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The impact of operative techniques to the onset of peritoneal tumor dissemination in patients with uterine leiomyosarcomas. Franka Menge, Eva Hartmann, Monika Mathew, Bernd Kasper, Peter Hohenberger Div. of Surgical Oncology & Thoracic Surgery Interdisciplinary Sarcoma Center - PowerPoint PPT Presentation
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Franka Menge, Eva Hartmann, Monika Mathew, Bernd Kasper, Peter Hohenberger
Div. of Surgical Oncology & Thoracic Surgery Interdisciplinary Sarcoma Center Faculty of Medicine Mannheim
University of Heidelberg, Germany
The impact of operative techniques to the onset of peritoneal tumor dissemination in patients
with uterine leiomyosarcomas
Disclosures
No disclosures
Introductory remarks
Uterine sarcomas are rare, but highly malignant tumors Approximately 8-10% of all uterine cancers Mostly diagnosed incidentally, postresectional < 2% of all hysterectomy specimens for uterine leiomyoma Historically, confusion in understanding of pathological
subtypes Different pathologies often combined in clinical reviews
Introductory remarks - 2
Main histologic subtypes:
Leiomyosarcoma (LMS) 67 %
Endometrial stromal sarcoma (ESS) 17-25 % Undifferentiated sarcomas (UES, AJSP2008) 8-17 %
Carcinosarcoma (former malignant Mullerian mixed tumor)
Surgical problems of treatment
Sarcoma is not recognized preoperatively Historical and ‚modern‘ operative techniques: ‚Hooking‘ and myoma drill of the tumor Intraabdominal morcellation Consequence: intraoperative tumor cell spillage Inoculation of the abdominal cavity
Morice, Eur J Gynaecol Oncol 2003 Einstein, Int J Gynaecol Cancer 2008
Perri, Int J Gynaecol Cancer 2009Seidman, PLOS One 2012
Courtesy: Storz Co.
Typical procedure for laparoscopic myoma removal from the uterus
Courtesy: Storz Co.
Typical procedure for laparoscopic myoma removal from the uterus
Courtesy: Storz Co.
Typical procedure for laparoscopic myoma removal from the uterus
Courtesy: Storz Co.
What if this leiomyoma is later diagnosed as a leiomyosarcoma ?
Case report:
Patient: 43 yrSigns and symptoms: abdominal pain, dysuria
Preoperative diagnosis: rapidly growing uterine leiomyomaTherapy: abdominal hysterectomy and salpingectomy with
intraabdominal morcellation (10/Dec/2012)
Histological diagnosis: uterine leiomyosarcoma FIGO IB (no grading) Course of disease: 10/Dec/12: operation and first diagnosis
30/Jan/13: CT scan: multiple intraabdominal mets. 06/Feb/13: treatment start with doxorubicin (trial)
result: PD 2nd line therapy: gemcitabine/docetaxel, result: PD3rd line therapy with pazopanib
Case #29, 43yr: this was later diagnosed as a leiomyosarcoma !
preoperative
2 month follow up
Trocar positioning
Courtesy: Storz Co.
preoperative
2 month follow up
Location of mets. as a consequence of trocar positioning
Methods
We tried to identify the impact of intrabdominal fragmentation or damage to the uterus on the occurrence and the time interval of peritoneal metastases of uterine LMS.
All female patients presenting with advanced sarcoma of uterine origin
2004 – 2013, negative selection, typically M1 or locoregionally recurrent
Retrospectively evaluated EORTC example of GIST study 62024
Quality of Surgery for Primary Gastro-Intestinal Stromal Tumors in Patients Undergoing Adjuvant
Imatinib Treatment. Experience of the EORTC STBSG 62024 Study
P. Hohenberger1, S. Bonvalot2, F. van Coevorden3, P. Rutkowski4, E. Stoeckle5, C. Olungu6, M. vanGlabbeke6, A. Gronchi7, P. Casali7
Mannheim University Medical Center1; Institute Gustave Roussy, Paris2; NKI/van Leuuvenhoek Ziekenhuis3; Maria Sklodowska Cancer Center Warsaw4; Bergonie,
Bordeaux5; EORTC Brussels6; Istituto Nazionale dei Tumori, Milano7
CTOS 2011:
Reason for surgery, n = 926 Circumstances of resection and technique
(emergency, open vs. laparoscopically) Extent of resection Concordance of preop. and intraop. findings Completeness of resection
Data to be reported :
The data of primary surgery were reviewed. Revision of all source data documents :
- operation records
- pathology report
- letter of discharge
- Data from 39 (46) patients could be reviewed
Adopted for uterine sarcoma
Endpoint of the analysis
retrospective comparison of the
cum survival time
without peritoneal recurrence of uterine LMS
in patients with or without
intraabdominal tumor fragmentation or damage.
