screening techniques for endometrial and cervical cancers.
Media courtesy: https://injuryrecoveryinstitute.com, https://www.dashdc.org, https://www.medpagetoday.com
