Accuracy of intraoperative frozen section for the evaluation of ovarian neoplasms: an institutional experience

Intraoperative frozen section evaluation of ovarian sex cord-stromal tumours and their mimics: a study of 121 cases with emphasis on potential diagnostic pitfalls

Ovarian sex cord-stromal tumours (SCSTs) present diagnostic difficulties during frozen section (FS) consultations due to their diverse morphology. This study aimed to evaluate the accuracy of FS evaluation of SCSTs in our institution, as well as to examine the reasons leading to incorrect FS diagnosis. Cases mimicking SCSTs and diagnosed as such during FS were also highlighted. We analysed 121 ovarian SCST cases and their mimics which underwent FS consultations over a 10-year period, to evaluate FS accuracy, reasons for deferrals and discrepancies. FS diagnoses were concordant, deferred and discrepant compared to the final diagnosis in 50 (41.3%), 39 (32.2%) and 32 (26.5%) cases, respectively. Major discrepancies (9/121, 7.4%) were mostly related to the diagnosis of adult granulosa cell tumour (AGCT). A fibromatous AGCT was misinterpreted as fibroma on FS, while a cystic AGCT was called a benign cyst. Conversely, a mesonephric-like adenocarcinoma, a sertoliform endometrioid carcinoma and a thecoma were misinterpreted as AGCT on FS. Another discrepant case was a Krukenberg tumour with prominent fibromatous stroma in which malignant signet ring cells were overlooked and misinterpreted as fibroma. Minor discrepancies were primarily associated with fibroma (21/23, 91.3%), wherein minor but potentially impactful details such as cellular fibroma and mitotically active cellular fibroma were missed due to sampling issues and misinterpretation as leiomyoma. FS evaluation for ovarian SCSTs demonstrated an overall accuracy of 78.5%, 81.0% and 81.8% for benign, uncertain/low malignant potential and malignant categories, respectively. There was no FS-related adverse clinical impact in all cases with available follow-up information (120/121 cases). Intraoperative FS evaluation of ovarian SCSTs is challenging. A small number of cases were misinterpreted, with AGCTs being the primary group where errors occur. Awareness of common diagnostic pitfalls and difficulties, alongside application of a stepwise approach, including (1) obtaining comprehensive clinical information, (2) thorough macroscopic examination and directed sampling, (3) meticulous microscopic examination with consideration of pitfalls and mimics, (4) effective communication with surgeons in difficult cases, and (5) consultation of subspecialty colleagues in challenging cases, will enhance pathologists' reporting accuracy and management of such cases in the future.

A Critical Appraisal of Intraoperative Frozen Section Analysis of Ovarian Tumors: A 3-Year Review of Accuracy and Clinicopathological Correlation at a Tertiary Care Center

Background

Intraoperative frozen section (IFS) plays a pivotal role in arriving at a diagnosis and guiding toward appropriate surgical management as there is a lack of effective ovarian cancer screening methods. Considering histopathology as the gold standard, the current study was conducted to examine the accuracy of frozen section in ovarian tumors.

Materials and Methods

A prospective analysis was conducted on 52 cases of IFS of ovarian masses over 3 years (April 2018 to March 2021). Frozen section and permanent paraffin section reports were compared, and overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated. The role of various clinicopathological parameters in predicting ovarian malignancy was also evaluated.

Results

The study group included 42 benign, 3 borderline, and 7 malignant tumors, with surface epithelial tumors being the most frequent. Discordance between IFS and histopathological diagnosis was observed in two cases. We observed a high sensitivity (90%), specificity (97%), PPV (90%), NPV (97%), and accuracy (94%) for frozen section of ovarian tumors. CA-125 (P = 0.007) and menopausal status (P = 0.05) emerged as significant for predicting malignancy statistically.

Conclusion

Intraoperative frozen represents that section envisages pathologic examination in a time-bound manner and promotes fruitful communication between clinicians and pathologists, so that appropriate information is shared to curtail errors. Despite the small sample size, this study reiterates that frozen section serves as an effective diagnostic tool for intraoperative evaluation of ovarian masses when utilized judiciously by pathologists and surgeons as the advantages surpass the limitations.

