Vascular "pseudo invasion" in laparoscopic hysterectomy specimens: a diagnostic pitfall.

Total laparoscopic hysterectomy has been shown to be an equally effective and safe technique when compared with conventional abdominal surgery for endometrial carcinoma. The procedure, as performed at our institution, involves the use of a uterine balloon manipulator (RUMI manipulator and Koh Colpotomizer system) for optimal surgical control. The fallopian tubes are cauterized to prevent transtubal spread of the tumor. The balloon manipulator thus creates a positive closed pressure system within the uterine cavity. After observing extensive displacement of tumor into small and large blood vessels in 1 case of grade 1, stage 1b endometrial carcinoma, we reviewed slides from 37 hysterectomy specimens (7 for endometrial carcinoma or atypical hyperplasia and 30 for benign conditions) performed laparoscopically between August 2004 and March 2006 at Emory University and Crawford Long Hospitals. We reviewed all slides for the presence or absence of endometrial tumor/tissue in vascular spaces. Patients with endometrial carcinoma/atypical complex hyperplasia included 6 FIGO grade I endometrioid carcinomas (3 stages 1A; 3 stages 1B) and 1 patient with atypical complex hyperplasia. Tumor within blood vessels was noted in 5 of 7 (71%) cases. In 3 cases, including the case of atypical complex hyperplasia, the number of vessels containing tumor were too numerous to count small and large caliber blood vessels. In the remainder, 1 case had 2 small vessels involved and in the other 7 small vessels showed tumor within vascular lumina. Benign endometrial glands and stromal tissue were noted within vascular spaces in 4 of 30 (13%) hysterectomy specimens removed for benign conditions. We describe a hitherto unreported artifact of vascular pseudo invasion in hysterectomy specimens obtained using the technique of total laparoscopic abdominal hysterectomy. We postulate that the creation of a closed pressure system generated as part of the operative technique is likely responsible for this phenomenon. Pathologists need to be aware of this artifact to avoid misinterpretation of vascular invasion in these cases with its associated therapeutic and prognostic implications.

Endometrial adenocarcinoma associated with elevated serum concentrations of the free beta subunit of human chorionic gonadotropin.

We report a case of a histologic grade II endometrial adenocarcinoma without trophoblastic differentiation in a 24-year-old woman with an elevated serum concentration of human chorionic gonadotropin (hCG) and with no evidence of pregnancy. Serum and urine specimens were used to study the hCG immunoreactivity. Qualitative tests performed on serum and urine using 5 different assays produced conflicting results. The hCG concentration in serum and urine was quantified using assays designed to detect different molecular forms of the molecule; analysis revealed that serum hCG immunoreactivity was due entirely to the presence of the free beta subunit. Immunohistochemical analysis performed on tissue samples showed strong cytoplasmic staining for hCG. While hCG is a well-recognized tumor marker in gynecologic malignant neoplasms, immunoreactivity most often is due to the presence of both intact molecule and the free beta subunit. To our knowledge, this is the first report of an endometrial adenocarcinoma producing only the free beta subunit of hCG.

Invasive squamous cell carcinoma of the vagina in the setting of true hermaphroditism.

BACKGROUND: Primary vaginal cancer constitutes less than 2% of all malignancies of the female genital tract and is even rarer in true hermaphrodites. A unique case report of the occurrence of both of these developments in the same patient is presented. CASE: A 31-year-old 46,XX hermaphrodite presented with a history of vague abdominal symptoms and weight loss. Surgery was performed, and pathology revealed invasive squamous cell cancer arising in an epithelial-lined tissue consistent with vagina. The patient subsequently completed whole pelvic external-beam radiation therapy with cisplatin chemosensitization. CONCLUSION: This is a case of primary vaginal cancer in a patient with true hermaphroditism, which is exceedingly rare. It is a reminder that malignant changes in residual mullerian tissue should be considered in these patients.

The role of optimal debulking in advanced stage serous carcinoma of the uterus.

OBJECTIVE: To evaluate the role of optimal surgical cytoreduction and postoperative therapy in women with advanced uterine serous carcinoma (USC). METHODS: A multi-institutional, retrospective review identified 52 women with stage IV USC. Patient factors, surgical findings, and follow-up data were collected. Differences in demographics, surgical treatments, and adjuvant therapies administered were assessed with Fisher's exact test. Analysis of survival was performed using Kaplan-Meier and comparisons of survival were made using the log-rank test. RESULTS: Twenty-six women were optimally debulked ( 0.05). Median survival was longer in the optimal group (15 vs. 8 m), however, this did not reach statistical significance (P > 0.05). Women who received adjuvant platinum-based chemotherapy had a longer median survival than those who did not receive platinum chemotherapy (21 vs. 2 m) (P < 0.0001). Optimal cytoreduction combined with adjuvant therapy demonstrated a trend toward prolonged survival when compared to suboptimal cytoreduction combined with adjuvant therapy. However, the results did not achieve statistical significance (P > 0.05). CONCLUSION: Although no clear survival advantage is shown in the women who underwent optimal versus suboptimal debulking, there was a trend towards longer median survival in those who were maximally cytoreduced. Adjuvant platinum-based chemotherapy is associated with significantly longer survival in all women, regardless of amount of residual disease.