Mucinous tumors of the ovary: a clinicopathologic study of 196 borderline tumors (of intestinal type) and carcinomas, including an evaluation of 11 cases with 'pseudomyxoma peritonei'

Impact of uterus-preserving surgery on Stage I primary mucinous epithelial ovarian carcinoma: A multi-institutional study with propensity score-weighted analysis

OBJECTIVE

To investigate the clinical characteristics of women with Stage I primary mucinous epithelial ovarian carcinoma (mEOC) and evaluate the impact of uterus-preserving surgery (UPS) in terms of survival prognosis.

METHODS

A regional multi-institutional retrospective study conducted between January 1986 and March 2017 by reviewing records of the Tokai Ovarian Tumor Study Group. Clinical and pathologic data and survival outcomes were assessed for women with Stage I primary mEOC. The baseline imbalance between women with and those without UPS was adjusted by an inverse probability of treatment weighting method using the propensity score (PS) of independent clinical variables.

RESULTS

Among 4730 women with malignant ovarian tumors, 185 had Stage I primary mEOC and were included in the study. The mean age was 47.6 years (range 12-87 years), and 56 (30.3%) women underwent UPS. After PS-based adjustment, women in the UPS group did not have a poorer prognosis regarding overall survival (P=0.776) or recurrence-free survival (P=0.683). Even after age stratification, there was no statistical difference in survival outcomes between the UPS and non-UPS groups.

CONCLUSION

UPS was not associated with decreased survival and may be a treatment option for women with Stage I primary mEOC irrespective of age.

Essentials for Pathological Evaluation of Peritoneal Surface Malignancies and Synoptic Reporting of Cytoreductive Surgery Specimens-A review and evidence-based guide

Peritoneal surface oncology has emerged as a subspecialty of surgical oncology, with the growing popularity of surgical treatment of peritoneal metastases comprising of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Pathological evaluation plays a key role in multidisciplinary management but there are still many areas where there are no guidelines or consensus on reporting. Some tumors presenting to a peritoneal surface oncology unit are rare and pathologists my not be familiar with diagnosing and classifying those. In this manuscript, we have reviewed the evidence regarding various aspects of histopathological evaluation of peritoneal tumors. It includes establishing a diagnosis, appropriate classification and staging of common and rare tumors and evaluation of pathological response to chemotherapy. In many instances, the information captured is of prognostic value alone with no direct therapeutic implications. But proper capturing of such information is vital for generating evidence that will guide future treatment trends and research. There are no guidelines/data set for reporting cytoreductive surgery specimens. Based on the authors' experience, a format for handling/grossing and synoptic reporting of these specimens is provided.

Detailed overview on rare malignant ovarian tumors

The group of rare malignant ovarian tumors includes the group of germ cell tumors, sex cords stromal ovarian tumors, small cell carcinoma, malignant Brenner tumors, rare epithelial tumors such as mucinous carcinoma, clear cell carcinoma, or low-grade serous carcinoma, as well as ovarian carcinosarcoma. Together they comprise about 10% of all ovarian tumors. Due to their low prevalence and their heterogeneity, data and treatment recommendations are limited. Even though all ovarian tumors are staged according to the FIGO staging of epithelial ovarian tumors, treatment differs especially in germ cell tumors and sex cords stromal ovarian tumors. Non-epithelial ovarian tumors can arise from a variety of ovarian precursor cells such as germ cells, granulosa cells, theca cells, or stromal fibroblasts. As can be expected already due to their divergent precursor lesions, these malignancies are substantially different but united by their rarity. This overview article gives a comprehensive summary on the pathology and clinical presentation, as well as therapy recommendations of a selection of those rare ovarian tumors, based on the latest national guidelines and related important publications.

Prognostic impact of pelvic and para-aortic lymphadenectomy on clinically-apparent stage I primary mucinous epithelial ovarian carcinoma: a multi-institutional study with propensity score-weighted analysis

BACKGROUND

The exact impact of full-staging lymphadenectomy on patients with primary mucinous epithelial ovarian carcinoma confined to the ovary is still unclear. In this study, we investigated the prognostic impact of lymphadenectomy covering both pelvic and para-aortic lymph nodes in patients with clinically-apparent stage I mucinous epithelial ovarian carcinoma, using data from multi-institutions under a central pathological review system and analyses with a propensity score-based method.

METHODS

We conducted a regional multi-institutional retrospective study between 1986 and 2017. Among 4730 patients with malignant ovarian tumors, a total of 186 women with mucinous epithelial ovarian carcinoma were eligible. We evaluated differences in survival outcomes between patients with both pelvic and para-aortic lymphadenectomy and those with only pelvic lymphadenectomy and/or clinical lymph node evaluation. To analyze the therapeutic effects, the baseline imbalance between patients with both pelvic and para-aortic lymphadenectomy and others was adjusted with an inverse probability of treatment weighting using propensity score involving independent clinical variables.

RESULTS

Fifty-five patients received both pelvic and para-aortic lymphadenectomy. With PS-based adjustment, both pelvic and para-aortic lymphadenectomy did not have additive effects regarding overall survival (P = 0.696) and recurrence-free survival (P = 0.978). Multivariate analysis similarly showed no significant impact of both pelvic and para-aortic lymphadenectomy on their prognosis.

CONCLUSIONS

The effect of pelvic and para-aortic lymphadenectomy is limited for clinically-apparent stage I primary mucinous epithelial ovarian carcinoma as long as full peritoneal and clinical lymph node evaluations are conducted. The results of this study should be used as the basis for additional studies, including prospective trials.

Mucinous borderline ovarian tumors with and without Intraepithelial Carcinoma: Differences in clinicopathologic features and fertility results

AIM

To investigate the clinicopathologic characteristic and fertility results of patients with mucinous borderline ovarian tumors (MBOTs), and the effects of intraepithelial carcinoma (IECA) on them.

METHODS

Fifty-two patients treated for MBOTs with or without IECA were retrospectively analyzed.

RESULTS

Patients with IECA were more frequently observed at stage Ic (3/12 vs 1/40, P = 0.034) and accompanied by microinvasive carcinoma (3/12 vs 1/40, P = 0.034). The detected rate of IECA by intraoperative frozen section (5/12, 41.7%) was much lower than that of MBOTs (82.5%, P = 0.010). About 61.5% patients in our study underwent fertility-sparing surgery. Follow-up information was retained completely in 41 patients. And all four tumor recurrences were observed (9.8%) in conservative surgery group in 66 months, though there was no statistical association (P = 0.280). There were three patients who recurred more than once, even one occurred tumor-related death. Only one recurrent patient was in IECA group (P > 0.05). However, patients with IECA were more likely to receive adjuvant chemotherapy (3 of 12 vs 0 of 40, P = 0.010) and surgical staging (75% vs 52.5%, P = 0.200). As for fertility results, nine patients wished to be pregnant and seven of them (77.8%) were successful.

CONCLUSION

For young patients with MBOTs, fertility results are satisfactory after conservative surgery. But patients should be fully informed about the relative high recurrent rate. And IECA has no statistical negative effects on MBOTs till now, but a long-term follow-up is required.

