An Evaluation of Frozen Section and Lymph Node Dissection Results for Mucinous Ovarian Tumors

Factors Affecting the Diagnostic Discordance Between Frozen and Permanent Sections in Mucinous Ovarian Tumors

Purpose

To investigate the accuracy of intraoperative frozen section (FS) diagnosis for predicting the permanent section (PS) diagnosis of mucinous ovarian tumors and evaluate the factors affecting the diagnostic discordance.

Patients and Methods

This retrospective cohort study was performed in Tianjin Medical University General Hospital. All women who underwent ovarian surgery with FS between January 2011 and December 2022 were identified, and those with a diagnosis of mucinous ovarian tumor (MOT) by FS or PS were reviewed. Clinical and pathologic data were extracted.

Results

A total of 180 women were included, of which 141 (78.33%) had diagnostic concordance between FS and PS, yielding a sensitivity of 83.43% and a positive predictive value (PPV) of 92.76%. Under- and over-diagnosis occurred in 28 cases (15.56%) and 11 cases (6.11%). Tumor size > 13cm (OR 3.79, 95% CI 1.12-12.73) was an independent risk factor for under-diagnosis, and tumor size ≤ 13cm (OR 16.78, 95% CI 0.01-0.49), laparoscopic surgery (OR 0.14, 95% CI 0.02-0.92), the combination of other tumor components (including serous, Brenner tumor, and chocolate cyst; OR 7.00, 95% CI 1.19-41.12) were independently associated with over-diagnosis. The Kaplan-Meier survival curves and the Log rank test showed no significant difference between misdiagnosed and accurately diagnosed patients (all P > 0.05).

Conclusion

Intraoperative frozen pathology of MOT is problematic for under- and over-diagnosis. The incorrect diagnosis of FS was related to determining the extent of surgery but had no impact on the patients' long-term recurrence and survival outcomes. In future clinical practice, surgeons need to obtain material accurately and enhance communication with pathologists during the operation to improve the accuracy of FS diagnosis.

Oncological and Reproductive Outcomes After Fertility-Sparing Surgery for Stage I Mucinous Ovarian Carcinoma

Background

Fertility-sparing surgery (FSS) has been widely used for patients with early-stage mucinous ovarian carcinoma (MOC). However, there is limited evidence regarding the reproductive outcomes as well as the impact of growth pattern on oncological outcomes after FSS. This study aims to evaluate the oncological and reproductive outcomes of patients with stage I primary MOC after FSS.

Methods

This retrospective study enrolled 159 women with histologically confirmed unilateral stage I MOC treated at Peking Union Medical College Hospital between 1997 and 2019. Sixty-seven cases were pathologically reviewed for the growth pattern. Seventy-eight patients had FSS, defined as conservation of the uterus and at least part of one ovary, while 81 underwent radical surgery (RS). Oncofertility outcomes were compared between the groups and clinicopathological factors associated with disease-free survival (DFS) were analyzed by univariate and multivariate analyses. Patients in the FSS group were contacted to collect data on reproductive outcomes.

Results

Eighteen patients developed recurrent disease during a median follow-up of 69 months, including 12 in the FSS and six in the RS group. There was one death each in the FSS and RS groups. There was no significant difference in DFS between the groups. CA125 >35 U/ml, stage IC, and incomplete staging were correlated with worse DFS according to multivariate analysis (P=0.001; 0.020 (stage IC) and 0.004 (incomplete staging) respectively). There was no significant difference in DFS between patients with stage IA and stage IC1 in the FSS group, while DFS was poorer in patients with stage IC2/3 than stage IA (P=0.028). In addition, DFS was significantly poorer in patients who underwent unilateral salpingo-oophorectomy (USO) compared with those receiving USO plus staging surgery (P=0.015). There was a tendency towards poorer DFS in the infiltrative tumors compared with the expansile tumors (P=0.056). Of 23 patients who attempted to conceive, 21 (91.3%) achieved 27 pregnancies, including 26 spontaneous pregnancies and one following assisted reproductive technology. Twenty patients gave birth to 24 healthy babies, including 21 full-term and three premature births. The live-birth rate was 88.9%.

Conclusions

FSS is a suitable option for young women with unilateral stage I expansile MOC, with acceptable oncological outcomes and meaningful pregnancy rates. Re-staging should be proposed in patients who undergo incomplete staging surgery.

