| Abstract|| |
Background: Laparoscopic surgery is a recent advance in the field of gynecological surgery. There are innumerable reports in literature on its advantages and disadvantages. However, problems faced by the surgical pathologist during grossing and histopathological reporting of these morcellated specimens have never been discussed before. We present our experience and the difficulties faced by a gynecologic pathologist (first author) and try to provide some clues for their solution. Materials and Methods: Sample size was 153 consecutive laparoscopic specimens, which varied from in toto uterus with cervix, fibroid or ovarian cyst to morcellated specimens. 153 non-laparoscopic gynecologic specimens constituted controls; 34.0% were ovarian cystectomies and remaining 66.0% were hysterectomies, myomectomies and salpingectomies, of which 36.6% were morcellated, rest were in toto. Result: Contents were not seen in majority of the ovarian cystectomies. Many more sections were taken in morcellated specimens, as compared to controls, for identification of endometrium, endocervix and ectocervix. Even then, in occasional cases identification was not possible. Congested bits in morcellated specimens interpreted as endometrium on grossing turned out to be parametrial tissue. Ectocervix could be identified as soft tissue bits covered by whitish membrane. Identification of transformation zone of the cervix was not possible in any of the morcellated hysterectomy specimens. Conclusion: The advantage of laparoscopic gynecological surgery to the patient need not prove to be so for surgical pathologist. The present study does not discourage gynecologists from performing laparoscopic surgeries but wishes to highlight the surgical pathologist's problems and limitations.
Keywords: Gynecologic pathologist, laparoscopic gynecologic surgery, laparoscopic surgery, surgical pathologist
|How to cite this article:|
Jashnani KD, Baviskar RR. The surgical pathologist and laparoscopic gynecologic surgeries. Indian J Pathol Microbiol 2010;53:634-9
| Introduction|| |
Although pathology is usually a second-year course in most medical colleges, students are rarely exposed to what the practice of surgical pathology actually entails. Actually, the pathologist serves as a consultant and partner to a surgeon.  In spite of the worthy efforts of a pathologist, there is a common misconception that "Pathology" is a place analogous to an Automatic Teller Machine (ATM) - you put something, and something spits out.
Gynecologists have utilized laparoscopy for many years in the performance of tubal ligation and evaluation of pelvic pain. Advances in laparoscopy have allowed surgeons to perform procedures previously accomplished only by laparotomy. These include surgeries like hysterectomy, myomectomy, salpingectomy for ectopic tubal pregnancy or hydrosalpinx excision or ovarian cystectomy. , The laparoscopic approach has several advantages over laparotomy for the patient as well as the gynecologist. However, problems faced by the surgical pathologist during grossing of these morcellated specimens as well as in final diagnosis have never been discussed before. Here we present our experiences in dealing with these specimens. We will discuss the difficulties faced by us during grossing and diagnosis as well as try to provide some clues or hints for their solution. This may be considered a pilot study.
| Materials and Methods|| |
This is a non-interventional, retrospective (1.5 years) and prospective (1.5 years) and longitudinal study in surgical pathology laboratory, of gynecological specimens removed by laparoscopic surgeries conducted in a tertiary care hospital. The study period extended from January 2005 to December 2007 i.e. three years. Exclusion criteria were laparoscopic biopsies and tubal ligation. Rest all laparoscopic gynecologic specimens were included. Initially, 162 cases were included as laparoscopic specimens of which nine were followed by open laparotomy. Hence, after excluding these nine cases, 153 cases formed the final study group.