Mucinous Cancer of the Ovary: Overview and Current Status

Mucinous ovarian cancer (MOC) is a rare subtype of epithelial ovarian carcinoma (EOC). Whereas all EOC subtypes are addressed in the same way, MOC is a distinct entity. Appreciating the pathological features and genomic profile of MOC may result in the improvement in management and, hence, the prognosis. Distinguishing primary MOC from metastatic mucinous carcinoma can be challenging but is essential. Early-stage MOC carries an excellent prognosis, with advanced disease having a poor outcome. Surgical management plays an essential role in the early stage and in metastatic disease. Chemotherapy is usually administered for stage II MOC and beyond. The standard gynecology protocol is frequently used, but gastrointestinal regimens have also been administered. As MOC is associated with multiple molecular alterations, targeted therapy could be the answer to treat this disease.

Histological grading of ovarian mucinous carcinoma - an outcome-based analysis of traditional and novel systems

AIMS

Grading of primary ovarian mucinous carcinoma (OMC) is inconsistent among practices. The International Collaboration on Cancer Reporting recommends grading OMC using the International Federation of Gynecology and Obstetrics (FIGO) system for endometrial endometrioid carcinoma, when needed. The growth pattern (expansile versus infiltrative), a known prognostic variable in OMC, is not considered in any grading system. We herein analysed the prognostic value of various grading methods in a well-annotated cohort of OMC.

METHODS AND RESULTS

Institutional OMCs underwent review and grading by the Silverberg and FIGO schemes and a novel system, growth-based grading (GBG), defined as G1 (expansile growth or infiltrative invasion in ≤10%) and G2 (infiltrative growth >10% of tumour). Of 46 OMCs included, 80% were FIGO stage I, 11% stage II and 9% stage III. On follow-up (mean = 52 months, range = 1-190), five patients (11%) had adverse events (three recurrences and four deaths). On univariate analysis, stage (P = 0.01, Cox proportional analysis), Silverberg grade (P = 0.01), GBG grade (P = 0.001) and percentage of infiltrative growth (P < 0.001), but not FIGO grade, correlated with disease-free survival. Log-rank analysis showed increased survival in patients with Silverberg grade 1 versus 2 (P < 0.001) and those with GBG G1 versus G2 (P < 0.001). None of the parameters evaluated was significant on multivariate analysis (restricted due to the low number of adverse events).

CONCLUSIONS

Silverberg and the new GBG system appear to be prognostically significant in OMC. Pattern-based grading allows for a binary stratification into low- and high-grade categories, which may be more appropriate for patient risk stratification. Despite current practices and recommendations to utilise FIGO grading in OMC, our study shows no prognostic significance of this system and we advise against its use.

A 27-kg Giant Ovarian Mucinous Cystadenoma in a 72-Year-Old Postmenopausal Patient: A Case Report

BACKGROUND Mucinous cystadenoma is a benign cystic ovarian tumor arising from the surface epithelium of the ovary; it usually presents with vague, unspecific abdominal symptoms. If not detected early, they have the potential to grow to a substantial size and can present with huge abdominal distention leading to various compression symptoms. Mucinous cystadenomas most commonly occur in the third to sixth decades of life, and rarely occur in extremes of age. The reported incidence of giant ovarian cystadenoma in postmenopausal women is low or relatively unknown due to widespread use of ultrasound and other radiological imaging modalities these days. Here, we report a case of giant mucinous cystadenoma in a 72-year-old postmenopausal woman with multiple comorbidities. CASE REPORT We present the case of a 72-year-old postmenopausal high-risk patient who presented with a huge abdominal distention which started gradually 1 year before. Abdominopelvic ultrasound showed a left giant multiloculated abdominal cyst. An intact 27-kg ovarian cyst was removed, and a total abdominal hysterectomy (TAH) along with bilateral salpingo-oophorectomy (BSO) was performed. The final histopathological report showed a benign ovarian mucinous cystadenoma. CONCLUSIONS Mucinous cystadenoma is a benign neoplastic disease that can reach a massive size. They are rare in the postmenopausal age group, but when they do occur, they pose a diagnostic and therapeutic challenge. This case report highlights the importance of early detection and management of adnexal masses in postmenopausal high-risk patients to decrease preoperative and postoperative complications and improve quality of life.

Ovarian tumors: a survey of selected advances of note during the life of this journal

The author reviews highlights of advances in knowledge concerning ovarian tumor pathology since the time of an essay in the first issue of this Journal written by Dr Robert E. Scully, who, both before and for several decades after the Journal was instituted, made many original contributions to the field and was the major architect of the 1973 World Health Organization classification of ovarian tumors which was much more clear and logical than prior ones. The current review considers the neoplasms in essentially the same order as was done in the first issue of this journal and presents a personal look at the highlights of new information concerning various well-known categories, surface epithelial, germ cell, sex cord-stromal, metastatic neoplasms and briefly, benign so-called tumor-like lesions. Some of the most notable developments are as follows: (1) an orderly approach to the classification of implants of serous borderline tumors into noninvasive and invasive categories; (2) recognition of distinctive micropapillary patterns seen in some borderline tumors and low-grade carcinomas; (3) a remarkable propensity for some endometrioid carcinomas to mimic sex cord- stromal tumors; (4) appreciation of the differences between primary mucinous tumors of intestinal and müllerian types; (5) the importance of distinguishing within primary mucinous carcinomas between expansile and destructive stromal invasion; (6) emphasis on the diagnosis of immature teratoma being based on the presence of primitive-embryonic-appearing tissues; (7) appreciation of variant morphology of cases of struma ovarii which may lead to significant diagnostic problems; (8) subdivision of granulosa cell tumors into adult and juvenile types because of the differing features of the two groups including in the second category the propensity for more malignant neoplasms to be mimicked; (9) recognition of a distinctive form of Sertoli-Leydig cell tumor, the retiform variant, with a propensity to occur in the young; (10) appreciation of a unique highly malignant neoplasm that typically afflicts the young and may be associated with hypercalcemia, so-called small cell carcinoma of hypercalcemic type; (11) greater awareness than was hitherto the case of the propensity for metastatic intestinal adenocarcinoma to mimic primary endometrioid carcinoma and similarly for metastatic mucinous carcinomas to simulate primary mucinous cystic tumors; (12) recognition of the distinctive features of low-grade appendiceal mucinous neoplasms that spread to the ovary and are typically associated with pseudomyxoma peritonei; and (13) appreciation that the histologic spectrum seen in cases of Krukenberg tumor is broader than often previously thought.

Treatment strategy for pediatric giant mucinous cystadenoma: A case report

Because of their rarity, the treatment strategy for pediatric ovarian epithelial tumors is controversial, especially for a giant cystadenoma. We report the largest mucinous cystadenoma (MCA) case in the pediatric literature thus far. A 12-year-old girl had abdominal distention and visited our hospital. She had a multilocular cyst with some protuberance on the inside and high values of CA 19-9 and CA-125. We diagnosed her with a left MCA and performed a left oophorectomy. The tumor was the stage IA borderline malignant MCA and weighed 11.8 kg. Five years have passed, the patient has not experienced recurrence or metastasis. The resection of giant tumors can affect respiration and circulation. However, pre- or intra-operative drainage may lead to dissemination and adhesion. When we treat pediatric giant ovarian epithelial tumors, we must understand the findings that suggest the possibility of malignancy to decide appropriately as to whether drainage should be performed.

