Sarcoma of the Uterus. Guideline of the DGGG and OEGGG (S2k Level, AWMF Register Number 015/074, February 2019)

Dominik Denschlag; Sven Ackermann; Marco Johannes Battista; Wolfgang Cremer; Gerlinde Egerer; Markus Follmann; Heidemarie Haas; Philipp Harter; Simone Hettmer; Lars-Christian Horn; Ingolf Juhasz-Boess; Karin Kast; Günter Köhler; Thomas Kröncke; Katja Lindel; Peter Mallmann; Regine Meyer-Steinacker; Alexander Mustea; Edgar Petru; Peter Reichardt; Dietmar Schmidt; Hans-Georg Strauss; Clemens Tempfer; Falk Thiel; Uwe Ulrich; Thomas Vogl; Dirk Vordermark; Paul Gass; Matthias W. Beckmann

doi:10.1055/a-0882-4116

Geburtshilfe und Frauenheilkunde, Table of Contents

Geburtshilfe Frauenheilkd 2019; 79(10): 1043-1060
DOI: 10.1055/a-0882-4116

GebFra Science

Guideline/Leitlinie

Georg Thieme Verlag KG Stuttgart · New York

Sarcoma of the Uterus. Guideline of the DGGG and OEGGG (S2k Level, AWMF Register Number 015/074, February 2019)

Article in several languages: English | deutsch

Dominik Denschlag

¹Frauenklinik, Hochtaunuskliniken Bad Homburg, Bad Homburg, Germany

,

Sven Ackermann

²Frauenklinik, Klinikum Darmstadt, Darmstadt, Germany

,

Marco Johannes Battista

³Universitätsmedizin Mainz, Klinik und Poliklinik für Geburtshilfe und Frauengesundheit, Mainz, Germany

,

Wolfgang Cremer

⁴Berufsverband der Frauenärzte, Hamburg, Germany

,

Gerlinde Egerer

⁵Universitätsklinik Heidelberg, Heidelberg, Germany

,

Markus Follmann

⁶Deutsche Krebsgesellschaft, Berlin, Germany

,

Heidemarie Haas

⁷Frauenselbsthilfe nach Krebs e. V., Erlangen, Germany

,

Philipp Harter

⁸Klinik für Gynäkologie und Gynäkologische Onkologie, Kliniken Essen Mitte, Essen, Germany

,

Simone Hettmer

⁹Universitätsklinik Freiburg, Freiburg, Germany

,

Lars-Christian Horn

¹⁰Abteilung für Mamma-, Urogenital, und Perinatalpathologie, Institut für Pathologie, Universitätsklinikum Leipzig, Leipzig, Germany

,

Ingolf Juhasz-Boess

¹¹Klinik für Gynäkologie, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany

,

Karin Kast

¹²Universitätsklinik Dresden, Dresden, Germany

,

Günter Köhler

¹³Deutsches klinisches Kompetenzzentrum für genitale Sarkome und Mischtumoren, Universitätsmedizin Greifswald, Greifswald, Germany

,

Thomas Kröncke

¹⁴Klinik für Radiologie, Klinikum Augsburg, Augsburg, Germany

,

Katja Lindel

¹⁵Klinik für Radioonkologie, Klinikum Karlsruhe, Karlsruhe, Germany

,

Peter Mallmann

¹⁶Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Köln, Köln, Germany

,

Regine Meyer-Steinacker

¹⁷Universitätsklinik Ulm, Ulm, Germany

,

Alexander Mustea

¹⁸Universitäts-Frauenklinik Greifswald, Greifswald, Germany

,

Edgar Petru

¹⁹Universitäts-Frauenklinik Graz, Graz, Austria

,

Peter Reichardt

²⁰Klinik für interdisziplinäre Onkologie, Helios Kliniken Berlin-Buch, Berlin, Germany

,

Dietmar Schmidt

²¹Institut für Pathologie Viersen, Viersen, Germany

,

Hans-Georg Strauss

²²Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Halle, Halle/Saale, Germany

