Professor and Chair, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Connecticut Health Center, Farmington
Dr. Brewer reports no financial relationships relevant to this field of study.
SYNOPSIS: There has been significant publicity about the risk of malignancy associated with morcellation in hysterectomy, but in reality the incidence is quite low.
SOURCE: Desai VB, Wright JD, Schwartz PE, et al. Occult gynecologic cancer in women undergoing hysterectomy or myomectomy for benign indications. Obstet Gynecol 2018;131:642-651.
Over the last several years, there has been increasing concern about the risk of an occult malignancy at the time of hysterectomy or myomectomy. There remains a risk of cervical, endometrial, or myometrial malignancy even when an adequate workup has been done. In addition, there have been many reports in the literature of occult fallopian tube and ovarian cancer in the BRCA+ population at the time of prophylactic bilateral salpingo-oophorectomy, ranging from 2-12% depending on the study. However, the risks had not been at the forefront until a physician in Boston had a laparoscopic hysterectomy with power morcellation and was found to have a leiomyosarcoma. When she recurred, she and her physician husband blamed the power morcellation for her recurrence, subsequent progression, and, ultimately, her death. Prior to her decline, she and her husband became active politically against the use of the power morcellator, stating it was an instrument of harm since its use potentially upstaged an occult cancer. The end-result was that this important laparoscopic tool was removed from the gynecologic surgery tool box, and surgeons were left with the quandary of how to remove tissue through small incisions. Despite significant data suggesting that leiomyosarcomas are rare cancers with poor ability to diagnose preoperatively and that the risk of malignancy is less than the risk for converting to an open procedure, hospital after hospital removed power morcellators from their shelves.
Desai et al analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), which is a voluntary reporting program with de-identified patient information. The database contains appropriate clinical information, including age, comorbidities, body mass index (BMI), pelvic inflammatory disease, prior surgeries, endometriosis, uterine weight, and surgical approach, but preoperative workup information is not available. According to ACS NSQIP, women who had hysterectomies for benign indications had a 1.44% risk of uterine cancer, 0.6% risk of cervical cancer, and 0.19% risk of ovarian cancer in their final pathology. The surgical approach influenced the risk, with a slightly higher risk in laparoscopic procedures and slightly lower risk in vaginal or supracervical hysterectomies. Women having myomectomy were younger and had a lower risk of malignancy, with a 0.21% risk of a uterine malignancy. Age was an important risk factor for malignancy, with women 55 years of age and older having a 9.72% risk of uterine cancer, compared to 1.06% in women younger than 55 years of age. Age of 55 years or older also was associated with an increased risk of both cervical and ovarian cancer. Given that the risk of malignancy increases with age, these results are not surprising.
In a prior article, Wright et al quoted a 0.19% risk of uterine cancer in women who did not undergo morcellation and 0.09% in women who did have morcellation. The risk of malignancy again was increased with age.1 In 2018, Yuk et all found hysteroscopy was associated with an even greater incidence of unexpected uterine malignancy, with a 0.86% risk with hysteroscopic myomectomy and 1.11% risk with polypectomy.2 These findings are not surprising because patients would have had a specific indication for the surgery, primarily abnormal bleeding, which has a higher risk of malignancy. Another large, single-institution study found occult malignancy in 0.19% of hysterectomies done for benign indications.3 Those premenopausal patients with an unexpected endometrial malignancy all had a BMI in the obese to morbidly obese range, which increased their risk of endometrial pathology. In 2016, Wise et al found that 5% of their patients younger than 45 years of age who presented with abnormal uterine bleeding had complex hyperplasia or cancer, and patients with a BMI ≥ 30 kg/m2 had a four-fold increased risk of endometrial pathology, suggesting that risk of malignancy is increased in young obese women.4 They concluded that BMI rather than age should be the criterion for endometrial sampling prior to hysterectomy.
Although there has been significant publicity about the risk of malignancy associated with morcellation, the reality is that the incidence is quite low (< 1% of an occult cancer at time of surgery). Older age and high BMI are both risk factors for occult malignancy. Endometrial biopsies prior to surgery will reduce the risk of an unexpected malignancy and aid in diagnosis most of the time. However, patients should be counseled that there is still a risk of malignancy when undergoing hysterectomy for benign indications, especially in older women with insufficient tissue on endometrial biopsy. However, given the very low risk of malignancy in carefully screened patients, the uproar and negative public opinion against power morcellation seems to have been blown out of proportion and was driven by politics rather than data.
- Wright JD, Tergas AI, Cui R, et al. Use of electric power morcellation and prevalence of underlying cancer in women who undergo myomectomy. JAMA Oncol 2015;1:69-77.
- Yuk JS, Shin JY, Moon HS, Lee JH. The incidence of unexpected uterine malignancy in women undergoing hysteroscopic myomectomy or polypectomy: A national population-based study. Eur J Obstet Gynecol Reprod Biol 2018;224:12-16.
- Parsons LHP, Pedersen R, Richardson DL, Kho KA. The prevalence of occult endometrial cancer in women undergoing hysterectomy for benign indications. Eur J Obstet Gynecol Reprod Biol 2018;223:108-112.
- Wise MR, Gill P, Lensen S, et al. Body mass index trumps age in decision for endometrial biopsy: Cohort study of symptomatic premenopausal women. Am J Obstet Gynecol 2016;215:598.e1-598.e8.