Alteration of BRCA-1 tumor suppressor gene expression in serous and mucinous ovarian neoplasms in the benign-borderline-malignant pathway

Alteration of expression of the tumor suppressor gene BRCA-1 has been widely studied in breast and ovarian carcinoma. However, pattern of this alteration in the benign-borderline-carcinoma sequence in serous and mucinous ovarian neoplasms have not yet fully described. Tissue sections from 214 formalin-fixed paraffin-embedded ovarian specimens were stained immunohistochemically with BRCA-1 antibody. Specimens were 10 normal ovarian surface epithelium, 10 fallopian tube epithelium, 70 benign adenoma (50 serous and 20 mucinous), 28 borderline (13 serous and 15 mucinous), 78 carcinoma (58 serous and 20 mucinous), and 18 metastatic deposit (13 serous and 5 mucinous). Expression was evaluated into 0, +1, +2, and +3. Score +3 staining similar to normal tissues was considered normal and other scores were considered altered expression. Strong expression was seen in all normal epithelium specimens. Altered expression was seen in 34 serous neoplasms; 17 of 50 (34%) of benign cystadenomas, 6 of 13 (46%) of borderline tumors, 43 of 58 (74%) of primary carcinoma, and in 8 of 13 (62%) of metastatic carcinoma. This alteration was significantly associated with higher histopathologic grade (P = 0.049), presence of necrosis (P = 0.0001), and higher proliferation rate (P = 0.001). In mucinous neoplasms; altered BRCA-1 was detected in 25 specimens; 7 of 20 (41%) of benign cystadenomas, 5 of 15 (33%) of borderline neoplasms, 9 of 20 (45%) of primary carcinoma, and 4 of 5 (80%) of the metastatic deposits. This alteration was not associated with any of the clinicopathologic tumor characteristics. In conclusion, alteration of BRCA-1 expression is more frequent in serous than in mucinous carcinomas and is associated with tumors of higher grades and high proliferation rate.

Mucinous Neoplasms of the Ovary: Radiologic-Pathologic Correlation

Mucinous neoplasms of the ovary account for 10%-15% of ovarian neoplasms. They may be benign, borderline, or malignant. The large majority are benign or borderline, accounting for 80% and 16%-17%, respectively. Mucinous neoplasms of the ovary most commonly affect women in their 20s to 40s. The clinical manifestation is nonspecific, but most mucinous ovarian neoplasms manifest as large unilateral pelvic masses. At gross pathologic analysis, mucinous ovarian neoplasms appear as large multiloculated cystic masses. The contents of the cyst loculi vary on the basis of differences in internal mucin content. At histologic analysis, mucinous ovarian neoplasms are composed of multiple cysts lined by mucinous epithelium, often resembling gastrointestinal-type epithelium. Imaging evaluation most commonly includes US and/or MRI. The imaging findings parallel the gross pathologic features and include a large, unilateral, multiloculated cystic mass. The cyst loculi vary in echogenicity, attenuation, and signal intensity depending on the mucin content. Mucinous neoplasms of the ovary are staged surgically using the FIGO (International Federation of Gynecology and Obstetrics) staging system. Primary treatment is surgical, with adjuvant chemotherapy considered in the uncommon case of mucinous carcinoma with extraovarian disease. Since most mucinous ovarian neoplasms are benign or borderline, the overall prognosis is excellent.

Mucinous Ovarian Tumors

Ovarian mucinous tumors range from benign cystadenomas to borderline tumors to frankly malignant adenocarcinomas, and may display either intestinal-type morphology or, less frequently, endocervical-type differentiation. The latter category has been the subject of recent controversy owing to its morphologic overlap with so-called "seromucinous" ovarian tumors, a group that shares more molecular features with endometrioid tumors than it does with either serous or mucinous ovarian neoplasias. Endocervical-type differentiation in ovarian mucinous tumors may also represent an endocervical metastasis. Distinction of primary ovarian mucinous tumors from gastrointestinal metastases can be difficult, as the morphology of intestinal-type ovarian mucinous primaries sometimes differs only subtly if at all from gastrointestinal metastases.

ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease

The development of guidelines is one of the core activities of the European Society for Medical Oncology (ESMO) and European Society of Gynaecologial Oncology (ESGO), as part of the mission of both societies to improve the quality of care for patients with cancer across Europe. ESMO and ESGO jointly developed clinically relevant and evidence-based recommendations in several selected areas in order to improve the quality of care for women with ovarian cancer. The ESMO-ESGO consensus conference on ovarian cancer was held on April 12-14, 2018 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of ovarian cancer. Before the conference, the expert panel worked on five clinically relevant questions regarding ovarian cancer relating to each of the following four areas: pathology and molecular biology, early-stage and borderline tumours, advanced stage disease and recurrent disease. Relevant scientific literature, as identified using a systematic search, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. The recommendations presented here are thus based on the best available evidence and expert agreement. This article presents the recommendations of this ESMO-ESGO consensus conference, together with a summary of evidence supporting each recommendation.

ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease†

The development of guidelines recommendations is one of the core activities of the European Society for Medical Oncology (ESMO) and European Society of Gynaecologial Oncology (ESGO), as part of the mission of both societies to improve the quality of care for patients with cancer across Europe. ESMO and ESGO jointly developed clinically relevant and evidence-based recommendations in several selected areas in order to improve the quality of care for women with ovarian cancer. The ESMO-ESGO consensus conference on ovarian cancer was held on 12-14 April 2018 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of ovarian cancer. Before the conference, the expert panel worked on five clinically relevant questions regarding ovarian cancer relating to each of the following four areas: pathology and molecular biology, early-stage and borderline tumours, advanced stage disease and recurrent disease. Relevant scientific literature, as identified using a systematic search, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. The recommendations presented here are thus based on the best available evidence and expert agreement. This article presents the recommendations of this ESMO-ESGO consensus conference, together with a summary of evidence supporting each recommendation.

Frontiers in the Pathology and Pathogenesis of Ovarian Cancer: Cancer Precursors and "Precursor Escape"

This article summarizes the pathogenesis of ovarian carcinoma, focusing on the paradox of high-grade serous carcinogenesis. The fallopian tube is the prime site of origin in early serous cancers. Because a subset of serous cancers is associated with early serous proliferations absent intramucosal carcinomas, "precursor escape" is emerging, whereby some advanced cancers trace their roots to early serous proliferations. This has parallels in the endometriosis model and opens up a novel mechanism by which advanced malignancy could emerge without an obvious tubal carcinoma. The impact of this concept on classification of serous cancer and expectations from preventive strategies are discussed.

[Biopathology of ovarian carcinomas early and advanced-stages: Article drafted from the French guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

OBJECTIVES

Ovarian carcinomas represent a heterogeneous group of lesions with specific therapeutic management for each histological subtype. Thus, the correct histological diagnosis is mandatory.

