Hysterectomy

Uterine-preserving treatments or hysterectomy reintervention after myomectomy or uterine artery embolization: a retrospective cohort study of long-term outcomes

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Abstract

Objective

To assess comparative rates of further uterine-preserving procedures (UPP) or hysterectomy reintervention, after myomectomy or uterine artery embolization (UAE)

Design

Population-based, retrospective cohort study

Setting

England

Population

Women who underwent myomectomy or UAE between 2010 and 2015 under the NHS.

Methods

Data was abstracted from NHS Health Episode Statistics datasets. Hazard ratios with 95% CIs were calculated using Cox proportional-hazards regression.

Main outcomes measures

30-day readmission, UPP and hysterectomy reintervention rates

Results

9443 and 6224 women underwent elective myomectomy or UAE, respectively. After 118136 total person years of follow-up, the rate of hysterectomy was 8.34 and 20.98 per 1000 patient years, for myomectomy or UAE, respectively. There was a 2.4-fold increased risk of undergoing hysterectomy after UAE when compared to myomectomy in adjusted models (HR 2.38 (2.10 – 2.66)) [adjusted for age, ethnicity, multiple deprivation index, geographical region and co-morbidities]. The hazard ratio for undergoing a UPP reintervention was 1.44 (1.29 – 1.60) in favour of myomectomy. The rate of hysterectomy was increased 22% following UAE compared to laparoscopic myomectomy (0.97 – 1.52). Age may influence reintervention rates, and there was variation in hysterectomy risk when stratified by geographical region.

Conclusions

After a median of seven years of follow-up, there is a 2.4-fold increased rate of hysterectomy and 44% increased risk of UPPs as reintervention after UAE, relative to myomectomy. These findings will aid pre-procedure counselling for women with fibroids. Future work should investigate the effect of other outcome modifiers, such as fertility intentions and fibroid anatomical characteristics.

Source: BJOG

Thyroid cancer risk increases with hysterectomy

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Among postmenopausal women, the risk for thyroid cancer is increased with hysterectomy regardless of oophorectomy status, according to recently published data.

Use of exogenous estrogen was associated with lower risk for thyroid cancer in women who had undergone hysterectomy without oophorectomy, particularly for those with long duration use of hormone therapy, researchers wrote.

Juhua Luo, PhD, associate professor in the department of epidemiology and biostatistics at the School of Public Health, Indiana University Bloomington, and colleagues evaluated data from the Women’s Health Initiative on 127,566 women aged 50 to 79 years who were enrolled between 1993 and 1998 to determine the relationships between hysterectomy, bilateral salpingo-oophorectomy and thyroid cancer incidence. Follow-up was a mean 14.4 years.

At baseline, 36.7% of women had undergone hysterectomy, and 55% of them had bilateral salpingo-oophorectomy. Through follow-up, 344 participants developed thyroid cancer.

An increased risk for thyroid cancer was related to hysterectomy, regardless of ovarian status (HR = 1.46; 95% CI, 1.16-1.85). A similar increased risk for thyroid cancer was found in participants with hysterectomy alone and participants with hysterectomy plus bilateral salpingo-oophorectomy compared with participants without hysterectomy.

The risk for thyroid cancer was not associated with HT use in participants without hysterectomy and participants with hysterectomy plus bilateral salpingo-oophorectomy, but HT use in participants with hysterectomy alone was associated with a significantly lower risk for thyroid cancer (HR = 0.47; 95% CI, 0.28-0.78). This was especially pronounced in participants using HT for 10 or more years (HR = 0.24; 95% CI, 0.11-0.52).

Compared with participants without hysterectomy, participants with hysterectomy had an increased risk for thyroid cancer (HR = 1.78; 95% CI, 1.33-2.37).

“Our large prospective study observed that hysterectomy regardless of oophorectomy status was associated with increased risk of thyroid cancer among postmenopausal women,” the researchers wrote. “[HT] use was associated with lower or no risk of thyroid cancer. These findings did not support that exogenous estrogen is a risk factor and estrogen deprivation is a protective factor for thyroid cancer. Our study suggests that when deciding to remove the uterus for benign conditions, possible increased risk of thyroid cancer should be considered.” – by Amber Cox

Vaginal Bleeding.

