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Casarin J, Ghezzi F, Lembo A, Artuso V, Schivardi G, Galati EF, Ambrosoli AL, Bogani G, Multinu F, Cromi A. Oncological outcomes of unexpected uterine leiomyosarcoma: A single-center retrospective analysis of 5528 consecutive hysterectomies. J Surg Oncol 2024; 129:517-522. [PMID: 37974522 DOI: 10.1002/jso.27509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/30/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND METHODS Uterine leiomyosarcomas (uLMS) are rare malignant tumors, often incidentally discovered, with an estimated annual incidence of five cases per one million women in the United States. This study aimed to compare the oncological outcomes of two groups of patients: those with uLMS incidentally found during surgery and those who underwent surgery due to suspected or confirmed uLMS before the procedure. The study assessed patients who had undergone hysterectomy and were diagnosed with stage I uLMS at a tertiary gynecologic oncology referral center in Italy between January 2000 and December 2019. Data on patients' baseline characteristics, surgical procedures, and oncological outcomes were collected. The patients were classified into two groups based on whether uLMS was unexpectedly discovered or suspected before the surgery. Survival rates and factors influencing recurrence were analyzed. RESULTS The study included 36 patients meeting the inclusion criteria, with 12 having preoperatively suspected or proven uLMS and 24 having incidentally discovered uLMS. No significant differences were observed between the two groups regarding disease-free survival (23.7 vs. 27.3 months, log rank = 0.28), disease-specific survival (median not reached, log rank = 0.78), or sites of relapse. Notably, among patients who underwent laparoscopic hysterectomy (compared to open surgery), a significantly higher rate of locoregional recurrence was found (78% vs. 33.3%, p = 0.04). Nevertheless, no significant differences in survival were observed based on the surgical approach. CONCLUSIONS Preoperative suspicion for uLMS did not seem to impact survival outcomes or the pattern of recurrence. Furthermore, although patients who underwent laparoscopic hysterectomy showed a higher rate of locoregional relapse, this did not affect their overall survival.
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Affiliation(s)
- Jvan Casarin
- Obstetrics and Gynecology Department of the University of Insubria, Women's and Children Del Ponte Hospital, Varese, Italy
| | - Fabio Ghezzi
- Obstetrics and Gynecology Department of the University of Insubria, Women's and Children Del Ponte Hospital, Varese, Italy
| | - Antonio Lembo
- Obstetrics and Gynecology Department of the University of Insubria, Women's and Children Del Ponte Hospital, Varese, Italy
| | - Valeria Artuso
- Obstetrics and Gynecology Department of the University of Insubria, Women's and Children Del Ponte Hospital, Varese, Italy
| | - Gabriella Schivardi
- Department of Gynecology, European Institute of Oncology (IEO), IRCCS, Milan, Italy
| | - Emanuele Filippo Galati
- Obstetrics and Gynecology Department of the University of Insubria, Women's and Children Del Ponte Hospital, Varese, Italy
| | - Andrea Luigi Ambrosoli
- Obstetrics and Gynecology Department of the University of Insubria, Women's and Children Del Ponte Hospital, Varese, Italy
| | - Giorgio Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Francesco Multinu
- Department of Gynecology, European Institute of Oncology (IEO), IRCCS, Milan, Italy
| | - Antonella Cromi
- Obstetrics and Gynecology Department of the University of Insubria, Women's and Children Del Ponte Hospital, Varese, Italy
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Yang Q, Ciebiera M, Bariani MV, Ali M, Elkafas H, Boyer TG, Al-Hendy A. Comprehensive Review of Uterine Fibroids: Developmental Origin, Pathogenesis, and Treatment. Endocr Rev 2022; 43:678-719. [PMID: 34741454 PMCID: PMC9277653 DOI: 10.1210/endrev/bnab039] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Indexed: 11/24/2022]
Abstract
Uterine fibroids are benign monoclonal neoplasms of the myometrium, representing the most common tumors in women worldwide. To date, no long-term or noninvasive treatment option exists for hormone-dependent uterine fibroids, due to the limited knowledge about the molecular mechanisms underlying the initiation and development of uterine fibroids. This paper comprehensively summarizes the recent research advances on uterine fibroids, focusing on risk factors, development origin, pathogenetic mechanisms, and treatment options. Additionally, we describe the current treatment interventions for uterine fibroids. Finally, future perspectives on uterine fibroids studies are summarized. Deeper mechanistic insights into tumor etiology and the complexity of uterine fibroids can contribute to the progress of newer targeted therapies.
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Affiliation(s)
- Qiwei Yang
- Qiwei Yang, Ph.D. Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, M167, Billings, Chicago, IL 60637, USA.
| | - Michal Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, ul. Cegłowska 80, 01-809, Warsaw, Poland
| | | | - Mohamed Ali
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo 11566, Egypt
| | - Hoda Elkafas
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, IL 60612, USA
- Department of Pharmacology and Toxicology, Egyptian Drug Authority, formerly National Organization for Drug Control and Research, Cairo 35521, Egypt
| | - Thomas G Boyer
- Department of Molecular Medicine, Institute of Biotechnology, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229-3900, USA
| | - Ayman Al-Hendy
- Correspondence: Ayman Al-Hendy, MD, Ph.D. Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, N112, Peck Pavilion, Chicago, IL 60637. USA.
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Roy M, Musa F, Taylor SE, Huang M. Uterine Sarcomas: How to Navigate an Ever-Growing List of Subtypes. Am Soc Clin Oncol Educ Book 2022; 42:1-10. [PMID: 35471831 DOI: 10.1200/edbk_350955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Uterine sarcomas are rare mesenchymal tumors that are aggressive cancers. The rarity of these tumors, and consequently limited prospective data, has made surgical management of uterine sarcomas challenging. One major obstacle in the management of uterine sarcomas is establishing the diagnosis prior to surgery, which is crucial for appropriate intraoperative management. This paper serves to review aspects of surgical management of uterine sarcomas that remain unanswered. Distinguishing common benign myomas from rare uterine sarcomas is important for operative planning and subspecialty care because benign myomas are frequently managed with minimally invasive hysterectomy or myomectomy, whereas the mainstay of management of uterine sarcomas is hysterectomy without specimen fragmentation. Preoperative clinical presentation, serum studies, imaging, and histologic examination all have limitations in establishing a preoperative diagnosis. In addition, patients are often of reproductive age and desire fertility preservation. Although surgery remains the cornerstone for management, high-quality data guiding best practices are sparse. Morcellation should be avoided. Expert pathologic review, imaging to assess for metastatic disease, and consideration of hormone receptor testing are advisable. Recent data have further informed surgical approach and fertility preservation in early-stage disease, but controversy remains. Despite substantial advancement in the medical management of uterine sarcomas, surgical management of uterine sarcomas remain challenging. Larger studies with long-term follow-up are needed to guide fertility preservation surgery options, both local resection and ovarian preservation, further in young women. Development of novel methods to differentiate between benign and malignant uterine masses is needed.
