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Kuessel L, Sandrieser L, Hofstetter G, Heinzl F, Mara M, Richtárová A, Montanari E, Wenzl R, Perricos-Hess A, Husslein H. Reducing Peritoneal Cell Dissemination in Laparoscopic Uterine Surgery: A Comparative Pilot Study on Morcellation Techniques and Peritoneal Irrigation. J Clin Med 2025; 14:3383. [PMID: 40429379 PMCID: PMC12112552 DOI: 10.3390/jcm14103383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2025] [Revised: 05/01/2025] [Accepted: 05/09/2025] [Indexed: 05/29/2025] Open
Abstract
Following the U.S. Food and Drug Administration's warning against power morcellators due to potential cell dissemination of occult malignancy, there has been a shift away from minimally invasive approaches. This concern also overshadows the well-documented advantages of minimally invasive surgery in benign gynecology. Objectives: To evaluate whether intraperitoneal cell dissemination during laparoscopic surgery for uterine fibroids can be reduced by (i) the choice of morcellation method and/or (ii) copious irrigation after the procedure. Methods: This prospective multicenter comparative pilot study included 72 women undergoing laparoscopic myomectomy (LM) or total laparoscopic hysterectomy (TLH) for benign conditions. Women were divided into four groups in order to compare different types of morcellation, including a reference group without morcellation: (i) LM with power morcellation (n = 21, Group A), (ii) TLH with en-bloc transvaginal tissue removal without morcellation (n = 17, Group B), (iii) TLH with manual vaginal morcellation (n = 19, Group C), and (iv) TLH with contained manual vaginal morcellation (n = 15, Group D). Patients receiving cold knife morcellation were randomized into Groups C or D. In order to assess cell spread before surgery, after surgery but before morcellation, after morcellation, and after abdominal irrigation with a total of 3000 mL saline solution, peritoneal washings were collected at six timepoints. Results: After specimen removal (TP3), cell spread was significantly higher in cases with power morcellation [13/19 (68%) in Group A] compared to transvaginal cold knife morcellation, both contained and uncontained [Group C 1/14 (7%) and Group D 1/19 (9%)] (p < 0.001), or to TLH with en bloc removal [Group B 1/17 (6%)]. Saline irrigation reduced the positive cytologies. After 3000 mL (TP6), the difference between Group A and the TLH groups was not significant [4/18 (22%) vs. 3/45 (7%), p = 0.079]. Conclusions: Our study shows that (i) transvaginal cold knife morcellation results in significantly less peritoneal cell dissemination than power morcellation, and (ii) peritoneal irrigation with 3000 mL of saline significantly reduces residual cell presence. These findings could support maintaining minimally invasive approaches while addressing safety concerns.
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Affiliation(s)
- Lorenz Kuessel
- Department of Obstetrics and Gynecology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Lejla Sandrieser
- Department of Obstetrics and Gynecology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Gerda Hofstetter
- Department of Obstetrics and Gynecology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Florian Heinzl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Michal Mara
- Department of Gynecology, Obstetrics and Neonatology, Charles University of Medicine in Prague, Katerinská 32, CZ-121 08 Prague, Czech Republic
| | - Adéla Richtárová
- Department of Gynecology, Obstetrics and Neonatology, Charles University of Medicine in Prague, Katerinská 32, CZ-121 08 Prague, Czech Republic
| | - Eliana Montanari
- Department of Obstetrics and Gynecology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - René Wenzl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Alexandra Perricos-Hess
- Department of Obstetrics and Gynecology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Heinrich Husslein