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Vaginal-Bleeding

70-year-old woman was seen in this hospital because of vaginal bleeding. An endometrial-biopsy specimen showed a poorly differentiated malignant neoplasm that was suggestive of mixed müllerian tumor (carcinosarcoma). A diagnostic and therapeutic procedure was performed.

The underlying cause of abnormal vaginal bleeding is age-dependent. Ten percent of premenopausal women with abnormal bleeding have a malignant tumor. In contrast, 75% of women over 70 years of age with postmenopausal bleeding have cancer, and the risk rises with age in postmenopausal women.

Clinical Pearls

• What is the typical presentation of carcinosarcoma of the uterus?

Postmenopausal vaginal bleeding is the most common manifestation of carcinosarcoma. Patients with carcinosarcoma also frequently present with the classic triad of painful postmenopausal bleeding, an enlarged uterus, and prolapsed tumor visible at the cervical os.

• Under what circumstances is surgery not the primary treatment for uterine cancer?

In only a few circumstances is surgery not the primary treatment for uterine cancer — when there is a desire to preserve fertility, high operative risk, and unresectable disease. The goals of surgical treatment are excision of all disease with at least a 1-cm margin and staging of the tumor. The initial spread is to regional lymph nodes; therefore, standard treatment is a radical total abdominal hysterectomy and bilateral salpingo-oophorectomy with lymphadenectomy. Endometrial cancers have several potential patterns of spread: direct invasion and expansion of the primary tumor, lymphatic invasion, hematogenous spread, and intraperitoneal dissemination. Because metastasis is common, preoperative combination positron-emission tomography and computed tomography (PET-CT) and a meticulous exploratory laparotomy are standard practice.

Morning Report Questions

Q: What features affect the overall prognosis of patients with carcinosarcoma?

A: Diagnostic features of malignant mixed mullerian tumor (carcinosarcoma) include the finding of a biphasic malignant tumor that is composed of high-grade carcinoma (most commonly endometrioid or serous) and sarcoma and is typically homologous (arising from mesenchymal tissue normally found in the uterus), although in up to 50% of cases, the tumor has a heterologous component (most commonly rhabdomyosarcoma or chondrosarcoma). There is no transition between the two components. Tumor stage is the most important prognostic factor in these tumors, although histologic features also affect outcome. The finding of serous or clear-cell carcinoma is associated with a more aggressive course. Sarcomatous components adversely affect the overall prognosis of patients with stage I tumors (5-year survival is 30% among patients with heterologous elements as compared with 80% among patients with homologous elements); myometrial and lymphovascular invasion are also associated with a poor prognosis.

Q: What are the treatment options for carcinosarcoma?

A: Carcinosarcoma is thought to require multiple methods of treatment. Radiation therapy has been shown to reduce the rates of local recurrence in the pelvis but does not increase the survival benefit among patients with carcinosarcoma. Adjuvant chemotherapy has not been shown to have an effect on recurrence rates or progression-free or overall survival among patients with carcinosarcoma. Hormonal therapy is of no use, since estrogen and progesterone receptors do not control tumor growth, even though they are typically present in patients with carcinosarcoma.

 

Sorce: NEJM

Cervical Cancer Screening Rates Encouraging, but Show Some Inappropriate Use .

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Declining rates of cervical cancer screening over the past decade are bringing clinical practice more in line with current guidelines; however, many women who’ve undergone hysterectomy are being screened unnecessarily, according to articles in MMWR.

A CDC analysis of young women‘s Papanicolaou screening histories based on telephone interviews found that in the 18–21 age group (a group not recommended to undergo screening) the proportion reporting never having undergone screening rose from 26% to 48% between 2000 and 2010. However, in the 22–30 group (which should undergo screening every 3 years) the proportion reporting never being screened rose from 6.6% to 9.0% over the decade.

A similar study among women aged 30 and older found a similar trend toward guideline goals. The exceptions were the estimated 20 million women who had undergone hysterectomy for benign causes but who nonetheless underwent unneeded screening over the course of the decade.

Source: MMWR