Uterine Sarcomas: Pre- and Intra-operative Considerations
Article Sidebar
Main Article Content
Abstract
Uterine leiomyomas are the most common indication for hysterectomy and myomectomy. Compared with the laparoscopic approach, the abdominal approach for hysterectomy is associated with a higher risk of a venous thromboembolic event, blood transfusion, prolonged hospital stays, wound pain, and infection. Unfortunately, some women with uterine mass undergoing surgery had unexpected uterine sarcomas. Spreading an unexpected uterine sarcoma during a hysterectomy or myomectomy can worsen the prognosis. Thus, a pre-operative diagnosis of uterine sarcomas is relatively challenging. Obstetrician-gynecologists should pre-operatively discuss the possibility of malignancy of the disease, risk, and benefit of the operative approach with the patient with a uterine mass. In this article, we reviewed the concerns of uterine sarcomas in patients with a uterine mass in terms of the disease incidence, pathological and clinical features, pre-operative evaluation tools such as biomarkers and imaging, intra-operative gross evaluation, and the roles of the intra-operative tissue containment system.
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
References
Zhang G, Yu X, Zhu L, Fan Q, Shi H, Lang J. Pre-operative clinical characteristics scoring system for differentiating uterine leiomyosarcoma from fibroid. BMC Cancer 2020;20:514.
Uterine Morcellation for Presumed Leiomyomas: ACOG Committee Opinion, Number 822. Obstet Gynecol 2021;137:e63-e74.
Oduyebo T, Rauh-Hain AJ, Meserve EE, Seidman MA, Hinchcliff E, George S, et al. The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol 2014;132:360-5.
Park JY, Park SK, Kim DY, Kim JH, Kim YM, Kim YT, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol. 2011;122:255-9.
Perri T, Korach J, Sadetzki S, Oberman B, Fridman E, Ben-Baruch G. Uterine leiomyosarcoma: does the primary surgical procedure matter? Int J Gynecol Cancer 2009;19:257-60.
UPDATED laparoscopic uterine power morcellation in hysterectomy and myomectomy [Internet]. 2014 [cited September 4, 2022]. Available from: https://wayback.archive-it.org/7993/20170404182209/https:/www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm.
Multinu F, Casarin J, Hanson KT, Angioni S, Mariani A, Habermann EB, et al. Practice patterns and complications of benign hysterectomy following the FDA statement warning against the use of power morcellation. JAMA Surg 2018;153:e180141.
UPDATE: The FDA recommends performing contained morcellation in women when laparoscopic power morcellation is appropriate [Internet]. 2020 [cited September 4, 2022]. Available from: https://www.fda.gov/medical-devices/safety-communications/update-fda-recommends-performing-contained-morcellation-women-when-laparoscopic-power-morcellation.
UPDATE: Perform only contained morcellation when laparoscopic power morcellation is appropriate: FDA safety communication [Internet]. 2020 [cited September 4, 2022]. Available from: https://www.fda.gov/medical-devices/safety-communications/update-perform-only-contained-morcellation-when-laparoscopic-power-morcellation-appropriate-fda.
Major FJ, Blessing JA, Silverberg SG, Morrow CP, Creasman WT, Currie JL, et al. Prognostic factors in early-stage uterine sarcoma. A Gynecologic Oncology Group study. Cancer 1993;71:1702-9.
Toro JR, Travis LB, Wu HJ, Zhu K, Fletcher CD, Devesa SS. Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978-2001: an analysis of 26,758 cases. Int J Cancer 2006;119:2922-30.
Hartmann KE, Fonnesbeck C, Surawicz T, Krishnaswami S, Andrews JC, Wilson JE, et al. Comparative effectiveness review number 195: management of uterine fibroids. Rockville: Agency for Healthcare Research and Quality (US), 2017.
Chantasartrassamee P, Kongsawatvorakul C, Rermluk N, Charakorn C, Wattanayingcharoenchai R, Lertkhachonsuk AA. Pre-operative clinical characteristics between uterine sarcoma and leiomyoma in patients with uterine mass, a case-control study. Eur J Obstet Gynecol Reprod Biol 2022;270:176-80.
Ruengkhachorn I, Phithakwatchara N, Nawapun K, Hanamornroongruang S. Undiagnosed uterine sarcomas identified during surgery for presumed leiomyoma at a national tertiary hospital in Thailand: a 10-year review. Int J Gynecol Cancer 2017;27:973-8.
Prat J. FIGO staging for uterine sarcomas. Int J Gynaecol Obstet 2009;104:177-8.
Mbatani N, Olawaiye AB, Prat J. Uterine sarcomas. Int J Gynaecol Obstet 2018;143 Suppl 2:51-8.
McCluggage WG. Malignant biphasic uterine tumours: carcinosarcomas or metaplastic carcinomas? J Clin Pathol 2002;55:321-5.
Lok J, Tse KY, Lee EYP, Wong RWC, Cheng ISY, Chan ANH, et al. Intraoperative Frozen Section Biopsy of Uterine Smooth Muscle Tumors: A Clinicopathologic Analysis of 112 Cases With Emphasis on Potential Diagnostic Pitfalls. Am J Surg Pathol 2021;45:1179-89.
D'Angelo E, Prat J. Uterine sarcomas: a review. Gynecol Oncol 2010;116:131-9.
