Accuracy of frozen section for the operative management of endometrial cancer

It is not the time to abandon intraoperative frozen section in endometrioid adenocarcinoma: A large-scale, multi-center, and retrospective study

INTRODUCTION

Stage IB (deep myometrial invasion) high-grade endometrioid adenocarcinoma (EA), regardless of LVSI status, is classified into high-intermediate risk groups, requiring surgical lymph node staging. Intraoperative frozen section (IFS) is commonly used, but its adequacy and reliability vary between reports. Hence, we determined the utility of IFS in identification of high-risk factors, including deep myometrial invasion and high-grade.

METHOD

We retrospectively analyzed 9,985 cases operated with hysterectomy and diagnosed with FIGO stage I/II EA in postoperative paraffin section (PS) results at 30 Chinese hospitals from 2000 to 2019. We determined diagnostic performance of IFS and investigated whether the addition of IFS to preoperative biopsy and imaging could improve identification of high-risk factors.

RESULTS

IFS and postoperative PS presented the highest concordance in assessing deep myometrial invasion (Kappa: 0.834), followed by intraoperative gross examination (IGE Kappa: 0.643), MRI (Kappa: 0.395), and CT (Kappa: 0.207). IFS and postoperative PS presented the highest concordance for high-grade EA (Kappa: 0.585) compared to diagnostic curettage (D&C 0.226) and hysteroscope (Hys 0.180). Sensitivity and specificity for detecting deep myometrial invasion were 86.21 and 97.20% for IFS versus 51.72 and 88.81% for MRI, 68.97 and 94.41% for IGE. These figures for detecting high-grade EA were 58.21 and 96.50% for IFS versus 16.42 and 98.83% for D&C, 13.43 and 98.64% for Hys. Parallel strategies, including MRI-IFS (Kappa: 0.626), D&C-IFS (Kappa: 0.595), and Hys-IFS (Kappa: 0.578) improved the diagnostic efficiencies of individual preoperative examinations. Based on the high sensitivity of IFS, parallel strategies improved the sensitivities of preoperative examinations to 89.66% (MRI), 64.18% (D&C), 62.69% (Hys), respectively, and these differences were statistically significant (p = 0.000).

CONCLUSION

IFS presented reasonable agreement rates predicting postoperative PS results, including deep myometrial invasion and high-grade. IFS helps identify high-intermediate risk patients in preoperative biopsy and MRI and guides intraoperative lymphadenectomy decisions in EA.

ZEB1 expression in endometrial biopsy predicts lymph node metastases in patient with endometrial cancer

Purpose. The purpose of this study was to analyze the expression of zinc-finger E-box-binding homeobox 1 (ZEB1) in endometrial biopsy and its correlation with preoperative characteristics, including lymph node metastases in patient with endometrial cancer. Methods. Using quantitative RT-PCR, ZEB1 expressions in endometrial biopsy from 452 patients were measured. The relationship between ZEB1 expression and preoperative characteristics was analyzed. Results. ZEB1 expressions were significantly associated with subtype, grade, myometrial invasion, and lymph node metastases. Lymph node metastases could be identified with a sensitivity of 57.8% at specificity of 74.1% by ZEB1 expression in endometrial biopsy. Based on combination of preoperative characteristics and ZEB1 expression, lymph node metastases could be identified with a sensitivity of 62.1% at specificity of 96.2% prior to hysterectomy. Conclusion. ZEB1 expression in endometrial biopsy could help physicians to better predict the lymph node metastasis in patients with endometrial cancer prior to hysterectomy.

The guidance of intraoperative frozen section for staging surgery in endometrial carcinoma: frozen section in endometrial carcinoma

The objective of this study was to evaluate the reliability of an intraoperative frozen section during the endometrial carcinoma staging surgery procedure. The paraffin section reports of 291 cases with endometrial carcinoma were compared with intraoperative frozen section reports, which were diagnosed in the Pathology Department of Cukurova University, Medical Faculty between June 2006 and December 2012. The reports were reviewed for diagnostic accuracy of the frozen section in terms of histological subtype, grade, and myometrial invasion. Concordance values between frozen and paraffin section reports were 86, 84.3, and 91.6% for histological subtype, grade, and myometrial invasion, respectively. When collectively evaluated, two (0.7%) of 291 patients were inappropriately operated on due to frozen section reports. Intraoperative frozen section is a reliable guide for surgeons to evaluate the risk group of patients with endometrial cancer and prevent an unnecessary staging surgery operation.

Preoperative and intraoperative assessment of myometrial invasion in endometrial cancer: comparison of magnetic resonance imaging and frozen sections

OBJECTIVE

To compare the diagnostic characteristics of the evaluation of myometrial invasion (MI) retrospectively between preoperative magnetic resonance imaging (MRI) and intraoperative frozen sections.