The impact of tumor morcellation on the prognosis of patients with uterine leiomyosarcoma
Results 1
Patients identified with an advanced uterine sarcoma, 2004-13 (n=46)
Leiomyosarcoma 50% (n=23)
Endometrial stroma sarcoma26% (n=12)undifferentiated endometrialsarcoma 4% (n=2)others 19% (n=9)
Clinical parameters of all patients with peritoneal metastatic spread :
No tumor violation
Morcellement/ myoma drill
Age Mean (range) yr 56,5 (28-75) 49,2 (43-59)
Initial presenting symptoms
Abdominal painVaginal bleedingPalpable massNot done
1224
1320
Preoperative presumptive diagnosis
Uterine leiomyomaUterine sarcomaOther, hypermenorrhoea)
310
4
2
FIGO stage IBIIBIIIAIVAn.d.
41103
20013
Grading G2G3n.d.
522
330
Size of tumor < 8cm> 8cmn.d.
261
213
Leiomyosarcoma (n= 25)
0
2
4
6
8
10
12
no metastasis 16% (n=4)
only peritoneal 12% (n= 3)
peritoneal and pulmonary40% (n=10)
primarily metastatic disease12% (n=3)
pulmonary and other site 4%(n=1)
peritoneal and other site 8%(n=2)
lost 8% (n=2)
The impact of tumor morcellation on the prognosis of patients with uterine leiomyosarcoma
Results 2
• 22/39 (58%) pts. had developed peritoneal metastases (13 LMS, 4 ESS, 5 other histologies)
• LMS : only two patients had M1PER at initial surgery. • LMS n=11, sarcoma had not being recognized at surgery.
• 6/11 women had a documented intrabd. morcellation or injured uterus due to the use of an myoma drill
• Time to diagnosis of the peritoneal metastases: 18,3 months (range, 2-39 mos.)
• 5/11 pts. without tumor damagetime to detection of peritoneal spread: 33,6 months (range, 14-51 mos.), p = 0.0804
The impact of tumor morcellation on the prognosis of patients with uterine leiomyosarcoma
Results 3
Cumulative peritoneal recurrence-free survival time C
umul
ativ
e D
isea
se -f
ree
Sur
viva
l
The impact of tumor morcellation on the prognosis of patients with uterine leiomyosarcoma
Results 4
p=0.0804
add 3 recent pts p=0.0677
Characteristics of patients with no tumor recurrence:
No Age (yr)
LMS grading
FIGO Tumor size (cm)
Tumor injury
Follow-up (months)
1 47 G1 IB 16 No 60
2 62 G2 IB 6 intravaginal morcellation
3
3 46 G2 IB 7 Myoma drill 18
4 51 n.d. IB 9 No 3
The impact of tumor morcellation on the prognosis of patients with uterine leiomyosarcoma
Results 5
Limitations of the study
Patient selection criteria !
Referral to tertiary center for metastatic disease
Atypical history, unclear histology, unclear relationship to previous abdominal surgery
Limited follow-up
Conclusions
Intraoperative mechanical damage such as morcellation and use of a myoma drill in unrecognized uterine leiomyosarcoma seems to have a (statistical) significant impact to the onset of intraperitoneal recurrence of the disease.
Conclusions
Preoperative diagnosis of uterine sarcoma and separation from benign leiomyoma is required.
Due to the lack of adequate preoperative diagnostics, surgery often performed as non-oncologic intended procedure
Abandonment of techniques with tumor cell spillage is a must as soon as there is any hint for malignancy.
How to influence surgical data in cancer:
Conclusions
A specimen extraction bag could be the easiest aid to avoid devastating tumor progression.
Influencing surgery (technique + indication) impacts the disease at the early stage
Very much cost-effectivein comparison tochemotherapy for M1PER
How to influence surgical data in cancer: