Pelvic Exenterations Including Vaginectomies

Pelvic Exenterations Including Vaginectomies

Vaginectomies for vaginal cancer include a por-tion of vagina attached to the uterus and cervix. These specimens can be handled in the same manner as radical hysterectomies for cervical cancer, although the paracervical soft tissues may not be present. Note that a clinical history of pre-natal diethylstilbestrol (DES) exposure is related to the presence of vaginal adenosis and clear cell adenocarcinoma of the vagina and cervix. Aden-osis appears as a red, granular change on the normally smooth, white vaginal mucosa. Also look for structural abnormalities of the cervix and fallopian tubes associated with DES exposure. Important observations include the size of the tumor and the distance of the tumor to the vaginal margin. If the uterus has been previously re-moved, the resulting vaginal pouch can be opened along one side and handled in the same manner as a large skin excision. Sections should be taken so as to demonstrate the greatest depth of tumor invasion, the tumor with adjacent normal-appearing mucosa, and the relationship of the tumor to the cervix. If the bladder is included with the uterus the resection is termed an anteriorexenteration, and if the rectum is included theresection is termed a posterior exenteration. With these added structures, additional sections in-clude documentation of the extent of tumor in-volvement of the bladder or rectal wall, and an evaluation of their respective surgical margins. Specifically, these include the urethral and ure-teral margins for the bladder, and the proximal and distal bowel margins for the rectum.

Exenterations are also performed for centrally recurrent cervical cancer. Perhaps the most daunting specimen received in the surgical pa-thology laboratory is a total pelvic exenteration, which includes the bladder, uterus with attached adnexa, vagina, and rectum. The evaluation of these specimens uses both a separate and an integrated approach, as described. Resection margins are best handled if each of the four main components (i.e., bladder, vagina, uterus, and rectum) is thought of separately. Appropriate examination of the central tumor involves demonstrating its in situ relationship to these surrounding organs.

When a total pelvic exenteration specimen is received for recurrent cervical cancer, do not panic. Instead, calmly note the organs present and their dimensions. Specifically, look for the ureters, urethra, bladder, uterus, fallopian tubes, ovaries, vagina, and rectum. Take shave sections of the vaginal, ureteral, and urethral margins. Take perpendicular sections from the proximal and distal rectal margins, providing ink for margin orientation. Next, ink all the exposed soft tissue that surrounds the cervix and tumor.

Fill the vagina with formalin-soaked gauze pads, and distend the bladder and rectum with formalin. Submerge the entire specimen in forma-lin, and fix it overnight. The fixed specimen may then be bisected in a sagittal plane to demonstrate the tumor and its relationship to surrounding structures. This is best accomplished by using probes in the urethra and uterine canal as midline guides. After the specimen has been sectioned, a diagram can facilitate the description of the tumor, including its extension. Take sections of the tumor to demonstrate invasion of the bladder, rectum, vagina, and/or paracervical tissue. Docu-ment the vaginal and paracervical soft tissue mar-gins with perpendicular or shave sections. Last, dissect the soft tissue surrounding the cervix, and submit for histology a section of any lymph nodes found.

Important Issues to Address in Your Surgical Pathology Report on Pelvic Exenterations

·  What procedure was performed, and what structures/organs are present?

·  What is the site of origin of the tumor?

·  What are the histologic type and grade of the tumor?

·  What is the size of the tumor?

·  What other organs are involved by the tumor? Specify the extent of tumor involvement into these structures. That is, does it reach the mus-cular wall, submucosa, or mucosa?

·  Does the tumor infiltrate the capillary–lym-phatic spaces?

·  Does the tumor involve any resection margins? Give the distance of the tumor from the closest margin (in centimeters).

·  Does the tumor involve any lymph nodes? In-clude the number of nodes involved and the number of nodes examined at each specified site.

·  Are any radiation effects present?