,

Clemens Tempfer

²³Universitäts-Frauenklinik Bochum, Bochum, Germany

,

Falk Thiel

²⁴Frauenklinik, Alb Fils Kliniken, Göppingen, Germany

,

Uwe Ulrich

²⁵Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus Berlin, Paul Gerhardt Diakonie, Berlin, Germany

,

Thomas Vogl

²⁶Institut für diagnostische und interventionelle Radiologie, Universitätsklinikum Frankfurt, Frankfurt/Main, Germany

,

Dirk Vordermark

²⁷Universitätsklinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle, Halle/Saale, Germany

,

Paul Gass

²⁸Frauenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; Comprehensive Cancer Center (CCC) Erlangen-EMN, Erlangen, Germany

,

Matthias W. Beckmann

²⁸Frauenklinik, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg; Comprehensive Cancer Center (CCC) Erlangen-EMN, Erlangen, Germany

› Author Affiliations

Abstract

Aims This is an official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). Because of their rarity and heterogeneous histopathology, uterine sarcomas are challenging in terms of how they should be managed clinically, and treatment requires a multidisciplinary approach. To our knowledge, there are currently no binding evidence-based recommendations for the appropriate management of this heterogeneous group of tumors.

Methods This S2k guideline was first published in 2015. The update published here is the result of the consensus of a representative interdisciplinary group of experts who carried out a systematic search of the literature on uterine sarcomas in the context of the guidelines program of the DGGG, OEGGG and SGGG. Members of the participating professional societies achieved a formal consensus after a moderated structured consensus process.

Recommendations The consensus-based recommendations and statements include the epidemiology, classification, staging, symptoms, general diagnostic work-up and general pathology of uterine sarcomas as well as the genetic predisposition to develop uterine sarcomas. Also included are statements on the management of leiomyosarcomas, (low and high-grade) endometrial stromal sarcomas and undifferentiated uterine sarcomas and adenosarcomas. Finally, the guideline considers the follow-up and morcellation of uterine sarcomas and the information provided to patients.

Key words

uterine sarcoma - leiomyosarcoma - endometrial stromal sarcoma - adenosarcoma - morcellation

