Incidental Gynecologic Malignancies in Morcellated Hysterectomies
Shahrzad Ehdaivand, Rochelle A Simon, C James Sung, Margaret M Steinhoff, W Dwayne Lawrence, M Ruhul Quddus. Warren Alpert Medical School of Brown University, Providence, RI; Women and Infants Hospital, Providence, RI
Background: Laparoscopic hysterectomy with morcellation (LHM) has become popular for being safe & less invasive; it has been shown to reduce postoperative hospital stay & shorten patient recovery. A decrease in morbidity, blood loss & recovery time has been noted compared to vaginal hysterectomy. Sparse cases of incidental gynecologic malignancies after LHM have been reported. The current study aimed to determine the frequency & types of incidental malignancies after LHM at a high volume institution.
Design: An electronic chart review was conducted searching all cases of LHM +/- cervices performed 01 January 2007 to 31 January 2012 at one institution. The incidence of gynecologic malignancies along with patient demographics & any preoperative investigation was noted.
Results: 352 cases of LHM were identified. There were three occult malignancies (0.9%), all with benign preoperative endometrial sampling. Case #1 was a 48 y/o with fibroids. Pathology after LHM revealed low grade endometrial stromal sarcoma with myometrial invasion & vascular space involvement. A focus of metastatic sarcoma was present in the right peri-adnexal soft tissue after subsequent staging. Case #2 was a 49 y/o with a longstanding history of menorrhagia s/p several D&Cs showing benign endometrial polyps. Pathology after LMH showed a grade 1 endometrioid adenocarcinoma, without myometrial invasion. Case #3 was a 47 y/o with menorrhagia and fibroids. Pathology after LHM showed a uterine tumor resembling ovarian sex cord tumor (UTROSCT) with an infiltrating growth pattern. There were four (1.1%) benign non-smooth muscle neoplasms (two adenomatoid tumors and two ovarian Brenner tumors). There were five (1.4%) atypical smooth muscle tumors, which posed a diagnostic dilemma because the border of the lesion and border of necrosis were disrupted due to the morcellation; the differential included smooth muscle tumors of unknown malignant potential (STUMP) and leiomyosarcoma.
Conclusions: Although LHM is a popular technique that is considered safe, there is a clinically important risk of occult malignancy. Proper pathologic evaluation, including staging, is limited when a malignant uterus is morcellated. In highly atypical smooth muscle lesions, diagnostic data maybe lost after LHM posing a diagnostic dilemma. This risk persists despite appropriate clinical preoperative work-up. Pathologists must be aware of the rate of malignancy (0.9%) in LHM specimens, approach these specimens grossly and microscopically with care, and educate clinicians.
Category: Gynecologic & Obstetrics
Monday, March 4, 2013 9:30 AM
Poster Session I Stowell-Orbison/Surgical Pathology/Autopsy Awards Poster Session # 175, Monday Morning