- Department of Obstetrics and Gynecology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Nguyen XL, Huynh QH, Nguyen PN. Assessing the Clinical Characteristics and the Role of Imaging Modalities in Uterine Sarcoma: A Single-Center Retrospective Study From Vietnam. JOURNAL OF CLINICAL ULTRASOUND : JCU 2025. [PMID: 40312923 DOI: 10.1002/jcu.24046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2025] [Revised: 02/10/2025] [Accepted: 03/31/2025] [Indexed: 05/03/2025]
Abstract
BACKGROUND This study aims to describe the clinical and imaging characteristics of uterine sarcomas and the role of imaging modalities in assessing them. MATERIALS AND METHODS This retrospective study enrolled all patients diagnosed with uterine sarcoma at Tu Du Hospital, Vietnam between January 2020 and December 2023. The findings of ultrasound (US) and magnetic resonance imaging (MRI) were compared to histology as the reference. RESULTS Among 78 patients, 46.2% of cases were menopause. Abnormal vaginal bleeding was the most common symptom. Three common types of uterine sarcoma were leiomyosarcoma (50.0%), low-grade endometrial stromal sarcoma (23.1%), and carcinosarcoma (19.2%). Some imaging features of uterine sarcomas were found including nontypical lesion of fibroid (89.7%), solitary mass (84.6%), inhomogeneous structure (76.9%), invisible endometrium (67.9%), moderate-rich vascularization on Doppler signal (57.7%), irregular border of tumor (48.7%), classification of FIGO 0 (44.9%), cystic area within tumor (42.3%), acoustic shadowing (34.6%), "cooked" appearance (9.0%), and calcification image in tumor (6.4%). The sensitivity of standard US, consultant US, and MRI was 56.4%, 88.4%, and 87.5%, respectively. CONCLUSIONS Besides clinical presentations, uterine sarcomas present some specific features on US. Consultant US and MRI could be added to standard US to increase the accuracy and help in surgical decision making where applicable.
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Affiliation(s)
- Xuan Lan Nguyen
- Department of Imaging Diagnosis, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Quang Huy Huynh
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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Jiang Z, Jia S, Zhang J, Liu C, Luo X, Tang Y, Zhang G, Zhu Y. Preoperative identification from occult leiomyosarcomas in laparoscopic hysterectomy and laparoscopic myomectomy: accuracy of the ultrasound scoring system (PRESS-US). LA RADIOLOGIA MEDICA 2024; 129:1864-1875. [PMID: 39476275 DOI: 10.1007/s11547-024-01903-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 10/15/2024] [Indexed: 12/17/2024]
Abstract
PURPOSE To assess the diagnostic performance and inter-observer agreement of a PREoperative sarcoma scoring based on ultrasound (PRESS-US) in differentiating uterine leiomyosarcoma (uLMS) from leiomyoma (LM). METHODS We conducted a retrospective evaluation of patients who underwent surgery and received standardized ultrasound examinations due to the presence of uterine myoma-like masses. Histological diagnosis was used as the reference standard. The masses were analyzed using morphological uterus sonographic assessment criteria, and the diagnostic accuracy of PRESS-US was evaluated using ROC curve analysis. Kappa (κ) statistics were used to assess the inter-observer agreement between a less experienced and an expert radiologist. RESULTS Among the 646 patients, 632 (97.8%) were diagnosed with LM, and 14 (2.2%) had uLMS. The malignancy rates for low-risk and high-risk patients were 0.35% and 13.48%, respectively. The optimal PRESS-US cutoff was 17.5, resulting in an AUC of 89.7% (95% CI, 0.79-1.00), with a sensitivity of 85.7% and a specificity of 87.8%. The inter-observer agreement between a less experienced and an expert radiologist was excellent (κ = 0.811, P < 0.001). CONCLUSIONS PRESS-US provides effective risk stratification for uLMS for radiologists with different levels of experience, with high reliability. Subgrouping high-risk patients helps in better risk stratification.