A total of 153 consecutive non-laparoscopic gynecologic specimens constituted the control group. Relevant clinical data was noted followed by grossing and histopathological reporting. The specimens varied from entire uterus with cervix or only fibroid or only ovarian cyst intoto to specimens received in bits and pieces (morcellated) depending on size of the specimen and mode of delivery. An effort was made to identify endometrial and endocervical cavities in cases of total laparoscopic hysterectomies (TLH). Ovarian cystectomy specimens received were usually flat membranous bits. Their nature of inner surfaces, any papillae or any adherent contents were noted. Fallopian tubes were tried to identify. Representative sections were taken next day after adequate fixation. The standard criterion of one section per cm of largest diameter of tumor for myomectomies and ovarian cystectomies was followed during grossing of these specimens. When endometrium, ectocervix or endocervix were not identified on microscopy, more sections were taken till they were finally identified. Magnifying lens was used for endocervical crypt identification in few cases.
| Results|| |
Out of 153 cases, the maximum number of cases in study group appears to be clustered in year 2007 with 71 cases (46.4%) followed by 52 cases (34.0%) in 2006 and 30 cases (19.6%) in 2005 year. This association was significant with p value of 4.74E-25. The age range varied from 14 years to 70 years. 93.8% of patients were in the age group from 21 years to 60 years. Clinical features in the study as well as control group varied from menstrual complaints to pain and lump in abdomen. None of the patients in the study group presented with prolapse, which was a complaint in 43.1% patients in control group. USG findings were available in 135 cases of the study group and in majority of the cases, findings correlated with the final diagnosis. In both the study and the control group, majority of the surgeries performed were hysterectomies. In the study group, 11 hysterectomies, 23 myomectomies and three salpingectomies were sent morcellated and the rest were intoto [Table 1]. 50 ovarian cystectomy specimens out of 52 cases in the study group were sent after aspiration of contents as flat membranous bits. Histopathological examination of the majority of study specimens revealed either normal physiologic or benign pathologic findings for that particular organ. There was one case each of cervical intraepithelial neoplasia (CIN II), borderline ovarian tumor and malignant focus in a leiomyoma.
|Table 1 :Type of surgeries conducted among two groups and number of in toto versus morcellated specimens |
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One to five more sections were taken in 30 cases of the study group as against only one to two more sections taken in four cases of the control group [Table 2]. More sections were taken for identification of endocervix, endometrium, ovarian cyst wall lining, stromal invasion etc. [Table 3]. Type of lesions which required four to five more sections included borderline cases like cervical intraepithelial neoplasia (CIN II) to look for severe dysplasia and stromal invasion and borderline papillary serous cyst adenoma to look for stromal invasion. One to three more sections were taken in routine cases where endocervix, ectocervix, or endometrium was not identified in initial sections. More sections were taken in 10 out of 37 morcellated specimens (27.0%) as compared to 12 out of 64 in toto specimens (18.7%). Majority of the cases could be diagnosed confidently after taking one - five more sections except in two cases. These two cases included one case of cervical intraepithelial neoplasia (CIN II) in one of the morcellated hysterectomy specimens where severe dysplasia could not be ruled out confidently. Also, in a case of morcellated myomectomy, malignant focus was seen in the midst of leiomyoma. Similar areas were not identified in other bits even after taking many more sections. So, the gynecologist was cautioned that the leiomyoma could be harboring a focus of metastasis and to look for primary, as well as to follow-up the patient. Endocervix was not identified in four cases and endometrium and ectocervix were not identified in one case each, even after taking up to five more sections. All these cases were asked to follow up regularly in gynecology OPD, even in absence of any symptoms. Transformation zone was not identified in any of the morcellated hysterectomy specimens. Likely reason for non-identification of endocervix could be that as many hysterectomy specimens came in bits and pieces, it was difficult to identify endocervix as a luminal space. In such difficult cases, magnifying lens was used for visualization of endocervical crypts and more sections were taken from these areas, if not taken initially. Surgical specimens including endocervical epithelium can be stained with 1% aqueous solution of toluidine blue, which gives blue color to endocervical tissue. However, this staining was not performed in our study.
| Discussion|| |
Operative laparoscopy is today replacing conventional gynecological surgery for treating pathological conditions, so much so that in some centers 70% of gynecological surgeries are done laparoscopically.  The advantages of operative laparoscopy mainly depend on the three basic principles of all surgeries i.e. surgical gentleness, efficacy and cost effectiveness. However, benefits of laparoscopic surgery to the patient and gynecologist in terms of minimal postoperative discomfort and short hospital stay need not prove to be so for a pathologist.
