Options on fibroid morcellation: a literature review
Tóm tắt
In laparoscopy, specimens have to be removed from the abdominal cavity. If the trocar opening or the vaginal outlet is insufficient to pass the specimen, the specimen needs to be reduced. The power morcellator is an instrument with a fast rotating cylindrical knife which aims to divide the tissue into smaller pieces or fragments. The Food and Drug Administration (FDA) issued a press release in April 2014 that discouraged the use of these power morcellators. This article has the objective to review the literature related to complications by power morcellation of uterine fibroids in laparoscopy and offer recommendations to laparoscopic surgeons in gynaecology. This project was initiated by the executive board of the European Society of Gynaecological Endoscopy. A steering committee on fibroid morcellation was installed and experienced ESGE members requested to chair an action group to address distinct clinical questions. Clinical questions were formulated with regards to the sarcoma risk in presumed uterine fibroids, diagnosis of sarcoma, complications of morcellation and future research. A literature review on the different subjects was conducted, systematic if appropriate and feasible. It was concluded that the true prevalence of uterine sarcoma in presumed fibroids is not known given the wide range of prevalences (0.45–0.014 %) from meta-analyses mainly based on retrospective trials. Age and certain imaging characteristics such as ‘lacunes’ suggesting necrosis and increased central vascularisation of the tumour are associated with a higher risk of uterine sarcoma, although the risks remain low. There is not enough evidence to estimate this risk in individual patients. Complications of morcellation are rare. Reported are direct morcellation injuries to vessels and bowel, the development of so-called parasitic fibroids requiring reintervention and the spread of sarcoma cells in the abdominal cavity, which may possibly or even likely upstaging the disease. Momentarily in-bag morcellation is investigated as it may possibly prevent morcellation complications. Because of lack of evidence, this literature review cannot give strong recommendations but offers only options which are condensed in a flow chart. Prospective data collection may clarify the issue on sarcoma risk in presumed fibroids and technology to extract tissue laparoscopically from the abdominal cavity should be perfected.
Tài liệu tham khảo
FDA (2014) FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids. Food Drug Adm 17:4, Ref Type: Internet Communication
Goff BA (2014) SGO not soft on morcellation: risks and benefits must be weighed. Lancet Oncol 15(4):e148–e2045
Ankum WA (2014) Food and drug administration ontraadt gebruik van morcellator (redactioneel commentaar). Ned Tijdschr Obstet Gynaecol 127:216–219
Patient safety must be a priority in all aspects of care. Lancet Oncol 2014; 15(2):123–2045
WGE (2014) Morcelleren: reactie van Werkgroep Gynaecologische Endoscopie op FDA-advies; FDA ontraadt gebruik van morcellator. Ned Tijdschr Obstet Gynaecol 127:215
Knight J, Falcone T (2014) Tissue extraction by morcellation: a clinical dilemma. J Minim Invasive Gynecol 21(3):319–320
Kho KA, Nezhat CH (2014) Evaluating the risks of electric uterine morcellation. JAMA 311(19):905–906
Leung F, Terzibachian JJ (2012) Re: “The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma”. Gynecol Oncol 124(1):172–173
European Society of Gynaecological Endoscopy (ESGE). Statement on morcellation (of presumed fibroids appearing to be sarcomas). ESGE executive board. 2014. Ref Type: Internet Communication
Eccles M, Mason J (2001) How to develop cost-conscious guidelines. Health Technol Assess 5(16):1–69
Ryan GL, Syrop CH, Van Voorhis BJ (2005) Role, epidemiology, and natural history of benign uterine mass lesions. Clin Obstet Gynecol 48(2):312–324