Full Text

References

References/Literatur
1 Wittekind C, Meyer HJ. TNM-Klassifikation maligner Tumoren. Weinheim: Wiley-VHC Verlag; 2010
2 Oliva E, Carcangiu ML, Carinelli SG, Ip P, Loening T, Longacre TA, Nucci MR, Prat J, Zaloudek CJ. Mesenchymal Tumors of the Uterus. In: Kurman RJ, Carcangiu ML, Herrington CS, Young RH. eds. WHO Classification of Tumours of female reproductive Tract. Lyon: IARC Press; 2014: 135-147
3 Conklin CM, Longacre TA. Endometrial stromal tumors: the new WHO classification. Adv Anat Pathol 2014; 21: 383-393
4 Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F. WHO Classification of soft Tissue and Bone. Lyon: IARC Press; 2013
5 McCluggage WG. Malignant biphasic uterine tumours: carcinosarcomas or metaplastic carcinomas?. J Clin Pathol 2002; 55: 321-325
6 Lopez-Garcia MA, Palacios J. Pathologic and molecular features of uterine carcinosarcomas. Semin Diagn Pathol 2010; 27: 274-286
7 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF). Diagnostik, Therapie und Nachsorge der Patientinnen mit Endometriumkarzinom, Langversion 1.0, 2018, AWMF Registernummer: 032/034-OL. Online: http://www.leitlinienprogramm-onkologie.de/leitlinien/endometriumkarzinom/ last access: 03.06.2019
8 Buttram jr. VC, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981; 36: 433-445
9 Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994; 83: 414-418
10 Amant F, Coosemans A, Debiec-Rychter M. et al. Clinical management of uterine sarcomas. Lancet Oncol 2009; 10: 1188-1198
11 Coffey D, Kaplan AL, Ramzy I. Intraoperative consultation in gynecologic pathology. Arch Pathol Lab Med 2005; 129: 1544-1557
12 Otis CN, Ocampo AC, Nucci MR. et al. Protocol for the Examination of Specimens From Patients With Sarcoma. 2013. Online: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2013/UterineSarcomaProtocol_3000.pdf last access: 27.08.2018
13 McCluggage WG, Fisher C, Hirschowitz L. Dataset for histological reporting of uterine sarcomas. 2014. Online: http://www.rcpath.org/publications-media/publications/datasets/uterine-sarcomas last access: 27.08.2018
14 Koivisto-Korander R, Martinsen JI, Weiderpass E. et al. Incidence of uterine leiomyosarcoma and endometrial stromal sarcoma in Nordic countries: results from NORDCAN and NOCCA databases. Maturitas 2012; 72: 56-60
15 Zaloudek CJ, Hendrickson MR, Soslow RA. Mesenchymal Tumors of the Uterus. In: Kurman RJ, Hedrick Ellenson L, Ronnett BM. eds. Blausteinʼs Pathology of the female genital Tract. 6th ed. New York, Dodrecht, Heidelberg, London: Springer; 2011
16 Skorstad M, Kent A, Lieng M. Preoperative evaluation in women with uterine leiomyosarcoma. A nationwide cohort study. Acta Obstet Gynecol Scand 2016; 95: 1228-1234
17 Oliva E. Cellular mesenchymal tumors of the uterus: a review emphasizing recent observations. Int J Gynecol Pathol 2014; 33: 374-384
18 Clement PB. The pathology of uterine smooth muscle tumors and mixed endometrial stromal-smooth muscle tumors: a selective review with emphasis on recent advances. Int J Gynecol Pathol 2000; 19: 39-55
19 DʼAngelo E, Prat J. Uterine sarcomas: a review. Gynecol Oncol 2010; 116: 131-139
20 Ip PP, Cheung AN. Pathology of uterine leiomyosarcomas and smooth muscle tumours of uncertain malignant potential. Best Pract Res Clin Obstet Gynaecol 2011; 25: 691-704
21 Ly A, Mills AM, McKenney JK. et al. Atypical leiomyomas of the uterus: a clinicopathologic study of 51 cases. Am J Surg Pathol 2013; 37: 643-649
22 Hart WR. Symposium 2: mesenchymal lesions of the uterus. Histopathology 2002; 41: 12-31
23 Toledo G, Oliva E. Smooth muscle tumors of the uterus: a practical approach. Arch Pathol Lab Med 2008; 132: 595-605