DESIGN

A retrospective study.

SETTING

University hospital.

SAMPLE

201 women diagnosed with endometrial carcinoma.

METHODS

All women underwent preoperative MRI and 111 of them also underwent intraoperative frozen section assessment. The final pathological evaluation was used as the definitive diagnosis.

MAIN OUTCOME MEASURES

In women who underwent MRI and frozen sections (n = 111), the accuracies of detection of MI and of deep invasion (defined as ≥50% invasion) were compared.

RESULTS

The accuracy, sensitivity, and specificity of MRI for detection of MI were 65.8, 58.8, and 88.5%, and those in frozen sections were 90.1, 90.6, and 88.5%, respectively. The accuracy and sensitivity of frozen sections were significantly higher (p < 0.001, p < 0.001), whereas the specificity of the two methods did not differ (p = 1.000). The accuracy, sensitivity, and specificity of MRI for detection of deep invasion were 83.8, 69.2, and 88.2%, and those of frozen sections were 93.7, 73.1, and 100.0%, respectively. The accuracy and specificity of frozen sections were significantly higher (p = 0.007 and p < 0.001, respectively), whereas sensitivity did not show a significant difference (p = 0.999).

CONCLUSION

In assessment of MI, the accuracy of frozen sections was significantly higher than that of MRI. Since the diagnostic characteristics differ between two methods, additional intraoperative frozen sections are recommended for more accurate assessment of MI when MRI is negative for the presence of any MI or positive for the presence of deep invasion.

Validation of intraoperative risk assessment on frozen section for surgical management of endometrial carcinoma

OBJECTIVE

This study aimed to evaluate the accuracy of risk assessment in intraoperative frozen section (IFS) in order to direct surgical management and also attempted to validate the clinical significance of using five variables for classification as low- or intermediate high-risk endometrial carcinoma in routine practice.

PATIENTS AND METHODS

Charts of 410 patients who underwent surgery for endometrial cancer between January 1992 and December 2003 were retrospectively reviewed, and risk assignment on the basis of IFS was compared with final pathological reports. Clinical relevance of risk assessment and its surgical consequences were studied on the basis of patient survival data.

RESULTS

In 303 (95%) of 318 cases, IFS-assessed risk corresponded with that estimated from final paraffin sections, giving a positive predictive value of 99% and a negative predictive value of 92%. Unrecognized lymphovascular invasion in IFS was the main factor responsible for the discrepancies between the two examinations. Survival analysis showed a highly significantly better outcome for patients with low-risk as compared to intermediate high-risk carcinomas for recurrence-free (RFS) and overall survival (OS). However, survival in patients with intermediate high-risk carcinomas who underwent lymphadenectomy (LNE) was not significantly improved as compared to those who did not. Moreover, in multivariate analysis lymph node involvement did not emerge as a variable with significant impact on survival. Age, tumor stage and intraoperatively assessed risk were seen to be independent prognosticators in this study (p<0.0001).

CONCLUSION

Our data show that IFS, when performed by experienced gynecopathologists, is a reliable and applicable tool in estimating risk in endometrial cancer and that systematic LNE seems to not be superior to radiotherapy with regard to patient survival.

Percent surface area involvement is a predictor of lymph node metastasis in endometrial cancer

OBJECTIVE

To determine if percent surface area involvement (SAI) of tumor in endometrial cancer is predictive of lymph node metastasis.

METHODS

A retrospective study was performed of all patients diagnosed with endometrial cancer at Magee Women's Hospital between January 1990 and December of 1995. Papillary serous and clear cell histologic subtypes were excluded. Pathology reports were reviewed for percent SAI, myometrial invasion, grade, histologic subtype, lymphovascular space invasion, and lymph node metastasis. Percent SAI was categorized into three groups: <35%, 35-80%, and >80%. The primary outcome variables were pelvic or periaortic lymph node metastasis. Univariate and multivariate analysis logistic regression models were used to determine predictors of nodal metastasis.

RESULTS

Of 558 patient records reviewed, 319 had lymph node dissections performed and 42 (13%) of those patients had positive lymph nodes. Two of 79 (3%) patients with <35% SAI had lymph node metastasis, 17 of 165 (10%) patients with 35-80% SAI had lymph node metastasis, and 23 of 75 (31%) patients with >80% SAI had lymph node metastasis. The percent SAI was significantly associated with lymph node metastasis (p<0.001). Multivariate logistic regression indicated that for patients with >80% SAI, the odds of having lymph node metastasis were 10.8 times (CI 1.3-90.4) that for patients with similar tumor histology, grade, and invasion, but <35% SAI (p=0.03). A subset analysis of patients with superficial myometrial invasion was performed and 16% of patients with <50% myometrial invasion and >80% SAI had positive lymph nodes, while only 1.4% of patients with <50% myometrial invasion and <35% SAI had positive lymph nodes (p=0.02).