Wallach EE, Vlahos NF (2004) Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol 104(2):393–406
Harlow BL, Weiss NS, Lofton S (1986) The epidemiology of sarcomas of the uterus. J Natl Cancer Inst 76(3):399–402
Lurain JR, Piver MS (1992) Uterine sarcomas: clinical features and management. In: Coppleson X, Monagham J, Morrow P, Tattersall M (eds) Gynecologic oncology. Chruchill Livingstone, London, pp 827–840
Ng JS, Han A, Chew SH, Low J (2010) A clinicopathologic study of uterine smooth muscle tumours of uncertain malignant potential (STUMP). Ann Acad Med Singap 39(8):625–628
Bojhar B, de Wilde RL, Tchartchian. (2014) Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy in 2013. (Personal Communication)
Ind TEJ, Rajab R, Manyonda I. (2014) Uterine sarcomas and myomectomy—a single institutions experience. (Unpublished Work)
Seidman MA, Oduyebo T, Muto MG, Crum CP, Nucci MR, Quade BJ (2012) Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS ONE 7(11):e50058
Rowland M, Lesnoch J, Edwards R, Richard S, Zom K, Sukumvanich P (2012) Occult uterine cancer in patients undergoing laparoscopic hysterectomy with morcellation. Gynecol Oncol 127(1):S29
Kamikabeya TS, Etchebehere RM, Nomelini RS, Murta EF (2010) Gynecological malignant neoplasias diagnosed after hysterectomy performed for leiomyoma in a university hospital. Eur J Gynaecol Oncol 31(6):651–653
Takamizawa S, Minakami H, Usui R, Noguchi S, Ohwada M, Suzuki M et al (1999) Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynecol Obstet Investig 48(3):193–196
Parker WH, Fu YS, Berek JS (1994) Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 83:414–418
Leibsohn S, D′Ablaing G, Mishell DR Jr, Schlaerth JB (1990) Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas. Am J Obstet Gynecol 162:968–974, discus:968–974
Wright JD, Tergas AI, Burke WM, Cui RR, Ananth CV, Chen L et al. (2014) Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA 312(12):1253–1255
Paul GP, Naik SA, Madhu KN, Thomas T (2010) Complications of laparoscopic myomectomy: a single surgeon’s series of 1001 cases. Aust N Z J Obstet Gynaecol 50(4):385–390
Sizzi O, Rossetti A, Malzoni M, Minelli L, La GF, Soranna L et al (2007) Italian multicenter study on complications of laparoscopic myomectomy. J Minim Invasive Gynecol 14(4):453–462
Brolmann H, Hehenkamp WJK, Huirne JAF (2014) Heeft het myoom zijn onschuld verloren? Ned Tijdschr Obstet Gynaecol 127:322–325
Oduyebo T, Rauh-Hain AJ, Meserve EE, Seidman MA, Hinchcliff E, George S et al (2014) The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol 132(2):360–365
Amant F, Coosemans A, Debiec-Rychter M, Timmerman D, Vergote I (2009) Clinical management of uterine sarcomas. Lancet Oncol 10(12):1188–1198
Aviram R, Ochshorn Y, Markovitch O, Fishman A, Cohen I, Altaras MM et al (2005) Uterine sarcomas versus leiomyomas: gray-scale and Doppler sonographic findings. J Clin Ultrasound 33(1):10–13
Bell SW, Kempson RL, Hendrickson MR (1994) Problematic uterine smooth muscle neoplasms. A clinicopathologic study of 213 cases. Am J Surg Pathol 18(6):535–558
Cormio G, Loizzi V, Ceci O, Leone L, Selvaggi L, Bettocchi S (2014) Unsuspected diagnosis of uterine leiomyosarcoma after laparoscopic myomectomy. J Obstet Gynaecol. doi: 10.1016/j.jmig.2009.08.181
Dizon DS, Birrer MJ (2014) Advances in the diagnosis and treatment of uterine sarcomas. Discov Med 17(96):339–345
Evans HL, Chawla SP, Simpson C, Finn KP (1988) Smooth muscle neoplasms of the uterus other than ordinary leiomyoma. A study of 46 cases, with emphasis on diagnostic criteria and prognostic factors. Cancer 62(2239–2247):2239–2247
Exacoustos C, Romanini ME, Amadio A, Amoroso C, Szabolcs B, Zupi E et al (2007) Can gray-scale and color Doppler sonography differentiate between uterine leiomyosarcoma and leiomyoma? J Clin Ultrasound 35(8):449–457