24 Pelmus M, Penault-Llorca F, Guillou L. et al. Prognostic factors in early-stage leiomyosarcoma of the uterus. Int J Gynecol Cancer 2009; 19: 385-390
25 Iasonos A, Keung EZ, Zivanovic O. et al. External validation of a prognostic nomogram for overall survival in women with uterine leiomyosarcoma. Cancer 2013; 119: 1816-1822
26 Garg G, Shah JP, Kumar S. et al. Ovarian and uterine carcinosarcomas: a comparative analysis of prognostic variables and survival outcomes. Int J Gynecol Cancer 2010; 20: 888-894
27 Pritts EA, Parker WH, Brown J. et al. Outcome of occult uterine leiomyosarcoma after surgery for presumed uterine fibroids: a systematic review. J Minim Invasive Gynecol 2015; 22: 26-33
28 Kapp DS, Shin JY, Chan JK. Prognostic factors and survival in 1396 patients with uterine leiomyosarcomas: emphasis on impact of lymphadenectomy and oophorectomy. Cancer 2008; 112: 820-830
29 Nasioudis D, Chapman-Davis E, Frey M. et al. Safety of ovarian preservation in premenopausal women with stage I uterine sarcoma. J Gynecol Oncol 2017; 28: e46
30 Leitao MM, Sonoda Y, Brennan MF. et al. Incidence of lymph node and ovarian metastases in leiomyosarcoma of the uterus. Gynecol Oncol 2003; 91: 209-212
31 Seagle BL, Sobecki-Rausch J, Strohl AE. et al. Prognosis and treatment of uterine leiomyosarcoma: A National Cancer Database study. Gynecol Oncol 2017; 145: 61-70
32 Bogani G, Fuca G, Maltese G. et al. Efficacy of adjuvant chemotherapy in early stage uterine leiomyosarcoma: A systematic review and meta-analysis. Gynecol Oncol 2016; 143: 443-447
33 Pautier P, Floquet A, Gladieff L. et al. A randomized clinical trial of adjuvant chemotherapy with doxorubicin, ifosfamide, and cisplatin followed by radiotherapy versus radiotherapy alone in patients with localized uterine sarcomas (SARCGYN study). A study of the French Sarcoma Group. Ann Oncol 2013; 24: 1099-1104
34 Hensley ML, Ishill N, Soslow R. et al. Adjuvant gemcitabine plus docetaxel for completely resected stages I–IV high grade uterine leiomyosarcoma: Results of a prospective study. Gynecol Oncol 2009; 112: 563-567
35 Hensley ML, Wathen JK, Maki RG. et al. Adjuvant therapy for high-grade, uterus-limited leiomyosarcoma: results of a phase 2 trial (SARC 005). Cancer 2013; 119: 1555-1561
36 Reed NS, Mangioni C, Malmström H. et al. European Organisation for Research and Treatment of Cancer Gynaecological Cancer Group. Phase III randomised study to evaluate the role of adjuvant pelvic radiotherapy in the treatment of uterine sarcomas stages I and II: an European Organisation for Research and Treatment of Cancer Gynaecological Cancer Group Study (protocol 55874). Eur J Cancer 2008; 44: 808-818
37 Bernstein-Molho R, Grisaro D, Soyfer V. et al. Metastatic uterine leiomyosarcomas: a single-institution experience. Int J Gynecol Cancer 2010; 20: 255-260
38 Leitao MM, Brennan MF, Hensley M. et al. Surgical resection of pulmonary and extrapulmonary recurrences of uterine leiomyosarcoma. Gynecol Oncol 2002; 87: 287-294
39 Levenback C, Rubin SC, McCormack PM. et al. Resection of pulmonary metastases from uterine sarcomas. Gynecol Oncol 1992; 45: 202-205
40 Weiser MR, Downey RJ, Leung DH. et al. Repeat resection of pulmonary metastases in patients with soft-tissue sarcoma. J Am Coll Surg 2000; 191: 184-190 discussion 190-191
41 Giuntoli 2nd RL, Garrett-Mayer E, Bristow RE. et al. Secondary cytoreduction in the management of recurrent uterine leiomyosarcoma. Gynecol Oncol 2007; 106: 82-88
42 Sutton GP, Blessing JA, Barrett RJ. et al. Phase II trial of ifosfamide and mesna in leiomyosarcoma of the uterus: a Gynecologic Oncology Group study. Am J Obstet Gynecol 1992; 166: 556-559
