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Table.  
Multivariable Models Among Women Who Underwent Morcellation
Multivariable Models Among Women Who Underwent Morcellation
1.
 Patient safety must be a priority in all aspects of care. Lancet Oncol. 2014;15(2):123.
PubMedArticle
2.
Kho  KA, Nezhat  CH.  Evaluating the risks of electric uterine morcellation. JAMA. 2014;311(9):905-906.
PubMedArticle
3.
Seidman  MA, Oduyebo  T, Muto  MG, Crum  CP, Nucci  MR, Quade  BJ.  Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One. 2012;7(11):e50058.
PubMedArticle
4.
Hagemann  IS, Hagemann  AR, LiVolsi  VA, Montone  KT, Chu  CS.  Risk of occult malignancy in morcellated hysterectomy: a case series. Int J Gynecol Pathol. 2011;30(5):476-483.
PubMedArticle
5.
Wright  JD, Ananth  CV, Lewin  SN,  et al.  Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698.
PubMedArticle
6.
Oduyebo  T, Rauh-Hain  AJ, Meserve  EE,  et al.  The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol. 2014;132(2):360-365.
PubMedArticle
Research Letter
September 24, 2014

Uterine Pathology in Women Undergoing Minimally Invasive Hysterectomy Using Morcellation

Author Affiliations
  • 1Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
  • 2Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
JAMA. 2014;312(12):1253-1255. doi:10.1001/jama.2014.9005

Even though minimally invasive surgery has improved outcomes for hysterectomy, the procedure requires removal of the uterus through small incisions. Morcellation, or fragmentation of the uterus into smaller pieces, is one method to remove the uterus. Recently, concern has been raised that morcellation may result in the spread of undetected malignancies.1

Despite the commercial availability of electric power morcellators for 2 decades, accurate estimates of the prevalence of malignancy at the time of electric power morcellation (herein referred to as morcellation) are lacking,1,2 with single-center studies reporting prevalences from 9 to 100 in 10 000.3,4 We used a large insurance database to investigate the prevalence of underlying cancer in women who underwent uterine morcellation.

Methods

The Perspective database was used to identify women who underwent a minimally invasive hysterectomy from 2006-2012. Perspective is an all-payer database including more than 500 hospitals capturing 15% of hospitalizations. Hospitals within this database are more frequently urban teaching centers and located in the southern United States. Data undergo a rigorous quality control process. Use of commercially available morcellators was captured by identification of charge codes.5 The analysis was deemed exempt by the Columbia University institutional review board.

The primary outcome was identification of uterine corpus cancer (all histologies) based on International Classification of Diseases, Ninth Revision, coding at surgery. We also examined the occurrence of uterine neoplasms of uncertain malignant potential; malignancies of other parts of the uterus, including cervical cancer, and surrounding adnexal structures (other gynecologic cancer); and endometrial hyperplasia.

Multivariable mixed-effects log-linear models, including clinical and demographic covariates and a random-intercept for the procedural hospital, were developed for uterine cancer and endometrial hyperplasia. The other outcomes were rare and the models did not converge.

All statistical analyses were 2-sided and performed with SAS version 9.4 (SAS Institute Inc). A P value of <.05 was considered statistically significant.

Results

Within the cohort of 232 882 women who underwent minimally invasive hysterectomy from 2006-2012, morcellation was performed in 36 470 (15.7%). Women who underwent morcellation differed in clinical and demographic characteristics from women who did not (eTable in the Supplement). Among those who underwent morcellation, 99 cases of uterine cancer were identified, a prevalence of 27/10 000 (95% CI, 22-32/10 000). Twenty-six cases of other gynecologic malignancies were found (a prevalence of 7/10 000 [95% CI, 4-10/10 000]), 39 uterine neoplasms of uncertain malignant potential (11/10 000 [95% CI, 7-14/10 000]), and 368 cases of endometrial hyperplasia (101/10 000 [95% CI, 91-111 per 10 000]).

Among women who underwent morcellation, advanced age was associated with underlying cancer and endometrial hyperplasia (Table). Compared with women younger than 40 years, the prevalence ratio for a uterine malignancy increased with increasing age from 4.97 (95% CI, 1.91-12.93) in women aged 50 to 54 years, to 19.37 (95% CI, 7.66-48.95) in those aged 55 to 59 years, to 21.36 (95% CI, 7.22-63.21) in those aged 60 to 64 years, and to 35.97 (95% CI, 14.14-91.53) for women aged 65 years or older.

Discussion

Our data demonstrate that uterine cancers occurred in 27 per 10 000 women undergoing morcellation. Other malignancies and precancerous abnormalities were also detected. Although morcellators have been in use since 1993, few studies have described the prevalence of unexpected pathology at the time of hysterectomy.24 Prevalence information is the first step in determining the risk of spreading cancer with morcellation. Although data are limited, women with apparent uterine-confined neoplasms at the time of morcellation have been found to have intraperitoneal tumor dissemination at the time of reexploration.3,6

We recognize a number of limitations including the inability to verify pathological findings, possible misclassification of pathology, potential undercapture of morcellation, and the fact that our findings may not be generalizable to all hospitals. Last, we lack data on long-term follow-up, and the outcome of women with pathological abnormalities who underwent morcellation requires further study. Patients considering morcellation should be adequately counseled about the prevalence of cancerous and precancerous conditions prior to undergoing the procedure.

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Article Information
Section Editor: Jody W. Zylke, MD, Senior Editor.

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, Eighth Floor, New York, NY 10032 (jw2459@columbia.edu).

Published Online: July 22, 2014. doi:10.1001/jama.2014.9005.

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Wright, Tergas, Burke, Ananth, Chen, Hershman.

Acquisition, analysis, or interpretation of data: Wright, Cui, Ananth, Chen.

Drafting of the manuscript: Wright, Chen, Hershman.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Ananth, Chen.

Obtained funding: Wright.

Administrative, technical, or material support: Wright.

Study supervision: Wright, Burke, Hershman.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr Wright (grant R01CA169121-01A1) and Dr Hershman (grant R01CA134964) are recipients of grants from the National Cancer Institute. Dr Tergas is the recipient of a fellowship (R25 CA094061-11) from the National Cancer Institute.

Role of the Sponsors: The National Cancer Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
 Patient safety must be a priority in all aspects of care. Lancet Oncol. 2014;15(2):123.
PubMedArticle
2.
Kho  KA, Nezhat  CH.  Evaluating the risks of electric uterine morcellation. JAMA. 2014;311(9):905-906.
PubMedArticle
3.
Seidman  MA, Oduyebo  T, Muto  MG, Crum  CP, Nucci  MR, Quade  BJ.  Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One. 2012;7(11):e50058.
PubMedArticle
4.
Hagemann  IS, Hagemann  AR, LiVolsi  VA, Montone  KT, Chu  CS.  Risk of occult malignancy in morcellated hysterectomy: a case series. Int J Gynecol Pathol. 2011;30(5):476-483.
PubMedArticle
5.
Wright  JD, Ananth  CV, Lewin  SN,  et al.  Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309(7):689-698.
PubMedArticle
6.
Oduyebo  T, Rauh-Hain  AJ, Meserve  EE,  et al.  The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol. 2014;132(2):360-365.
PubMedArticle
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