Understanding the safety of using a morcellator during fibroid removal
When laparoscopic myomectomy is performed for the removal of uterine fibroid(s), the fibroid tumor is ground into small pieces and extracted through a small incision. Most often, a device called a morcellator is used for the procedure. This device consists of a cylindrical blade that rotates and cuts into the fibroid – similar to an apple corer – and the “cored” pieces are then removed through the cylindrical port.
When the blade is spinning, small bits of fibroid tissue can be spewed into the abdominal cavity.
Recently the risk of inadvertently spreading cancer with use of a morcellator has been brought to the public attention by the case of one woman, Amy Reed. Ms. Reed had her uterus removed through morcellation. Afterwards, the uterine tissue was found to have leiomyosarcoma, a rare cancer.
Since February 2014 when the story surfaced, numerous reports have contended that when morcellation of a uterus is performed, and later the diagnosis of sarcoma is made, the prognosis for the patient is worse. Amy and her husband have asked the FDA to ban the use of morcellation.
In response, the FDA has issued a statement “discouraging” its routine use. The focus on morcellation should be how to make it safe rather than abandoning its use.
Basic facts about uterine fibroids and uterine sarcoma cancer:
- Benign uterine fibroids are the most common pelvic tumor in women (estimated lifetime risk of 70-80 percent).
- Uterine sarcoma is very rare (3 to 7 cases per 100,000 women in the United States).
- The likelihood of sarcoma in women undergoing hysterectomy or myomectomy for a presumed benign fibroid is about 0.20 percent.
- In most cases, diagnosis of sarcoma is made after the hysterectomy or myomectomy based on the pathology review of the removed tissue. Currently, an accurate screening test for sarcoma does not exist.
- Known risk factors for sarcoma include: women 60 years and older, menopause, long-term use of the medication Tamoxifen and pelvic irradiation.
- The risk for a premenopausal woman, with a presumed fibroid of having a sarcoma, is lower than 0.16 percent.
- Uterine sarcoma has an extremely poor prognosis.
- Surgery that disrupts a uterine cancer (myomectomy or hysterectomy, especially when the specimen is morcellated) may spread malignant cells and worsen the prognosis.
- Non-surgical treatments for fibroids (birth control pills, endometrial ablation, uterine artery embolization, magnetic resonance guided focused ultrasound and laparoscopic thermal coagulation or cryoablation) can miss the diagnosis of cancer because a tissue sample is not requested.
- Benign uterine fibroids do not development into sarcoma.
Because the diagnosis of sarcoma is such grave news for a woman, it is of great importance to note that any intervention carries risk. For this reason it’s best to diagnose the cancer before any surgical procedure.
Pre-operative testing for sarcoma:
- Pelvic ultrasound, typically the first screening for a uterine fibroid.
- A pelvic exam is always important.
- MRI with, and without, contract dye is theoretically the most useful imaging test to raise suspicion of cancer, but – as with most testing – it’s not 100 percent accurate.
- An endometrial biopsy, especially if there is a history of abnormal bleeding, can pick up cancer before surgery in 30-60 percent of cases.
- One study evaluated the use of MRI combined with a blood test for LDH isoenzymes and showed a strong positive prediction when the tests were abnormal.
Currently, the safest surgery to prevent a worse prognosis from sarcoma is hysterectomy with removal of the cervix. Since the probability that a young, premenopausal woman has sarcoma is rare, it is not appropriate to recommend hysterectomy for most young, pre-menopausal women.
In low-risk women, minimally invasive surgery such as a myomectomy is still considered safe.
However, because a pre-operative diagnosis is difficult, it is possible that a woman considered low risk would have a laparoscopic myomectomy with morcellation, inadvertently increasing her mortality risk from that cancer.
The American Association of Gynecologic Laparoscopists (AAGL) has initiated efforts to explore ways to improve the safety of the morcellator and to find alternative ways to remove fibroids with minimally invasive surgery.
Currently, two minimally invasive surgical procedures are recommended to reduce the chance of inadvertently spreading cancer with morcellation:
1.) Remove the fibroid through a larger skin incision and not use power morcellation.
2.) Place the fibroid in a plastic bag and morcellate in the bag so the cells are contained within the bag and not spread in the abdominal cavity.
When the diagnosis of sarcoma is made, the patient should be referred to a gynecologic oncologist for additional evaluation and treatment.