Dr. Advincula: First, it’s important to define prevalence and incidence when discussing risks. Prevalence would be the number of patients with a leiomyosarcoma per 100,000 women, whereas incidence is the number of patients given a diagnosis of leiomyosarcoma within a year per 100,000 women. In this case, a 35-year-old woman would have a prevalence of leiomyosarcoma, in the general population, of 3 to 7 per 100,000 women and an incidence of less than 1%.
My preoperative assessment would involve MRI of the pelvis with T2 weighted images to better characterize her uterus. Although there has been much discussion lately about the use of lactate dehydrogenase (LDH) isoenzyme panels in combination with MRI to detect occult leiomyosarcoma, the reliability and reproducibility of that combined approach are not fully vetted and, as yet, are not a standard part of my workup. Endometrial sampling would certainly be warranted with any associated history of abnormal uterine bleeding.
Dr. Wright: As I mentioned earlier, most data on power morcellation have been derived from studies of women undergoing hysterectomy. To date, accurate estimates to predict the risk of occult cancer in this patient planning to undergo myomectomy are largely lacking. For women undergoing hysterectomy using power morcellation, advanced age is the strongest risk factor for occult malignancy. Although this patient’s risk of cancer likely is relatively low, she should be counseled that precise estimates are lacking.
Preoperatively, she should undergo endometrial sampling if she has abnormal bleeding. However, the reliability of endometrial sampling, as well as imaging, is limited in the detection of uterine sarcomas.
Case 2: Perimenopausal patient undergoing hysterectomy
OBG Management: How would your approach to preoperative assessment change if this patient were a 47-year-old perimenopausal woman with a single large fibroid to be removed by hysterectomy?
Dr. Bradley: It would be the same preoperative assessment—an MRI and an endometrial biopsy.
Dr. Iglesia: The risk of occult malignancy would be greater than with the first patient. Again, I would use pelvic ultrasound, endometrial biopsy, and cervical cytology to assess her, and I would perform vaginal or TLH. MRI would be indicated if there is a possibility of performing intraperitoneal morcellation. I would prefer doing any morcellation in a bag or via laparotomy.
Dr. Wright: Based on age alone, this perimenopausal patient’s risk for an underlying cancer is 0.2%.2 If the patient has any abnormal bleeding, she should undergo endometrial sampling preoperatively. The diagnostic modalities currently available—which include endometrial sampling as well as imaging, even MRI—are unreliable in the diagnosis of uterine sarcomas, and the patient should be counseled accordingly if she is considering power morcellation.
If it is technically feasible, vaginal hysterectomy or a minimally invasive hysterectomy without power morcellation are preferred. If neither modality is feasible and the patient is considering power morcellation, she should be carefully counseled about the underlying risk not only of uterine cancer but also of other adverse pathologic abnormalities.
Case 3: Postmenopausal woman scheduled for hysterectomy
OBG Management: Let’s change the details of the case again. This time she’s 55 years old and postmenopausal. She, too, has a large fibroid to be removed via hysterectomy. What is her risk of occult cancer? How would you assess her preoperatively?
Dr. Bradley: My approach would be the same as in the first two cases. However, because this patient is menopausal, morcellation would be off the table. (And it already is off the table—for any patient—at the Cleveland Clinic.) I usually prefer open hysterectomy for these patients, which is very different from what we were doing 1 year ago.
I want to expand on Dr. Wright’s comments about other pathologic abnormalities. As a woman ages, her cancer risk becomes greatest for malignancy of the endometrium rather than cancer in a fibroid. If this were my 55-year-old patient, and I had been seeing her for 20 years, and her fibroids had remained the same size but she was now having bleeding, I’d be more concerned about an endometrial problem—hyperplasia, a polyp, or cancer.
If the patient were having bulk symptoms, new pain, and imaging that shows, over 10 years between perimenopause and postmenopause, that there has been growth of the fibroids, I would be concerned about a sarcoma.
Some women who present with postmenopausal bleeding have ovarian cancer, and some studies show that a significant percentage of women with ovarian cancer present with bleeding as a primary symptom.3 So in a postmenopausal patient, I really want to know about the health of the ovaries. Are they enlarged on imaging?
There is also a bimodal distribution of human papillomavirus (HPV) infection and cervical cancer, with peaks of infection at ages 26 to 30 years and again at 46 to 50 years in some populations. The second age peak is followed by an increase in cervical intraepithelial neoplasia (CIN) 2 and 3 and invasive cervical cancer 20 years later.4 So I also want to consider the possibility of cervical cancer in this population.