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Affiliation(s)
- Molly Roy
- Sylvester Comprehensive Center Cancer/University of Miami Miller School of Medicine, Miami, FL
| | | | | | - Marilyn Huang
- Sylvester Comprehensive Center Cancer/University of Miami Miller School of Medicine, Miami, FL
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Suchetha S, Vijayashanti T, Rema P, Sivaranjith J, kumar A, Krishna KMJ, James FV. Uterine Sarcoma: Retrospective Study From A Single institute. J Obstet Gynaecol India. [PMID: 35928081 PMCID: PMC9343530 DOI: 10.1007/s13224-021-01612-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022] Open
Abstract
Abstract Uterine sarcomas are heterogeneous group of tumours comprising 1% of gynaecological malignancies. There is lack of concences on optimal treatment of uterine sarcomas. This is because of lack of randomised controlled trials due to rarity of these tumours. Surgical management without spill remains the standard primary treatment. Most of the times uterine sarcomas are diagnosed postoperatively from histopathology report of either myomectomy or hysterectomy. This retrospective study analysed the clinico pathological characteristics, prognostic factors, treatment details and survival outcome of different types of uterine sarcomas. Materials and methods This is a retrospective analysis of 59 patients of uterine sarcomas. All patients underwent surgery. Adjuvant chemotherapy or radiation treatment were given according to histopathological report and FIGO stage. Patients were followed up every three months for first two years and then every six months. Disease free survival (DFS) and Overall survival (OS) were calculated. Statistical analysis The data were summarized using descriptive statistics as mean, percent and range. Survival probabilities were estimated using Kaplan-Meier method and the significance of difference between the survival curves were calculate using log-rank test. Results Uterine sarcomas are rare and aggressive tumours of uterus. Majority of these tumours present in early stage. Surgery remains the main treatment modality. Role of adjuvant radiation treatment remains controversial. Tumour stage is the most important prognostic factor.
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Chantasartrassamee P, Kongsawatvorakul C, Rermluk N, Charakorn C, Wattanayingcharoencha R, Lertkhachonsuk AA. Preoperative clinical characteristics between uterine sarcoma and leiomyoma in patients with uterine mass, a case-control study. Eur J Obstet Gynecol Reprod Biol 2022; 270:176-180. [DOI: 10.1016/j.ejogrb.2022.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 12/12/2022]
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American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice. Uterine Morcellation for Presumed Leiomyomas: ACOG Committee Opinion, Number 822. Obstet Gynecol 2021; 137:e63-74. [PMID: 33595252 DOI: 10.1097/AOG.0000000000004291] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.
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Mynbaev OA, Sparic R, Stark M, Malvasi A, Marinelli E, Zaami S, Tinelli A. The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective. Curr Pharm Des 2020; 26:318-325. [PMID: 32013843 DOI: 10.2174/1381612826666200204093737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/27/2020] [Indexed: 12/23/2022]
Abstract
Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.
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Affiliation(s)
- Ospan A Mynbaev
- Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russian Federation
| | | | - Michael Stark
- Department of Obstetrics and Gynecology, GVM Care & Research Santa Maria Hospital, Bari, Italy. Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russian Federation
| | - Antonio Malvasi
- Clinical Centre of Serbia, Clinic for Gynecology and Obstetrics, and University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Enrico Marinelli
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, "Veris delli Ponti" Hospital, Scorrano, Lecce, Italy
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Li D, Yin N, Du G, Wang S, Xiao Z, Chen J, Chen W. A Real-World Study on Diagnosis and Treatment of Uterine Sarcoma in Western China. Int J Biol Sci 2020; 16:388-395. [PMID: 32015676 PMCID: PMC6990907 DOI: 10.7150/ijbs.39773] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/21/2019] [Indexed: 12/21/2022] Open
Abstract
Uterine sarcomas constitute a rare heterogeneous group of gynecological malignancies with aggressive characteristics and poor prognosis. They have similar clinical features to benign leiomyomata making them difficult to reliably identify prior to hysterectomy. The preoperative prediction of uterine sarcoma remains a clinical dilemma. The current study conducted a multicentre, retrospective study to examine the accuracy of preoperative diagnosis, the consequent influence on therapy, and survival factors in patients with uterine sarcoma in Western China. Four affiliated hospitals of the medical college in Western China over a six-year period. One hundred and fourteen patients diagnosed with low-grade endometrial stromal sarcoma (LG-ESS), high-grade endometrial stromal sarcoma (HG-ESS), undifferentiated uterine sarcoma (UUS), leiomyosarcoma (LMS), or adenosarcoma (AS) were analyzed. The median age at diagnosis was 47 years. Eighty (70.2%) patients were premenopausal and 34 (29.8%) post-menopausal. The most common pathological type was LG-ESS (43.9%). The diagnostic sensitivity of ultrasound for uterine malignant tumors was 11.0%, much lower than MRI (35.3%) and CT (63.0%). Unlike MRI, most of the patients who underwent CT (88.2%) examination were at the advanced stage. Forty-seven (41.2%) patients with uterine sarcoma were diagnosed with uterine malignant tumor before operation. Thirty-two (47.8%) patients who were misdiagnosed before operation needed reoperation and five patients (4.6%) diagnosed after radical surgery developed distant metastasis simultaneously. The recommended treatment of 87.0% of the patients with uterine sarcoma was total hysterectomy and bilateral salpingooophorectomy, and 53.7% of patients received adjuvant chemotherapy after operation. Pelvic lymph node status were clarified in 47 patients (43.5%), which were higher in HG-ESS and UUS groups, and lower in LMS group (P = 0.013). In univariate analysis, we found a significant association between tumour histological types, tumour stage, menstrual status, elevated preoperative neutrophil/lymphocyte ratio and overall survival. In multivariate analysis, we only observed a significant association between tumour histological types and tumour stage and overall survival.
