The Wall St Journal this week puts in perspective the dilemma the past decade of whether or not to have vaginal powertool uterine morcellation – mincing- as the less risky procedure for vaginal hysterectomy, as opposed to the oldfashioned open surgery. “Gynecologists Resist FDA Over Popular Surgical Tool Doctors Continue to Use Morcellators Months After Regulator Warned They Can Spread Undetected Cancer. These doctors say they believe the risks of unknown cancer have been overblown and the government shouldn’t interfere with patient treatment. ” Shades of overdiagnosis of breast and prostate cancer by mass screening of the well.
This lack of good evidence as to what is good best practice hasnt stopped lawyers like Weitz and Luxenberg from chasing lucrative compensation claims. Their mission statement says it all: “Weitz & Luxenberg is New York City’s largest personal injury and mass-tort plaintiffs’ law firm. Built on the philosophy that every client’s case is our most important, we have won more verdicts than most other U.S. law firms. Our goal is to set an unmatched standard of excellence for mass tort litigation — which is why, since our founding in 1986, our attorneys have relentlessly sought to deliver justice in cases involving asbestos and mesothelioma, defective drugs and medical devices, medical malpractice, general negligence, and environmental pollution, among others. We are unflinching in our belief that our clients deserve our absolute best work. ”
The recent June analysis from Harvard
– George, Muto ea- sums it up: highly malignant LMS leiomyosarcomas in fibroids are rare; many such sarcomas are difficult to be sure histologically; with no reliable preoperative techniques to distinguish LMS from benign leiomyoma
Vag hyst Morcellation studies show that it has ~40% shorter hospitalization time than total hysterectomy without morcellation because of almost 2/3 lower surgical risks. as Wiki says, hysterectomy Short term mortality (within 40 days of surgery) has been reported in the range of 1–6 cases per 1000 when performed for benign causes. Risks for surgical complications are presence of fibroids, younger age (vascular pelvis with higher bleeding risk and larger uterus), dysfunctional uterine bleeding and parity. The mortality rate is several times higher when performed in patients that are pregnant, have cancer or other complications.
But considering perhaps more than a million hysterectomies a year worldwide, the ?>300 000 uterine morcellations done the past almost 20 years (the procedure has been around since at least 1949- Allen
), the incidence of missed LMS is rare, below 1:300- in fact very few cases of clinical LMS spread have been reported in morcellation reviews, perhaps ~ 1:1000.
so where hysterectomy is essential (it seldom is- but is fashionable for sporty women, lucrative for hospital staff),
its up to the woman to decide for herself with informed consent whether to risk the numerous complications of conventional hysterectomy/myomectomy- which with a big fibroid is high-
versus having morcellation, then awaiting the <1:300 likelihood of a positive pathology report that her fibroid contained LMS, and facing recall for chemo.
some studies show that LMS can be suspected based on preop ultrasound.
Since LMS are highly vascular and big, thermography may also be helpful in selecting those rare fibroids that show bright due to high vascularity, that should not risk morcellation..
so its like screening the well for breast, prostate or colon cancer- are the mass programs screening everyone regularly worth while, or a huge unnecessary racket with risk of overdiagnosis and overtreatment?
or like the hard choice we all- women and our partners- face– with early breast cancer: mastectomy only? or local excision plus radiotherapy? or bilateral mastectomy? when latest studies show that there is little to choose in longterm survival between the three, but if anything women having local excision and DXRT survive the longest; or with silent early prostate cancer- watchful waiting? or local excision , hormone therapy?
It seems clear that vag. morcellation does better for most (299/300) women, but those with big fibroids (the Rome 2007, and Japanese 1990
papers) need more careful screening for suspicion of LMS, and thus may be wiser to choose clean surgical hysterectomy/myomectomy. If the mean LMS recurrence-free survival is still only 40months vs 10 months after morcellation, these rare cases have grim prognosis irrespective.
Fibroids and LMS, like breast and uterine cancer, are driven by estrogens- an increasing problem in our fattening age and the pernicious manmade Feminization of Nature that is destroying reproduction.
. So the first thing for those with growing breasts/lumps or fibroids are to eliminate, balance the excess estrogens. Dr Dee analyses this thoroughly at http://www.leiomyosarcoma.info/hormones.htm
and Dr Mostovoy at http://www.thermographyclinic.com/hysterectomy
. We do see breast and uterine fibroids turn around with such approach- but of course likely malignancies need to be typed by biopsy. .
.Then consider carefully whether and what tests and surgery to have, and by whom.
