Overtreatment by Misdiagnosis of Pseudoinvasion in TLH

Junko Wroblewski, MD, PhD, Hidehiro Kawagoe, MD, PhD, Hiroki Nasu, MD, Kyoko Kawamura, MD, PhD, Yoshihiko Tashiro, MD, PhD, Greggory Wroblewski, BS, MA, Naofumi Okura, MD, PhD

Department of Obstetrics and Gynecology (Drs J. Wroblewski, Kawagoe, Nasu, Kawamura, and Okura) and Pathology (Dr Tashiro), National Hospital Organization Kokura Medical Center, Kitakyushu, Japan. Division of Functional Neuroanatomy, Yamaguchi University Graduate School of Medicine, Ube, Japan (G. Wroblewski).


Introduction: Despite reports of pseudo lymphovascular space involvement (LVSI) in total laparoscopic hysterectomy (TLH) in recent years, we recently experienced a misdiagnosis of pseudo-LVSI after TLH for uterine myoma, having observed irregularities in excised specimens. Additional surgery found no abnormalities, resulting in an unfortunate case of overtreatment. For this reason, we reviewed cases of TLH for benign uterine disorders performed at our hospital for the presence of similar pseudoinvasion.

Case Description: We re-examined 53 cases for the presence of intravascular endometrial tissue from patients who had undergone TLH for benign uterine disorders. In a 42-year-old patient who had undergone TLH for uterine myoma, we found a small amount of complex atypical endometrial hyperplasia and observed intravascular agglomerations of atypical endometrial cells at multiple sites, leading to a diagnosis of LVSI. We performed additional surgery (laparotomy), but findings were unremarkable. Pseudo-LVSI was identified in 8 of 53 cases (15.1%): in 2 of 21 (9.5%) operations performed with the ClearView uterine manipulator and in 6 of 32 (18.8%) performed with the Vcare uterine manipulator.

Discussion: Differentiation between “true” LVSI and grossing artifacts remains difficult, and a noteworthy case of overtreatment such as this highlights the need to reinstitute differentiation as a salient topic of discussion among surgeons and pathologists. Similarly, the existence of pseudoinvasion in a significant number of the retrospectively reviewed cases, in light of its still-undetermined clinical significance, is an interesting finding that warrants additional investigation to avoid both overtreatment and undertreatment of such cases.

Key Words: Laparoscopic hysterectomy, LVSI, Misdiagnosis, Overtreatment, Pseudoinvasion.

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