43 Look KY, Sandler A, Blessing JA. et al. Gynecologic Oncology Group (GOG) Study. Phase II trial of gemcitabine as second-line chemotherapy of uterine leiomyosarcoma: a Gynecologic Oncology Group (GOG) Study. Gynecol Oncol 2004; 92: 644-647
44 Thigpen T, Blessing JA, Yordan E. et al. Phase II trial of etoposide in leiomyosarcoma of the uterus: a Gynecologic Oncology Group study. Gynecol Oncol 1996; 63: 120-122
45 Rose PG, Blessing JA, Soper JT. et al. Prolonged oral etoposide in recurrent or advanced leiomyosarcoma of the uterus: a gynecologic oncology group study. Gynecol Oncol 1998; 70: 267-271
46 Miller DS, Blessing JA, Kilgore LC. et al. Phase II trial of topotecan in patients with advanced, persistent, or recurrent uterine leiomyosarcomas: a Gynecologic Oncology Group Study. Am J Clin Oncol 2000; 23: 355-357
47 Gallup DG, Blessing JA, Andersen W. et al. Gynecologic Oncology Group Study. Evaluation of paclitaxel in previously treated leiomyosarcoma of the uterus: a gynecologic oncology group study. Gynecol Oncol 2003; 89: 48-51
48 Sutton G, Blessing JA, Malfetano JH. Ifosfamide and doxorubicin in the treatment of advanced leiomyosarcomas of the uterus: a Gynecologic Oncology Group study. Gynecol Oncol 1996; 62: 226-229
49 Hensley ML, Maki R, Venkatraman E. et al. Gemcitabine and docetaxel in patients with unresectable leiomyosarcoma: results of a phase II trial. J Clin Oncol 2002; 20: 2824-2831
50 Gupta AA, Yao X, Verma S. et al. Sarcoma Disease Site Group and the Gynecology Cancer Disease Site Group. Systematic chemotherapy for inoperable, locally advanced, recurrent, or metastatic uterine leiomyosarcoma: a systematic review. Clin Oncol (R Coll Radiol) 2013; 25: 346-355
51 Maki RG, Wathen JK, Patel SR. et al. Randomized phase II study of gemcitabine and docetaxel compared with gemcitabine alone in patients with metastatic soft tissue sarcomas: results of sarcoma alliance for research through collaboration study 002 [corrected]. J Clin Oncol 2007; 25: 2755-2763
52 Pautier P, Floquet A, Penel N. et al. Randomized multicenter and stratified phase II study of gemcitabine alone versus gemcitabine and docetaxel in patients with metastatic or relapsed leiomyosarcomas: a Federation Nationale des Centres de Lutte Contre le Cancer (FNCLCC) French Sarcoma Group Study (TAXOGEM study). Oncologist 2012; 17: 1213-1220
53 Seddon B, Strauss SJ, Whelan J. et al. Gemcitabine and docetaxel versus doxorubicin as first-line treatment in previously untreated advanced unresectable or metastatic soft-tissue sarcomas (GeDDiS): a randomised controlled phase 3 trial. Lancet Oncol 2017; 18: 1397-1410
54 Demetri GD, Chawla SP, von Mehren M. et al. Efficacy and safety of trabectedin in patients with advanced or metastatic liposarcoma or leiomyosarcoma after failure of prior anthracyclines and ifosfamide: results of a randomized phase II study of two different schedules. J Clin Oncol 2009; 27: 4188-4196
55 van der Graaf WT, Blay JY, Chawla SP. et al. EORTC Soft Tissue and Bone Sarcoma Group; PALETTE study group. Pazopanib for metastatic soft-tissue sarcoma (PALETTE): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet 2012; 379: 1879-1886
56 Chew I, Oliva E. Endometrial stromal sarcomas: a review of potential prognostic factors. Adv Anat Pathol 2010; 17: 113-121
57 Chang KL, Crabtree GS, Lim-Tan SK. et al. Primary uterine endometrial stromal neoplasms. A clinicopathologic study of 117 cases. Am J Surg Pathol 1990; 14: 415-438
58 Barney B, Tward JD, Skidmore T. et al. Does radiotherapy or lymphadenectomy improve survival in endometrial stromal sarcoma?. Int J Gynecol Cancer 2009; 19: 1232-1238