2014 Jun 12. doi: 10.1002/cncr.28844. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma.
Uterine leiomyosarcoma (ULMS) is identified in 0.1% to 0.2% of hysterectomy specimens of presumed leiomyoma. To date, there is no preoperative technique that reliably differentiates ULMS from uterine leiomyoma. Increasing use of minimally invasive approaches for the management of leiomyomas may result in inadvertently morcellated ULMS with resultant intraperitoneal dissemination of tumor. The objective of this study was to assess the impact of intraperitoneal morcellation on the outcomes of patients with ULMS. METHODS: In this retrospective cohort study, all patients with ULMS who attended the authors’ institutions from 2007 to 2012 were reviewed. Demographics and outcomes were compared between those who underwent morcellation or total abdominal hysterectomy (TAH) as their first surgery for uterus-limited ULMS. RESULTS:In total, 58 patients were identified, including 39 who underwent TAH and 19 who underwent intraperitoneal morcellation. Intraperitoneal morcellation was associated with a significantly increased risk of abdominal/pelvic recurrences (P = .001) and with significantly shorter median recurrence-free survival (10.8 months vs 39.6 months; P = .002). A multivariate adjusted model demonstrated a >3 times increased risk of recurrence associated with morcellation (hazard ratio, 3.18; 95% confidence interval, 1.5-6.8; P = .003). CONCLUSIONS: Intraperitoneal morcellation of presumed leiomyoma worsens the outcomes of women with ULMS. Because there are no reliable preoperative techniques to distinguish ULMS from benign leiomyoma, all efforts to minimize intraperitoneal uterine morcellation should be considered.
, Arduini D
. ea Univ Rome analyzed the preoperative gray-scale and color Doppler sonographic findings of 8 patients with LMS, 21 patients with cellular leiomyomas, and 3 patients with smooth muscle tumors of uncertain malignant potential and compared these findings to 225 patients with benign LM. All patients underwent myomectomy or hysterectomy. Number, size, echotexture, degenerative changes, and vascularity (central or peripheral; absent, mild, moderate, or marked) were recorded and correlated to the histologic findings RESULTS: LMSs were significantly larger than other uterine smooth muscle tumors. They were all solitary, and 7/8 lesions had a diameter >or=8 cm. Degenerative cystic changes were observed in 4 lesions, and increased peripheral and central vascularity was demonstrated in 7 lesions. Sensitivity, specificity, and positive predictive value of increased central and peripheral vascularity in the diagnosis of LMS were 100%, 86%, and 19%, respectively. Combining other sonographic findings with marked central vascularity, positive predictive value increased to 60%, but sensitivity decreased to 75%.
It does not show that metformin causes any heart or thyroid dysfunction ie change in thyroid hormone levels, merely that it reduces TSH in those on thyroid replacement.- indicating that thyroid dose may be able to be tapered.
A parallel new study from Italy Metformin-induced thyrotropin suppression is not associated with cardiac effects confirms there is no heart risk- quite the contrary.
People tend to fatten and slow down as they age, and these people tend to metabolic syndrome ie obesity, cholesterolemia, hypertension, vascular disease and thus diabetes- same as patients with hypothyroidism. So type 2 diabetes, hypothyroidism (sometimes preceded by hyperthyroidism) and aging go together- usually without demonstrable direct cause and effect.
This new McGill University metformin study does not claim any cause and effect. The link may be simply that metformin (which is simply a carbon-hydrogen -nitrogen molecule) improves all metabolic functions- antioxidant, nitric oxidant- including iodine/TRH/ TSH / thyroid/insulin hormone responses. .
So as with all nutritional supplements and exercise that improve metabolism, metformin may improve treated hypothyroidism by improving peripheral thyrooxine receptors , and thus lower need for thyroid replacement.
Metformin or the parent galega a medicinal plant extract used for many centuries reduces new diabetes and all diseases and deaths by 1/3 to 2/3.
it is among other things a prohormone regulator, improving common insulin resistance.
the definition of low TSH is arbitrary. If much below 1, it is suspicious of thyroid overactivity, excess thyroid hormones-
but rarely may reflect central ie pituitary failure to produce enough TRH/TSH and thus cause central hypothyroidism.
so TSH unless way outside the ‘normal’ range of 1 to 2 is a poor guide to health and disease, which is based on clinical state and the thyroid hormone and antibody levels.
Most aging people develop some degrees of thyroid underactivity, which generally responds to replacement of deficient selenium, iodine and sex hormones without addition of risky thyroid hormones- for which conventional blood levels are a poor guide.
so as in all patients whatever their state and treatment, thyroid function should like all other functions be considered periodically.
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Tagged diabetes, heart disease, metformin, thyroid, TSH