Fukunishi H, Funaki K, Ikuma K, Kaji Y, Sugimura K, Kitazawa R et al (2007) Unsuspected uterine leiomyosarcoma: magnetic resonance imaging findings before and after focused ultrasound surgery. Int J Gynecol Cancer 17(3):724–728
Geyer H (1968) LDH isoenzymes in tumors of the human uterus. Klin Wochenschr 46(7):389–390
Giuntoli RL, Gostout BS, DiMarco CS, Metzinger DS, Keeney GL (2007) Diagnostic criteria for uterine smooth muscle tumors: leiomyoma variants associated with malignant behavior. J Reprod Med 52(11):1001–1010
Goto A, Takeuchi S, Sugimura K, Maruo T (2002) 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 12(4):354–361
Hadoux J, Morice P, Lhomme C, Duvillard P, Balleyguier C, Haie-Meder C et al (2013) Uterine leiomyosarcoma: epidemiology, pathology, biology, diagnosis, prognosis and treatment. Bull Cancer 100(9):903–915
Hata K, Hata T, Makihara K, Aoki S, Takamiya O, Kitao M et al (1990) Sonographic findings of uterine leiomyosarcoma. Gynecol Obstet Investig 30(4):242–245
Hata K, Hata T, Maruyama R, Hirai M (1997) Uterine sarcoma: can it be differentiated from uterine leiomyoma with Doppler ultrasonography? A preliminary report. Ultrasound Obstet Gynecol 9(2):101–104
Janus C, White M, Dottino P, Brodman M, Goodman H (1989) Uterine leiomyosarcoma–magnetic resonance imaging. Gynecol Oncol 32(1):79–81
Juang CM, Yen MS, Horng HC, Twu NF, Yu HC, Hsu WL (2006) Potential role of preoperative serum CA125 for the differential diagnosis between uterine leiomyoma and uterine leiomyosarcoma. Eur J Gynaecol Oncol 27(4):370–374
Kawamura N, Ichimura T, Ito F, Shibata S, Takahashi K, Tsujimura A et al (2002) Transcervical needle biopsy for the differential diagnosis between uterine sarcoma and leiomyoma. Cancer 94(6):1713–1720
Lusby K, Savannah KB, Demicco EG, Zhang Y, Ghadimi MP, Young ED et al (2013) Uterine leiomyosarcoma management, outcome, and associated molecular biomarkers: a single institution’s experience. Ann Surg Oncol 20(7):2364–2372
Melia P, Maestro C, Bruneton JN, Gasperoni A, Peyrottes I, Teissier E et al (1995) MRI of uterine leiomyosarcoma. Apropos of 2 cases. J Radiol 76(1):69–72
Milman D, Zalel Y, Biran H, Open M, Caspi B, Hagay Z et al (1998) Unsuspected uterine leiomyosarcoma discovered during treatment with a gonadotropin-releasing hormone analogue: a case report and literature review. Eur J Obstet Gynecol Reprod Biol 76(2):237–240
Murase E, Siegelman ES, Outwater EK, Perez-Jaffe LA, Tureck RW (1999) Uterine leiomyomas: histopathologic features, MR imaging findings, differential diagnosis, and treatment. Radiographics 19(5):1179–1197
Nappi L, Di Spiezio SA, Indraccolo U, Bettocchi S (2008) Hysteroscopic resection of uterine leiomyosarcoma: a case report and literature review. J Minim Invasive Gynecol 15(3):380–383
Pattani SJ, Kier R, Deal R, Luchansky E (1995) MRI of uterine leiomyosarcoma. Magn Reson Imaging 13(2):331–333
Posy HE, Elkas JC, Yemelyanova AV, Diaz-Montes TP, Bristow RE, Giuntoli RL (2009) Metastatic leiomyosarcoma diagnosed after uterine artery embolization. Eur J Gynaecol Oncol 30(2):199–202
Rauh-Hain JA, Oduyebo T, Diver EJ, Guseh SH, George S, Muto MG et al (2013) Uterine leiomyosarcoma: an updated series. Int J Gynecol Cancer 23(6):1036–1043
Takemori M, Nishimura R, Sugimura K (1992) Magnetic resonance imaging of uterine leiomyosarcoma. Arch Gynecol Obstet 251(4):215–218
Tulandi T, Ferenczy A (2014) Biopsy of uterine leiomyomata and frozen sections before laparoscopic morcellation. J Minim Invasive Gynecol 14:10
Ueda M, Otsuka M, Hatakenaka M, Torii Y (2000) Uterine endometrial stromal sarcoma located in uterine myometrium: MRI appearance. Eur Radiol 10(5):780–782
Ueda H, Togashi K, Konishi I, Kataoka ML, Koyama T, Fujiwara T et al (1999) Unusual appearances of uterine leiomyomas: MR imaging findings and their histopathologic backgrounds. Radiographics 19:S131–S145