59 Park JY, Baek MH, Park Y. et al. Investigation of hormone receptor expression and its prognostic value in endometrial stromal sarcoma. Virchows Arch 2018; 473: 61-69
60 Chu MC, Mor G, Lim C. et al. Low-grade endometrial stromal sarcoma: hormonal aspects. Gynecol Oncol 2003; 90: 170-176
61 Einstein MH, Barakat RR, Chi DS. et al. Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. Int J Gynecol Cancer 2008; 18: 1065-1070
62 Chan JK, Kawar NM, Shin JY. et al. Endometrial stromal sarcoma: a population-based analysis. Br J Cancer 2008; 99: 1210-1215
63 Bai H, Yang J, Cao D. et al. Ovary and uterus-sparing procedures for low-grade endometrial stromal sarcoma: a retrospective study of 153 cases. Gynecol Oncol 2014; 132: 654-660
64 Shah JP, Bryant CS, Kumar S. et al. Lymphadenectomy and ovarian preservation in low-grade endometrial stromal sarcoma. Obstet Gynecol 2008; 112: 1102-1108
65 Si M, Jia L, Song K. et al. Role of Lymphadenectomy for Uterine Sarcoma: A Meta-Analysis. Int J Gynecol Cancer 2017; 27: 109-116
66 Gadducci A, Cosio S, Romanini A. et al. The management of patients with uterine sarcoma: a debated clinical challenge. Crit Rev Oncol Hematol 2008; 65: 129-142
67 Yamaguchi M, Erdenebaatar C, Saito F. et al. Long-Term Outcome of Aromatase Inhibitor Therapy With Letrozole in Patients With Advanced Low-Grade Endometrial Stromal Sarcoma. Int J Gynecol Cancer 2015; 25: 1645-1651
68 Amant F, De Knijf A, Van Calster B. et al. Clinical study investigating the role of lymphadenectomy, surgical castration and adjuvant hormonal treatment in endometrial stromal sarcoma. Br J Cancer 2007; 97: 1194-1199
69 Sampath S, Schultheiss TE, Ryu JK. et al. The role of adjuvant radiation in uterine sarcomas. Int J Radiat Oncol Biol Phys 2010; 76: 728-734
70 Piver MS, Rutledge FN, Copeland L. et al. Uterine endolymphatic stromal myosis: a collaborative study. Obstet Gynecol 1984; 64: 173-178
71 Nam JH. Surgical treatment of uterine sarcoma. Best Pract Res Clin Obstet Gynaecol 2011; 25: 751-760
72 Weitmann HD, Knocke TH, Kucera H. et al. Radiation therapy in the treatment of endometrial stromal sarcoma. Int J Radiat Oncol Biol Phys 2001; 49: 739-748
73 Kortmann B, Reimer T, Gerber B. et al. Concurrent radiochemotherapy of locally recurrent or advanced sarcomas of the uterus. Strahlenther Onkol 2006; 182: 318-324
74 Cheng X, Yang G, Schmeler KM. et al. Recurrence patterns and prognosis of endometrial stromal sarcoma and the potential of tyrosine kinase-inhibiting therapy. Gynecol Oncol 2011; 121: 323-327
75 Dahhan T, Fons G, Buist MR. et al. The efficacy of hormonal treatment for residual or recurrent low-grade endometrial stromal sarcoma. A retrospective study. Eur J Obstet Gynecol Reprod Biol 2009; 144: 80-84
76 Maluf FC, Sabbatini P, Schwartz L. et al. Endometrial stromal sarcoma: objective response to letrozole. Gynecol Oncol 2001; 82: 384-388
77 Pink D, Lindner T, Mrozek A. et al. Harm or benefit of hormonal treatment in metastatic low-grade endometrial stromal sarcoma: single center experience with 10 cases and review of the literature. Gynecol Oncol 2006; 101: 464-469
78 Thanopoulou E, Aleksic A, Thway K. et al. Hormonal treatments in metastatic endometrial stromal sarcomas: the 10-year experience of the sarcoma unit of Royal Marsden Hospital. Clin Sarcoma Res 2015; 5: 8
79 Hendrickson MA, Tavassoli FA, Kempson RL, McCluggage WG, Haller U, Kubik-Huch RA. Mesenchymal Tumors and related Lesions. In: Tavassoli FA, Devilee P. eds. Pathology and Genetics of Tumours of the Breast and female genital Organs World Health Organization Classification of Tumours. IARC Press; 2003: 233-249 Online: https://www.iarc.fr/wp-content/uploads/2018/07/BB4.pdf last access: 03.06.2019