Use and Accuracy of Intraoperative Frozen Section Analysis for Ovarian Masses in Children and Adolescents

STUDY OBJECTIVE

Describe the current practice patterns and diagnostic accuracy of frozen section (FS) pathology for children and adolescents with ovarian masses DESIGN: Prospective cohort study from 2018 to 2021 SETTING: Eleven children's hospitals PARTICIPANTS: Females age 6-21 years undergoing surgical management of an ovarian mass INTERVENTIONS: Obtaining intraoperative FS pathology MAIN OUTCOME MEASURE: Diagnostic accuracy of FS pathology RESULTS: Of 691 patients who underwent surgical management of an ovarian mass, FS was performed in 27 (3.9%), of which 9 (33.3%) had a final malignant pathology. Among FS patients, 12 of 27 (44.4%) underwent ovary-sparing surgery, and 15 of 27 (55.5%) underwent oophorectomy with or without other procedures. FS results were disparate from final pathology in 7 of 27 (25.9%) cases. FS had a sensitivity of 44.4% and specificity of 94.4% for identifying malignancy, with a c-statistic of 0.69. Malignant diagnoses missed on FS included serous borderline tumor (n = 1), mucinous borderline tumor (n = 2), mucinous carcinoma (n = 1), and immature teratoma (n = 1). FS did not guide intervention in 10 of 27 (37.0%) patients: 9 with benign FS underwent oophorectomy, and 1 with malignant FS did not undergo oophorectomy. Of the 9 patients who underwent oophorectomy with benign FS, 5 (55.6%) had benign and 4 (44.4%) had malignant final pathology.

CONCLUSIONS

FSs are infrequently utilized for pediatric and adolescent ovarian masses and could be inaccurate for predicting malignancy and guiding operative decision-making. We recommend continued assessment and refinement of guidance before any standardization of use of FS to assist with intraoperative decision-making for surgical resection and staging in children and adolescents with ovarian masses.

Utility of frozen section in pediatric and adolescent malignant ovarian nonseminomatous germ cell tumors: A report from the children's oncology group

PURPOSE

In adult women, most malignant ovarian tumors are epithelial in origin. The use of intra-operative frozen section to distinguish between benign and malignant histology is reliable in guiding operative decision-making to determine the extent of surgical staging required. Pediatric and adolescent patients with ovarian masses have a much different spectrum of pathology with most tumors arising from germ cell precursors. This review was undertaken to assess the concordance between the intra-operative frozen section and the final diagnosis as an aid to guide extent of surgical staging in a group of pediatric and adolescent patients with malignant ovarian germ cell tumors.

METHODS

Records of patients aged 0 to 20 years with malignant ovarian germ cell tumors enrolled on Children's Oncology Group study AGCT0132 were reviewed. Pathology reports from patients who had both intra-operative frozen section diagnosis and final paraffin section diagnosis were compared using descriptive statistics. By inclusion criteria for the study, all patients had a final diagnosis of malignancy with required yolk sac tumor, choriocarcinoma or embryonal carcinoma histology. Available central review of pathology final paraffin section slides were compared with final institution pathology reports.

RESULTS

Of 131 eligible patients with ovarian germ cell tumors, 60 (45.8%) had both intra-operative frozen section and final paraffin section diagnoses available. Intra-operative frozen section diagnoses were classified as: incorrect diagnosis of benign tumor (13.3%), confirmation of malignancy (61.7%), immature teratoma (16.7%), germ cell tumor not otherwise specified (5%) and no diagnosis provided (3.3%). Intra-operative frozen section was incorrect in 23 of 60 (38.3%) patients evaluated. Central pathology review was concordant with the final institution pathology diagnosis in 76.3% of patients. Central pathology review identified additional germ cell tumor components in 23.7% of patients.

CONCLUSIONS

In pediatric and adolescent patients with a confirmed final diagnosis of ovarian germ cell malignancy, intra-operative frozen section diagnosis is not reliable to inform the extent of surgical staging required. Central review by an expert germ cell tumor pathologist provides important additional information to guide therapy.

Stain-free identification of tissue pathology using a generative adversarial network to infer nanomechanical signatures

Intraoperative frozen section analysis can be used to improve the accuracy of tumour margin estimation during cancer resection surgery through rapid processing and pathological assessment of excised tissue. Its applicability is limited in some cases due to the additional risks associated with prolonged surgery, largely from the time-consuming staining procedure. Our work uses a measurable property of bulk tissue to bypass the staining process: as tumour cells proliferate, they influence the surrounding extra-cellular matrix, and the resulting change in elastic modulus provides a signature of the underlying pathology. In this work we accurately localise atomic force microscopy measurements of human liver tissue samples and train a generative adversarial network to infer elastic modulus from low-resolution images of unstained tissue sections. Pathology is predicted through unsupervised clustering of parameters characterizing the distributions of inferred values, achieving 89% accuracy for all samples based on the nominal assessment (n = 28), and 95% for samples that have been validated by two independent pathologists through post hoc staining (n = 20). Our results demonstrate that this technique could increase the feasibility of intraoperative frozen section analysis for use during resection surgery and improve patient outcomes.

