Evaluation of vascular space involvement in endometrial adenocarcinomas: laparoscopic vs abdominal hysterectomies

Abstract

Recent reports have described 'vascular pseudoinvasion' in total laparoscopic hysterectomies with endometrial carcinoma. To better understand this phenomenon, we compared pathologic findings in these laparoscopic and total abdominal hysterectomies performed for uterine endometrioid adenocarcinoma. Reports from 58 robotically assisted laparoscopic and 39 abdominal hysterectomies with grade 1 or 2 endometrioid endometrial adenocarcinomas were reviewed for stage, depth of invasion, vascular space involvement, uterine weight, and lymph node metastases. In addition, attention was given to possible procedural artifacts, including vertical endomyometrial clefts, and inflammatory debris, benign endometrial glands, and disaggregated tumor cells in vascular spaces. All foci with vascular involvement were reviewed by three gynecologic pathologists. Nine of the 58 (16%) laparoscopic and 3 of the 39 (7%) abdominal hysterectomies contained vascular space involvement based on the original pathology reports (P-value ¼ 0.0833). No one histologic feature consistently distinguished laparoscopic from abdominal cases on blind review of the available cases. Disaggregated intravascular tumor cells were significantly associated with reported vascular involvement in both procedures (P-valueso0.001 and 0.016), most of which were corroborated on review. Laparoscopic procedures tend to have a higher index of vascular involvement, which is associated with lower stage, fewer lymph node metastases, and less myometrial invasion; however, pathologists cannot consistently determine the procedure on histologic findings alone. Moreover, there is significant inter-observer variability in distinguishing true from artifactual vascular space involvement, even among pathologists at the same institution. The clinical significance of apparent true vascular space involvement seen adjacent to artifacts is unclear, as is the impact of laparoscopic hysterectomy on recurrence risk.

Letter-to-the-Editor “Laparoscopic treatment of early-stage endometrial cancer with and without uterine manipulator: Our experience and review of literature” by Tinelli R et al. (Surgical Oncology 25 (2016) 98–103)

“…Although even with well-defined criteria for discrimination between LVSI and pseudoinvasion, inter-observer variability among pathologists is significant, the use of these criteria would have reinforced the results of this study [3,4]. LVSI is associated with lymph node metastasis and recurrent disease, whereas pseudoinvasion incorrectly classified as LVSI is not correlated with lymph node metastasis and recurrent disease.…”

Does a uterine manipulator affect cervical cancer pathology or identification of lymphovascular space involvement?

“…Conversely, Kitahara et al [7] speculated that uterine manipulators probably disrupt surface tumor leading to a situation where the grossing process could artificially disseminate tumor cells or fragments into the lymphovascular spaces. In contrast to these three studies, Folkins et al [8] and Frimer et al [9] were unable to identify any differences in LVSI between the manipulated and non-manipulated endometrial cancer specimen. Frimer et al [9] did report a correlation between LVSI and lymph node metastasis, but could not find a correlation between uterine manipulators and LVSI or micrometastasis.…”

“…However, some surgeons avoid the use of a uterine manipulator due to the theoretical risk of altering the tumor morphology or creating false lymphovascular space invasion (LVSI) [5][6][7]. This artifact has been described in cases of endometrial carcinoma as "pseudo-vascular invasion", although some question the legitimacy of this concept and its etiology [8,9]. Nevertheless, pseudo-vascular invasion has not been investigated or reported in cervical cancer specimens removed with the use of a uterine manipulator.…”

Lymphovascular Space Invasion for Endometrial Cancer: Undertreatment and Overtreatment Risks

“…11,40 In the same line, recent reports have suggested that the use of the uterine manipulator's balloon can induce LVSI. This phenomenon is known as vascular pseudoinvasion (VPI) (Fig.…”

“…Closed positive pressure in the endometrial cavity by the intrauterine balloon, 28 and the mechanical manipulation of the specimen during pathologic processing, 17 produces the disruption and displacement of the tumor into vascular spaces, simulating vascular invasion, as an artifact. 40 Vascular pseudoinvasion seems close or into the tumor, as irregular lacunar structures that remind of the vessel's lumen, covered of fragmented muscle, stroma, and tumor cells, with floating noncohesive cells. Differences between LVSI and VPI are shown in Table 3.…”