Umesaki N, Tanaka T, Miyama M, Kawamura N, Ogita S, Kawabe J et al (2001) Positron emission tomography with (18) F-fluorodeoxyglucose of uterine sarcoma: a comparison with magnetic resonance imaging and power Doppler imaging. Gynecol Oncol 80(3):372–377
Vellanki VS, Rao M, Sunkavalli CB, Chinamotu RN, Kaja S (2010) A rare case of uterine leiomyosarcoma: a case report. J Med Case Rep 4:222. doi:10.1186/1752-1947-4-222-222-224
Widy-Kierska K, Roszkowski I (1969) LDH isoenzymes in patients with uterine tumors. Obstet Gynecol 33(2):173–176
Yanai H, Wani Y, Notohara K, Takada S, Yoshino T (2010) Uterine leiomyosarcoma arising in leiomyoma: clinicopathological study of four cases and literature review. Pathol Int 60(7):506–509
Zhang HJ, Zhan FH, Li YJ, Sun HR, Bai RJ, Gao S (2011) Fluorodeoxyglucose positron emission tomography/computed tomography and magnetic resonance imaging of uterine leiomyosarcomas: 2 cases report. Chin Med J (Engl) 124(14):2237–2240
Schwartz LB, Diamond MP, Schwartz PE (1993) Leiomyosarcomas: clinical presentation. Am J Obstet Gynecol 168:180–183
Schwartz LB, Diamond MP, Schwartz PE (1993) Leiomyosarcomas: clinical presentation. Am J Obstet Gynecol 168(1 Pt 1):180–183
Kawamura N, Iwanaga N, Hada S, Maeda K, Sumi T, Ishiko O et al (2001) Transient shrinkage of a uterine leiomyosarcoma treated with GnRH agonist for a presumed uterine leiomyoma: comparison of magnetic resonance imaging finding before and during GnRH agonist treatment. Oncol Rep 8(6):1255–1257
Wang PH, Lee WL, Chao HT, Shu LP, Kao HL, Wu CW et al (1999) Relationship between hormone receptor concentration and tumor shrinkage in uterine myoma after treatment with a GnRHa. Zhonghua Yi Xue Za Zhi (Tapei) 62(5):294–299
Yoshida Y, Kiyono Y, Tsujikawa T, Kurokawa T, Okazawa H, Kotsuji F (2011) Additional value of 16 alpha-[18F] fluoro-17 beta-oestradiol PET for differential diagnosis between uterine sarcoma and leiomyoma in patients with positive or equivocal findings on [18F] fluorodeoxyglucose PET. Eur J Nucl Med Mol Imaging 38(10):1824–1831
Bansal N, Herzog TJ, Burke W, Cohen CJ, Wright JD (2008) The utility of preoperative endometrial sampling for the detection of uterine sarcomas. Gynecol Oncol 110(1):43–48
Hansen NM, Ye X, Grube BJ, Giuliano AE (2004) Manipulation of the primary breast tumor and the incidence of sentinel node metastases from invasive breast cancer. Arch Surg 139(6):634–639
Martin RC, Scoggins CR, Ross MI, Reintgen DS, Noyes RD, Edwards MJ et al (2005) Is incisional biopsy of melanoma harmful? Am J Surg 190(6):913–917
Steiner RA, Wight E, Tadir Y, Haller U (1993) Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol 81(3):471–474
Milad MP, Milad EA (2014) Laparoscopic morcellator-related complications. J Minim Invasive Gynecol 21(3):486–491
Milad MP, Sokol E (2003) Laparoscopic morcellator-related injuries. Am J Assoc Gynecol Laparosc 10(3):383–385
Nezhat C, Kho K (2010) Iatrogenic myomas: new class of myomas? J Minim Invasive Gynecol 17(5):544–550
Donnez O, Jadoul P, Squifflet J, Donnez J (2009) A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 116(4):492–500
Cucinella G, Granese R, Calagna G, Somigliana E, Perino A (2011) Parasitic myomas after laparoscopic surgery: an emerging complication in the use of morcellator? Description of four cases. Fertil Steril 96(2):e90–e96
Leren V, Langebrekke A, Qvigstad E (2012) Parasitic leiomyomas after laparoscopic surgery with morcellation. Acta Obstet Gynecol Scand 91(10):1233–1236
Sinha R, Hegde A, Mahajan C, Dubey N, Sundaram M (2008) Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy? J Minim Invasive Gynecol 15(3):292–300
Ordulu Z, Dal CP, Chong WW, Choy KW, Lee C, Muto MG et al (2010) Disseminated peritoneal leiomyomatosis after laparoscopic supracervical hysterectomy with characteristic molecular cytogenetic findings of uterine leiomyoma. Genes Chromosom Cancer 49(12):1152–1160
