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LSH: Ca Risk With Abnormal Bleeding After 40


 

From the Annual Meeting of the AAGL

LAS VEGAS – The overall incidence of malignancy was low among 808 women who underwent laparoscopic supracervical hysterectomy, but those aged 40 years and older with abnormal bleeding were at increased risk.

The findings, which were from a retrospective chart review, suggest that older women who have abnormal bleeding should be considered for total hysterectomy rather than laparoscopic supracervical hysterectomy (LSH) with morcellation. This is especially true for women aged 50 years and older with postmenopausal bleeding, said Dr. Kristal Taylor of the University of Texas, Houston.

LSH with morcellation has been increasing in popularity over the last few decades, given its advantages of less invasiveness, decreased morbidity and mortality, and reduced risk of pelvic floor and sexual dysfunction. However, there is a concern that the morcellation can lead to gross spillage of tumor (if present), resulting in up-staging and possible adverse consequences.

Indeed, in a recent study of 17 patients who were diagnosed with endometrial cancer after supracervical hysterectomy between January 2000 and March 2006, 2 of the 13 who underwent completion surgery were up-staged, both of whom had leiomyosarcoma originally resected with morcellation. No patient who initially underwent supracervical hysterectomy without morcellation was up-staged at the second surgery (Int. J. Gynecol. Cancer 2008;18:1065-70).

There have been no previous reports quantifying the risk of malignancy in LSH in the setting of general practice. Dr. Taylor and her associates reviewed the charts of all consecutive women who underwent planned LSH at the Women's Hospital of Texas, Houston, between Jan. 1, 2002, and Dec. 31, 2008.

The 808 women had a median age of 44 years (range, 23-79 years), body mass index of 27 kg/m

Of the total 808, 96% (777) underwent LSH with or without bilateral salpingo-oophorectomy, whereas the other 31 patients were converted to other types of operations. Adhesions were the most common indication for conversion (17 of the 31).

Endometrial neoplasia was found in 2.5% of the 808 (20 patients), including 13 with endometrial hyperplasia, 3 with hyperplasia confined to a polyp, and 4 with uterine cancer (two endometrial cancers, one leiomyosarcoma, and one stromal carcinoma).

In all, the risk for cancer among the total 808 study population was 0.5%, Dr. Taylor reported.

By age, the incidence of neoplasia (including both hyperplasia and cancer) was 1.9% of the 212 women aged younger than 40 years, and 1.7% of 454 patients aged 40-49 years, compared with 5.6% of the 142 aged 50 years and older. The difference between women aged at least 50 vs. younger than 50 years was statistically significant, with an odds ratio of 3.25 and confidence interval that does not include one, suggesting that the two groups most likely do have different odds of neoplasia.

However, Dr. Taylor noted, “It's a pretty wide confidence interval. … Bottom line, if we had more cases, we might be more confident that the odds are truly greater in the older women.”

Neoplasia was found in 3.1% of the 548 women with abnormal bleeding (either menorrhagia or postmenopausal bleeding), compared with just 1.2% of the 260 without abnormal bleeding. That overall difference was not statistically significant.

But there was a relationship with age. Among the women aged younger than 40 years (none of whom had overt cancer), the risk for neoplasia with abnormal bleeding was 2.2%, compared with 1.4% without abnormal bleeding, an insignificant difference. Similarly, the neoplasia risk among those aged 40-49 (including three with overt cancer) was 2.1% with abnormal bleeding vs. 0.8% without, also not statistically different.

There were 58 patients identified as “menopausal” in a total of 142 who were aged 50 years and older, and there were 77 women aged 50 years and older with abnormal bleeding. In all, 26 women were coded as having postmenopausal bleeding, including 6 who were aged 40-49 years and 20 who were aged 50 and older. No neoplasias were found in the younger group, compared with five (19.2%) in the older group.

Thus, the incidence of neoplasia among women with postmenopausal bleeding was 25% (5 of 20) for those aged 50 and older vs. 0% (0 of 6) for those younger than 50. Among those aged 50 and older, the risk for neoplasia among those with abnormal bleeding was 9.1% (7 of 77), compared with just 1.5% for those without abnormal bleeding (1 of 65). Here, the difference between those aged at least 50 vs. younger than 50 was not statistically significant, but did represent a strong trend, Dr. Taylor said.

Of the total eight women aged 50 and older with neoplasia, six had hyperplasia, one had a polyp with hyperplasia, and one had overt cancer, she reported.

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