In the JournalsPerspective

Power morcellation technique increases mortality risk for women with occult uterine sarcoma

Xiao Xu, PhD
Xiao Xu

Uncontained power morcellation appeared associated with increased risk for mortality among women with occult uterine sarcoma, according to study results published in Journal of Clinical Oncology.

Researchers noted especially higher mortality risk for women with occult leiomyosarcoma.

“Our findings highlight the importance of preoperative evaluation for women undergoing hysterectomy and myomectomy,” Xiao Xu, PhD, associate professor in the department of obstetrics, gynecology and reproductive sciences at Yale School of Medicine, told HemOnc Today. “We need adequate preoperative assessment to help rule out uterine cancer as well as identify women at higher risk for uterine cancer so that we can plan their surgery appropriately. For women at higher risk for uterine cancer, power morcellation should be avoided if possible.”

Concerns about the safety of laparoscopic power morcellation surfaced in 2014, when the FDA issued a warning that the procedure may inadvertently spread cancer cells in women with undetected uterine cancer. However, evidence of an impact on prognosis has been limited.

For this reason, Xu and colleagues sought to determine whether an association existed between uncontained power morcellation at the time of hysterectomy or myomectomy for presumed benign indications and increased mortality risk among 843 women with occult endometrial carcinoma (median age, 60 years; 70.1% non-Hispanic white) and 334 women with occult uterine sarcoma (median age, 52 years; 58.7% non-Hispanic white), including a subset of 231 women with leiomyosarcoma (median age, 53 years; 55% non-Hispanic white).

Investigators compared disease-specific and all-cause mortality among women who underwent laparoscopic supracervical hysterectomy or laparoscopic myomectomy with that of women who underwent supracervical abdominal hysterectomy or total abdominal hysterectomy between October 2003 and December 2013. They used multivariable Cox regressions and a propensity score method to adjust for patient characteristics.

Median follow-up was 53 months for women with endometrial carcinoma, 41 months for women with uterine sarcoma and 38 months for women with leiomyosarcoma.

Results showed an association of laparoscopic supracervical hysterectomy/laparoscopic myomectomy with increased risk for disease-specific mortality compared with total abdominal hysterectomy among women with occult uterine sarcoma (adjusted HR [aHR] = 2.66; 95% CI, 1.11-6.37; adjusted difference in 5-year disease-specific survival = 19.4%; 95% CI, 35.8% to 3.1%).

Among the subset of women with occult leiomyosarcoma, laparoscopic supracervical hysterectomy/laparoscopic myomectomy appeared even more strongly associated with an increased risk for disease-specific mortality compared with supracervical abdominal hysterectomy (aHR = 3.64; 95% CI, 1.5-8.86; adjusted difference in 5-year disease-specific survival, 31.2%; 95% CI, 50% to 12.3%) and total abdominal hysterectomy (aHR = 4.66; 95% CI, 1.97-11; adjusted difference in 5-year disease-specific survival, 37.3%; 95% CI, 54.2% to 20.3%).

Researchers did not observe a significant association between surgical approach and disease-specific mortality among women with occult endometrial cancer.

The researchers cited several study limitations, including a lack of information regarding method of specimen removal and the possibility that some malignancies were suspected before surgery. They also noted that the risk adjustment used cancer stage documented in the cancer registry, which may have masked potential upstaging caused by morcellation and underestimated the impact of morcellation on mortality risk.

“The FDA warning about uterine power morcellation has led to substantial changes in clinical practice. For instance, some providers have switched to alternative surgical approaches to avoid power morcellation. We hope to better understand the impact of these practice changes on patient safety and longer-term health outcomes in future research,” Xu told HemOnc Today. – by Jennifer Southall

For more information:

Xiao Xu, PhD, can be reached at Yale School of Medicine, 310 Cedar St., LSOG 205B, New Haven, CT 06520; email: xiao.xu@yale.edu.

Disclosures: Xu reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Xiao Xu, PhD
Xiao Xu

Uncontained power morcellation appeared associated with increased risk for mortality among women with occult uterine sarcoma, according to study results published in Journal of Clinical Oncology.

Researchers noted especially higher mortality risk for women with occult leiomyosarcoma.

“Our findings highlight the importance of preoperative evaluation for women undergoing hysterectomy and myomectomy,” Xiao Xu, PhD, associate professor in the department of obstetrics, gynecology and reproductive sciences at Yale School of Medicine, told HemOnc Today. “We need adequate preoperative assessment to help rule out uterine cancer as well as identify women at higher risk for uterine cancer so that we can plan their surgery appropriately. For women at higher risk for uterine cancer, power morcellation should be avoided if possible.”

Concerns about the safety of laparoscopic power morcellation surfaced in 2014, when the FDA issued a warning that the procedure may inadvertently spread cancer cells in women with undetected uterine cancer. However, evidence of an impact on prognosis has been limited.