Anupama R, Ahmad SZ, Kuriakose S, Vijaykumar DK, Pavithran K, Seethalekshmy NV (2011) Disseminated peritoneal leiomyosarcomas after laparoscopic “myomectomy” and morcellation. J Minim Invasive Gynecol 18(3):386–389
Della BC, Karini H (2010) Endometrial stromal sarcoma diagnosed after uterine morcellation in laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol 17(6):791–793
Morice P, Rodriguez A, Rey A, Pautier P, Atallah D, Genestie C et al (2003) Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients. Eur J Gynaecol Oncol 24(3–4):237–240
Einstein MH, Barakat RR, Chi DS, Sonoda Y, Alektiar KM, Hensley ML et al (2008) Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. Int J Gynecol Cancer 18(5):1065–1070
Perri T, Korach J, Sadetzki S, Oberman B, Fridman E, Ben-Baruch G (2009) Uterine leiomyosarcoma: does the primary surgical procedure matter? Int J Gynecol Cancer 19(2):257–260
Park JY, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH (2011) The impact of tumor morcellation during surgery on the outcomes of patients with apparently early low-grade endometrial stromal sarcoma of the uterus. Ann Surg Oncol 18(12):3453–3461
Park JY, Park SK, Kim DY, Kim JH, Kim YM, Kim YT et al (2011) The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 122(2):255–259
Pritts E, Parker WH, Brow J, Olive DL (2014) Outcome of occult uterine leiomyosarcoma after surgery for presumed uterine fibroids: a systematic review. J Min Invasive Gynecol 22(1):26–33
Hagemann IS, Hagemann AR, LiVolsi VA, Montone KT, Chu CS (2011) Risk of occult malignancy in morcellated hysterectomy: a case series. Int J Gynecol Pathol 30(5):476–483
Rivard C, Salhadar A, Kenton K (2012) New challenges in detecting, grading, and staging endometrial cancer after uterine morcellation. J Minim Invasive Gynecol 19(3):313–316
Schneider A (1997) Recurrence of unclassifiable uterine cancer after modified laparoscopic hysterectomy with morcellation. Am J Obstet Gynecol 177(2):478–479
Cohen SL, Greenberg JA, Wang KC, Srouji SS, Gargiulo AR, Pozner CN et al (2014) Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. J Minim Invasive Gynecol 14:10
Cohen SL, Einarsson JI, Wang KC, Brown D, Boruta D, Scheib SA et al (2014) Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 124(3):491–497
Einarsson JI, Cohen SL, Fuchs N, Wang KC (2014) In bag morcellation (IBM). J Minim Invasive Gynecol 14:10
Favero G (2013) Tips and tricks for successful manual morcellation: a response to “vaginal morcellation: a new strategy for large gynecological malignant tumors extraction. A pilot study”. Gynecol Oncol 128(1):151
Wu SD, Lesani OA, Zhao LC, Johnston WK, Wolf JS Jr, Clayman RV et al (2009) A multi-institutional study on the safety and efficacy of specimen morcellation after laparoscopic radical nephrectomy for clinical stage T1 or T2 renal cell carcinoma. J Endourol 23(9):1513–1518
Barrett PH, Fentie DD, Taranger LA (1998) Laparoscopic radical nephrectomy with morcellation for renal cell carcinoma: the Saskatoon experience. Urology 52(1):23–28
Tsivian A, Sidi AA (2003) Port site metastases in urological laparoscopic surgery. J Urol 169(4):1213–1218
Parekh AR, Moran ME, Newkirk RE, Desai PJ, Calvano CJ (2000) Tissue removal utilizing steiner morcellator within a lapsac: effects of a fluid-filled environment. J Endourol 14(2):185–189
Meng MV, Koppie TM, Stoller ML (2003) Pathologic sampling of laparoscopically morcellated kidneys: a mathematical model. J Endourol 17(4):229–233
Arkenbout EA, van den Haak L, Driessen SR, Thurkow A.L., Jansen FW (2014) Assessing basic ‘physiology’ of the morcellation process and tissue spread: a time action analysis. J Minim Invasive Gynaecol. pii: S1553-4650(14)01448-4. doi: 10.1016/j.jmig.2014.10.009
Pitkin RM, Parker WH (2010) Operative laparoscopy: a second look after 18 years. Obstet Gynecol 115(5):890–891