527: Beyond the Surgeon's Eye: Solving the Pathology-Visual Disconnect in Endometriosis Surgery

Sunday, November 15, 2026
2:00 pm - 3:00 pm

Room: RM302

Chairs: Tarek Toubia, Erin T. Carey

Faculty: Tarek Toubia, Erin T. Carey, Lori Scanga, Tamer Seckin

Description: Every endometriosis surgeon faces a diagnostic dilemma: compelling visual disease that tests negative on pathology, or conversely, uncertain-appearing tissue that proves pathologically positive. When visually classic endometriosis returns negative pathology, surgeons face difficult questions: Was the tissue adequately sampled? Did inflammation, fibrosis or hormonal treatment obscure the diagnosis? Should treatment decisions rely on visual findings despite pathologic contradiction? Conversely, when uncertain or atypical lesions prove positive for endometriosis, we must confront what visual cues we're missing and how to improve intraoperative recognition. These scenarios create clinical uncertainty, delay diagnosis, and leave every surgeon grappling with a fundamental dilemma: how to avoid both unnecessary excisions of benign tissue and missed excisions of true endometriosis. This interactive panel brings together experienced endometriosis surgeons and a gynecologic pathologist specializing in endometriosis to comprehensively dissect both sides of this diagnostic mismatch. Through case-based presentations, audience engagement, and expert discussion, we will explore why surgical-pathologic discordance happens, how to minimize its occurrence through optimized technique and communication, and most importantly, how to navigate it clinically when it does occur. The panel will: 1. Present the dual diagnostic problem through structured clinical scenarios: • Scenario A: Visually classic endometriosis that returns negative pathology Why does this happen? Contributing factors include sampling error (lesion not captured in specimen), inflammatory or fibrotic changes obscuring endometriotic tissue, superficial disease not reaching adequate tissue depth for biopsy, and limitations of standard histologic processing. What are the clinical implications for treatment decisions and patient counseling when visual impression contradicts pathology? • Scenario B: Uncertain or atypical lesions that prove pathologically positive What visual characteristics distinguish subtle endometriosis from benign findings? How can surgeons improve intraoperative recognition of atypical presentations including clear cell lesions, deeply infiltrative disease without surface manifestations, and microscopic disease in grossly normal-appearing peritoneum? 2. Showcase real surgical findings through case-based presentations featuring high-quality intraoperative images with detailed descriptions of lesion characteristics (color, texture, vascularity, depth), anatomic location (peritoneal, ovarian, deeply infiltrative, extrapelvic), surrounding tissue context, and surgeon's real-time clinical impression. 3. Engage the audience interactively by presenting surgical findings and polling participants on their predicted pathology results--then revealing the actual pathologic outcomes using live audience response technology. This active learning approach allows surgeons to test their diagnostic acumen in real-time, then compare their assessments to actual histopathologic results. The reveal and subsequent discussion will highlight common diagnostic pitfalls, reinforce visual recognition skills, and demonstrate the complexity of surgical-pathologic correlation. 4. Review the pathologic evidence of key endometriosis variants, presented by our expert gynecologic pathologist. This segment will explain: • Why standard hematoxylin and eosin (H&E) staining misses certain endometriosis presentations, including early lesions with minimal stromal component, extensively fibrotic lesions with gland atrophy, and lesions with hemorrhage obscuring diagnostic features • What enhanced pathology protocols can detect, including immunohistochemical staining (CD10, ER, PR), deeper tissue sectioning, and correlation with clinical history • How pathologists approach diagnostic uncertainty and what information from surgeons enhances pathologic interpretation • The limitations and appropriate interpretation of "negative for endometriosis" pathology reports 5. Provide actionable, evidence-based strategies for optimizing specimen collection, requesting enhanced pathology workup, and improving surgeon-pathologist communication 6. Explore the role of emerging intraoperative diagnostic tools that may enhance endometriosis detection and reduce surgical-pathologic discordance, including near-infrared fluorescence imaging with indocyanine green (NIR-ICG), artificial intelligence (AI) and machine learning platforms, intraoperative laparoscopic ultrasound (IO-US), narrow-band imaging (NBI), and methylene blue staining techniques. Why this matters: Negative pathology following excision of visually suspicious tissue should not be reflexively interpreted as unnecessary surgery. Sampling limitations, processing artifacts, and the inherent heterogeneity of endometriosis all contribute to false-negative results. Understanding these limitations prevents inappropriate surgical self-doubt and supports evidence-based clinical decision-making that integrates both visual and histopathologic data. Conversely, uncertain or atypical-appearing lesions warrant thoughtful evaluation rather than dismissal. Atypical presentations of endometriosis are well-documented in the literature, and subtle disease may be invisible to the untrained eye or obscured by adhesions, inflammation, or anatomic location. Dismissing uncertain lesions risks missing true disease, perpetuating diagnostic delay, and allowing disease progression.

Learning Objectives: At the end of this course, the participant will be able to:

1. Recognize dual diagnostic scenarios, understand their incidence, and recognize clinical implications. Participants will recognize and distinguish between the two key diagnostic paradoxes in endometriosis (negative pathology on visually compelling disease AND positive pathology on uncertain lesions) and will articulate the incidence and clinical implications of each using evidence from the literature;
2. Explain the pathologic mechanisms underlying false-negative diagnoses in endometriosis Participants will explain at least three specific pathologic mechanisms that result in false-negative endometriosis diagnoses despite true disease being present—thereby understanding the molecular and cellular basis for why standard H&E staining fails to identify certain endometriosis variants; and
3. Apply evidence-based strategies to optimize pathology yield and improve diagnostic accuracy Participants will apply evidence-based strategies to maximize endometriosis diagnostic accuracy by (1) modifying intraoperative specimen collection technique, (2) requesting enhanced pathology workup, and (3) interpreting negative standard histology in clinical context, thereby enabling them to make more accurate endometriosis diagnoses, reduce false-negatives, and improve communication between gynecologic surgeons and pathologists.

COURSE OUTLINE

2:00 PM Welcome, Introduction and Course Overview

T. Toubia

2:05 PM When What We See Doesn't Match What We Get: The Endometriosis Diagnostic Paradox in the OR

T. Toubia

2:15 PM From Mismatch to Management: Practical Strategies to Improve Endometriosis Diagnostic Accuracy

E. Carey

2:25 PM Why Pathology Says 'No' When It Should Say 'Yes'

L. Scanga

2:35 PM TBD

T. Seckin

2:45 PM Discussion Questions & Answers

3:00 PM Adjourn