80 Benson C, Miah AB. Uterine sarcoma – current perspectives. Int J Womens Health 2017; 9: 597-606
81 Malouf GG, Lhomme C, Duvillard P. et al. Prognostic factors and outcome of undifferentiated endometrial sarcoma treated by multimodal therapy. Int J Gynaecol Obstet 2013; 122: 57-61
82 Tanner EJ, Garg K, Leitao jr. MM. et al. High grade undifferentiated uterine sarcoma: surgery, treatment, and survival outcomes. Gynecol Oncol 2012; 127: 27-31
83 Schick U, Bolukbasi Y, Thariat J. et al. Outcome and prognostic factors in endometrial stromal tumors: a Rare Cancer Network study. Int J Radiat Oncol Biol Phys 2012; 82: e757-e763
84 Baniak N, Adams S, Lee CH. et al. Extrapelvic Metastases in Endometrial Stromal Sarcomas: A Clinicopathological Review With Immunohistochemical and Molecular Characterization. Int J Surg Pathol 2019; 27: 208-215 doi:10.1177/1066896918794278
85 Fleming NA, Hopkins L, de Nanassy J. et al. Mullerian adenosarcoma of the cervix in a 10-year-old girl: case report and review of the literature. J Pediatr Adolesc Gynecol 2009; 22: e45-e51
86 McCluggage WG. Mullerian adenosarcoma of the female genital tract. Adv Anat Pathol 2010; 17: 122-129
87 Wells M, Oliva E, Palacios J, Prat J. Mixed epithelial and mesenchymal Tumors of the Uterus. In: Kurman RJ, Carcangiu ML, Herrington CS, Young RH. eds. WHO Classification of Tumours of female reproductive Tract. Lyon: IARC Press; 2014: 148-151
88 McCluggage WG, Fisher C, Hirschowitz L. Dataset for histological reporting of uterine sarcomas. 2016. Online: http://www.rcpath.org/publications-media/publications/datasets/uterine-sarcomas last access: 27.08.2018
89 Seagle BL, Kanis M, Strohl AE. et al. Survival of women with Mullerian adenosarcoma: A National Cancer Data Base study. Gynecol Oncol 2016; 143: 636-641
90 Tanner EJ, Toussaint T, Leitao jr. MM. et al. Management of uterine adenosarcomas with and without sarcomatous overgrowth. Gynecol Oncol 2013; 129: 140-144
91 Beckmann MW, Juhasz-Boss I, Denschlag D. et al. Surgical Methods for the Treatment of Uterine Fibroids – Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG. Geburtsh Frauenheilk 2015; 75: 148-164
92 Brohl AS, Li L, Andikyan V. et al. Age-stratified risk of unexpected uterine sarcoma following surgery for presumed benign leiomyoma. Oncologist 2015; 20: 433-439
93 Kundu S, Zachen M, Hertel H. et al. Sarcoma Risk in Uterine Surgery in a Tertiary University Hospital in Germany. Int J Gynecol Cancer 2017; 27: 961-966
94 Bojahr B, De Wilde RL, Tchartchian G. Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH). Arch Gynecol Obstet 2015; 292: 665-672
95 [Anonym] Statement of the Society of Gynecologic Oncology to the Food and Drug Administrationʼs Obstetrics and Gynecology Medical Devices Advisory Committee Concerning Safety of Laparoscopic Power Morcellation. 2014. Online: https://www.sgo.org/wp-content/uploads/2014/04/SGO-Testimony-to-FDA-on-Power-Morcellation-FINAL.pdf last access: 20.07.2018
96 Halaska MJ, Haidopoulos D, Guyon F. et al. European Society of Gynecological Oncology Statement on Fibroid and Uterine Morcellation. Int J Gynecol Cancer 2017; 27: 189-192
97 [Anonym] AAGL Advancing Minimally Invasive Gynecology Worldwide. Morcellation During Uterine Tissue Extraction. 2014. Online: https://www.aagl.org/wp-content/uploads/2014/05/Tissue_Extraction_TFR.pdf last access: 20.07.2018
98 US Food and Drug Administration. FDA Updated Assessment of The Use of Laparoscopic Power Morcellators to Treat Uterine Fibroids. 2017. Online: https://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/UCM584539.pdf last access: 20.07.2018
