Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN; Department of Gynecology, IEO, European Institute of Oncology IRCSS, Milan, Italy.
Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN.
Am J Obstet Gynecol. 2019 Feb;220(2):179.e1-179.e10. doi: 10.1016/j.ajog.2018.11.1086. Epub 2018 Nov 14.
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.
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.
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.
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.
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.
微创子宫切除术可能需要使用切碎术来切除子宫。如果存在意外肉瘤，切碎术会有播散恶性细胞和恶化生存结果的风险。因此，美国食品和药物管理局于 2014 年发布了一项黑框警告，禁止使用电动切碎器治疗子宫肌瘤。然而，在因良性指征行子宫切除术时，意外肉瘤的比例仍不清楚。
本研究旨在估计在明尼苏达州奥姆斯特德县因良性指征行子宫切除术的女性中肉瘤的发生率，时间为 1999 年至 2013 年。
我们进行了一项基于人群的研究，纳入了 1999 年 1 月 1 日至 2013 年 12 月 31 日期间在奥姆斯特德县因良性指征行子宫切除术的所有女性。通过罗切斯特流行病学项目的病历-链接系统确定病例，并由一名妇科医生对每位接受子宫切除术的女性的完整病历进行摘录。一名病理专家审查了每个肉瘤的病理切片，以确保诊断的准确性。以每 100 人计，分别计算了（总体和按肉瘤类型）肉瘤的总体发生率和分层发生率（按绝经状态、手术指征和子宫重量）。
在研究期间共进行了 4232 次子宫切除术。其中，我们发现了 16 例肉瘤，其中 11 例（69%）术前可疑，5 例（31%）为意外。在所有子宫切除术患者中，3759 例（88.8%）为良性指征。其中，意外肉瘤的发生率为 0.13%（5/3759 [95%置信区间，0.04%-0.31%]）。子宫纤维瘤占所有良性指征子宫切除术的 27.3%（n=1025），是最常与意外肉瘤诊断相关的指征。在因子宫纤维瘤而行的手术中，意外肉瘤的发生率为绝经前女性 0.35%（3/851），围绝经期/绝经后女性 0.57%（1/174），所有 4 例意外肉瘤均为平滑肌肉瘤。随着子宫重量的增加，意外肉瘤的发生率逐渐增加，子宫重量<250g 的女性发生率为 0.03%（1/2993），而子宫重量≥2000g 的女性发生率为 15.4%（2/13）。
所有因良性指征行子宫切除术的女性中，意外子宫肉瘤的发生率较低（0.13%或 752 例手术中有 1 例），但在患有子宫纤维瘤的女性中发生率较高（0.39%或 256 例手术中有 1 例）。围绝经期/绝经后女性、子宫较大的女性和年龄≥45 岁是肉瘤的危险因素。