For this reason, Xu and colleagues sought to determine whether an association existed between uncontained power morcellation at the time of hysterectomy or myomectomy for presumed benign indications and increased mortality risk among 843 women with occult endometrial carcinoma (median age, 60 years; 70.1% non-Hispanic white) and 334 women with occult uterine sarcoma (median age, 52 years; 58.7% non-Hispanic white), including a subset of 231 women with leiomyosarcoma (median age, 53 years; 55% non-Hispanic white).

Investigators compared disease-specific and all-cause mortality among women who underwent laparoscopic supracervical hysterectomy or laparoscopic myomectomy with that of women who underwent supracervical abdominal hysterectomy or total abdominal hysterectomy between October 2003 and December 2013. They used multivariable Cox regressions and a propensity score method to adjust for patient characteristics.

Median follow-up was 53 months for women with endometrial carcinoma, 41 months for women with uterine sarcoma and 38 months for women with leiomyosarcoma.

Results showed an association of laparoscopic supracervical hysterectomy/laparoscopic myomectomy with increased risk for disease-specific mortality compared with total abdominal hysterectomy among women with occult uterine sarcoma (adjusted HR [aHR] = 2.66; 95% CI, 1.11-6.37; adjusted difference in 5-year disease-specific survival = 19.4%; 95% CI, 35.8% to 3.1%).

Among the subset of women with occult leiomyosarcoma, laparoscopic supracervical hysterectomy/laparoscopic myomectomy appeared even more strongly associated with an increased risk for disease-specific mortality compared with supracervical abdominal hysterectomy (aHR = 3.64; 95% CI, 1.5-8.86; adjusted difference in 5-year disease-specific survival, 31.2%; 95% CI, 50% to 12.3%) and total abdominal hysterectomy (aHR = 4.66; 95% CI, 1.97-11; adjusted difference in 5-year disease-specific survival, 37.3%; 95% CI, 54.2% to 20.3%).

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Researchers did not observe a significant association between surgical approach and disease-specific mortality among women with occult endometrial cancer.

The researchers cited several study limitations, including a lack of information regarding method of specimen removal and the possibility that some malignancies were suspected before surgery. They also noted that the risk adjustment used cancer stage documented in the cancer registry, which may have masked potential upstaging caused by morcellation and underestimated the impact of morcellation on mortality risk.

“The FDA warning about uterine power morcellation has led to substantial changes in clinical practice. For instance, some providers have switched to alternative surgical approaches to avoid power morcellation. We hope to better understand the impact of these practice changes on patient safety and longer-term health outcomes in future research,” Xu told HemOnc Today. – by Jennifer Southall

For more information:

Xiao Xu, PhD, can be reached at Yale School of Medicine, 310 Cedar St., LSOG 205B, New Haven, CT 06520; email: xiao.xu@yale.edu.

Disclosures: Xu reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Jubilee Brown

    Jubilee Brown

    Xu and colleagues used New York statewide hospital discharge records during a 10-year time span to tease out the effect of power morcellation on outcomes of women who undergo uterine procedures, including abdominal or laparoscopic supracervical hysterectomy or myomectomy. Although the measures they used are indirect and, in fact, proxies for uncontained power morcellation, they are probable valid surrogates that appropriately characterize the effect of these procedures on occult uterine malignancy.

    Previous studies evaluating the effect of uncontained power morcellation have been either small or flawed but have suggested a trend toward worse outcomes for women with occult uterine sarcomas. Although this study did not provide a direct measure of patient outcomes, the authors detected higher disease-specific mortality overall among women with laparoscopic supracervical hysterectomy or myomectomy and among women with uterine sarcoma. As an isolated finding, this could represent bias or limited sample size, but the authors have included women with endometrial carcinoma as a comparator. Carcinomas have distinctly different biologic behavior than uterine sarcomas, as carcinomas are not as aggressive and unlikely to have poor outcomes even if tumor spill occurs. Because the outcomes were worse in the cohort of women with sarcoma and were unaffected in the cohort of women with carcinoma, this comparator effectively acted as an internal control and supported the validity of the study findings. This is an important distinction, as outside of case-control studies and small retrospective reviews, the outcomes of uterine carcinomas and sarcomas have not been directly compared.

    Congruent with the FDA’s advisory, these findings suggest that uncontained power morcellation should be avoided for women with known or suspected malignancies. This highlights the importance of adequate screening, contained and/or intact extraction when possible, and informed consent in the management of women undergoing surgery in the setting of suspected uterine fibroids. The field has moved forward, and these important contributions inform updated medical practice.

    • Jubilee Brown, MD
    • Levine Cancer Institute at Atrium Health

    Disclosures: Brown reports no relevant financial disclosures.