99 Sizzi O, Manganaro L, Rossetti A. et al. Assessing the risk of laparoscopic morcellation of occult uterine sarcomas during hysterectomy and myomectomy: Literature review and the ISGE recommendations. Eur J Obstet Gynecol Reprod Biol 2018; 220: 30-38
100 Singh SS, Scott S, Bougie O. et al. SOGC Clinical Practice-Gynaecology Committee; GOC Executive Committee. Technical update on tissue morcellation during gynaecologic surgery: its uses, complications, and risks of unsuspected malignancy. J Obstet Gynaecol Can 2015; 37: 68-81
101 Bogani G, Cliby WA, Aletti GD. Impact of morcellation on survival outcomes of patients with unexpected uterine leiomyosarcoma: a systematic review and meta-analysis. Gynecol Oncol 2015; 137: 167-172
102 George S, Barysauskas C, Serrano C. et al. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer 2014; 120: 3154-3158
103 Park JY, Park SK, Kim DY. et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 2011; 122: 255-259
104 Raspagliesi F, Maltese G, Bogani G. et al. Morcellation worsens survival outcomes in patients with undiagnosed uterine leiomyosarcomas: A retrospective MITO group study. Gynecol Oncol 2017; 144: 90-95
105 Raine-Bennett T, Tucker LY, Zaritsky E. et al. Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With Morcellation. Obstet Gynecol 2016; 127: 29-39
106 Lin KH, Torng PL, Tsai KH. et al. Clinical outcome affected by tumor morcellation in unexpected early uterine leiomyosarcoma. Taiwan J Obstet Gynecol 2015; 54: 172-177
107 Nemec W, Inwald EC, Buchholz S. et al. Effects of morcellation on long-term outcomes in patients with uterine leiomyosarcoma. Arch Gynecol Obstet 2016; 294: 825-831
108 Lee JY, Kim HS, Nam EJ. et al. Outcomes of uterine sarcoma found incidentally after uterus-preserving surgery for presumed benign disease. BMC Cancer 2016; 16: 675
109 Gao Z, Li L, Meng Y. Correction: A Retrospective Analysis of the Impact of Myomectomy on Survival in Uterine Sarcoma. PLoS One 2016; 11: e0153996
110 Gao Z, Li L, Meng Y. A Retrospective Analysis of the Impact of Myomectomy on Survival in Uterine Sarcoma. PLoS One 2016; 11: e0148050
111 Wasson M, Magtibay 2nd P, Magtibay 3rd P. et al. Incidence of Occult Uterine Malignancy Following Vaginal Hysterectomy With Morcellation. J Minim Invasive Gynecol 2017; 24: 665-669
112 Zhang J, Li T, Zhang J. et al. Clinical Characteristics and Prognosis of Unexpected Uterine Sarcoma After Hysterectomy for Presumed Myoma With and Without Transvaginal Scalpel Morcellation. Int J Gynecol Cancer 2016; 26: 456-463
113 Ebner F, Friedl TW, Scholz C. et al. Is open surgery the solution to avoid morcellation of uterine sarcomas? A systematic literature review on the effect of tumor morcellation and surgical techniques. Arch Gynecol Obstet 2015; 292: 499-506
114 Wickerham DL, Fisher B, Wolmark N. et al. Association of tamoxifen and uterine sarcoma. J Clin Oncol 2002; 20: 2758-2760
115 Schmeler KM, Lynch HT, Chen LM. et al. Prophylactic surgery to reduce the risk of gynecologic cancers in the Lynch syndrome. N Engl J Med 2006; 354: 261-269
116 Leal MA, Pinera A, De Santiago J. et al. Novel Technique for Contained Power Morcellation through Umbilicus with Insufflated Bag. Gynecol Obstet Invest 2017; 82: 205-207
117 McKenna JB, Kanade T, Choi S. et al. The Sydney Contained In Bag Morcellation technique. J Minim Invasive Gynecol 2014; 21: 984-985
118 Frasca C, Degli Esposti E, Arena A. et al. Can In-Bag Manual Morcellation Represent an Alternative to Uncontained Power Morcellation in Laparoscopic Myomectomy? A Randomized Controlled Trial. Gynecol Obstet Invest 2018; 83: 52-56
119 Venturella R, Rocca ML, Lico D. et al. In-bag manual versus uncontained power morcellation for laparoscopic myomectomy: randomized controlled trial. Fertil Steril 2016; 105: 1369-1376