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Affiliation(s)
- Zhuolin Jiang
- Department of Ultrasound, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China (UESTC), NO. 55, Section 4, Renmin South Road, Chengdu, 610041, China
| | - Shijun Jia
- Department of Pathology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China (UESTC), Chengdu, 610041, China
| | - Jie Zhang
- Department Gynecologic Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China (UESTC), NO. 55, Section 4, Renmin South Road, Chengdu, 610041, China
| | - Chun Liu
- Department of Ultrasound, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China (UESTC), NO. 55, Section 4, Renmin South Road, Chengdu, 610041, China
| | - Xinyi Luo
- Department of Ultrasound, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China (UESTC), NO. 55, Section 4, Renmin South Road, Chengdu, 610041, China
| | - Yixin Tang
- Department of Ultrasound, Suining Central Hospital, Suining, 629000, China
| | - Guonan Zhang
- Department Gynecologic Oncology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China (UESTC), NO. 55, Section 4, Renmin South Road, Chengdu, 610041, China.
| | - Yi Zhu
- Department of Ultrasound, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China (UESTC), NO. 55, Section 4, Renmin South Road, Chengdu, 610041, China.
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Woo S, Beier SR, Tong A, Hindman NM, Vargas HA, Kang SK. Utility of ADC Values for Differentiating Uterine Sarcomas From Leiomyomas: Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2024; 223:e2431280. [PMID: 38899844 DOI: 10.2214/ajr.24.31280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND. Uterine sarcomas are rare; however, they display imaging features that overlap those of leiomyomas. The potential for undetected uterine sarcomas is clinically relevant because minimally invasive treatment of leiomyomas may lead to cancer dissemination. ADC values have shown potential for differentiating benign from malignant uterine masses. OBJECTIVE. The purpose of this study was to perform a systematic review of the diagnostic performance of ADC values in differentiating uterine sarcomas from leiomyomas. EVIDENCE ACQUISITION. We searched three electronic databases (the MEDLINE, Embase, and Cochrane databases) for studies distinguishing uterine sarcomas from leiomyomas using MRI, including ADC values, with pathologic tissue confirmation or imaging follow-up used as the reference standard. Data extraction and QUADAS-2 quality assessment were performed. Sensitivity and specificity were pooled using hierarchical models, including bivariate and hierarchical summary ROC models. Metaregression was used to assess the impact of various factors on heterogeneity. EVIDENCE SYNTHESIS. Twenty-one studies met the study inclusion criteria. Pooled sensitivity and specificity were 89% (95% CI, 82-94%) and 86% (95% CI, 78-92%), respectively. The area under the summary ROC curve was 0.94 (95% CI, 0.92-0.96). The context of the ADC interpretation (i.e., used as a stand-alone assessment vs integrated as part of multiparametric MRI [mpMRI]) was the only factor found to account significantly for heterogeneity (p = .01). Higher specificity (95% [95% CI, 92-99%] vs 82% [95% CI, 75-89%]) and similar sensitivity (94% [95% CI, 89-99%] vs 88% [95% CI, 82-93%]) were observed when ADC was evaluated among mpMRI features rather than as a stand-alone ADC assessment. ADC cutoff values ranged from 0.87 to 1.29 × 10-3 mm2/s but were not associated with statistically different performance (p = .37). Pooled mean ADC values for sarcomas and leiomyomas were 0.904 × 10-3 mm2/s and 1.287 × 10-3 mm2/s, respectively. CONCLUSION. As part of mpMRI evaluation of uterine masses, a mass ADC value of less than 0.904 × 10-3 mm2/s may be a useful test-positive threshold for uterine sarcoma, consistent with the findings of a prior expert consensus statement. Institutional protocols may influence locally selected ADC values. CLINICAL IMPACT. Using ADC as part of mpMRI assessment improves detection of uterine sarcoma, which could influence candidate selection for minimally invasive treatments. TRIAL REGISTRATION. Prospective Register of Systematic Reviews CRD42024499383.