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Affiliation(s)
- Dan Li
- Key Laboratory of Ultrasound Engineering in Medicine Co-Founded by Chongqing and the Ministry of Science and Technology, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing Collaborative Innovation Center for Minimally-invasive and Noninvasive Medicine, Chongqing 400016, China
| | - Na Yin
- Department of Obstetrics and Gynecology, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing 400038, China
| | - Guobo Du
- Department of Oncology, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Shaohua Wang
- Department of Pathology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Zhibo Xiao
- Department of Radiology, First Affiliated Hospital of Chongqing Medical University, Chongqing 400042, China
| | - Jinyun Chen
- Key Laboratory of Ultrasound Engineering in Medicine Co-Founded by Chongqing and the Ministry of Science and Technology, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing Collaborative Innovation Center for Minimally-invasive and Noninvasive Medicine, Chongqing 400016, China.,Ultrasound Ablation Center, First Affiliated Hospital of Chongqing Medical University, Chongqing 400042, China
| | - Wenzhi Chen
- Key Laboratory of Ultrasound Engineering in Medicine Co-Founded by Chongqing and the Ministry of Science and Technology, College of Biomedical Engineering, Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing Collaborative Innovation Center for Minimally-invasive and Noninvasive Medicine, Chongqing 400016, China.,Clinical Center for Tumor Therapy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
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Abstract
Aim: We examine the impact of the new risk information about a surgical device on surgery and patient outcomes for hysterectomy in the inpatient setting. Methods: We utilize a difference-in-differences approach to assess the impact of new risk information on patient outcomes in the inpatient setting between 2009 and 2014. The inpatient data come from a nationally representative sample of hospitalizations in the USA. We use the likelihood of laparoscopic surgery, measures of resource use and surgical complications as outcome variables. Results: We estimate a three-percentage point decrease in the likelihood of receiving laparoscopic hysterectomy, a one-percentage point increase in the likelihood of experiencing a surgical complication and no impact on resource use, relative to pre-existing means. Conclusion: Our findings show that there was movement away from laparoscopic surgery in the months following the dissemination of new risk information. These changes had limited effect on patient outcomes.
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Affiliation(s)
- Ehren Schuttringer
- Food & Drug Administration Office of the Commissioner, 10903 New Hampshire Ave, Silver Spring, Maryland, MD 20993, USA
| | - Trinidad Beleche
- Food & Drug Administration Office of the Commissioner, 10903 New Hampshire Ave, Silver Spring, Maryland, MD 20993, USA
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Desai VB, Wright JD, Lin H, Gross CP, Sallah YH, Schwartz PE, Xu X. Laparoscopic Hysterectomy Route, Resource Use, and Outcomes: Change After Power Morcellation Warning. Obstet Gynecol 2019; 134:227-38. [DOI: 10.1097/aog.0000000000003375] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Desai VB, Wright JD, Schwartz PE, Jorgensen EM, Fan L, Litkouhi B, Lin H, Gross CP, Xu X. Occult Gynecologic Cancer in Women Undergoing Hysterectomy or Myomectomy for Benign Indications. Obstet Gynecol 2018; 131:642-51. [PMID: 29528920 DOI: 10.1097/AOG.0000000000002521] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To estimate the prevalence of corpus uteri, cervix uteri, and ovarian malignancy in women undergoing hysterectomy or myomectomy for presumed benign indications. METHODS We conducted a secondary analysis of data from the 2014-2015 American College of Surgeons National Surgical Quality Improvement Program. Adult women undergoing hysterectomies and myomectomies without evidence for known or suspected cancer at the beginning of surgery were identified from the database. Our primary outcome measure was pathology-confirmed malignancy in the corpus uteri, cervix uteri, and ovary. We performed adjusted logistic regression analysis to examine the association of patient characteristics with the risk for malignancy. RESULTS Our sample included 24,076 women undergoing hysterectomy and 2,368 women undergoing myomectomy. Malignancy of the corpus uteri was found in 1.44% (95% CI 1.29-1.59%) of the women undergoing hysterectomy. The prevalence varied considerably across surgical routes with the rate being 0.23% (95% CI 0.06-0.58%) in laparoscopic supracervical hysterectomy and 1.89% (95% CI 1.65-2.14%) in total laparoscopic or laparoscopic-assisted vaginal hysterectomy. Older women were significantly more likely to have preoperatively undetected malignancy of the corpus uteri (adjusted odds ratio 6.46, 95% CI 4.96-8.41 for age 55 years or older vs age 40-54 years). Additionally, 0.60% (95% CI 0.50-0.70%) and 0.19% (95% CI 0.14-0.25%) of the women undergoing hysterectomy were found to have malignancy of the cervix uteri and the ovary, respectively. Among patients undergoing myomectomy, 0.21% (95% CI 0.03-0.40%) were found to have malignancy of the corpus uteri with no occult cervical or ovarian cancer identified. CONCLUSION Prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route.
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Cao H, Li L, Yang B, Luo G, Lou J, Xi M. Unexpected uterine sarcomas after hysterectomy and myomectomy for presumed leiomyoma: a retrospective study of 26,643 patients. Cancer Manag Res 2019; 11:7007-7014. [PMID: 31440089 PMCID: PMC6664248 DOI: 10.2147/cmar.s208405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/21/2019] [Indexed: 11/23/2022] Open
Abstract
Objectives We conducted this study to explore the clinical characteristics, prognosis, and prevalence of unexpected uterine sarcoma (UUS) after hysterectomy and myomectomy for presumed leiomyoma. Study design The records of women who underwent hysterectomy or myomectomy through laparoscopy or laparotomy for preoperatively presumed uterine leiomyomas from January 2009 to December 2016 were reviewed and data were retrospectively analyzed. Results Eleven patients had morcellation of uterine sarcoma. Eighty-eight patients were diagnosed with uterine sarcomas (total prevalence: 0.33%) including 29 leiomyosarcomas (LMS), 48 endometrial stromal sarcomas (ESS), and 11 adenosarcomas. ESS patients with advanced stage were significantly associated with worse overall survival (p<0.01). Conclusion Only 0.33% of patients who underwent surgery for presumed leiomyoma experienced UUS, and advanced stage seemed to be the single prognostic factor for sarcoma. However, the time interval between initial treatment and secondary definitive surgery was not shown to impact prognosis. In addition, the small number of UUS patients having morcellation (4 LMS and 7 ESS) may be underpowered to detect differences in survival.