This study aims at exploring those aspects of surgical pathology most relevant to laparoscopic surgeries with the hope of enhancing communication between these two specialties. Maximum numbers of laparoscopic surgeries were done in year 2007. This could be due to the fact that the percentage of gynecological surgeries done laparoscopically increased as expertise of the gynecologists improved. Majority of the patients in the study as well as control group were in the age group of 21-60. None of the patients from study group were above the age of 60 as against 8 patients in control group. Reason for this could be laparoscopic surgery is relatively contra-indicated in elderly patients who are more often hypertensive, obese or might have prior laparotomy done.
A few elderly patients may not give consent for laparoscopic surgery. Also surgery time is prolonged for laparoscopic surgery in these patients. USG findings were available in 88.2% cases of the study group as compared to only 41.8% cases from the control group. In majority of the cases, findings correlated with final diagnosis. In the study group, 45.1% of the patients underwent total laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy as against 94.8% cases from the control group who had conventional abdominal or vaginal hysterectomy. Laparoscopic ovarian cystectomy was done in 34% cases and myomectomy in 15.7% cases. In the study group, 5.2% patients had salpingectomy done for ectopic pregnancy or hydrosalpinx. None of the patients from control group underwent salpingectomy. In nine cases, laparoscopic surgery was followed by open laparotomy. Of these, seven patients had uncontrollable bleeding, one had ureteral injury and one had bowel injury. All these nine cases were excluded from the study.
In the specimen type which included hysterectomy, myomectomy and salpingectomy, 36.6% specimens were sent after morcellation as shown in [Table 2]. All hysterectomy and myomectomy specimens from control group were sent in toto. In study group, in year 2005, all hysterectomy specimens were removed through colpotomy incision and hence were sent in toto. Only one hysterectomy specimen from year 2006 was morcellated and 10 specimens from year 2007 were sent after morcellation. Here, it is evident that as the surgical expertise of the gynecologist increased over a period of time, more and more hysterectomy specimens were removed through laparoscopic ports after morcellation.
Morcellated specimens constituted 15.9% of total laparoscopic hysterectomy as against 84.1% intoto hysterectomy specimens in the study group. Majority of the myomectomy specimens in the study group (95.8%) were sent after morcellation. Congested bits interpreted as endometrium on gross turned out to be parametrial tissue. Endometrium was not found in one of the morcellated hysterectomy specimens even after taking up to five more sections. Though in occasional cases, we were lucky enough to identify endometrium as a slit like space [Figure 1]. Ectocervix could be identified as soft tissue bits covered by whitish membrane. Identification of transformation zone of cervix was not possible in any of the morcellated hysterectomy specimens. Ovarian cystectomy specimens from study group sent as flat membranous bits after aspiration of contents constituted 96.1%. Gross inspection of contents of the cysts helps in final diagnosis. If contents are clear, mucinous, pultaceous, or hemorrhagic,, it is more likely a benign cyst. If it is serosanginous or yellow, it may be malignant.  However, contents were not available for gross examination in majority of the study cases. Specimens of mature cystic teratoma had some contents and hair strands adherent to the inner wall [Figure 2].
|Figure 1 :In occasional cases, endometrium was identified as a slit like space|
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|Figure 2 :Mature cystic teratoma, sent as bits and pieces, though a few pultaceous contents and hair strands are seen adherent to inner wall|
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One to five more sections were taken in 30 cases of the study group as against only one to two more sections taken in four cases of the control group.This may explain additional work, cost and potential delay in processing the specimen. The extra time and efforts put by a surgical pathologist and technical staff cannot be underestimated. Since ours is a tertiary care center in a municipal corporation setup where financial constraints are already in place, this may sound like a drain of finances. More sections were taken for identification of endometrium, endocervix, ectocervix, ovarian cyst wall lining and also to look for stromal invasion in cases where borderline features were found on histology.
