Hysterectomy, Fibroids, and a Cancer Controversy

Up until 20 years ago, there was no efficient way to laparoscopically remove a uterus enlarged by fibroids. Most fibroids are far larger than the tiny abdominal incisions used to perform a laparoscopic hysterectomy (removal of the uterus) or myomectomy (removal of fibroids with preservation of the uterus). The breakthrough in technology that enabled the surgeon to use these minimally invasive techniques to remove any size fibroid or uterus through a tiny incision is a device known as a power morcellator.

A power morcellator is an instrument that cuts a large uterus or fibroid into smaller strips of tissue, which then can be easily removed through a half-inch incision. An accomplished surgeon can remove even a large fibroid in a matter of minutes.

In 2015 there concerns were raised aboutspreading the cells of an undetected uterine cancer in the event that what appear to be fibroids (non-cancerous tumors) are actually a type of cancer called leiomyosarcoma (li-o-my-o-sarcoma).

Different Types of Uterine Cancers

Most uterine cancers are endometrial cancers, not leiomyosarcomas, and this is almost always known prior to surgery. Since endometrial cancer is usually detected in an early stage, the cure rate is over 90 percent. If an undetected endometrial cancer is inadvertently morcellated, the outcome is no worse for the woman.

Leiomyosarcoma, on the other hand, is a very serious, rare form of uterine cancer.

While leiomyosarcoma can occur at any age, it most commonly occurs in women over the age of 50. Many, not all, cases are characterized by rapid tumor growth. A leiomyosarcoma can often be discovered by a biopsy prior to surgery, but not all are detected or predicted prior to removal. Morcellation does NOT cause the cancer. But IF an unknown leiomyosarcoma is present, the process of morcellation will spread cancer cells throughout the abdominal cavity. Hysteroscopic morcellation is not an issue since there is no spread of cells outside of the uterine cavity. If cancer cells are spread during the process of morcellation either by power morcellation or hand morcellation, the outcome may be worse.

Keep in mind, even if a traditional hysterectomy is performed, with no morcellation, this is a serious cancer and only 40 percent of women survive at the five-year mark.

The frequency of leiomyosarcoma in women having fibroid removal procedures is highly controversial and ranges have been reported from between 1 in 370 cases of fibroids and 1 in 12,000. Most experts believe that the 1 in 370 number is not correct. Here’s why:

Fibroids Are Common, Leiomyosarcomas Are Not

Fibroids are very common and are present in up to 80 percent of women. The majority of women with fibroids do not require, and do not have any treatment. Women who do need treatment often undergo uterus-sparing solutions such as myomectomy or fibroid embolization.

If one in 370 women with fibroids had a leiomyosarcoma, every gynecologist would see dozens of cases during their career! In fact, most gynecologists see only one or two. If the 1 in 370 number were accurate, then every woman with fibroids should have a hysterectomy!

Following the FDA warning about morcellation, JAMA published data from 41,777 women who underwent myomectomy (removal of fibroids) in order to determine the true incidence of leiomyosarcoma, and even more important, to determine who is at highest risk.

Of women who did NOT have morcellation, uterine cancer was detected in:

  • 0.05 percent of women under the age of 40
  • 0.62 percent of women age 50-59
  • 3.4 percent of women over age 60

Of women who did have morcellation, uterine cancer was detected in:

  • ZERO percent of women under the age of 40
  • 0.97 percent of women age 50-59
  • ZERO percent of women over age 60

This was reassuring and important news since without the option of morcellation, the majority of women who are now candidates for a laparoscopic or robotic assisted myomectomy or hysterectomy would require a large incision resulting in a longer recovery, more pain, slower return to normal activities, and higher risk of scar tissue.

Minimizing the Risk of Morcellation

This week, MedPage Today (a doctor's website) published an article confirming what experts such as myself have been saying all along. The risk of morcellation was overblown, the FDA warning inappropriate and fueled by a media campaign that was not scientifically accurate. This new information confirms that the answer is not to eliminate the option of morcellation, but instead to minimize the risk associated with morcellation. In addition, it is now clear that women are being harmed, not helped by the ban on morcellation given the higher complication rate of an open procedure.

So, here's how to reduce the already very small risk even further:

First of all, a uterine biopsy (a sample from the lining of the uterus) should always be performed pre-operatively. If there is a known or suspected cancer, morcellation should not be used.

A specimen “bag” can be used during morcellation to contain the uterine tissue and eliminate the risk of spread in the abdomen and pelvis. That’s right: If a surgeon inserts an unbreakable bag into the abdominal cavity and morcellates the tissue INSIDE the bag, there will be no spill of cells outside the bag. In the rare event of an undiagnosed cancer, there will be no spread. Many experts are already doing this, and as the technique becomes widely known, I suspect it will become the standard of care.

If you are over age 60, myomectomy is not appropriate and morcellation of fibroids should be avoided, or at minimum, performed in a bag.

Like every surgeon, I can guarantee you that my primary goal is for my patients to have the best outcome possible. As an informed consumer, you need to know the facts so you can have a conversation with your doctor. If you require fibroid removal or hysterectomy and are a candidate for a minimally invasive procedure, let your doctor know if you are comfortable with a morcellation procedure and, particularly if you are older, ask if a bag technique will be used. Understand that an open incision will not eliminate your risk, (and will increase surgical risk) but is always an option.

When I wrote The Essential Guide to Hysterectomy, it was with the premise that if women are given good, accurate information, they will make good, informed decisions.

Now you can.

Photo credit: Alamy