Accuracy and Reproducibility of Frozen Section Diagnosis in Ovarian Tumors: A 10-Year Experience at a Tertiary Cancer Center

CONTEXT.—

Intraoperative consultation-frozen section diagnosis (FSD)-determines tumor pathology and guides the optimal surgical management of ovarian neoplasms intraoperatively.

OBJECTIVE.—

To evaluate the diagnostic accuracy of the FSD and analyze the discrepancy between the FSD and final diagnosis.

DESIGN.—

This is a retrospective study of 618 ovarian neoplasm FSDs from 2009 to 2018 at a tertiary health care center. The discrepant cases were reviewed and reevaluated by gynecologic and general surgical pathologists. The outcomes of interest were performing unnecessary procedure, returning for a second surgery, and 30-day postoperative mortality.

RESULTS.—

The sensitivity and the positive predictive value of the FSD were lower in borderline tumors than in benign and malignant epithelial ovarian tumors. Major and minor discrepancies were identified in 5.3% (33 of 618) and 12.3% of (76 of 618) cases, respectively. A root cause analysis of the major discrepant cases showed that sampling error accounted for 43% (14 of 33). The discrepancy distributions of gynecologic and general surgical pathologists were statistically similar in the overall cohort (P = .65). The overall κ for diagnostic agreement among gynecologic pathologists, general surgical pathologists, and final diagnosis was 0.18 (0.10-0.26, P < .001), implying only a slight overall agreement. Of the major discrepant cases, only 3 had a clinical implication. One overdiagnosed patient underwent unnecessary procedure and 2 underdiagnosed patients were recommended to return for a second surgery. No patient had 30-day postoperative mortality.

CONCLUSIONS.—

Frozen section diagnosis remains a definitive diagnostic tool in ovarian neoplasms and plays a crucial role in guiding intraoperative surgical management.

Factors Influencing the Discordancy Between Intraoperative Frozen Sections and Final Paraffin Pathologies in Ovarian Tumors

Aim

To retrospectively investigate the pre-operative clinical factors and ultrasonographic features that influence the accuracy of the intraoperative frozen section (IFS) of ovarian tumors.

Patients and methods

Women with ovarian tumors that underwent IFS in one tertiary medical center were recruited from January 2010 to December 2018. Demographic and clinical data of these women were retrieved from medical records in the hospital's centralized database.

Results

A total of 903 ovarian tumors were enrolled, including 237 (26.2%) benign, 150 (16.6%) borderline tumor, and 516 (57.2%) malignant. The overall accuracy of IFS among all specimens was 89.9%. The sensitivities of IFS in diagnosing borderline tumors (82.0%) and malignant tumors (88.2%) were lower than in diagnosing benign tumors (98.7%, p <0.001, Z-test). The specificity of diagnosing malignant tumors (99.7%) was significantly higher than that of diagnosing benign tumors (94.7%, p <0.001, Z-test). The group with discordant IFS and final paraffin pathology (FPP) had younger age (47.2 ± 14.0 vs. 51.5 ± 11.8 years, p = 0.013, Mann-Whitney U test), and higher percentage of early-stage disease (85.2% vs. 65.1%, p = 0.001, chi-square test) and mucinous (39.3% vs. 3.3%) and endometrioid histologic types (34.4% vs. 20.2%) than the concordant group (all by chi-square test). Menopause (OR 0.34, 95% CI 0.15-0.76, p = 0.009), multicystic tumor in ultrasound (OR 2.14, 95% CI 1.14-4.01, p = 0.018), and ascites existence (OR 0.33, 95% CI 0.14-0.82, p = 0.016) were factors related to the discordant IFS by multivariate analysis.

Conclusions

IFS has good accuracy in the diagnosis of ovarian tumors. We recommend more frozen tissue sampling for sonographic multicystic tumors in premenopausal women to improve the accuracy of IFS.