More sections were taken in 27% of morcellated specimens of the study group as against in only 18.7% of in toto specimens. This association was found to be statistically significant. Histopathological examination revealed two cases of simple endometrial hyperplasia in study group. One of the morcellated leiomyoma showed presence of atypical epithelial cells [Figure 3]. In occasional morcellated hysterectomy specimens, it was difficult to decide whether there was adenomyosis surrounded by hypertrophic smooth muscle bundles or was it a benign adenomyoma.
|Figure 3 :Focus of atypical cells in leiomyoma from morcellated myomectomy specimen (H and E, ×400)|
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Cervical intraepithelial neoplasia (CIN II) was reported in a morcellated total hysterectomy specimen of a 45 year old lady who came to gynecology OPD with complaints of menorrhagia. She did not have other complaints like postcoital bleeding or foul smelling discharge suggestive of cervical malignancy. USG abdomen showed presence of bulky uterus. Grossly, the aggregate of specimen in bits and pieces measured 100 Χ 60 Χ 40 mm. Endometrium was in secretory phase with no abnormal findings. Myometrium showed presence of adenomyosis. Sections taken from cervix showed squamous metaplasia with dysplasia. Four more sections were taken to rule out stromal invasion in other cervical bits. Even after taking many more sections, it was not possible to rule out severe dysplasia or stromal invasion in other cervical bits with confidence.
One case of the control group showed presence of clear cell carcinoma of cervix. Other cases from study as well as control group showed features of cervicitis. Morcellated hysterectomy specimens may pose a difficult problem with histopathological diagnosis, particularly in lesions such as endometrial stromal tumor where important criterion for diagnosis of malignancy is invasion of stromal-tumor interface. Equally difficult is diagnosis of endometrial carcinoma arising within a polyp with focal myometrial invasion which is difficult to demonstrate. Patients with symptoms suggestive of endometrial tumor should undergo all necessary pre-operative investigations and if required, conventional non-laparoscopic surgery to avoid future complications.
Histopathological examination of ovarian cystectomy specimens of study group showed features of benign ovarian cyst in 65.4%, mature cystic teratoma in 21.2% and endometriotic cyst in 5.8% cases. One specimen sent as ovarian cyst was found to be paratubal cyst on microscopy. One more case sent as ovarian cyst showed lining by pseudostratified ciliated columnar epithelium, at places thrown into polypoidal projections with muscle in the wall. Hence, diagnosis of hydrosalpinx was made. A diagnosis of borderline papillary serous cystadenoma was made in a 28 year old female with complaints of lump in abdomen. Right adnexal mass was seen on USG pelvis with resistive index (RI) < 0.45 on color Doppler suggestive of benign nature of the cyst. Grossly the specimen was sent as bits and pieces, measuring 10 cm in largest dimension, already cut open with no contents available for examination. It had one solid grayish homogenous area measuring 2 Χ 2 cm, from which sections were taken. Microscopy revealed cyst wall lined by single to stratified layer of tall columnar epithelium with atypical, hyperchromatic nuclei, thrown into polypoidal projections at places. Stromal invasion was ruled out after taking adequate number of sections. Repeat laparoscopy was performed after one week to reexamine abdomen and perform abdominal lavage and cytological study. It did not show any atypical cells. The patient did follow-up with the gynecologist without any complaints.
Endoscopic surgery is not recommended for ovarian cancer diagnosed before surgery. But it is safe and effective for the treatment of borderline tumors of the ovary.  Here, preoperative vaginal sonography is extremely valuable and malignancy should be ruled out. Repeat laparoscopy should be performed after one week to remove remaining ipsilateral ovarian or adnexal tissues, reexamine the abdomen and perform abdominal lavage and cytological study. Of eight salpingectomy cases, five had ectopic pregnancy and three had hydrosalpinx. Mean age of the patients in study group was 35.9 years as compared to 43.2 years in control group.