A Novel Case of Recurrent Mucinous Borderline Ovarian Tumor: Early Relapse and Fatal Outcome

Unlike ovarian carcinomas, borderline ovarian tumors (BOTs) are associated with a favorable prognosis: their recurrence rate is around 5–7%, and the survival rate is more than 97% when diagnosed early. There are only a few reports of recurrence and fatal outcomes. Herein, we report a novel case of recurrent mucinous BOT, with a literature review. A 63-year-old woman presented to a local doctor with abdominal fullness. She was diagnosed as having a polycystic tumor. The lesion was suspected to be a mucinous BOT (M-BOT) on magnetic resonance imaging. Upper and lower gastrointestinal endoscopy revealed no digestive cancerous lesions, and surgery was performed. Intra-operative diagnosis confirmed the diagnosis, and total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were performed. The final pathological diagnosis was non-invasive M-BOT (stage I c1 (T1c1N0M0)). The result of immunohistochemical staining supported the diagnosis of primary ovarian mucinous tumor.Four months after surgery, relapse occurred. Blood tests revealed an elevated carbohydrate antigen 19-9 level, and computed tomography revealed multiple liver metastases, peritoneal dissemination, left ureter infiltration, and carcinomatous peritonitis. Although the patient underwent chemotherapy, she died. This case of a very short progression-free and overall survival in stage I M-BOT indicates that some M-BOTs could result in fatal clinical outcomes despite diagnosis at an early stage. Frequent follow-up appointments after surgery could help detect relapse and increase survival in such cases.

Predicting Lymph Node Involvement in Borderline Ovarian Tumors with a Quantitative Model and Nomogram: A Retrospective Cohort Study

Purpose

This study aimed to establish a predictive model for lymph node involvement (LNI) in patients with borderline ovarian tumor (BOT) using clinicopathological factors.

Patients and Methods

We collected clinical data from consecutive patients who underwent lymphadenectomy for BOT between 2001 and 2018 and analyzed their clinicopathological features. Multivariate logistic regression was used to identify all independent risk factors associated with LNI; these were then incorporated into the prediction model.

Results

In total, we included 248 patients with BOT who were undergoing lymphadenectomy. These were divided into a training cohort (n=174) and a validation cohort (n=74). When considering histopathological data, 16 and 5 patients were identified to have LNI in the training and validation cohorts, respectively. Overall, 13.5% (21/156) patients with serous BOT had LNI while 0% (0/92) patients with non-serous BOT had LNI. We identified several predictors of LNI: the largest tumor being ≥ 12.2cm in diameter, the presence of lesions on the ovarian surface, and the presence of pelvic or abdominal lesions. We created a prediction model and nomogram that incorporated these three risk factors for serous BOT. The model achieved good discriminatory abilities of 0.951 and 0.848 when predicting LNI in the training and validation cohorts, respectively. The LNI-predicting nomogram had an area under curve (AUC) of 0.951 and generated well-fitted calibration curves.

Conclusion

Non-serous BOT may not require lymphadenectomy as part of surgical staging. The individual risk of LNI in patients with serous BOT can be accurately estimated using our prediction model and nomogram. The use of LNI criteria provides a practical way to support the clinician in making an optimal decision relating to surgical scope for patients with BOT.

Feasibility of Single-Port Access (SPA) Laparoscopy for Large Ovarian Tumor Suspected to Be Borderline Ovarian Tumor

Objectives

To compare the surgical, pathological and oncological outcomes of single-port access (SPA) laparoscopy against laparotomy for large ovarian tumor (>15 cm) suspected to be a borderline ovarian tumor (BOT) on preoperative imaging.

Methods

A retrospective review of the patients who underwent SPA laparoscopy (SPA Group) or laparotomy (Laparotomy Group) for suspected BOT was performed. Surgical outcomes, including the rates of iatrogenic spillage of tumor contents, and oncological outcomes, such as recurrence-free survival (RFS) and overall survival (OS), were compared between the two groups. Correlation between intraoperative frozen section analysis and permanent pathology results was also assessed.

Results

A total of 178 patients underwent surgical treatment for suspected large BOT. Among them, 105 patients with a mean tumor diameter of 20.9 ± 6.5 cm underwent SPA laparoscopy, and the other 73 patients, with a mean tumor diameter 20.2 ± 5.9 cm, underwent laparotomy. The mean operation time did not differ between the two groups (99.1 ± 41.9 min for SPA Group vs. 107.3 ± 35.7 min for Laparotomy Group, p = 0.085). There was no difference in the occurrence of iatrogenic spillage of tumor contents between the groups either (11.4% in the SPA Group vs. 6.8% in the Laparotomy Group, p = 0.381). However, the postoperative complication rates were significantly higher in the Laparotomy Group compared with SPA Group (16.4% vs. 5.7%, p = 0.025). The surgical approach was not associated with the misdiagnosis rates of frozen section analysis (19% in the SPA Group vs. 26% in the Laparotomy Group, p = 0.484). The most common histologic type of the tumors was mucinous in both groups.

Conclusion

SPA laparoscopy is feasible, safe, and not inferior to laparotomy for surgical treatment of large ovarian tumors that suspected to be BOT on preoperative imaging.

