JAMA Research Letter of July 22, 2014–Uterine Pathology in Women Undergoing Minimally Invasive Hysterectomy Using Morcellation

What is the appropriate evaluation and treatment of endometrial cancer diagnosed after (and as a result of) supracervical morcellation removal of the uterus? I have a number of blog posts concerning this issue. A complete list of those posts can be accessed by reviewing the Oncology category.

In this post, I review the very recent JAMA Research Letter of July 22, 2014–Uterine Pathology in Women Undergoing Minimally Invasive Hysterectomy Using Morcellation.

In the Discussion Section the authors state:

“Our data demonstrate that uterine cancers occurred in 27 per 10 000 women undergoing morcellation. Other malignancies and precancerous abnormalities were also detected. Although morcellators have been in use since 1993, few studies have described the prevalence of unexpected pathology at the time of hysterectomy.2– 4 Prevalence information is the first step in determining the risk of spreading cancer with morcellation. Although data are limited, women with apparent uterine-confined neoplasms at the time of morcellation have been found to have intraperitoneal tumor dissemination at the time of reexploration.3,6

“We recognize a number of limitations including the inability to verify pathological findings, possible misclassification of pathology, potential undercapture of morcellation, and the fact that our findings may not be generalizable to all hospitals. Last, we lack data on long-term follow-up, and the outcome of women with pathological abnormalities who underwent morcellation requires further study. Patients considering morcellation should be adequately counseled about the prevalence of cancerous and precancerous conditions prior to undergoing the procedure.”

The references in this article refer to the risk of spreading the neoplasm in women with uterine sarcomas not the risks in spreading  endometrial cancers.

For readers concerned about the management of endometrial cancer diagnosed after a morcellation procedure, be sure to read the case report about an adenocarcinoma after morcellation* and review all the very relevant  resources in that article. 

For links to some excellent guidelines on the treatment of endometrial cancer see:  

Summary Statements from 2013 Canadian Guidelines: “The Role of Adjuvant Therapy In Endometrial Cancer (my blog post of 4-04-2014) 

“Epidemiology and Investigations for Suspected Endometrial Cancer”, Summary Statements from the 2013 Canadian Guidelines (my blog post also of 4-04-2014), Summary From The 2013 Canadian Guidelines on the Role of Surgery in Endometrial Cancer (my blog post of 3-31-2014).

Other Resources:

*Sentinel node mapping in high risk endometrial cancer after laparoscopic supracervical hysterectomy with morcellation. [PubMed] [Full Text PDF] International Journal of Surgery Case Reports Volume 4, Issue 10, Pages 809–812, 2013.

Metastatic adenocarcinoma after laparoscopic supracervical hysterectomy with morcellation: A case report. [PubMed] Gynecol Oncol Case Rep. Aug 2013; 5: 19–21.           The authors state “In our case report, the primary site of the malignancy was uncertain.”                                                                                                                                                              US agency warns against morcellation in hysterectomies and myomectomies.             BMJ 2014;348:g2872

Evaluating the Risks of Electric Uterine Morcellation.                                                                    JAMA. 2014 Mar 5;311(9):905-6.

Patient safety must be a priority in all aspects of care.                                                              The Lancet Oncology, Volume 15, Issue 2, Page 123, February 2014.

Peritoneal Dissemination Complicating Morcellation of Uterine Mesenchymal Neoplasms.     Published: November 26, 2012DOI: 10.1371/journal.pone.0050058.

Risk of occult malignancy in morcellated hysterectomy: a case series. [PubMed]                     Int J Gynecol Pathol. 2011;30(5):476-483.

The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. [PubMed]  Gynecol Oncol. 2014 Feb;132(2):360-5. doi: 10.1016/j.ygyno.2013.11.024. Epub 2013 Dec 1.

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