MATERIAL AND METHODS

References were searched by PubMed from January 2000 to January 2018 and original articles in French and English literature were selected.

RESULTS AND CONCLUSIONS

In case of ovarian mass suspicious for cancer, a frozen section analysis may be proposed, if it could impact the surgical management. A positive histological diagnosis of ovarian carcinoma (type and grade) has to be rendered on histological (and not cytological) material before any chemotherapy with multiples and large sized biopsies. In case of needle biopsy, at least three fragments with needles>16G are needed. Histological biopsies need to be formalin-fixed (4% formaldehyde) less than 1h after resection and at least 6hours fixation is mandatory for small size biopsies. Tissue transfer to pathological labs up to 48hours under vacuum and at +4°C (in case of large surgical specimens) may be an alternative. Gross examination should include the description of all specimens and their integrity, the site of the tumor and the dimension of all specimens and nodules. Multiples sampling is needed, including the capsule, the solid areas, at least 1 to 2 blocks per cm of tumor for mucinous lesions, the Fallopian tube in toto, at least 3 blocks on grossly normal omentum and one block on the largest omental nodule. WHO classification should be used to classify the carcinoma (type and grade), with the use of a panel of immunohistochemical markers. High-grade ovarian carcinomas (serous and endometrioid) should be tested for BRCA mutation and in case of a detectable tumor mutation, the patient should be referred to an oncogenetic consultation.

Histopathological Patterns of Microinvasion in Ovarian Serous Borderline Tumors

Stromal microinvasion in ovarian serous borderline tumors can take various aspects, some of which are difficult to identify. Thus, the identification of stromal microinvasion is relatively simple for typical intracystic papillary proliferations such as serous borderline tumors, but may be difficult for tumors with glandular component. The study analyzed 14 cases of ovarian serous borderline tumors diagnosed in patients with mean age of 47,1 years. Histopathologically all tumors corresponded to typical forms in which we identified only two cases of stromal microinvasion. In one case, microinvasion was of eosinophilic type, and in the other case was observed a glandular and micropapillary pattern, being associated with the noninvasive peritoneal implants.

The pathologic distinction of primary and metastatic mucinous tumors involving the ovary: A re-evaluation of algorithms based on gross features

The problems associated with the pathologic distinction of primary ovarian mucinous tumors from their metastatic counterparts are well-recognized. Herein, we systematically evaluate a variety of gross parameters to determine the combination of features that most optimally separate primary from secondary mucinous ovarian tumors, and to address the tumor types that are most frequently associated with exceptions. 129 consecutive mucinous tumors involving the ovary formed the study set, including 61 primary mucinous tumors (16 carcinomas, 45 borderline tumors), and 68 metastatic carcinomas (21 colon; 28 appendix; 5 breast; 3 lung; 3 pancreas; 3 cervix; 1 bladder; 4 stomach). Consistent with prior studies, we found that as compared with metastases, primary ovarian mucinous tumors tend to be larger, more frequently unilateral and were more likely to be predominantly cystic and devoid of surface nodules. 41 of the 68 cases in the metastatic group showed intraperitoneal disease, as compared with only 3 of the 61 cases in the primary group (p < 0.0001). In 21% (14/68) of the metastatic group, the ovarian tumor was the first clinical indication of the primary tumor, and 82% of those cases were of gastrointestinal tract primary; this group of cases showed significantly larger tumors than ovarian tumors for patients with an established diagnosis of cancer. Receiver operating curve analyses showed that a tumor size cut off of <13 cm for metastatic disease yielded the maximal area under the curve of 0.877 (sensitivity 80%; specificity 80%); the most frequent exception to the size cut off of <13 cm for metastases was colorectal carcinoma, 30% of which were ≥13 cm. An algorithm whereby a tumor ≥13 cm is considered primary unless it displays surface nodules or bilaterality, and a tumor <13 cm is considered metastatic unless it is unilateral, correctly classified 94% (64/68) of the metastatic tumors and 98% (60/61) of the primary tumors. 3 of the 4 incorrectly classified cases in the metastatic group had intraperitoneal disease. We conclude that gross features are very useful in the distinction of primary from metastatic mucinous tumors in the ovary, and the presence of intraperitoneal disease provides additional diagnostic information. Although algorithms such as the one described herein are imperfect classifiers, they do provide baseline information on which additional findings, including microscopic features, can be added to ultimately provide the most accurate diagnostic classification.

Characteristics and Prognosis of Stage I Ovarian Mucinous Tumors According to Expansile or Infiltrative Type

BACKGROUND

The present study retrospectively determined the outcomes and prognoses in stage I mucinous ovarian carcinoma according to histological type (ie, expansile or infiltrative).

METHODS

A centralized pathologic review of tumors in patients treated from 1976 to 2016 for ovarian mucinous carcinoma was performed by 2 expert pathologists according to the 2014 World Health Organization classification. Only patients with stage I disease were analyzed. Tumors were typed as expansile or infiltrative and oncological issues analyzed.

RESULTS

A total of 114 cases were reviewed. Fifty were excluded (stage > I in 30 cases and no accessibility to a pathological review for 20 cases). Thus, 64 patients fulfilled the inclusion criteria: 29 had expansile-type and 35 infiltrative-type disease. The characteristics of both groups of patients were comparable, except the use of nodal staging surgery, which was more frequent in patients with infiltrative type. The International Federation of Gynecology and Obstetrics stages in expansile and infiltrative types were as follows: IA in 13 (45%) and 20 (57%), and IC in 16 (55%) and 15 (43%), respectively. Recurrence occurred in 3 patients with expansile type and 6 patients with infiltrative type. Two cases of expansile recurrence had pelvic recurrence and were salvaged after secondary surgery and chemotherapy, whereas 5 cases of infiltrative recurrence had extrapelvic spread and died from disease or were alive with progressive disease.

CONCLUSIONS

Recurrence occurred in both types of stage I mucinous ovarian cancer. However, lethal recurrences were observed mainly in infiltrative type.

Early stage mucinous ovarian cancer: A review

Mucinous ovarian carcinomas (MOCs) are an uncommon subset of epithelial neoplasms, both clinically and molecularly distinct from other ovarian cancers. Pathologic diagnosis proves challenging, and metastatic disease from other sites-especially the digestive tract-must be excluded. Fortunately, most patients are diagnosed at an early stage of disease and often present with large, unilateral adnexal masses. Survival for patients with stage IA disease approaches over 90%, and surgery alone is sufficient. Patients with stage IB-II disease should receive adjuvant treatment but the specific regimen is controversial. In the following review, we provide an overview of mucinous ovarian carcinomas, with a particular focus on the treatment of patients with early stage disease.