Jones MW, Norris HJ. Clinicopathologic study of 28 uterine leiomyosarcomas with metastasis. Int J Gynecol Pathol 1995;14:243-9.
Chen I, Firth B, Hopkins L, Bougie O, Xie RH, Singh S. Clinical characteristics differentiating uterine sarcoma and fibroids. JSLS 2018;22:e2017.00066.
Lawlor H, Ward A, Maclean A, Lane S, Adishesh M, Taylor S, et al. Developing a pre-operative algorithm for the diagnosis of uterine leiomyosarcoma. Diagnostics (Basel) 2020;10:735.
Satthapong D, Wilailak S. Prognostic factors and survival outcome of uterine sarcoma patients: 21 years experience at Ramathibodi Hospital. Thai J Obstet Gynaecol. 2017;19:58-66.
Siedhoff MT, Doll KM, Clarke-Pearson DL, Rutstein SE. Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroids: an updated decision analysis following the 2014 Food and Drug Administration safety communications. Am J Obstet Gynecol 2017;216:259.e1-.e6.
Peters A, Sadecky AM, Winger DG, Guido RS, Lee TTM, Mansuria SM, et al. Characterization and pre-operative risk analysis of leiomyosarcomas at a high-volume tertiary care center. Int J Gynecol Cancer 2017;27:1183-90.
Multinu F, Casarin J, Tortorella L, Huang Y, Weaver A, Angioni S, et al. Incidence of sarcoma in patients undergoing hysterectomy for benign indications: a population-based study. Am J Obstet Gynecol 2019;220:179.e1-.e10.
Adishesh M, Hapangama DK. Enriching personalized endometrial cancer research with the harmonization of biobanking standards. Cancers (Basel) 2019;11:1734.
Jeong MJ, Park JH, Hur SY, Kim CJ, Nam HS, Lee YS. Pre-operative neutrophil-to-lymphocyte ratio as a prognostic factor in uterine sarcoma. J Clin Med 2020;9:2898.
Goto A, Takeuchi S, Sugimura K, Maruo T. Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus. Int J Gynecol Cancer 2002;12:354-61.
Parra-Herran C, Howitt BE. Uterine Mesenchymal tumors: update on classification, staging, and molecular features. Surg Pathol Clin 2019;12:363-96.
Smith J, Zawaideh JP, Sahin H, Freeman S, Bolton H, Addley HC. Differentiating uterine sarcoma from leiomyoma: BET1T2ER Check! Br J Radiol 2021;94:20201332.
Bi Q, Xiao Z, Lv F, Liu Y, Zou C, Shen Y. Utility of clinical parameters and multiparametric MRI as predictive factors for differentiating uterine sarcoma from atypical leiomyoma. Acad Radiol 2018;25:993-1002.
Lakhman Y, Veeraraghavan H, Chaim J, Feier D, Goldman DA, Moskowitz CS, et al. Differentiation of uterine leiomyosarcoma from atypical leiomyoma: diagnostic accuracy of qualitative MR imaging features and feasibility of texture analysis. Eur Radiol 2017;27:2903-15.
Santos P, Cunha TM. Uterine sarcomas: clinical presentation and MRI features. Diagn Interv Radiol 2015;21:4-9.
Takeuchi M, Matsuzaki K, Harada M. Clinical utility of susceptibility-weighted MR sequence for the evaluation of uterine sarcomas. Clin Imaging 2019;53:143-50.
Kaganov H, Ades A, Fraser DS. Pre-operative magnetic resonance imaging diagnostic features of uterine leiomyosarcomas: a systematic review. Int J Technol Assess Health Care 2018;34:172-9.
Abdel Wahab C, Jannot AS, Bonaffini PA, Bourillon C, Cornou C, Lefrère-Belda MA, et al. Diagnostic algorithm to differentiate benign atypical leiomyomas from malignant uterine sarcomas with diffusion-weighted MRI. Radiology 2020;297:361-71.
Rha SE, Byun JY, Jung SE, Lee SL, Cho SM, Hwang SS, et al. CT and MRI of uterine sarcomas and their mimickers. Am J Roentgenol 2003;181:1369-74.
WHO Classification of Tumours Editorial Board. WHO Classification of Tumours: Female Genital Tumours. 5th ed. Lyon (France): International Agency for Research on Cancer 2020.
Nucci MR, Quade BJ. Uterine mesenchymal tumors. In: Crum CP, Nucci MR, Lee KR, editors. Diagnostic gynecologic and obstetric pathology. 2nd ed. Philadelphia: Elsevier Saunders 2011:582-639.
FDA allows marketing of first-of-kind tissue containment system for use with certain laparoscopic power morcellators in select patients [Internet]. 2016 [cited September 14, 2022]. Available from: https://www.fda.gov/news-events/press-announcements/fda-allows-marketing-first-kind-tissue-containment-system-use-certain-laparoscopic-power.
PneumoLiner is the first and only power morcellation containment device specifically designed for intra-abdominal insufflation during GYN procedures [Internet]. 2013 [cited December 16, 2022]. Available from: Contained Tissue Extraction System | Olympus America | Medical
Miller CE. Morcellation equipment: past, present, and future. Curr Opin Obstet Gynecol 2018;30:69-74.
Siedhoff MT, Cohen SL. Tissue extraction techniques for leiomyomas and uteri during minimally invasive surgery. Obstet Gynecol 2017;130:1251-60.