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Affiliation(s)
- Hanyu Cao
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Lin Li
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Bowen Yang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Gupo Luo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Jiangyan Lou
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
| | - Mingrong Xi
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu City, Sichuan Province, People's Republic of China
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Wais M, Tepperman E, Bernardini MQ, Gien LT, Jimenez W, Murji A. A Multicentre Retrospective Review of Clinical Characteristics of Uterine Sarcoma. J Obstet Gynaecol Can 2017; 39:652-8. [PMID: 28729098 DOI: 10.1016/j.jogc.2017.03.090] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/03/2017] [Accepted: 03/06/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Professional societies have recently urged gynaecologists to counsel patients about the risks of encountering uterine sarcoma at fibroid surgery especially when morcellation is used. Our objective was to learn the preoperative and postoperative characteristics of patients with uterine sarcoma to better counsel patients undergoing surgery for presumably benign fibroids. METHODS This is a multicentre, retrospective cohort study. Three academic tertiary cancer centres in Southern Ontario over a 13-year period (2001-2014). Patients diagnosed with leiomyosarcoma or endometrial stromal sarcoma were included after identification using pathology databases. A retrospective chart review was conducted to determine clinical characteristics and survival data. RESULTS The study included 302 patients with uterine sarcomas (221 leiomyosarcomas, 81 endometrial stromal sarcomas). Mean age at diagnosis was 55 years, and 59% were postmenopausal. Sarcoma diagnosis was made following endometrial sampling (25%), hysterectomy (69% laparotomy, 2.7% laparoscopic/vaginal), and myomectomy (3.3%). Of all the patients who underwent endometrial sampling, 65% were diagnosed with a uterine sarcoma in this manner. A general gynaecologist performed the primary surgical procedure in 166 of 302 patients (55%). Tumour disruption at the time of primary surgery occurred in 57 of 295 patients (19%): subtotal hysterectomy (21), myomectomy (10), dissection of adherent tumour (17), and morcellation (9). Morcellation, to facilitate a minimally invasive approach, was performed with scalpel (2 at laparotomy, 5 vaginally) and with a laparoscopic electro-mechanical morcellator (2). At a median follow-up of 2.9 years, there was no significant difference in survival for stage I and II patients with tumour disruption (n = 32) compared with those without tumour disruption (n = 143), regardless of sarcoma type (P = 0.6). CONCLUSION The majority of patients with uterine sarcomas were postmenopausal. Many can be diagnosed preoperatively with endometrial sampling. Forty-one percent of patients with uterine sarcomas had a high preoperative index of suspicion, resulting in intervention by an oncologist. Morcellation with laparoscopic electro-mechanical morcellator was rare.
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Ghirardi V, Bizzarri N, Guida F, Vascone C, Costantini B, Scambia G, Fagotti A. Role of surgery in gynaecological sarcomas. Oncotarget 2019; 10:2561-2575. [PMID: 31069017 PMCID: PMC6493462 DOI: 10.18632/oncotarget.26803] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/19/2019] [Indexed: 12/13/2022] Open
Abstract
Gynaecological sarcomas account for 3-4% of all gynaecological malignancies and have a poorer prognosis compared to gynaecological carcinomas. Pivotal treatment for early-stage uterine sarcoma is represented by total hysterectomy. Whereas oophorectomy provides survival advantage in endometrial stromal sarcoma is still controversial. When the disease is confined to the uterus, systematic pelvic and para-aortic lymphadenectomy is not recommended. Removal of enlarged lymph-nodes is indicated in case of disseminated or recurrent disease, where debulking surgery is considered the standard of care. Fertility sparing surgery for uterine leiomyosarcoma is not supported by strong evidence, whilst available data on fertility sparing treatment for endometrial stromal sarcoma are more promising. For ovarian sarcomas, in the absence of specific data, it is reasonable to adapt recommendations existing for uterine sarcomas, also regarding the role of lymphadenectomy in both early and advanced stage disease. Specific recommendations on cervical sarcomas' surgery are lacking. Existing data on surgical approach vary from radical hysterectomy to fertility-preserving surgery in the form of trachelectomy or wide local excision, however no definite conclusions can be drafted on the recommended surgical approach. For vulval sarcomas, complete surgical excision with at least 2 cm of free margin is considered to be the primary treatment which is associated with good prognosis. The aim of this review is to provide highest quality evidence to guide gynaecologic oncologists throughout surgical management of gynaecological sarcomas.
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Affiliation(s)
- Valentina Ghirardi
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome 00168, Italy.,Catholic University of Sacred Heart, Rome 00168, Italy
| | - Nicolò Bizzarri
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome 00168, Italy.,Catholic University of Sacred Heart, Rome 00168, Italy
| | - Francesco Guida
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome 00168, Italy.,Catholic University of Sacred Heart, Rome 00168, Italy
| | - Carmine Vascone
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome 00168, Italy.,Catholic University of Sacred Heart, Rome 00168, Italy
| | - Barbara Costantini
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome 00168, Italy.,Catholic University of Sacred Heart, Rome 00168, Italy
| | - Giovanni Scambia
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome 00168, Italy.,Catholic University of Sacred Heart, Rome 00168, Italy
| | - Anna Fagotti
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome 00168, Italy.,Catholic University of Sacred Heart, Rome 00168, Italy
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Wagner P, Kommoss F, Kommoss S, Hartkopf A, Pasternak I, Oberlechner E, Greif K, Wallwiener M, Neis F, Abele H, Krämer B, Reisenauer C, Staebler A, Wallwiener D, Brucker S, Taran F. Unexpected malignant uterine pathology: Incidence, characteristics and outcome in a large single-center series of hysterectomies for presumed benign uterine disease. Gynecol Oncol 2019; 153:49-54. [DOI: 10.1016/j.ygyno.2018.12.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/23/2018] [Accepted: 12/28/2018] [Indexed: 02/06/2023]
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Rubisz P, Ciebiera M, Hirnle L, Zgliczyńska M, Łoziński T, Dzięgiel P, Kobierzycki C. The Usefulness of Immunohistochemistry in the Differential Diagnosis of Lesions Originating from the Myometrium. Int J Mol Sci 2019; 20:E1136. [PMID: 30845657 DOI: 10.3390/ijms20051136] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 02/20/2019] [Accepted: 03/01/2019] [Indexed: 12/15/2022] Open
Abstract
Uterine leiomyomas (LMs), currently the most common gynecological complaint around the world, are a serious medical, social and economic problem. Accurate diagnosis is the necessary prerequisite of the diagnostic-therapeutic process. Statistically, mistakes may occur more often in case of disease entities with high prevalence rates. Histopathology, based on increasingly advanced immunohistochemistry methods, is routinely used in the diagnosis of neoplastic diseases. Markers of the highest sensitivity and specificity profiles are used in the process. As far as LMs are concerned, the crux of the matter is to identify patients with seemingly benign lesions which turn out to be suspicious (e.g., atypical LM) or malignant (e.g., leiomyosarcoma (LMS)), which is not uncommon. In this study, we present the current state of knowledge about the use of immunohistochemical markers in the differential diagnosis of LM, atypical LM, smooth muscle tumors of uncertain malignant potential (STUMP), and LMS, as well as their clinical predictive value.