In none of the cases, primary diagnosis offered was proved wrong. All patients were asked to follow-up for a minimum period of five years. None of the patients had any complaints during routine follow-up, though many patients did not report back. It can be taken as there were no complications whatsoever in these patients. However, the case of malignant focus in the morcellated leiomyoma remained a mystery as the patient was lost to follow-up. Follow-up is necessary to assess whether primary diagnosis offered was correct or wrong. It is all the more important in borderline cases such as cervical intraepithelial neoplasia (CIN II) or borderline serous cystadenoma of ovary, where stromal invasion was difficult to diagnose. None of these patients had recurrence of tumor or symptoms of metastasis till last follow-up.
Studies emphasizing difficulties faced by a surgical pathologist while grossing and making histopathological diagnosis of laparoscopic gynecologic specimens have not been reported in literature as yet. Hence, it is not possible to compare the results of our study with studies performed on similar basis. One of the limitations to the pathologic evaluation of a laparoscopically obtained specimen is inability to determine completeness in case of a fragmented specimen. For example, ovarian remnant syndrome (ORS) is a well known risk with laparoscopically removed ovaries. , Here, pathologist cannot determine completeness of a specimen and thereby completeness of a surgery, if the tissue comes in bits and pieces.
Predisposing factors for ORS include endometriosis, pelvic inflammatory disease, history of pelvic surgeries, difficult dissection as a result of extensive adhesions and alteration of the anatomy by neoplasia. Risk factors for ORS might also include imprecise use of looped suture ligatures or linear stapler and incomplete extraction of ovarian fragments from pelvis. Neoplasms have developed in ovarian remnant tissue. 
Another problem often faced by a surgical pathologist is specimen orientation in cases of morcellated specimens. In these cases, labelingwith diagrams, placement of a suture or a face-to-face discussion with the gynecologist will help ensure that the question gets answered. As already discussed, in this study, we have tried identifying difficulties faced by a surgical gynecologic pathologist while grossing and final diagnosis of laparoscopic specimens. We have also provided some clues for these problems, though some questions still remain unanswered.
Limitations of the present study are less number of morcellated specimens received and evaluated. Reasons for the reduced number of morcellated specimens received being non-availability of the morcellator in gynecology operation theater during the first half of the study period. Also, the expertise of the gynecologic laparoscopist improved during the second half of the study period. We feel that we could have addressed the problems in grossing and histopathological diagnosis of morcellated specimens more accurately, if we had access to more number of morcellated specimens. Similar studies on a larger scale should be done to solve these problems.
To summarize the findings of our study,
- Endometrium can be identified grossly as a slit like spaceCongested bits interpreted as endometrium turned out to be parametrial tissue.
- Ectocervix can be identified grossly as soft tissue bits covered by whitish membrane.
- Identification of transformation zone of the cervix was not possible in any of the morcellated hysterectomy specimens. This is significant, as most of the cervical malignancies start in this area.
- Almost all ovarian cysts are sent after aspiration of contents as membranous bits and pieces.
- A thorough search should be done to look for papillae, any solid areas or any irregularities in the ovarian cyst and sections from these areas should be taken.
- Adequate number of sections should be taken in the first sitting to avoid delay in dispatching the final report.
Finally, it is worth mentioning that any pathologist reporting on morcellated gynecological specimens should have vast experience in gynecologic pathology in general and wherever necessary, second opinion should be taken to avoid diagnostic pitfalls. Reporting on morcellated specimens removed laparoscopically should not be done by a naοve pathologist with little experience in the subject.
We would like to conclude that this study is not to discourage gynecologists from performing laparoscopic surgeries, but to make them aware of inherent limitations of the procedure to a surgical pathologist.
| Acknowledgement|| |
Dr. C. V. Hegde, Professor, Department of Obstetrics and Gynecology, T. N. Medical College & BYL. Nair Charitable Hospital, Mumbai for his expertise in laparoscopic surgery.
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Kusum D Jashnani
8, Aashirwad, 1st floor, Opposite Kakad Industrial Estate, Lady Jamshedji Cross Road-3, Mahim, Mumbai-400 016
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]