Examination of the use of needle biopsy to perform laparoscopic surgery safely on uterine smooth muscle tumors

Abstract

The warning statement issued by the United States Food and Drug Administration against the use of laparoscopic power morcellators prompted a discussion about the methods of preoperative diagnosis of uterine myometrial lesions. Since 1994, transcervical needle biopsies have been performed to differentiate between uterine leiomyomas and leiomyosarcomas. Needle biopsies are also useful for performing laparoscopic surgery on uterine smooth muscle tumors with histopathological safety. In the present study, data from hematoxylin and eosin (HE)-stained specimens obtained by transcervical needle biopsies from 331 patients with smooth muscle tumors and high intensity regions on T1 weighted images (WI) and/or T2WI from magnetic resonance imaging (MRI) scans were retrospectively examined. From a total of 10 patients with moderate or severe cytological atypia, 4 exhibited smooth muscle tumors of uncertain malignant potential and 6 exhibited leiomyosarcomas. The final diagnosis in 3 patients with ≥10 mitotic figures/high-power field was leiomyosarcoma. A total of 5 patients with coagulative tumor cell necrosis exhibited final diagnoses of leiomyosarcoma. Patients without cytological atypia, mitotic figures or coagulative tumor cell necrosis were not diagnosed with either leiomyosarcomas or smooth muscle tumors of uncertain malignant potential. The present study revealed that laparoscopic surgery is safe when HE-stained specimens obtained by transcervical needle biopsy from areas of high intensity on an MRI scan are negative for all three criteria assessed-cytological atypia, mitotic figures and coagulative tumor cell necrosis.

Keywords: histopathologically safe; laparoscopic surgery; leiomyosarcoma; needle biopsy; uterine smooth muscle tumors.

Figure 1.

Tumors identified as exhibiting cytological atypia and/or mitotic figures and/or coagulative tumor cell necrosis classified according to final diagnoses. The values indicate the number of cases in each category. S, severe; Mo, moderate; Mi, mild; Po, positive; Su, suspicious; LMS, leiomyosarcoma; STUMP, smooth muscle tumor of uncertain malignant potential; LM, leiomyoma; CTCN, coagulative tumor cell necrosis.

Figure 2.

Allocation of tumors with cytological atypia into 4 groups based on the degree of atypia shown as % of diagnosis in each group. LMS, leiomyosarcoma; STUMP, smooth muscle tumor of uncertain malignant potential; LM, leiomyoma

Figure 3.

Allocation of tumors with mitotic figures to 3 groups based on mitotic count shown as the percent of diagnoses in each group. The Mann-Whitney U test was used to ascertain the significances of differences in mitotic count. LMS, leiomyosarcoma; STUMP, smooth muscle tumor of uncertain malignant potential; LM, leiomyoma. *P<0.05.

Figure 4.

Allocation of tumors with coagulative tumor cell necrosis to 3 groups based on the presence or absence of coagulative tumor cell necrosis shown as % of diagnosis in each group. LMS, leiomyosarcoma; STUMP, smooth muscle tumor of uncertain malignant potential; LM, leiomyoma.

Figure 5.

(A) CTCN positive: CTCN was characterized by an abrupt transition from viable cells to ghost cells without an interposed zone of granulation tissue or hyalinized tissue between the viable and necrotic cells. Magnification, ×4. (B) CTCN suspicious: Presence of ghost cells with an unclear abrupt transition. Magnification, ×20. (C) CTCN negative: Hyalinization only. Magnification, ×4. CTCN, coagulative tumor cell necrosis.

Figure 6.

Proposed algorithm for indications for laparoscopic surgery by transcervical needle biopsy. CD34(+), >10 CD34-stained vessels in necrotic areas; CD34(−), <10 CD34-positive vessels in necrotic areas. CD, cluster of differentiation; CTCN, coagulative tumor cell necrosis; CA, cytological atypia.