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Feb 2017

Common Surgical Device May Spread Cancer?

A morcellator is a surgical instrument most commonly used for gynecological surgeries such as hysterectomies (removal of uterus) and myomectomies (removal of uterine fibroids), and may also be used for removal of ovarian tumors.

Morcellation for these surgeries involves making a small incision in the patient’s abdomen and inserting the tool. Tissue needing to be removed is shredded up into smaller pieces and extracted. It is a minimally invasive surgery, normally having a shorter recovery time than hysterectomies and myomectomies performed without morcellators and with more traditional, larger abdominal cuts.

“Morcellators are almost like meat grinders, and the most common reason to use one is for the removal of fibroids,” said Leonard J. Lawson, M.D., a practicing obstetrician and gynecologist since 1978. Lawson has done many hysterectomies and myomectomies with and without morcellators.

Other than making larger, more invasive abdominal cuts, an alternative to using morcellators is to perform vaginal hysterectomies and myomectomies with a scope where no incisions are needed.

Ideally, doctors would be able to determine more before the patient undergoes any type of procedure. It is usually difficult to see whether a fibroid is malignant before surgery. A diagnosis is usually made after the specimen is removed and sent to pathology.

Before surgery, doctors can look out for certain red flags. For example, if a patient has a rapidly growing fibroid it might be a sarcoma, but there are no studies or x-rays that can determine this before surgery

According to the American College of Obstetricians and Gynecologists (ACOG), manual morcellation has been practiced for decades during both vaginal and open abdominal surgeries for hysterectomies and myomectomies.

In 1993, the power morcellator was introduced, which the Food and Drug Administration (FDA) approved.

According to ACOG, “[i]t is well established that minimally invasive techniques spare thousands of women each year from the increased morbidity and mortality associated with open or abdominal gynecologic surgery.”

In April 2014, the FDA issued a safety warning discouraging use of power morcellators because “it poses a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, beyond the uterus.” The warning also states, “…approximately 1 in 350 women who are undergoing hysterectomy or myomectomy for fibroids have an unsuspected type of uterine cancer called uterine sarcoma. 

“Uterine fibroids are almost invariably benign,” Lawson said. “There are a small number of fibroids that are sarcomas.”

In his career, Lawson has seen only two uterine sarcomas.

According to UpToDate, an online clinical decision support resource, “[u]terine sarcoma is rare (3 to 7/100,000 in the United States population).”

A recent study conducted by the Journal of the American Medical Association (JAMA), revealed use of morcellators for hysterectomies and myomectomies have declined since the FDA issued their warning.

Other risks associated with morcellation may include the spreading of benign (harmless, non-cancerous) tissue which may become implanted in the body.  This may result in issues including endometriosis, when tissue lining the uterus grows outside of the uterus.

Sometimes a retrieval or containment bag is used (kind of like a plastic bag) around the morcellator in order to prevent the spreading of tissue.

As a practicing physician who regularly performs hysterectomies and myomectomies, Lawson said that despite the low incidence of uterine sarcomas, he must follow the recommendations of the FDA, because if a patient does in fact have cancer,  a morcellator may spread cancerous tissue.

Perhaps it is the fight against cancer and cancer prevention that needs to be at the forefront of this discussion.

“The real issue is anyone who has a uterine sarcoma has a pretty bad prognosis whether you use a morcellator or not,”  said Lawson.

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