Update on rare epithelial ovarian cancers: based on the Rare Ovarian Tumors Young Investigator Conference

There has been significant progress in the understanding of the pathology and molecular biology of rare ovarian cancers, which has helped both diagnosis and treatment. This paper provides an update on recent advances in the knowledge and treatment of rare ovarian cancers and identifies gaps that need to be addressed by further clinical research. The topics covered include: low-grade serous, mucinous, and clear cell carcinomas of the ovary. Given the molecular heterogeneity and the histopathological rarity of these ovarian cancers, the importance of designing adequately powered trials or finding statistically innovative ways to approach the treatment of these rare tumors has been emphasized. This paper is based on the Rare Ovarian Tumors Conference for Young Investigators which was presented in Tokyo 2015 prior to the 5th Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup (GCIG).

Results of Fertility-Sparing Surgery for Expansile and Infiltrative Mucinous Ovarian Cancers

BACKGROUND

No series had been reported focusing on the results of fertility-sparing surgery in stage I mucinous ovarian cancers according to histotype (infiltrative vs. expansile). Investigating such outcomes was the aim of the present study.

MATERIALS AND METHODS

The present study was a retrospective analysis of patients treated conservatively with preservation of the uterus and contralateral ovary from 1976 to 2016. The pathology of the tumors was reviewed by two expert pathologists according to the 2014 World Health Organization (WHO) classification criteria. Oncologic and fertility results were analyzed.

RESULTS

Twenty-one patients fulfilled the inclusion criteria, twelve with expansile and nine with infiltrative cancer. All patients had a unilateral tumor and underwent unilateral salpingo-oophorectomy in one-step (n = 6) or two-step (n = 15) surgeries. All but one had complete peritoneal staging surgery based on cytology, omentectomy, and random peritoneal biopsies. Ten had nodal staging surgery. The International Federation of Gynecology and Obstetrics stages were IA (n = 9), IC1 (n = 6), and IC2 (n = 6); the nuclear grades were grade 1 (n = 9), grade 2 (n = 5), and grade 3 (n = 1). Two patients recurred (one expansile and one infiltrative type) 19 and 160 months after surgery, respectively. One stage IA, nuclear grade 2 expansile tumor recurred on the spared ovary; the patient remains alive. The other stage IA infiltrative tumor recurred as peritoneal spread; the patient is alive with disease. Six patients became pregnant; four with expansile tumors and two with infiltrative tumors.

CONCLUSION

The type of mucinous cancer has no impact on the oncologic outcome in this series of patients treated conservatively. Fertility-sparing surgery should be considered for early-stage infiltrative-type tumors.

IMPLICATIONS FOR PRACTICE

According to the most recently updated World Health Organization classification guidelines, mucinous cancers should be classified as either expansile or infiltrative. The infiltrative type has a poorer prognosis, but there are no data about the safety of fertility-sparing surgery (FSS) in this context. A collection of 21 cases reviewed by two expert pathologists this study is the first devoted to the conservative treatment of mucinous tumors according to both subtypes. The key result was that the type of mucinous cancer has no impact on the oncologic outcome; thus, FSS may be considered in both subtypes.

Low-Stage High-Grade Serous Ovarian Carcinomas: Support for an Extraovarian Origin

Many adnexal high-grade serous carcinomas (HGSCs) may derive from microscopic precursors in the fallopian tube. By studying a series of low-stage ovarian carcinomas, we anticipated that HGSCs would be distributed in a pattern suggesting secondary involvement, helping to indirectly validate the fallopian tube origin theory, and that most ovarian carcinomas other than serous carcinomas would demonstrate features consistent with derivation from precursors located in or transplanted to the ovary. Seventy-six patients with low-stage (FIGO I/II) sporadic ovarian carcinoma who underwent primary surgical management at Memorial Sloan Kettering Cancer Center from 1980 to 2000 were included in the study. Histologic type was assigned using Gilks' criteria. Similar to the approach taken when distinguishing primary and metastatic mucinous or endometrioid carcinoma involving ovary, cases interpreted as showing a "primary" pattern of ovarian involvement had ≥3 of the following features: unilateral tumor, size >12 cm, no surface involvement, no multinodularity, and no destructive stromal invasion. All other cases were considered to show a "metastatic" pattern of ovarian involvement. Cases were evaluated for p53 and WT-1 expression, using standard techniques on a tissue microarray. TP53 gene sequencing was also performed. Cases comprised HGSC (n=22), endometrioid carcinoma (n=30), clear cell carcinoma (n=13), and mucinous carcinoma (n=11). HGSCs displayed substantially more "metastatic features" than the non-HGSC group and a mean overall size that was smaller (8.85 vs. 14.1 cm). Statistically significant differences were found for bilaterality (63% vs. 7.3%), P=0.0001; multinodularity (55% vs. 7.3%), P=0.0001; tumor size, P=0.003; and surface involvement (50% vs. 13%), P=0.002. Five of 22 (23%) of HGSCs showed a "primary pattern" of ovarian involvement. There were no significant differences between these cases and "metastatic pattern" HGSCs when comparing morphology, immunophenotype, TP53 mutational status, and clinical outcomes. Most low-stage HGSCs demonstrate patterns of ovarian involvement that suggest metastasis from another source, such as the fallopian tube. Both metastatic pattern HGSCs and unilateral, low-stage HGSCs can behave aggressively.

Is uterine preservation combined with bilateral salpingo-oophorectomy to promote subsequent fertility safe in infiltrative mucinous ovarian cancer?

According to the latest World Health Organization classification (2014), mucinous ovarian cancers should be classified histologically as being either expansile or infiltrative. Compared to other epithelial cancers, both of these mucinous patterns are diagnosed, in the main, at an early stage, although they can affect relatively young patients. The infiltrative subtype is characterized by a morphologically and clinically more aggressive disease versus the expansile form. Consequently, even in young patients who would prefer fertility sparing management, the removal of both ovaries (even for a unilateral tumor) remains a common recommendation. However case reports describing the preservation of the uterus for a further potential pregnancy (following oocyte donation) have now been described. In this series, we present six patients treated for stage I mucinous infiltrative cancer using bilateral salpingo-oophorectomy with uterine preservation. All but one patient underwent 1-step (n = 1) or 2-step (n = 4) surgery, including peritoneal and nodal (4 patients) procedures. Disease stages were IA (n = 2), IC1 (n = 1), IC2 (n = 2), or IC3 (n = 1). While two patients subsequently became pregnant, two patients also suffered disease recurrence. For one patient, recurrence was at the pelvic peritoneum. For the second patient, an ultimately lethal disease recurrence involved the uterine serosa with nodal involvement. The results of this short series lead us to question the safety of this uterine-preserving strategy.

The histopathological classification, diagnosis and differential diagnosis of mucinous appendiceal neoplasms, appendiceal adenocarcinomas and pseudomyxoma peritonei

The vermiform appendix is the primary site of several distinctive benign and malignant neoplasms. Some can produce the clinical syndrome of pseudomyxoma peritonei (PMP). A consensus on their terminology was reached by an international panel of pathologists and clinicians working under the auspices of the Peritoneal Surface Oncology Group International (PSOGI), and this review discusses the application of the PSOGI classification to routine reporting. We discuss diagnosis and differential diagnosis together with implications for patient management, covering low-grade appendiceal mucinous neoplasms, high-grade appendiceal mucinous neoplasms, serrated polyps, adenomas and adenocarcinomas. We do not cover goblet cell tumours or neuroendocrine neoplasms in this paper.