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Affiliation(s)
- Sungmin Woo
- Department of Radiology, NYU Langone Health, 660 First Ave, Rm 333, New York, NY 10016
| | - Sarah R Beier
- Department of Radiology, NYU Langone Health, 660 First Ave, Rm 333, New York, NY 10016
| | - Angela Tong
- Department of Radiology, NYU Langone Health, 660 First Ave, Rm 333, New York, NY 10016
| | - Nicole M Hindman
- Department of Radiology, NYU Langone Health, 660 First Ave, Rm 333, New York, NY 10016
| | - Hebert A Vargas
- Department of Radiology, NYU Langone Health, 660 First Ave, Rm 333, New York, NY 10016
| | - Stella K Kang
- Department of Radiology, NYU Langone Health, 660 First Ave, Rm 333, New York, NY 10016
- Department of Population Health, NYU Langone Health, New York, NY
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Al Khuri M, Al Salmi I, Al Ajmi H, Al Hadidi A, Alabousi A, Haider E, Vasudev P, Al Salmi A, Jose S, Alrahbi N. Validating the diagnostic accuracy of an MRI-based scoring system for differentiating benign uterine leiomyomas from leiomyosarcomas. Int J Gynecol Cancer 2024; 34:1027-1033. [PMID: 38658016 DOI: 10.1136/ijgc-2023-005220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/12/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVE Uterine leiomyomas are the most common benign uterine tumors. They are difficult to distinguish from their malignant counterparts-smooth muscle tumors of unknown malignant potential (STUMP) and leiomyosarcoma. The purpose of this study is to propose and validate the diagnostic accuracy of the MRI-based Oman-Canada Scoring System of Myometrial Masses (OCSSMM) to differentiate uterine leiomyomas from STUMP/leiomyosarcomas. METHODS This is a retrospective study performed at two tertiary care centers. All patients with a pathology-proven uterine mass who underwent pre-operative pelvic MRI between January 2010 and January 2020 were included. Using a 1.5T MRI machine, sequences included were axial/coronal/sagittal T2 and T1 weighted imaging, axial diffusion weighted and apparent diffusion coefficient map, and axial or sagittal dynamic contrast-enhanced sequences. A scoring system was designed based on previously published worrisome MRI features for uterine leiomyosarcoma. Each feature was allocated a score from 0 to 2 according to the strength of association with malignancy. Subsequently, the MR images were blindly and independently reviewed by a fellowship-trained radiologist and a clinical fellow/senior resident. Each uterine mass was scored according to their imaging features. The scores were divided into five categories according to the sum of scores. Category III and above was considered positive for leiomyosarcoma/STUMP. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS A total of 244 women were included (age range 20-74 years, mean 40). Of these, 218 patients had benign leiomyoma, 13 had STUMP, and 13 had leiomyosarcoma. The sensitivity and specificity of the scoring system were 92.3% and 64.7%, respectively. The negative predictive value was 98.6%. No leiomyosarcoma was missed using this scoring system. The presence of non-cystic T2 hyperintensity or diffusion restriction in a uterine mass were the most sensitive signs of a leiomyosarcoma/STUMP. CONCLUSION The proposed multi-parametric MRI scoring system may be useful in differentiating benign uterine leiomyomas from leiomyosarcomas/STUMP.
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Affiliation(s)
- Maryam Al Khuri
- Radiology Department, Sohar Hospital, Sohar, Al Batinah North, Oman
- Department of Medical Imaging, McMaster University, Hamilton, Canada
| | - Ishaq Al Salmi
- Radiology Department, The Royal Hospital, Seeb, Muscat, Oman
| | - Hawra Al Ajmi
- Radiology Department, Sohar Hospital, Sohar, Al Batinah North, Oman
| | - Aymen Al Hadidi
- Radiology Department, Khoula Hospital, Mina Al Fahal, Muscat, Oman
| | - Abdullah Alabousi
- Department of Medical Imaging, McMaster University, Hamilton, Canada
- Diagnostic Imaging, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Ehsan Haider
- Department of Medical Imaging, McMaster University, Hamilton, Canada
- Diagnostic Imaging, St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Pooja Vasudev
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
- St Joseph's Healthcare Hamilton, Hamilton, Canada
| | - Ahmed Al Salmi
- Radiology Department, Rustaq Hospital, Rustaq, Al Batinah South, Oman
| | - Sachin Jose
- Research and Studies Department, Oman Medical Speciality Board, Al-Athaiba, Muscat, Oman
| | - Nasser Alrahbi
- Histopathology Department, The Royal Hospital, Seeb, Muscat, Oman
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