morcellation

Question 1

What are the risks of morcellation (3)

Answer 1

• Injury to surround structures
• Dissemination - if malignant upstaging the disease and affecting the need for adjutant treatment
• Assessment of pathology - the loss of anatomical relationships may complicate analysis

Question 2

How to safely use Electromechanical morcellation

Answer 2

• Should be resitricted to the use of AGES RANZCOG level 5 and above
• non suspicion of malignancy pre op or periop
• Maintain the tip of the instrument in view at all times
• Caintain control of the specimen at all times
• Feed the specimen into the morcellatory in a controlled manner
• Minimalse spillage fragments when ever possible
• post morcellation retrieve all marcoscopic fragments

Question 3

How to manage risk of dissemination

Answer 3

o need to adequate case selection
o ensure pre op assessment including pap smear, USS, tumor markers if indicated, endometrial sampling, extended imaging
o Patient consent - they must be engaged in the discussion
o Intraoperative assessment is generally poor but if it appears suspicious call for a gynae onc opinion intraop, abandon, use a technique that avoids dissemination eg endopouch or minilaparotomy

Question 4

What is the incidence of leiomyosarcomas

Answer 4

The incidence of leiomyosarcoma (LMS) has been variably quoted at between 0.02 to 0.3%, depending on the study population.

Question 5

Reported demographic risk factors for LMS include: (7)

Answer 5

• Age (mean age of diagnosis: 60)
• Menopausal status
• African American ethnic background
• Current or prior tamoxifen exposure
• History of pelvic Irradiation
• Hereditary Leiomyomatosis and Renal Cell Carcinoma (HLRCC) syndrome
• Survivors of childhood retinoblastoma

Question 6

What is the clinical assessment should make you concerned about LMS?

Answer 6

• Rapidly expanding mass
• Postmenopausal bleeding or variants of abnormal uterine bleeding, in premenopausal women with an unusual pattern
• Ascites
• Lymphadenopathy
• Evidence of secondary spread

Question 7

What are the imaging risk factors for LMS?

6

Answer 7

• Large size or large interval growth
• Tissue signal heterogeneity
• Central necrosis
• Ill-defined margins
• Ascites
• Metastases

Question 8

There are no tumor markers associated with LMS - what one indicator may be elevated ?

Answer 8

LDH indicating cell turn over