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Multinu F, Casarin J, Tortorella L, Huang Y, Weaver A, Angioni S, Melis GB, Mariani A, Stewart EA, Laughlin-Tommaso SK. Incidence of sarcoma in patients undergoing hysterectomy for benign indications: a population-based study. Am J Obstet Gynecol 2019; 220:179.e1-179.e10. [PMID: 30447212 DOI: 10.1016/j.ajog.2018.11.1086] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/24/2018] [Accepted: 11/08/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Minimally invasive hysterectomy may require the use of morcellation to remove the uterus. In the presence of unexpected sarcoma, morcellation risks disseminating malignant cells and worsening survival outcomes. As a consequence, in 2014 the US Food and Drug Administration issued a black box warning against the use of power morcellator for the treatment of uterine fibroids. However, the proportion of unexpected sarcoma at the time of hysterectomy for presumed benign indication remains unclear. OBJECTIVE The objective of the study was to estimate the incidence of sarcoma among women undergoing hysterectomy for benign indication in Olmsted County, MN, between 1999 and 2013. STUDY DESIGN We conducted a population-based study including all hysterectomies performed for benign indication in Olmsted County women between Jan. 1, 1999, and Dec. 31, 2013. Cases were identified using the medical records-linkage system of the Rochester Epidemiology Project, and data were abstracted by a gynecologist who reviewed the complete medical records of each woman who underwent hysterectomy. An expert pathologist reviewed the pathologic slides of each sarcoma to ensure the accuracy of the diagnosis. Incidences of sarcoma (overall and by type of sarcoma) were estimated both overall and stratified by menopausal status, indication for surgery, and uterine weight as a rate per 100 persons. RESULTS A total of 4232 hysterectomies were performed during the study period. Among them, we identified 16 sarcomas, of which 11 (69%) were suspected preoperatively and 5 (31%) were unexpected. Of the total number of hysterectomies, 3759 (88.8%) were performed for benign indication. Among those, the incidence of unexpected sarcoma was 0.13% (5 per 3759 [95% confidence interval, 0.04-0.31%]). Uterine fibroids comprised 27.3% of all hysterectomies for benign indication (n = 1025) and was the indication most commonly associated with diagnosis of unexpected sarcoma. The incidence of unexpected sarcoma among surgeries for uterine fibroids was 0.35% (3 of 851) for premenopausal women and 0.57% (1 of 174) for peri/postmenopausal, and all 4 unexpected sarcomas were leiomyosarcoma. The incidence of unexpected sarcoma progressively increased with higher uterine weight with an incidence of 0.03% (1 of 2993) among women with a uterine weight <250 g vs 15.4% (2 of 13) with a uterine weight ≥2000 g. CONCLUSION Unexpected uterine sarcoma was low in all women undergoing hysterectomy for benign indication (0.13% or 1 in 752 surgeries) while it was increased in women with uterine fibroids (0.39% or 1 in 256 surgeries). Peri/postmenopausal women, women with large uteri, and age ≥45 years were risk factors for sarcoma.
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Schmitt JJ, Occhino JA, Weaver AL, Mcgree ME, Gebhart JB. Outcomes of Vaginal Hysterectomy With and Without Perceived Contraindications to Vaginal Surgery: . Female Pelvic Med Reconstr Surg 2019; 25:41-8. [DOI: 10.1097/spv.0000000000000469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chen Q, Shi H, Lu W, Lu B. Unexpected uterine sarcomas in 4478 patients with electric power morcellation for leiomyomas. Eur J Obstet Gynecol Reprod Biol 2018; 230:85-89. [PMID: 30245442 DOI: 10.1016/j.ejogrb.2018.09.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/28/2018] [Accepted: 09/12/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Our objective is to investigate the prevalence, pathology and prognosis of uterine sarcomas in laparoscopic hysterectomy/myomectomy with electric power morcellation for presumed leiomyomas. STUDY DESIGN We retrospectively reviewed patients with laparoscopic power morcellation (LPM) for presumed leiomyomas in a Chinese tertiary institution by chart review from September 1, 2013 to December 31, 2016. RESULTS Twenty-four in 4478 patients (0.54%) with LPM for presumed leiomyomas had unexpected cancers. The patients showed the highest frequency of occult cancers (10/375, 2.6%) at 51-60 years and lowest (0/255) before 30 years. The pathology included 14 endometrial stromal sarcomas (ESS) (low-grade 12 and high-grade 2), 9 leiomyosarcomas, and 1 malignant mixed mesodermal tumor. The patients underwent abdominal re-exploration including total hysterectomy with bilateral salpingo-oophorectomy and staging surgery. Three patients were at advanced FIGO stage (IIIb-IVb) and 21 at stage I. Seven patients recurred within 1-25 (mean 6.29) months including 5 leiomyosarcomas, 1 high-grade and 1 low-grade ESS. Four recurrent patients with leiomyosarcomas and one with high-grade ESS died of disease in 1-3 months. Seventeen patients had no relapse and were alive for 6-41 (mean 24) months. CONCLUSIONS Our study suggests that patients with LPM for presumed leiomyomas appear to have a considerable risk of unexpected cancers. Moreover, morcellation is potentially associated with adverse prognosis in patients with high-grade sarcomas. Informed consent on unexpected cancers that should be discussed before morcellation.
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Affiliation(s)
- Qin Chen
- Department of Surgical Pathology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Haiyan Shi
- Department of Surgical Pathology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
| | - Weiguo Lu
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China; Center for Uterine Cancer Diagnosis & Therapy of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.
| | - Bingjian Lu
- Department of Surgical Pathology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China; Center for Uterine Cancer Diagnosis & Therapy of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China.
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Mori KM, Abaid LN, Mendivil AA, Brown JV, Beck TL, Micha JP, Epstein HD, Goldstein BH. The incidence of occult malignancy following uterine morcellation: A ten-year single institution experience retrospective cohort study. Int J Surg 2018; 53:239-242. [DOI: 10.1016/j.ijsu.2018.03.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/01/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
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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; 223:108-12. [DOI: 10.1016/j.ejogrb.2018.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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DiNapoli MN, Truong MD, Halfon JK, Burke WM. Unsuspected Uterine Sarcoma in an Urban Hospital: Does Surgical Approach Matter? J Minim Invasive Gynecol 2018; 25:491-497. [DOI: 10.1016/j.jmig.2017.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 10/08/2017] [Accepted: 10/09/2017] [Indexed: 11/16/2022]
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Wong AWY, Tsaltas J, Manley TR, Ratner RT, Yim CCM, Barel O. Unsuspected uterine sarcomas undergoing morcellation: A retrospective multicenter study. Journal of Endometriosis and Pelvic Pain Disorders 2018. [DOI: 10.1177/2284026517748554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: To evaluate the prevalence of unsuspected uterine sarcomas undergoing morcellation at the time of hysterectomy or myomectomy. Design: A retrospective cohort study. Settings: A teaching health service in Melbourne, Australia, consisting of four hospitals which provide gynecology and gynecology oncology services including one tertiary referral center. Population: All women undergoing any form of hysterectomy or myomectomy from 1998 to 2016. Methods: Patient demographics and the presence of morcellation were collected. All cases of confirmed uterine sarcomas were further examined and their histological subtype, patient demographics, preoperative investigations, and surgical indication were also identified. Results: A total of 7584 cases were studied. Overall, 33 uterine sarcomas were identified. Of these, seven cases were unsuspected malignancies. All seven cases were leiomyosarcomas. None of the malignant specimens underwent morcellation. The overall prevalence of uterine sarcomas in the total study population was 0.44%. The rate of unsuspected uterine sarcomas in women undergoing hysterectomy or myomectomy for presumed benign indications was 0.13% or 1 in 769. The rate of unintended morcellation of a uterine sarcoma in our center was 0%. The diagnosis of endometrial sarcoma was prompted by endometrial sampling in 58% of the cases when performed. Conclusion: The risk of inadvertent morcellation of unsuspected uterine sarcomas is low. Patients should be appropriately selected with adequate investigations and a detailed history and examination prior to surgery. Further studies are needed to identify effective preoperative screening methods for uterine sarcomas.
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Affiliation(s)
- Avelyn WY Wong
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Mercy Health, Heidelberg, VIC, Australia
| | - Jim Tsaltas
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
- Melbourne IVF, East Melbourne, VIC, Australia
| | - Tom R Manley
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
- Melbourne IVF, East Melbourne, VIC, Australia
| | - Roni T Ratner
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
| | - Cheryl CM Yim
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
| | - Oshri Barel
- Women’s and Children’s Program, Monash Health, Clayton, VIC, Australia
- Gynaecological Endoscopy Unit, Monash Health, Bentleigh East, VIC, Australia
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Affiliation(s)
- Jessica Shim
- Department of Obstetrics and Gynecology, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Kimberly Kenton
- Female Pelvic Medicine and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Melinda G. Abernethy
- Female Pelvic Medicine and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL
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Wilkie GL, Reus E, Leung K, Bradford L, Manning MJ, Moore Simas TA. Occult Malignancy Incidence and Preoperative Assessment in Hysterectomies with Morcellation. J Gynecol Surg 2018; 34:18-26. [DOI: 10.1089/gyn.2017.0036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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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. [PMID: 28498251 DOI: 10.1097/IGC.0000000000000968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the rate, clinical characteristics, and survival outcomes of an undiagnosed uterine malignancy in patients who underwent surgical treatment for presumed leiomyomas. METHODS Medical records of patients who underwent surgical treatment for presumed leiomyomas, from January 2004 to September 2013, were retrospectively reviewed, and the data were followed until September 2016. Demographic data, tumor characteristics, oncologic treatment, and response rate were analyzed by descriptive statistics. Kaplan-Meier method was used for survival analysis. This study includes follow-up data through December 31, 2016. RESULTS A total of 11,258 medical records of presumed leiomyoma patients undergoing hysterectomy during the studied period were reviewed. Pathology of uterine sarcoma was found in 22 patients (0.2%), all of whom were included. Nineteen patients had leiomyosarcoma, and 3 had endometrial stromal sarcoma. Mean age of patients was 48.3 ± 6.9 years. All patients underwent total abdominal hysterectomy, with 20 patients undergoing concurrent bilateral salpingo-oophorectomy. Uterine sarcoma was classified as stage IB in 21 patients and stage IIIC in 1 patient. Fifteen patients were prescribed the following adjuvant treatment: chemotherapy in 13 patients and megestrol acetate in 2 patients. Thirteen patients had recurrent disease, and 3 patients died of their disease. The mean progression-free survival was 50.1 ± 41.3 months, and overall survival was 59.3 ± 43.0 months. CONCLUSIONS One in 512 patients who underwent hysterectomy because of presumed uterine leiomyomas had inadvertent uterine sarcomas. Even with adjuvant therapy, treatment outcome was rather poor, with almost 60% recurrence rate and median progression-free survival and overall survival of less than 5 years.
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Sizzi O, Manganaro L, Rossetti A, Saldari M, Florio G, Loddo A, Zurawin R, van Herendael B, Djokovic D. Assessing the risk of laparoscopic morcellation of occult uterine sarcomas during hysterectomy and myomectomy: Literature review and the ISGE recommendations. Eur J Obstet Gynecol Reprod Biol 2018; 220:30-38. [DOI: 10.1016/j.ejogrb.2017.10.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 02/07/2023]
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Price JT, Zimmerman LD, Koelper NC, Sammel MD, Lee S, Butts SF. Social determinants of access to minimally invasive hysterectomy: reevaluating the relationship between race and route of hysterectomy for benign disease. Am J Obstet Gynecol 2017; 217:572.e1-572.e10. [PMID: 28784416 DOI: 10.1016/j.ajog.2017.07.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 07/22/2017] [Accepted: 07/31/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Racial and socioeconomic disparities exist in access to medical and surgical care. Studies of national databases have demonstrated disparities in route of hysterectomy for benign indications, but have not been able to adjust for patient-level factors that affect surgical decision-making. OBJECTIVE We sought to determine whether access to minimally invasive hysterectomy for benign indications is differential according to race independent of the effects of relevant subject-level confounding factors. The secondary study objective was to determine the association between socioeconomic status and ethnicity and access to minimally invasive hysterectomy. STUDY DESIGN A cross-sectional study evaluated factors associated with minimally invasive hysterectomies performed for fibroids and/or abnormal uterine bleeding from 2010 through 2013 at 3 hospitals within an academic university health system in Philadelphia, PA. Univariate tests of association and multivariable logistic regression identified factors significantly associated with minimally invasive hysterectomy compared to the odds of treatment with the referent approach of abdominal hysterectomy. RESULTS Of 1746 hysterectomies evaluated meeting study inclusion criteria, 861 (49%) were performed abdominally, 248 (14%) vaginally, 310 (18%) laparoscopically, and 327 (19%) with robot assistance. In univariate analysis, African American race (odds ratio, 0.80; 95% confidence interval, 0.65-0.97) and Hispanic ethnicity (odds ratio, 0.63; 95% confidence interval, 0.39-1.00) were associated with lower odds of any minimally invasive hysterectomy relative to abdominal hysterectomy. In analyses adjusted for age, body mass index, income quartile, obstetrical and surgical history, uterine weight, and additional confounding factors, African American race was no longer a risk factor for reduced minimally invasive hysterectomy (odds ratio, 0.82; 95% confidence interval, 0.61-1.10), while Hispanic ethnicity (odds ratio, 0.45; 95% confidence interval, 0.27-0.76) and Medicaid enrollment (odds ratio, 0.59; 95% confidence interval, 0.38-0.90) were associated with significantly lower odds of treatment with any minimally invasive hysterectomy. In adjusted analyses, African American women had nearly half the odds of receiving robot-assisted hysterectomy compared to whites (adjusted odds ratio, 0.57; 95%, confidence interval 0.39-0.82), while no differences were noted with other hysterectomy routes. Medicaid enrollment (compared to private insurance; odds ratio, 0.51; 95% confidence interval, 0.28-0.94) and lowest income quartile (compared to highest income quartile; odds ratio, 0.57; 95% confidence interval, 0.38-0.85) were also associated with diminished odds of robot-assisted hysterectomy. CONCLUSION When accounting for the effect of numerous pertinent demographic and clinical factors, the odds of undergoing minimally invasive hysterectomy were diminished in women of Hispanic ethnicity and in those enrolled in Medicaid but were not discrepant along racial lines. However, both racial and socioeconomic disparities were observed with respect to access to robot-assisted hysterectomy despite the availability of robotic assistance in all hospitals treating the study population. Strategies to ensure equal access to all minimally invasive routes for all women should be explored to align delivery of care with the evidence supporting the broad implementation of these procedures as safe, cost-effective, and highly acceptable to patients.
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Macciò A, Chiappe G, Kotsonis P, Lavra F, Serra M, Demontis R, Madeddu C. Abdominal leiomyosarcomatosis after surgery with external morcellation for occult smooth muscle tumors of uncertain malignant potential: A case report. Int J Surg Case Rep 2017; 38:107-110. [PMID: 28755615 PMCID: PMC5537390 DOI: 10.1016/j.ijscr.2017.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 07/12/2017] [Indexed: 12/18/2022] Open
Abstract
We present a rare case of abdominal sarcomatosis from uterine leiomyosarcoma. The patient underwent myomectomy for occult STUMP 3 years before. Risk of relapse, dissemination and malignant transformation of STUMP is uncertain. STUMPs require a close surveillance especially after conservative surgery. Laparoscopy may allow timely diagnosis and treatment of STUMP recurrence.
Introduction Although rare, cases of abdominal sarcomatosis (AS) after laparotomy/laparoscopic interventions for uterine smooth muscle tumors of uncertain malignant potential (STUMP) have been reported. Presentation of case We describe a rare case of diffuse abdominal sarcomatosis in a patient that some year earlier had undergone myomectomy for a suspected uterine myoma, which was histologically proven to be a STUMP. Once the patient was admitted at our Department, she underwent a diagnostic laparoscopy that confirmed a condition of peritoneal sarcomatosis disseminated through the entire abdomen, and then a laparotomic total hysterectomy, bilateral salpingo-oophorectomy, and total omentectomy, achieving a complete cytoreduction. Histological examination showed high-grade uterine leyomiosarcoma (LMS). Since there is no evidence of any clinical benefit of adjuvant treatment, given the risk of disease recurrence, we decided, with the patient’s agreement, to conduct close follow-up with a Positron Emission Tomography (PET)/Computed Tomography (CT) scan every 3 months and diagnostic laparoscopy every 6 months, even in the absence of PET/CT positivity. After 2 years PET/CT showed a relapse of LMS in the perigastric region and, therefore the patient underwent a diagnostic/operative laparoscopy with complete removal of the neoplastic recurrence. To date, the patient is disease-free. Discussion and conclusion STUMPs should be submitted to a frequent surveillance for their risk of recurrence, dissemination and transformation into LMS, even many years after the first diagnosis. A follow-up including surgical re-exploration with laparoscopy and PET/CT imaging may allow early detection and timely treatment of the relapse with good long-term outcome, as demonstrated by our case.
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Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, A. Businco Hospital, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy.
| | - Giacomo Chiappe
- Department of Gynecologic Oncology, A. Businco Hospital, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy
| | - Paraskevas Kotsonis
- Department of Gynecologic Oncology, A. Businco Hospital, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy
| | - Fabrizio Lavra
- Department of Gynecologic Oncology, A. Businco Hospital, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy
| | - Michele Serra
- Department of Gynecologic Oncology, A. Businco Hospital, Azienda Ospedaliera Brotzu, via Jenner, 09100, Cagliari, Italy
| | - Roberto Demontis
- Department of Public Health and Medical Sciences, University of Cagliari, 09042 Monserrato, Cagliari, Italy
| | - Clelia Madeddu
- Department of Public Health and Medical Sciences, University of Cagliari, 09042 Monserrato, Cagliari, Italy
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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.e1-259.e6. [PMID: 27890646 DOI: 10.1016/j.ajog.2016.11.1039] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/15/2016] [Accepted: 11/17/2016] [Indexed: 01/07/2023]
Abstract
Previous decision analyses demonstrate the safety of minimally invasive hysterectomy for presumed benign fibroids, accounting for the risk of occult leiomyosarcoma and the differential mortality risk associated with laparotomy. Studies published since the 2014 Food and Drug Administration safety communications offer updated leiomyosarcoma incidence estimates. Incorporating these studies suggests that mortality rates are low following hysterectomy for presumed benign fibroids overall, and a minimally invasive approach remains a safe option. Risk associated with morcellation, however, increases in women age >50 years due to increased leiomyosarcoma rates, an important finding for patient-centered discussions of treatment options for fibroids.