Staging surgery in early-stage ovarian mucinous tumors according to expansile and infiltrative types

The aim of this study is to determine the value of surgical staging for the two histologic types (expansile or infiltrative) of apparent stage I mucinous ovarian carcinoma. We retrospectively analyzed patients treated from 1976 and 2016 for apparent macroscopic stage I ovarian mucinous carcinoma. Extra-ovarian disease and tumors that metastasized to the ovaries were excluded. Two expert pathologists performed pathologic reviews of tumor data, according to 2014 WHO classification criteria. Tumors were typed as expansile or infiltrative and clinical and histologic characteristics were studied. The value of staging procedures (peritoneal and nodal) was based on the rate of microscopic involvement in macroscopically normal specimens.

Of 114 cases reviewed, 46 were excluded (26 with macroscopic stage > I; 20 inaccessible for pathologic review). Of 68 patients included, 29 had expansile and 39 had infiltrative types. 27 patients received one-step surgery and 41 received restaging surgery. 52 patients received “complete” peritoneal surgical staging (including cytology, peritoneal biopsies, and an omentectomy or large omental biopsies). 24 underwent appendectomies and 31 underwent lymphadenectomies (8 expansile and 23 infiltrative). Before histologic analyses of staging specimens, 35 had “initial” stage IA and 33 had IC disease. After histologic analyses of lymph nodes, 4 cases (17%, all infiltrative) had nodal involvement, and 2 showed microscopic peritoneal disease (1 omentum and 1 right diaphragm peritoneum). Three patients were upstaged based on isolated positive peritoneal cytology.

To conclude, peritoneal staging procedures are required for both types of mucinous ovarian carcinoma. Lymphadenectomy could be omitted in expansile, but required in infiltrative type.

•

Interest of staging procedures according to both subtypes of mucinous ovarian cancer are studied.

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52 patients underwent peritoneal surgical staging and 31 a lymphadenectomies.

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After lymphadenectomy 4 cases (all infiltrative) had nodal involvement and 5 peritoneal disease.

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Peritoneal staging procedures are required for both types of mucinous ovarian carcinoma.

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Lymphadenectomy could be omitted in expansile subtype.

Imaging in gynecological disease (11): clinical and ultrasound features of mucinous ovarian tumors

OBJECTIVE

To describe the clinical and ultrasound findings in patients with mucinous ovarian tumors.

METHODS

In this retrospective study, women with a histological diagnosis of mucinous ovarian tumor who had undergone preoperative ultrasound examination were identified from the database of a single ultrasound center. The histological examination was performed by the same pathologist in all cases, and the ultrasound appearance of the tumors was described using the terms and definitions of the International Ovarian Tumor Analysis group.

RESULTS

We identified 123 women with a histological diagnosis of mucinous ovarian tumor, of whom 57 (46%) had benign cystadenoma, 34 (28%) had gastrointestinal (GI)-type borderline tumor, 10 (8%) had endocervical-type borderline tumor and 22 (18%) had GI-type invasive carcinoma. On ultrasound examination, 65% (37/57) of cystadenomas were multilocular, of which 59% had ≤ 10 locules, and 79% (27/34) of GI-type borderline tumors were multilocular, of which 89% had > 10 locules. Conversely, 60% (6/10) of endocervical-type borderline tumors had papillations. Eighty-two percent (18/22) of invasive masses contained solid components and 55% (12/22) were multilocular-solid cysts. Bilateral mucinous cystadenomas were found in two women (4% of women with benign tumors) and bilateral borderline tumors of endocervical type in two women (20% of women with borderline tumors of endocervical type). No woman had a bilateral GI-type borderline tumor or a bilateral invasive tumor.

CONCLUSIONS

A multilocular cyst with 2-10 locules is representative of a benign cystadenoma, whereas a multilocular cyst with > 10 locules is indicative of a GI-type borderline tumor. Most invasive tumors of mucinous GI-type contain solid components, the most typical ultrasound appearance being that of a multilocular-solid tumor. Papillary projections are typical features of endocervical-type borderline tumors. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Adnexal masses associated with peritoneal involvement: diagnosis with CT and MRI

Given the unique intra-peritoneal anatomic location of the adnexa, tubo-ovarian diseases can commonly spread into the peritoneal cavity. Peritoneal seeding may occur in a spectrum of adnexal conditions including infectious diseases, endometriosis, and benign or malignant primary or secondary ovarian tumors. CT is usually the imaging modality on which the concomitant involvement of the peritoneum and the ovary is depicted. The first diagnosis to be considered by the radiologist is generally peritoneal carcinomatosis from ovarian cancer but other conditions cited above have also to be borne in mind and may be suggested on the basis of careful assessment of CT findings or on further MR findings. MRI may indeed help characterize the lesions in some cases. The purpose of this review is to describe the clinical and imaging patterns of peritoneal involvement that may be found in association with different ovarian lesions. Familiarity with these patterns and diagnoses will help the radiologist narrow the differential diagnosis and make an accurate diagnosis, thus facilitating patient management and avoiding unnecessary invasive treatment.

Early-Stage Mucinous Ovarian Adenocarcinoma with Extensive Clotting in a Previously Healthy Young Female Patient: An Uncommon Presentation of a Relatively Uncommon Disease

Patient: Female, 24

Final Diagnosis: Mucinous ovarian adenocarcinoma

Symptoms: Nonproductive cough • shortness of breath with exertion

Medication: —

Clinical Procedure: —

Specialty: Oncology

TFF3 Expression as Stratification Marker in Borderline Epithelial Tumors of the Ovary

Borderline tumors (BOT) of the ovary account for 10% to 20% of ovarian neoplasms. Like ovarian cancer, BOT encompass several different histological subtypes (serous, mucinous, endometrioid, clear cell, transitional cell and mixed) with serous (SBOT) and mucinous (MBOT) the most common. Current hypotheses suggest low-grade serous carcinoma may develop in a stepwise fashion from SBOT whereas the majority of high grade serous carcinomas develop rapidly presumably from inclusion cysts or ovarian surface epithelium. The pathogenesis of mucinous ovarian tumors is still puzzling. Molecular markers could help to better define relationships between such entities. Trefoil factor-3 (TFF3) is an estrogen-regulated gene associated with prognosis in different types of cancer. It has also been included in a recent marker panel predicting subtypes of ovarian carcinoma. We analyzed the expression of TFF3 by immunohistochemistry in a cohort of 137 BOT and its association with histopathological features. Overall expression rate of TFF3 was 21.9%. None of the BOT with serous and endometrioid histology displayed strong TFF3 expression. On the other hand, TFF3 was highly expressed in 61.4% of MBOT cases and 33.3% of BOT with mixed histology (P < 0.001) suggesting a potential function of the protein in that subtypes. Associations of TFF3 expression with FIGO stage and micropapillary pattern were significant in the overall cohort but confounded by their correlation with histological subtypes. The highly specific expression of TFF3 in MBOT may help to further clarify potential relationships of tumors with mucinous histology and warrants further studies.