CONCLUSION

Our analysis indicates that percent SAI is an independent risk factor for lymph node metastasis. Furthermore, assessing SAI with myometrial invasion gives a more accurate prediction of lymph node metastasis than myometrial invasion alone. This becomes clinically relevant when assessing risk factors for lymph node metastasis intraoperatively.

Can We Omit Para-Aorta Lymph Node Dissection in Endometrial Cancer?

BACKGROUND

Patients with endometrial cancer can present with various complicating illnesses, including obesity, diabetes mellitus, hypertension and advanced aging. These patients are at high risk of severe post-operative complications. Thus, the question of whether or not to perform systemic pelvic and para-aortic lymphadenectomy remains controversial for all patients. It is reported that external iliac lymph nodes are the most commonly involved lymph nodes in endometrial cancer, and para-aortic lymph node (PAN) metastases spread via a route shared by the common iliac lymph nodes. The aim of this study was to evaluate the potential efficacy of omitting PAN dissection when metastasis of the common iliac and external iliac lymph nodes is negative.

METHODS

Between January 1994 and June 2004, a total of 101 patients at Akita University Hospital who had undergone total hysterectomy and bilateral salpingo-oophorectomy, total pelvic lymphadenectomy and para-aortic lymphadenectomy to the level of the renal vein for endometrial cancer were enrolled in this study.

RESULTS

Eleven patients in all were found to have metastasis for PANs. Among 13 patients with common and/or external iliac positive lymph nodes, 10 showed PAN metastasis. Of the 88 patients with negative lymph nodes, 87 showed no PAN metastasis. Based on these data, common and/or external iliac lymph nodes had 90.9% sensitivity (10/11) and 96.7% specificity (87/90) for detecting PAN metastasis.

CONCLUSION

Para-aortic lymphadenectomy might be avoided by the negativity of such lymph nodes, thereby minimizing post-operative complications.

Imaging of endometrial adenocarcinoma

Endometrial cancer is the most common gynaecological malignancy and the incidence rising. Prognosis depends on age of patient, histological grade, depth of myometrial invasion and cervical invasion and lymph node metastases. Myometrial invasion and accurate cervical involvement cannot be predicted clinically. Pre-treatment knowledge of these criteria is advantageous in order to plan treatment. The clinical challenge is to effectively select patients at risk of relapse for more radical treatment whilst avoiding over treating low risk cases. This is important as endometrial cancer predominately occurs in postmenopausal women with co-morbidities. Modern imaging provides important tools in the accurate pre-treatment assessment of endometrial cancer and may optimize treatment planning. However, there is little consensus to date on imaging in the routine preoperative assessment of endometrial carcinoma and practice varies amongst many gynaecologists. Transvaginal ultrasound is often the initial imaging examination for women with uterine bleeding. However, once the diagnosis of endometrial cancer has been made, contrast-enhanced magnetic resonance imaging (MRI) provides the best assessment of the disease. The results of contrast-enhanced MRI may identify patients who need more aggressive therapy and referral to a cancer centre. In this article we review the role of imaging in the diagnosis and staging/preoperative assessment of endometrial carcinoma.

Reliability of intraoperative frozen sections in the management of Hirschsprung's disease

BACKGROUND

The use of a 1-stage pull-through for Hirschsprung's disease (HD) is dependent on accurate identification of the normally innervated bowel on intraoperative frozen sections (IOFS). The authors wished to determine the incidence and sources of error during this process.

METHODS

All HD patients undergoing IOFS over a 15-year period were reviewed.

RESULTS

Three hundred four patients underwent a total of 700 IOFS. In 9 cases (3%), there was discrepancy between IOFS and permanent sections. Two of these were false-positive (ganglion cells incorrectly believed to be present at IOFS); both required a second operation as a result of the error. Seven were false-negative (presence of ganglion cells not recognized at IOFS); none required a subsequent operation, but 2 had a significantly more extensive colonic resection than was necessary. Responsible factors included sampling from the transition zone, freezing artifact, and misinterpretation of ganglion cells in very young patients owing to pathologist inexperience. There was significant variability in the error rate among the 11 pathologists. However, the numbers were too small for statistical analysis to determine whether there was a correlation between the rate of errors and the volume of cases done or years of experience.

CONCLUSIONS

Error in reading of IOFS is rare but can have significant repercussions in patient care. Multiple factors, including technical issues and pathologist experience, may have a role in contributing to these errors.

Surgical chores and approach in the management of endometrial cancer

Carcinoma of the uterine corpus is the most common malignancy in the female pelvis. Surgical resection and staging are now the accepted approach to therapy, with excellent survival compared with other gynecologic malignancies. Several controversies exist, however, regarding optimal surgical management. Some of these controversies are addressed in this article, with a review of their recent and historic literature.