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Affiliation(s)
- Matthew T Siedhoff
- Center for Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Kemi M Doll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Daniel L Clarke-Pearson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Sarah E Rutstein
- Department of Health Policy and Management, School of Medicine, University of North Carolina, Chapel Hill, NC
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Ricci S, Stone RL, Fader AN. Uterine leiomyosarcoma: Epidemiology, contemporary treatment strategies and the impact of uterine morcellation. Gynecol Oncol 2017; 145:208-216. [PMID: 28209496 DOI: 10.1016/j.ygyno.2017.02.019] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 12/17/2022]
Abstract
Leiomyosarcoma, a rare tumor subtype, accounts for 1% of all uterine malignancies, but contributes to a significant proportion of uterine cancer deaths. Surgery is considered the mainstay of treatment for all soft tissue sarcomas, including uterine variants. However, uterine leiomyosarcoma is challenging to diagnose preoperatively and can mimic the appearance of benign uterine leiomyomas. Recently, concerns have grown in this regard, as surgeons have utilized uterine morcellation and myomectomy procedures unknowingly in the setting of occult uterine sarcoma. Because of aggressive tumor biology and relative chemotherapy and radiotherapy resistance, efficacious therapies to achieve prolonged survival or cure in those with both early and advanced-stage uterine leiomyosarcoma have been elusive. The strongest determinant of survival remains stage at diagnosis, though prediction models may provide a more accurate prognosis. Given the aggressive nature of this sarcoma subtype, novel early detection strategies and targeted therapies are the focus of several recently published and ongoing studies. While gemcitabine/docetaxel and doxorubicin remain the most active regimens in the treatment of advanced or recurrent disease, currently available cytotoxic regimens remain inadequate, with 5-year disease-specific survival of <30%. Pazopanib, trabectedin and olaratumab, are FDA-approved, targeted therapies with activity in uterine and other leiomyosarcomas, while aromatase inhibitors and immunotherapies are under active investigation. This review provides a critical appraisal of the literature regarding the contemporary surgical and medical management of uterine leiomyosarcoma, the role of targeted therapies, and the implications of uterine morcellation on gynecologic surgical practice.
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Affiliation(s)
- Stephanie Ricci
- Division of Gynecologic Oncology, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca L Stone
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Amanda N Fader
- Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Abstract
OBJECTIVE To estimate the frequency of unsuspected uterine sarcoma identified postoperatively in women undergoing surgery for presumed benign uterine fibroids at a single university hospital. MATERIAL AND METHODS This was a retrospective single-center study; the records of all 2275 patients with uterine fibroids and uterine sarcomas from 2003 to 2015 were reviewed. Descriptive statistics were used to analyze demographic and clinical characteristics. To calculate confidence intervals (CIs), the Clopper-Pearson Exact method was applied. RESULTS Preoperatively, 2269 patients had presumed benign uterine fibroids, and six patients had suspected uterine sarcoma. Among the 2269 patients who underwent surgery for presumed uterine fibroids, endometrial stromal sarcoma was histopathologically revealed in only one patient [0.044%, 95% CI: (0.001-0.25)] after laparoscopic subtotal hysterectomy with morcellation. All six patients who were preoperatively diagnosed having uterine sarcoma underwent direct conventional cancer treatment. Histopathologic analyses confirmed four cases of uterine leiomyosarcoma, one high-grade undifferentiated uterine sarcoma, and one embryonal rhabdomyosarcoma. Altogether, seven women were diagnosed as having uterine sarcomas over this twelve-year period. CONCLUSION In our institution, the frequency of unsuspected uterine sarcomas was 1/2269 (0.044%) among women who underwent myomectomies and hysterectomies to treat presumed benign uterine fibroids.
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Affiliation(s)
- Liselotte Mettler
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Germany
| | - Nicolai Maass
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Germany
| | - Khulkar Abdusattarova
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Germany
| | - Astrid Dempfle
- Institute of Medical Informatics and Statistics, University Hospital Schleswig-Holstein, Christian Albrecht-University, Kiel, Germany
| | - Ibrahim Alkatout
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Germany
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Hannemann B, McKnoulty M, Kothari A. Beware of a multi-fibroid uterus: The importance of ultrasound reporting in the early detection of uterine sarcomas. Australas J Ultrasound Med 2016; 19:154-159. [PMID: 34760461 DOI: 10.1002/ajum.12030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Primary uterine malignancy masquerading as a benign leiomyoma is a rare yet devastating condition if missed on ultrasound. Although there are no current guidelines to aide in early ultrasound identification of these high-risk patients prior to histological analysis, certain imaging characteristics may heighten the suspicion of malignancy. Unfortunately, these atypical features are often not included in ultrasonographic reports resulting in delayed treatment and catastrophic consequences. We present a case of a uterine Ewing's sarcoma (ES), which was diagnosed as a multi-fibroid uterus on initial ultrasound. The lack of clinical suspicion resulted in a delay to definitive diagnosis and a sub-optimal surgical resection. We compare this to a standard case of a multi-fibroid uterus in order to highlight the differences in ultrasonographic appearance. This case delineates the importance of accurate identification and open reporting of suspicious features in order to assist ultrasonographers and specialist gynaecologists in creating a differential diagnosis of an otherwise common condition. A high index of suspicion of atypical lesions may lead to early life-saving interventions and careful tissue control during surgery, resulting in improved patient outcomes.
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Affiliation(s)
- Bernard Hannemann
- Redcliffe Hospital Redcliffe Queensland Australia.,Oceania University of Medicine Apia Samoa.,The University of Queensland St Lucia Queensland Australia
| | - Matthew McKnoulty
- Redcliffe Hospital Redcliffe Queensland Australia.,Griffith University Brisbane Queensland Australia
| | - Alka Kothari
- Redcliffe Hospital Redcliffe Queensland Australia.,The University of Queensland St Lucia Queensland Australia
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Skorstad M, Kent A, Lieng M. Uterine leiomyosarcoma - incidence, treatment, and the impact of morcellation. A nationwide cohort study. Acta Obstet Gynecol Scand 2016; 95:984-90. [DOI: 10.1111/aogs.12930] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/21/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Mette Skorstad
- Department of Obstetrics and Gynecology; Vestfold Hospital; Tonsberg Norway
| | - Andrew Kent
- Department of Gynecology; Royal Surrey Hospital; Guildford UK
| | - Marit Lieng
- Department of Gynecology; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
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Risk of Occult Uterine Sarcoma in Women Undergoing Hysterectomy for Benign Indications. Obstet Gynecol 2016; 127:968. [DOI: 10.1097/aog.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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