Dual Immunostain With SATB2 and CK20 Differentiates Appendiceal Mucinous Neoplasms From Ovarian Mucinous Neoplasms

OBJECTIVES

Determination of the primary site of origin for mucinous neoplasms identified in the peritoneal and/or pelvic cavities may be challenging, with major differential diagnoses including appendiceal mucinous neoplasm (AMN) and ovarian mucinous neoplasm (OMN). Special AT-rich sequence binding protein 2 (SATB2) has been shown to be highly selectively expressed in the lower gastrointestinal tract, including the appendix.

METHODS

We investigated the utility of a dual stain (DS) with SATB2 or caudal type homeobox 2 (CDX2) and cytokeratin 20 (CK20) or villin in distinguishing AMNs from OMNs. Tissue microarrays with 40 AMNs and 18 OMNs were stained with SATB2 or CDX2 paired with either CK20 or villin.

RESULTS

SATB2 single stain showed a good sensitivity of 83% and the highest specificity of 78% for AMNs over OMNs among all four stains. DS with SATB2 and villin showed an identical sensitivity of 78% but specificity increased to 94%, while DS with SATB2 and CK20 showed a sensitivity of 80% and a specificity of 100%. In contrast, DS with CDX2 and CK20/villin showed slightly higher sensitivity but much lower specificity.

CONCLUSIONS

DS with SATB2/CK20 shows the greatest potential clinical utility in distinguishing AMNs from OMNs and is superior to DS with CDX2/CK20. Importantly, DS could be helpful for specimens with limited tissues.

FOXA1 is expressed in ovarian mucinous neoplasms

FOXA1 is a transcription factor essential for the binding and action of other transcription factors on the chromatin. It is the major regulator of endoderm differentiation. It has important roles in breast, prostate and endometrial cancer. It has never been studied in ovarian tumours. The aim of this study was to investigate its expression in ovarian epithelial neoplasms. A total of 195 primary ovarian epithelial borderline or malignant tumours were immunohistochemically studied for the expression of FOXA1. Nineteen percent of the tumours strongly and diffusely expressed FOXA1. Of these, 75.7% belong to the mucinous category (p < 0.0001). Seventy-five per cent of mucinous borderline tumours and 46.7% of mucinous carcinomas overexpressed FOXA1. Brenner tumours also expressed FOXA1. FOXA1 was rarely expressed in serous (6/115) and endometrioid tumours (1/11). Clear cell tumours were completely negative (0/16). Of normal structures, ciliated tubal cells, Walthard nests and transitional metaplasias of the tubal-mesothelial junction, all strongly expressed FOXA1. In conclusion, FOXA1 is found in ovarian mucinous and Brenner tumours.

Ovarian borderline tumors in the 2014 WHO classification: evolving concepts and diagnostic criteria

Borderline ovarian tumors (BOT) are uncommon but not rare epithelial ovarian neoplasms, intermediate between benign and malignant categories. Since BOT were first identified >40 years ago, they have inspired controversies disproportionate to their incidence. This review discusses diagnostic criteria for the histologic subtypes of BOT, highlighting areas of diagnostic challenges, ongoing controversies, and changes in terminology implemented by the recent 2014 WHO Classification of Tumours of the Female Genital Organs. Emerging knowledge supports the notion that subtypes of borderline ovarian tumors comprise distinct biologic, pathogenetic, and molecular entities, precluding a single unifying concept for BOT. Serous borderline tumors (SBT) share molecular and genetic alterations with low-grade serous carcinomas and can present at higher stages with peritoneal implants and/or lymph node involvement, which validates their borderline malignant potential. All other (non-serous) subtypes of BOT commonly present at stage I confined to the ovary(ies) and are associated with overall survival approaching that of the general population. An important change in the WHO 2014 classification is the new terminology of non-invasive implants associated with SBT, as any invasive foci (previously called “invasive implants”) are now in line with their biological behavior considered peritoneal low-grade serous carcinoma (LGSC). The controversy regarding the terminology of non-serous borderline tumors, called by some pathologists “atypical proliferative tumor” in view of their largely benign behavior, has not been resolved. The concepts of intraepithelial carcinoma and microinvasion may evolve in further studies, as their presence appears to have no prognostic impact and is subject to considerable inter-observer variability.

Pathology of borderline and invasive cancers

Epithelial ovarian tumors are heterogeneous neoplasms primarily classified according to cell type. They are further subdivided into benign, borderline, and malignant (carcinomas), and this subdivision is very important as it correlates with behavior. Borderline ovarian tumors show epithelial proliferation higher than that seen in their benign counterparts and variable nuclear atypia; however, in contrast to carcinomas, there is no destructive stromal invasion, and their prognosis is much better. Ovarian carcinomas are the most common ovarian cancers and the most lethal gynecological malignancies. On the basis of histopathology and molecular genetics, they are divided into five types (high-grade serous (70%), endometrioid (10%), clear cell (10%), mucinous (3%), and low-grade serous carcinomas (<5%)), which are morphologically diverse and account for over 95% of cases. These tumors are essentially distinct diseases, as indicated by differences in epidemiological and genetic risk factors, precursor lesions, patterns of spread, molecular alterations, response to chemotherapy, and prognosis. For a successful specific treatment, reproducible histopathological diagnosis of the tumor cell type is critical.

Prevalence of Appendiceal Lesions in Appendicectomies Performed During Surgery for Mucinous Ovarian Tumors: A Retrospective Study

Objectives

The aim of this study was to assess the frequency of appendiceal pathology in women undergoing surgery for mucinous ovarian neoplasm and to evaluate whether appendicectomy is necessary.

Methods

This single-institution retrospective study reviewed prevalence of appendiceal lesions in all patients operated on at our institution from 2002 to 2013 with the final diagnosis of mucinous tumor of the ovary. Clinicopathological data were analyzed.

Results

One hundred twenty-three cases were identified. These included 45 (37%) benign mucinous ovarian neoplasms, 63 (51%) borderline, and 11 (9%) invasive mucinous ovarian tumors. In addition, 4 (3%) cases of metastatic tumors to the ovary were also identified. Appendiceal pathology was found in association with all types of mucinous ovarian tumors (benign, borderline, and malignant). In 24% of cases, appendix was macroscopically abnormal at the time of the surgery, prompting the surgical removal. Regardless of the gross findings, microscopic abnormality in the appendix was seen in 24% of all cases. The prevalence of significant occult microscopic appendiceal pathology, that is, when the appendix was grossly normal, was 6%.

Conclusions

Given the prevalence of coexisting appendiceal pathology found in this study and the reported low rates of complications associated with the procedure, an appendicectomy is recommended in the management of all mucinous ovarian neoplasms.