[Borderline ovarian tumours: CNGOF Guidelines for clinical practice - Biopathology of ovarian borderline tumors]

OBJECTIVES

Ovarian borderline tumors (OBT) represent a heterogeneous group of lesions with specific 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

OBT should be classified according to the last WHO classification. Any micro-invasion (foci<5mm) or microcarcinoma (foci<5mm with nuclear atypia and desmoplastic stromal reaction) should be indicated in the pathology report. In case of serous OBT, variants (classical or the micropapillary/cribriform) should be indicated (grade C). The peritoneal implants associated with OBT, should be classified as invasive or noninvasive, according to the extension into the underlying adipous tissue. If no adipous tissue is seen the term undetermined should be used (grade B). In case of mucinous OBT bilateral and/or with peritoneal implants or peritoneal pseudomyxoma a search for primitive gastrointestinal, appendiceal or biliopancreatic tumor should be performed (grade C). In case of OBT, a thorough sampling of the tumor is recommended, with 1 block/cm and 2 blocks/cm in case of mucinous OBT, serous OBT micropapillary variant, OBT with intraepithelial carcinoma or/and micro-invasion. Peritoneal implants should be examined in toto. Omentum without macroscopic lesion should be sampled in 4 to 6 blocks (grade C). In case of ovarian cyst suspicious for OBT, fine needle aspiration is not recommended (grade C). In case of ovarian tumor suspicious for OBT, intraoperative examination should be performed by a gynecological pathologist (grade C).

Borderline tumours of the ovary: Common practice in the Netherlands

Objectives

Discordance between frozen section diagnosis and the definite histopathological diagnosis and the fact that the frozen section result is not always unambiguous, may contribute to differences in clinical practice regarding perioperative treatment and follow-up of borderline ovarian tumours (BOTs) patients amongst gynaecologic oncologists, which may lead to over- and undertreatment. The aim of the study was to map the Dutch gynaecologists' preferred treatment and follow-up strategy in case of BOTs.

Methods

A questionnaire was sent to all Dutch gynaecologists involved in ovarian surgery with perioperative frozen section analysis, and the outcomes were assessed using descriptive statistics.

Results

Nearly half of the respondents (41.0%) would not perform a staging procedure in case of a BOT. In case of an ambiguous frozen section diagnosis, tending towards invasive carcinoma, a considerable number (sBOT 56.4%; mBOT 30.8%) would perform a lymph node sampling as part of the staging procedure. A relaparotomy/relaparoscopy, to perform a lymph node sampling in case of a serous or mucinous carcinoma after a BOT frozen section diagnosis, would be performed by 97.4% and 48.7% of the respondents, respectively.

Conclusions

A considerable number of gynaecologists would perform a staging procedure that is recommended for ovarian cancer in case of an ambiguous BOT frozen section diagnosis, especially for serous tumours. In addition, nearly all gynaecologists would perform a second procedure including a lymph node sampling in case of a serous invasive carcinoma after a BOT frozen section diagnosis, which applies to half of the gynaecologists in case of a mucinous carcinoma.

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In case of an unambiguous frozen section BOT diagnosis, a staging procedure is omitted by nearly half of the gynaecologists.

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When the frozen section BOT diagnosis is ambiguous, a full ovarian cancer staging procedure is frequently performed.

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Most gynaecologists perform a second procedure to complete staging when definitive diagnosis shows invasive ovarian cancer.

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Full staging is performed more frequently in case of serous histopathology, when compared to mucinous tumours.

Diagnostic accuracy of frozen section analysis of borderline ovarian tumors: a meta-analysis with emphasis on misdiagnosis factors

Objective: First, to evaluate the sensitivity and positive predictive value (PPV) of intra-operative frozen section (FS) diagnosis in borderline ovarian tumors (BOTs), and to explore the factors affecting the diagnostic accuracy. Second, to assess the clinical outcomes of misdiagnosed BOT patients.

Methods: We performed a retrospective study of all patients diagnosed as BOT through FS or paraffin section (PS) at Qilu Hospital between January 2005 and December 2015. Clinical and pathologic data were extracted. Univariate analysis was performed using standard two-sided statistical tests. We also performed a meta-analysis to further validate the findings.

Results: In our retrospective study, 155 patients were included. Agreement between FS and PS diagnosis was observed in 127/155 (81.9%) patients, yielding a sensitivity of 92.7% and a PPV of 87.6%. Under-diagnosis and over-diagnosis occurred in 22 cases (14.2%) and 6 cases (3.9%), respectively. In our univariate analysis of our retrospective study, tumor size (p=0.048) and surgery approach (p=0.024) were significantly associated with misdiagnosis.

The pooled analysis of 13 studies including 1,577 patients indicated that the accuracy (69.2%), sensitivity (82.5%), and PPV (81.1%) were low; also under-diagnosis (20.2%) and over-diagnosis (10.5%) were frequent. The meta-analysis results showed that mucinous histology (p < 0.0001, OR=2.03 [1.47-2.81]) and unilateral tumors (p=0.001, OR=2.39 [1.41-4.06]) were associated with the misdiagnosis of BOT. In our retrospective study, there was no statistical significance of clinical outcome such as extent of surgery (p=0.838), recurrence (p=0.586), fertility (p=0.560), death (p=0.362) between misdiagnosed and accurately diagnosed BOT patients.

Conclusions: FS analysis of BOTs has low accuracy, sensitivity, and PPV. Under-diagnosis and over-diagnosis are frequent. Meta-analysis results verify that mucinous histology and unilateral tumors are associated with misdiagnosis of FS. Nevertheless, misdiagnosed patients have a good clinical outcome despite the high frequency of misdiagnosis through FS.