What is the Prevalence of Occult Malignancy During Hysterectomy or Myomectomy for Benign Indications?

BACKGROUND AND PURPOSE:

• Hysterectomy and myomectomy are common gynecologic surgeries, often done for benign conditions
• Desai et al. (Obstet Gynecol, 2018) estimated the prevalence of occult uterine, cervical and ovarian malignancy in women undergoing hysterectomy or myomectomy for benign indications

METHODS:

• Secondary analyses of data from American College of Surgeons National Surgical Quality Improvement Program (2014-2015)
• Adult women undergoing hysterectomies and myomectomies without evidence of cancer were included in the analyses
• Primary outcome was pathology-confirmed uterine, cervical and ovarian malignancy
• Secondary outcome was that of stage of identified occult malignancies
• Results were adjusted to account for confounders using logistic regression analysis

RESULTS:

• 24,076 women underwent hysterectomy; 2,368 underwent myomectomy
• For those women undergoing hysterectomy, prevalence of occult cancers were as follows
  • Uterine cancer: 1.44%
  • Cervical cancer: 0.60%
  • Ovarian cancer: 0.19%
• The prevalence of uterine cancer varied depending on surgical procedure
  • Laparoscopic supracervical hysterectomy: 0.23%
  • Total laparoscopic or laparoscopic-assisted vaginal hysterectomy 1.89%
• Older women were significantly more likely to have preoperatively undetected uterine malignancy when comparing women age ≥55 years vs age 40-54 years
  • Adjusted odds ratio 6.46; 95% CI, 4.96-8.41
• Among patients undergoing myomectomy, 0.21% were found to have malignancy of the corpus uteri with no occult cervical or ovarian cancer identified
• Staging
  • 80% of uterine cancers and 60.9% of ovarian cancers were stage I-IC neoplasms
  • 44.1% of cervical cancers were diagnosed at stage I-IB2 and 40.7% had stage ‘not otherwise specified’ (NOS)

CONCLUSION:

• Large and diverse patient population
• Results provide additional information regarding the potential for malignancy with intracorporeal electromechanical morcellation
• Prevalence varied based on patient age and surgical route
  • Prolapse may be associated with lower risk of malignancy
  • Surgeons may opt for complete removal of the uterus in women who may be at higher risk for malignancy, hence the higher risk of malignancy using this approach
• The results indicate the importance of a thorough workup for malignancy in women who are 55 years of age or older

The ‘ACOG Statement on FDA Regulation of Morcellation’ (2015) states

As a result of the continuing conversation about morcellation, obstetrician-gynecologists are better able to evaluate each individual woman’s risk of an undiagnosed sarcoma, and to counsel her to receive the right approach for her own unique medical needs.

Learn More – Primary Sources:

Occult Gynecologic Cancer in Women Undergoing Hysterectomy or Myomectomy for Benign Indications

ACOG Statement on FDA Regulation of Morcellation