CONVENTIONAL SURGICAL HYSTERECTOMY OR MORCELLATION FOR FIBROIDS. DONT MINCE MATTERS?

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.^[45]   The mortality rate is several times higher when performed in patients that are pregnant, have cancer or other complications.^[46]

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.

Cancer. 2014 Jun 12. doi: 10.1002/cncr.28844. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma.

George S¹,, Muto MG ea    Harvard Medical School, Boston, Massachusetts.

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.

J Clin Ultrasound. 2007 ;35:449-57.Can gray-scale and color Doppler sonography differentiate between uterine leiomyosarcoma and leiomyoma?

Exacoustos C¹, 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%.  

Gynecol Obstet Invest. 1990;30(4):242-5.   Sonographic findings of uterine leiomyosarcoma.   Hata K^1, Nagaoka S ea .  Univ Japan    describe various sonographic features of uterine leiomyosarcoma. Transabdominal scanning (TAS) revealed an image indistinguishable from benign leiomyoma, with evidence of degeneration. Transvaginal scanning (TVS) clearly showed the thinness of the myometrium, and the possibility of deep myometrial invasion was suspected at intraoperative open direct ultrasonography (ODU). A very high peak systolic velocity and a slightly increased diastolic component at the periphery of the tumor were evident with pulsed Doppler ultrasound. Thus, TAS, TVS, ODU and Doppler ultrasound will yield useful information for the physician attempting to evaluate the extent and vascularity of uterine leiomyosarcoma.