Elsevier

Gynecologic Oncology

Volume 122, Issue 2, August 2011, Pages 255-259
Gynecologic Oncology

The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma,☆☆

https://doi.org/10.1016/j.ygyno.2011.04.021Get rights and content

Abstract

Objective.

Uterine leiomyosarcoma (LMS) is usually diagnosed after surgery for leiomyoma; thus tumor morcellation frequently occurs. We evaluated the impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine LMS.

Methods.

Outcomes were retrospectively compared between patients who underwent total abdominal hysterectomy without tumor morcellation and those who underwent surgery that included abdominal, vaginal or laparoscopic tumor morcellation.

Results.

We assessed 56 consecutive patients with stage I and II uterine LMS between 1989 and 2010, 25 with and 31 without tumor morcellation. There were no significant between group differences in age, parity, menopausal status, body mass index, stage, mitotic count, tumor grade, lymph node dissection, adjuvant therapy, and follow-up duration. However, tumor size was significantly smaller (9.8 cm vs. 7.3 cm, P = 0.022) and ovarian tissue was more frequently preserved (38.7% vs. 72%, P = 0.013) in patients with tumor morcellation. In univariate analysis, only tumor morcellation was significantly associated with poorer disease-free survival (DFS) (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.03–6.50; P = 0.043), and higher stage (I vs. II; (OR, 19.12; 95% CI, 1.19–307.11; P = 0.037)) and tumor morcellation (OR, 3.07; 95% CI, 1.05–8.93; P = 0.040) were significantly associated with poorer overall survival (OS). In multivariate analysis, higher stage (OR, 20.34; 95% CI, 1.27–325.58; P = 0.033) and tumor morcellation (OR, 3.11; 95% CI, 1.07–9.06; P = 0.038) were significantly associated with poorer OS. The percentage of patients with abdomino–pelvic dissemination, as shown by peritoneal sarcomatosis or vaginal apex recurrence, was significantly greater in patients with than without tumor morcellation (44% vs. 12.9%, P = 0.032).

Conclusion.

Tumor morcellation during surgery increased the rate of abdomino–pelvic dissemination and adversely affected DFS and OS in patients with apparently early uterine LMS.

Highlights

► Inadvertent tumor morcellation during surgery increases abdomino–pelvic dissemination. ► It adversely affects disease-free and overall survival in early stage leiomyosarcoma. ► En bloc resection without tumor injury is also important for treatment outcomes.

Introduction

Uterine leiomyosarcoma (LMS) is a rare but highly malignant tumor of the uterus, accounting for about 1.5% of all uterine malignancies and 30% of uterine sarcomas [1]. As with other soft tissue sarcomas, complete surgical excision is the only established curative treatment modality [2], [3], [4]. Other treatment modalities, including radiation therapy, chemotherapy, hormone therapy, targeted therapy, and their combinations, are not effective [5], with none of these postoperative adjuvant treatment modalities shown to decrease recurrence or prolong survival [5], [6]. Complete excision of early LMS confined to the uterus can therefore result in cure or prolonged survival.

Most patients with early uterine LMS undergo surgery for presumed uterine leiomyoma because no specific symptoms or signs or diagnostic modality can preoperatively differentiate LMS from uterine leiomyoma [7], [8]. Therefore, many patients with early uterine LMS are diagnosed after surgical management, which may include tumor morcellation. Tumor morcellation and spillage during surgery may adversely affect treatment outcomes in patients with these highly malignant tumors. However, few studies to date have evaluated the impact of tumor morcellation on the outcomes of these patients [9], [10], [11]. We therefore compared treatment outcomes and patterns of recurrence in patients with apparently early uterine LMS who did and did not undergo tumor morcellation during surgery.

Section snippets

Study population

After obtaining the approval of Institutional Review Board of Asan Medical Center (AMC, Seoul, Korea), we searched the cancer registry and computerized database of AMC for patients with early LMS confined to the uterus who were treated and followed at AMC from 1989 to 2010. We recorded demographic data, including patient age, parity, menopausal status, and body mass index; clinicopathologic data including International Federation of Obstetrics and Gynecology (FIGO) stage, tumor size, mitotic

Results

During the study period, 77 patients with uterine LMS were treated and followed at AMC; of these, 56 patients had apparently early disease confined to the uterus at initial surgery. Of the 56 patients, 31 (55%) underwent total abdominal hysterectomy without tumor morcellation (non-morcellation group) and 25 (45%) underwent surgery that included abdominal, vaginal or laparoscopic tumor morcellation (morcellation group).

Table 1 shows the characteristics of patients and tumors. There were no

Discussion

We have shown here that, in patients with apparently early LMS, tumor morcellation during surgery increased the rate of abdomino–pelvic dissemination, in the form of peritoneal sarcomatosis or vaginal apex recurrence, and affected adversely DFS and OS.

Following iatrogenic or spontaneous rupture, soft tissue sarcomas including uterine sarcomas can spread through the peritoneal surface, laparoscopic port or biopsy tract [12], [13], [14], [15], [16], [17]. Because most leiomyosarcomas are

Conflict of interest statement

The authors declare that there are no conflicts of interest.

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Financial disclosure: The authors have no potential conflicts of interest to disclose.

☆☆

Some part of this paper was presented as oral presentation at the focused plenary session of the Society of Gynecologic Oncologists (SGO) 42nd Annual Meeting which was held March 6–9, 2011 in Orlando, Florida, USA.

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