School of Medicine; Senior Scholars Program; Department of Obstetrics and Gynecology
Tiffany Moore Simas, MD, MPH, MEd
Female Urogenital Diseases and Pregnancy Complications | Neoplasms | Obstetrics and Gynecology | Oncology | Women's Health
Background: The use of power morcellation in gynecologic surgery has come under scrutiny secondary to concerns for occult malignancy dissemination. The incidence of undiagnosed gynecologic malignancy when hysterectomy performed for benign indications is not definitive but has been quoted as high as 2.7% (1:37). There is not a standard recommended preoperative evaluation, and variation is anticipated by preoperative complaint or diagnosis.
Objectives: To quantify the malignancy incidence in women undergoing hysterectomy for benign indications and to compare the preoperative evaluation of patients undergoing hysterectomy with and without morcellation.
Methods: Retrospective cohort of women undergoing hysterectomies between October 2007 and June 2014 was identified by procedural codes through the hospital billing system. Exclusions included hysterectomies performed by gynecologic oncologists or non-gynecologic surgeons and surgeries performed outside the UMass healthcare system. Chart abstraction included demographics; pre-hysterectomy evaluation, including current cervical cytology, pathologic endometrial assessment (biopsy, dilation and curettage), and imaging (ultrasound, MRI, CT scan, sonohysterogram, or hysteroscopy); intraoperative factors; and final diagnosis.
Results: Analytic cohort included 2,332 women undergoing hysterectomy with 396 (17.0%) including use of morcellation. The malignancy incidence on final pathology was 2.1% and was different between non-morcellated versus morcellated specimens (2.5% vs. 0.3%, p<0.001). Intraoperative gynecologic oncology consults and/or frozen pathologic evaluations were performed in 1.2% (n=27) and 5.4% (n=126) of cases, respectively. There was no significant difference in current cervical cytology (68.9% vs. 71.3%) and imaging (39.6% vs. 34.9%) rates between the non- versus morcellated groups; however, those experiencing morcellation were less likely to have preoperative pathologic endometrial assessment (21.7% vs. 34.2%, p<0.001).
Conclusion: The incidence of malignancy at time ofhysterectomy performed by non-oncology trained gynecologists was 2.1% overall, and 0.3% in morcellated cases. The pre-operative evaluation of patients undergoing hysterectomy with morcellation is similar to those without morcellation, except for lower rates of pathologic endometrial assessment. An argument could be made that a pathology assessment is indicated in this group due to risk of dissemination in the case of occult malignancy. The risk of occult malignancy is rare, but this should be discussed with patients and taken into account during the pre-operative evaluation.
hysterectomy, morcellation, malignancy
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2016 Senior Scholars Program Poster Presentation Day
Wilkie, Gianna L.; Reus, Emily; Leung, Katherine G.; Bradford, Leslie; Manning, Mark; and Moore Simas, Tiffany A., "The Incidence of Malignancy and the Preoperative Assessment of Women Undergoing Hysterectomy with Morcellation for Benign Indications" (2016). University of Massachusetts Medical School. Senior Scholars Program. Paper 238.