Pattern classification of endocervical adenocarcinoma: reproducibility and review of criteria

Previously, our international team proposed a three-tiered pattern classification (Pattern Classification) system for endocervical adenocarcinoma of the usual type that correlates with nodal disease and recurrence. Pattern Classification-A tumors have well-demarcated glands lacking destructive stromal invasion or lymphovascular invasion, Pattern Classification-B tumors show localized, limited destructive invasion arising from A-type glands, and Pattern Classification-C tumors have diffuse destructive stromal invasion, significant (filling a 4 × field) confluence, or solid architecture. Twenty-four cases of Pattern Classification-A, 22 Pattern Classification-B, and 38 Pattern Classification-C from the tumor set used in the original description were chosen using the reference diagnosis originally established. One H&E slide per case was reviewed by seven gynecologic pathologists, four from the original study. Kappa statistics were prepared, and cases with discrepancies reviewed. We found a majority agreement with reference diagnosis in 81% of cases, with complete or near-complete (six of seven) agreement in 50%. Overall concordance was 74%. Overall kappa (agreement among pathologists) was 0.488 (moderate agreement). Pattern Classification-B has lowest kappa, and agreement was not improved by combining B+C. Six of seven reviewers had substantial agreement by weighted kappas (>0.6), with one reviewer accounting for the majority of cases under or overcalled by two tiers. Confluence filling a 4 × field, labyrinthine glands, or solid architecture accounted for undercalling other reference diagnosis-C cases. Missing a few individually infiltrative cells was the most common cause of undercalling reference diagnosis-B. Small foci of inflamed, loose or desmoplastic stroma lacking infiltrative tumor cells in reference diagnosis-A appeared to account for those cases up-graded to Pattern Classification-B. In summary, an overall concordance of 74% indicates that the criteria can be reproducibly applied by gynecologic pathologists. Further refinement of criteria should allow use of this powerful classification system to delineate which cervical adenocarcinomas can be safely treated conservatively.

Pathology of Mucinous Appendiceal Tumors and Pseudomyxoma Peritonei

Neoplasms of the appendix are rare, but because of their unusual presentation and unpredictable biologic behavior, it is important to diagnose them correctly. Mucinous tumors account for 58 % of malignant tumors of appendix in SEER database and the remaining are carcinoids. The mucinous appendiceal tumors have a potential to spread to the peritoneum and viscera in the form of gelatinous material with or without neoplastic cells resulting in Pseudomyxoma peritonei. (PMP) PMP is a clinical entity that has a unique biological behavior and can arise from seemingly benign tumors to frankly malignant ones. Several classifications exist for PMP of which Ronnet's classification has been the most popular. In 2010, the WHO proposed a 2 tier classification that classified PMP as either low grade or high grade based on the presence of mucin, cytological and architectural features. According to this classification when the underlying cause for PMP is an appendiceal tumor it is always a mucinous adenocarcinoma rather than a mucocoele or adenoma and these terms should no longer be used. This system of classification helps in predicting the behavior of the tumor and proper treatment strategies. The understanding of the pathogenesis of the disease has also improved with identification of newer biomarkers and molecular genetic alterations. IHC markers CK 20, CDX2 and MUC2 are found to be positive in these tumors in addition to KRAS mutation and loss of heterozygosity in some gene loci. Proper histopathologic classification and predicting the tumor behavior requires a close interaction between the pathologist and the surgeon. The use of the combined modality treatment of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has led to a 5-year survival ranging from 62.5 % to 100 % for low grade, and 0 %-65 % for high grade disease. This article focuses on the etiopathogenesis, clinical behavior, diagnosis and classification of mucinous tumors of the appendix and pseudomyxoma peritonei.

Significance of epithelial cell clusters in pseudomyxoma peritonei

BACKGROUND

Pseudomyxoma peritonei (PMP) is a rare clinical syndrome characterised by distension of the peritoneum by jelly-like ascites. Cytological evaluation of peritoneal fluid is often an initial diagnostic test for possible ovarian and/or appendiceal primary tumours.

AIMS AND OBJECTIVES

The present work was conducted to study the usefulness of peritoneal fluid cytomorphology in the early diagnosis of PMP and to evaluate the significance of the presence of epithelial cell (EC) clusters and their prognostic implications.

MATERIALS AND METHODS

We evaluated the detailed cytological features of 21 cases of PMP retrospectively. Both conventional and liquid-based cytology smears of peritoneal fluid were reviewed, cytological features were compared with histological findings and cases were classified into disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis (PMCA).

RESULTS

In our study, the common causes of PMP were primary gastrointestinal malignancies (appendix and colorectal, 57.14%), followed by primary ovarian mucinous neoplasms (28.57%) and synchronous ovarian and appendicular tumours (14.28%). Thick mucinous material was present in all cases (100%). ECs were present in 18 of 21 (85.17%) patients, with mild nuclear atypia in the majority of cases. Histiocytes, mesothelial cells and fibroblast-like, spindle-shaped cells with entrapped mucin were also noted in the background. The cases of PMCA showed greater numbers of EC clusters in cytology smears and these patients had recurrent episodes of PMP.

CONCLUSION

On cytomorphology, high-grade tumours were more cellular and frequently showed EC clusters with moderate to severe atypia, prominent nucleoli and mitosis, and were more prone to PMCA.

Serous and mucinous borderline ovarian tumours: differences in clinical presentation, high-risk histopathological features, and lethal recurrence rates

BACKGROUND

Mucinous and serous borderline ovarian tumours (mBOTs and sBOTs) are controversial diseases.

OBJECTIVES

With this systematic review we aim to evaluate the different high-risk histopathological features and recurrence rates.

SEARCH STRATEGY

The PubMed database was searched using two terms: {serous AND [(borderline) OR (low malignant potential)] AND ovarian AND tumour} and {mucinous AND [(borderline) OR (low malignant potential)] AND ovarian AND tumour}.

SELECTION CRITERIA

Cohorts of either sBOT or mBOT, peer-reviewed, retrospective, or prospective.

DATA COLLECTION AND ANALYSIS

Lethal recurrence data for micropapillary patterns (MPs), microinvasion, non-invasive and invasive implants, and intraepithelial carcinoma (IECA). The primary measure of effect was the odds ratio of lethal recurrence reduction.

RESULTS

Data from patients in 42 studies including 4414 sBOTs and 12 studies including 894 mBOTs were pooled. Of these, 53.3% presented early-stage typical sBOTs, 24.4% presented with MPs, 22.3% presented with microinvasion, 34.4% presented with non-invasive implants, and 7.3% presented with invasive implants. The pooled lethal recurrence rates were, respectively: 18.3, 16.8, 10.7, 16.2, and 33.8%. Patients with MPs were more likely to suffer lethal recurrence when compared with high-stage sBOTs (odds ratio, OR 0.501; P = 0.003), whereas the trend in microinvasive sBOTs did not reach statistical significance. Regarding mBOTs, 61.6% presented with early-stage typical mBOTs, 19.6% presented with microinvasion, 34.8% presented with IECA, and six patients presented with non-invasive implants; none presented with invasive implants. The lethal recurrence rates were, respectively: 3.6, 0, 3.7, and 0%.

CONCLUSION

Micropapillary patterns (MPs) showed a higher risk for lethal recurrence when compared with high-stage sBOTs. Regarding mBOTs, IECA and microinvasion do not play a role in the lethal recurrence rate.

TWEETABLE ABSTRACT

Micropapillary pattern confirmed as high-risk in BOT. IECA and microinvasion don't play a role in mucinous BOT.