Incidence of occult malignancies identified during hysterectomies performed for benign indications

Incidence and Predictors of Unexpected Malignancy in Benign Myomectomy or Hysterectomy

Introduction Detection of gynecological cancers preoperatively is imperative for practitioners for optimal patient management and outcome. This study aimed to estimate the incidence of unexpected malignancy (UM) in patients who underwent hysterectomy or myomectomy for presumed benign indications and to detect the predictive factors of UM. Methods A retrospective analytical study that included patients who underwent hysterectomy or myomectomy for benign indications from January 1st, 2016, to December 31st, 2020, was conducted at the Department of Obstetrics and Gynecology at Salmaniya Medical Complex, Bahrain. The main outcome was the overall incidence of UM and the incidence of each malignancy. Characteristics of UM were compared with benign pathologies. Fisher's exact and Pearson's chi-square tests were used to compare categorical variables and the Mann-Whitney U test or student's t-test for continuous variables. Binary logistic regression was used to identify the predictors of occurrence of UM. Confidence interval (CI) was set at 95%. A probability value (p-value) less than 0.05 was considered statistically significant. Results Out of 513 patients who underwent hysterectomy or myomectomy, 379 (73.9%) fulfilled the inclusion criteria, 314 (82.8%) hysterectomies and 65 (17.2%) myomectomies. The overall incidence of UM was 1.3% (n=5/379), 1.3% (n=4/314) among hysterectomies and 1.5% (n=1/65) among myomectomies. Three (0.8%) pre-malignant pathologies were identified: one (0.26%) smooth muscle tumor of unknown malignant potential, leiomyoma with bizarre nuclei, and mucinous borderline tumor of endocervical type of ovary each. The types of UM were sarcomas in three (0.26%) patients (two (0.5%) leiomyosarcoma and one (0.26%) endometrial stromal sarcoma) and endometrial adenocarcinoma and ovarian cancer in one (0.26%) patient each. No significant difference was found between the characteristics of UM and benign pathologies. Conclusion Although this study demonstrated a low incidence of UM among both hysterectomies and myomectomies, the age at the diagnosis of our patients with UM was as young as 34 years of age, and sarcomas were the most common type of UM. Disconcertingly, none of the studied independent variables had significantly predicted the occurrence of UM.

The incidence of unexpected gynaecological malignancies in hysterectomies carried out for benign indications

The aim of the present study was to determine the incidence of unexpected gynaecological malignancies in patients undergoing hysterectomy for benign indications and to evaluate their clinical characteristics. Data from 6448 cases who had undergone hysterectomy for benign indications between the dates of 01.01.2008-01.01.2018 were recorded retrospectively from the database of the institution. The mean age of the cases with malignancy was 59.2 ± 9.66 (45-80) and 76,31% were (29/38) postmenopausal. The mean gravidity was 3.94 ± 1.73 and parity was 3.31 ± 1.45. Their mean BMI was 29.6 ± 4.26 kg/m² (22.4-41.9 kg/m² range). These patients were followed for a mean duration of 60.68 ± 37.66 months and during this period death associated with malignancy occurred in 4/38 (%10.52) cases, all of whom had leiomyosarcoma. The benign indications of procedure were as follows: myoma uteri (2675, 41.48%), abnormal uterine bleeding (1508, 23.38%), uterine prolapsus (793, 12.29%), ovarian cyst (619, 9.59%), endometriosis (303, 4.69%), endometrial polyp (264, 4.09%), pelvic pain (238, 3.69%) and other benign causes (48, 0.74%). Unexpected gynaecological malignancy was found in 20 cases (0.31%) with endometrial cancer, in eight cases (0.12%) with uterine sarcoma, in seven cases (0.10%) with ovarian cancer, in one case (0.01%) with tubal cancer and in two (0.03%) with cervical cancer. Gynaecological malignancy was found in 38 of 6648 cases who underwent hysterectomy for benign indications, yielding an incidence rate of 0.58%.IMPACT STATEMENTWhat is already known on this subject? Hysterectomy is the most common gynaecological surgery in the world and although most are performed for benign indications, unexpected gynaecological malignancy is possible in the final pathology results.Although there are available publications investigating unexpected gynaecological malignancy incidences after hysterectomies for benign reasons, the incidence is still not clear. We aimed to contribute to the existing literature with this study, which includes a large number of cases.What do the results of this study add? Our study adds new findings to the body of the knowledge on the incidence of unexpected gynaecological malignancies in hysterectomies for benign indications. Gynaecological malignancy was found in 38 of 6648 cases who underwent hysterectomy for benign indications, yielding an incidence rate of 0.58%.What are the implications of these findings for clinical practice and/or further research? There is an unexpected possibility of gynaecological malignancy even in cases where it is expected to be benign with current diagnostic methods. In cases that are expected to be benign, detailed preoperative evaluation should be performed in all patients to prevent unexpected gynaecological malignancies. More sensitive screening methods should be developed especially in the preoperative differential diagnosis of leiomyoma and leiomyosarcoma.

Morcellation in gynecology: short review and suggestions from Turkish Society of Minimally Invasive Gynecologic Oncology

Morcellation allows the removal of a large uterus and fibroids through small incisions with minimally invasive surgery. It helps to prevent the complications associated with large incisions in both hysterectomy and myomectomy operations. Currently, there is much debate regarding the use of power morcellation in laparoscopic hysterectomy and myomectomy, mainly due to the risk of peritoneal dissemination of undiagnosed uterine sarcomas. Unfortunately, there is no valid pre-operative diagnostic method that can differentiate sarcomas from myomas, and the currently available scientific literature regarding morcellation is insufficient. As the Turkish Society of Minimally Invasive Gynecological Oncology, we present our consensus opinion and suggestions for the preoperative evaluation and morcellation of fibroids, in line with the recent literature.