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The use of clinical characteristics to help prevent morcellation of leiomyosarcoma: An analysis of 491 cases

      Objective

      Minimally invasive surgery results in shorter recovery and improved quality of life.
      • Wright J.D.
      • Ananth C.V.
      • Lewin S.N.
      • et al.
      Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease.
      The removal of the uterus or fibroids using morcellators to fragment the specimen can potentially spread unsuspected malignancy and result in poor prognosis.
      • Kho K.A.
      • Nezhat C.H.
      Evaluating the risks of electric uterine morcellation.
      Uterine leiomyosarcomas (LMS) comprise only 3% of uterine malignancies, but have similar characteristics to uterine fibroids.
      • Wright J.D.
      • Tergas A.I.
      • Burke W.M.
      • et al.
      Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation.
      Serum biomarkers and radiologic diagnostic criteria to preoperatively identify LMS have not been widely adopted. Factors related to increased risk of LMS in patients with presumed benign leiomyoma, including older age and black race, have not been well defined.
      AAGL Advancing Minimally Invasive Gynecology Worldwide
      AAGL practice report: morcellation during uterine tissue extraction.
      We studied demographic and clinical characteristics of LMS patients to further characterize the clinical profile of LMS.

      Study Design

      Data from 2010 through 2011 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute. Histology codes for LMS were based on the International Classification of Diseases, Ninth Revision. We provide descriptive statistics for all extracted cases, and identify a subset of patients based on 4 characteristics that may be used to help prevent the morcellation of LMS. Statistical analyses were 2-sided and performed with software (SAS, version 9.3; SAS Institute, Cary, NC). A P value < .05 was considered statistically significant. Since SEER is a nationwide, deidentified database, our study was exempt from approval by our institutional review board.

      Results

      We identified 491 LMS patients, the demographic and clinicopathologic details of whom are provided in the Table. Younger (<55 years) patients were more likely to have smaller (≤5 cm) tumors confined to the uterus compared to older women (66% vs 33%; P = .12). Of the reproductive age (≤45 years) patients with stage IA disease (intrauterine disease, tumors ≤5 cm), 50% (6/12) were black. We selected known risk factors including age, race, tumor size, and extrauterine (stage II-IV) disease to better characterize patients with LMS. Over 98.7% of LMS patients had ≥1 of 4 factors: older age, black race, larger (>5 cm) tumor size, and extrauterine disease.
      TableDemographic and clinicopathologic characteristics of leiomyosarcoma patients (n = 491)
      FactorNo. of patients (%)
      Age, y
       <55243 (49.5)
       ≥55248 (50.5)
       Median, range55, 25–88
      Race
       White330 (67.2)
       Black107 (21.8)
       Asian or Pacific Islander51 (10.4)
       Other3 (.6)
      Stage
       IA39 (7.9)
       IB160 (32.6)
       IIA24 (4.9)
       IIB22 (4.5)
       IIIA16 (3.3)
       IIIB5 (1.0)
       IIIC12 (2.4)
       IVA12 (2.4)
       IVB137 (27.9)
       Unknown or NOS64 (13.1)
      Tumor grade
       I16 (3.3)
       II28 (5.7)
       III–IV221 (45.0)
       Unknown226 (46.0)
       Clinical selection factors
      Age, race, extrauterine disease (stage II-IV), and tumor size are factors used to exclude patients at risk for leiomyosarcoma.
       Age ≤45 y89 (18.1)
       Age ≤45 y, non-black67 (13.6)
       Age ≤45 y, non-black, intrauterine disease50 (10.2)
       Age ≤45 y, non-black, intrauterine disease, tumors ≤5 cm6 (1.2)
      NOS, not otherwise specified.
      Chan. Clinical characteristics help prevent morcellation of leiomyosarcoma. Am J Obstet Gynecol 2015.
      a Age, race, extrauterine disease (stage II-IV), and tumor size are factors used to exclude patients at risk for leiomyosarcoma.

      Conclusion

      Uterine sarcomas are diagnosed in 1600 women in the United States annually, and the disease-specific survival for patients with stage I disease is as high as 65-76%.
      • Kapp D.S.
      • Shin J.Y.
      • Chan J.K.
      Prognostic factors and survival in 1396 patients with uterine leiomyosarcomas: emphasis on impact of lymphadenectomy and oophorectomy.
      Since the overall clinical features of LMS and leiomyomas are difficult to differentiate, we analyzed 491 LMS cases to help refine the characteristics reported in clinical guidelines.
      AAGL Advancing Minimally Invasive Gynecology Worldwide
      AAGL practice report: morcellation during uterine tissue extraction.
      We found that only 6 of 491 cases (1.2%) were non-black women of reproductive age with small tumors and no evidence of extrauterine disease. Our study was limited by potential misclassification of LMS without central pathology review. We did not have data on the clinical profiles of LMS patients who underwent morcellation, which may differ from the LMS characteristics reported in this series. Further, the SEER database did not have information regarding other risk factors for LMS including tamoxifen use, prior radiation, and hereditary diseases. Our study found factors related to LMS included older age, black race, large tumor size, and extrauterine disease.

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        • Ananth C.V.
        • Lewin S.N.
        • et al.
        Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease.
        JAMA. 2013; 309: 689-698
        • Kho K.A.
        • Nezhat C.H.
        Evaluating the risks of electric uterine morcellation.
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        • Tergas A.I.
        • Burke W.M.
        • et al.
        Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation.
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        AAGL practice report: morcellation during uterine tissue extraction.
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        • Shin J.Y.
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        Prognostic factors and survival in 1396 patients with uterine leiomyosarcomas: emphasis on impact of lymphadenectomy and oophorectomy.
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