A Case of Endometrial Carcinoma Removed Laparoscopically–What Should be done?

Please be sure an see the Addendum below which deals with the totally different case of a leimyosarcoma removed by morcellation (meaning in pieces laparoscopically)

(Addendum, 9-9-2014: Since I wrote this post, I have become aware of an article that is worth reviewing: Sentinel node mapping in high risk endometrial cancer after laparoscopic supracervical hysterectomy with morcellation, International Journal of Surgery Case Reports, Volume 4, Issue 10, Pages 809–812, 2013. [Full Text HTML] [PubMed Abstract,Citations, and Related Articles])

A postmenopausal patient with uterine fibroids and post menopausal bleeding (previously negative endometrial biopsy, previous pelvic ultrasound and clinical exam showed 16 week uterus). 

Patient underwent bilateral salpingo-ophorectomy and supracervical hysterectomy (meaning the cervix was left behind). The uterus was removed by morcellation (meaning in pieces by laparoscopic surgery).

Uterine pathology indicated a FIGO histologic grade 2. “Accurate diagnosis of the depth of invasion is limited due to the fact that this is a morcellated specimen. In examined sections the adenocarcinoma does not appear to invade more than half of the myometrium and will provisionally be staged as IA based on available findings (again accurate depth of invasion is difficult to accurately ascertain in a morcellated specimen, and the cervix is also not available for examination).”

The questions to discuss with your oncologist (that is, these questions are in addition to the usual questions for endometrial carcinoma that are detailed in the post When the Diagnosis is Endometrial Cancer–Questions to Ask the Doctor):

1. Does morcellation (removal of the uterus in small pieces [necessary for laparoscopic removal]) allow for adequate staging of uterine endometrial carcinoma?

2. What additional evaluation (if any) is indicated because the endometrial carcinama was removed in pieces (morcellation).

3. Does morcellation of endometrial carcinoma make spread of disease more likely than an abdominal hysterectomy would?

4. Does morcellation of endometrial carcinoma change the survival statistics versus an abdominal hysterectomy?

5. What additional evaluation and treatment (if any) are indicated?

 The following studies address these issues: 

1. Walker JL, Piedmonte MR, Spirtos NM, et al.: Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol 27 (32): 5331-6, 2009.  [PUBMED Abstract]

2. Mourits MJ, Bijen CB, Arts HJ, et al.: Safety of laparoscopy versus laparotomy in early-stage endometrial cancer: a randomised trial. Lancet Oncol 11 (8): 763-71, 2010.  [PUBMED Abstract]

3. Kornblith AB, Huang HQ, Walker JL, et al.: Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study. J Clin Oncol 27 (32): 5337-42, 2009. [PUBMED Abstract]

3.Vergote I, Amant F, Neven P: Is it safe to treat endometrial carcinoma endoscopically? J Clin Oncol 27 (32): 5305-7, 2009.  [PUBMED Abstract] Full text of this article is available at https://jco.ascopubs.org/content/27/32/5305.long

4. Walker JL, Piedmonte MR, Spirtos NM, et al.: Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. J Clin Oncol 30 (7): 695-700, 2012.  [PUBMED Abstract] Full text of this article is available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295548/.


*It is important to note that the above case is very different from the case of a laparoscopically removed leiomyosarcoma that was discussed in USA Today article of 2-18-2014 When a hysterectomy can be a death sentence. See Articles Below:

5. The Society of Gynecologic Oncology addresses the problem of laparascopic removal of leimyosarcomas in: Morcellation December 2013.

6. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma, abstract.  Gynecol Oncol. 2011 Aug;122(2):255-9. doi: 10.1016/j.ygyno.2011.04.021. Epub 2011 May 12. 

7. Big Concerns about Inadvertent Use of Morcellation in Previously Undiagnosed Uterine Leiomyosarcoma, full text, Oncology Times: 25 May 2011 – Volume 33 – Issue 10 – pp 64,66-67. In this article, Dr. Park, the author of the study of Note 7, discusses the problem at the Meeting on Women’s Cancer of the Society of Gyncologic Oncology.

8. [Hysterectomies performed for presumed leiomyomas: should the fear of leiomyosarcoma make us apprehend non laparotomic surgical routes?],  [Article in French], abstract. Gynecol Obstet Fertil. 2009 Feb;37(2):109-14. doi: 

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