Frozen section diagnosis of borderline ovarian tumors with suspicious features of invasive cancer is a devil's dilemma for the surgeon: A systematic review and meta-analysis

Introduction

Frozen section diagnoses of borderline ovarian tumors are not always straightforward and a borderline frozen section diagnosis with suspicious features of invasive carcinoma (reported as “at least borderline” or synonymous descriptions) presents us with the dilemma of whether or not to perform a full surgical staging procedure. By performing a systematic review and meta‐analysis, the prevalence of straightforward borderline and “at least borderline” frozen section diagnoses, as well as proportion of patients with a final diagnosis of invasive carcinoma in these cases, were assessed and compared, as quantification of this dilemma may help us with the issue of this clinical decision.

Material and methods

PubMed, EMBASE and Cochrane library databases were searched and studies discussing “at least borderline” frozen section diagnoses were included in the review. Numbers of specific frozen section diagnoses and subsequent final histological diagnoses were extracted and pooled analysis was performed to compare the proportion of patients diagnosed with invasive carcinoma following borderline and “at least borderline” frozen section diagnoses, presented as risk ratio and risk difference with 95% confidence intervals (95% CI).

Results

Of 4940 screened records, eight studies were considered eligible for quantitative analysis. A total of 921 women was identified and 230 (25.0%) of these women were diagnosed with “at least borderline” ovarian tumor at the time of frozen section. Final histological diagnoses were reported in five studies, including 61 women with an “at least borderline” diagnosis and 290 women with a straightforward borderline frozen section diagnosis. Twenty‐five of 61 women (41.0%) of the “at least borderline” group had invasive cancer at final diagnosis, compared with 28 of 290 women (9.7%) of the straightforward borderline frozen section group (risk difference −0.34, 95% CI −0.53 to −0.15; relative risk 0.25, 95% CI 0.13–0.50).

Conclusions

Women diagnosed with “at least borderline” frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis when compared with women with a straightforward borderline frozen section diagnosis (41.0% vs 9.7%). Especially in the serous subtype, and after preoperative consent, full staging during initial surgery might be considered in these cases to prevent a second surgical procedure.

MRI-Based Machine Learning for Differentiating Borderline From Malignant Epithelial Ovarian Tumors: A Multicenter Study

BACKGROUND

Preoperative differentiation of borderline from malignant epithelial ovarian tumors (BEOT from MEOT) can impact surgical management. MRI has improved this assessment but subjective interpretation by radiologists may lead to inconsistent results.

PURPOSE

To develop and validate an objective MRI-based machine-learning (ML) assessment model for differentiating BEOT from MEOT, and compare the performance against radiologists' interpretation.

STUDY TYPE

Retrospective study of eight clinical centers.

POPULATION

In all, 501 women with histopathologically-confirmed BEOT (n = 165) or MEOT (n = 336) from 2010 to 2018 were enrolled. Three cohorts were constructed: a training cohort (n = 250), an internal validation cohort (n = 92), and an external validation cohort (n = 159).

FIELD STRENGTH/SEQUENCE

Preoperative MRI within 2 weeks of surgery. Single- and multiparameter (MP) machine-learning assessment models were built utilizing the following four MRI sequences: T₂ -weighted imaging (T₂ WI), fat saturation (FS), diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC), and contrast-enhanced (CE)-T₁ WI.

ASSESSMENT

Diagnostic performance of the models was assessed for both whole tumor (WT) and solid tumor (ST) components. Assessment of the performance of the model in discriminating BEOT vs. early-stage MEOT was made. Six radiologists of varying experience also interpreted the MR images.

STATISTICAL TESTS

Mann-Whitney U-test: significance of the clinical characteristics; chi-square test: difference of label; DeLong test: difference of receiver operating characteristic (ROC).

RESULTS

The MP-ST model performed better than the MP-WT model for both the internal validation cohort (area under the curve [AUC] = 0.932 vs. 0.917) and external validation cohort (AUC = 0.902 vs. 0.767). The model showed capability in discriminating BEOT vs. early-stage MEOT, with AUCs of 0.909 and 0.920, respectively. Radiologist performance was considerably poorer than both the internal (mean AUC = 0.792; range, 0.679-0.924) and external (mean AUC = 0.797; range, 0.744-0.867) validation cohorts.

DATA CONCLUSION

Performance of the MRI-based ML model was robust and superior to subjective assessment of radiologists. If our approach can be implemented in clinical practice, improved preoperative prediction could potentially lead to preserved ovarian function and fertility for some women.

LEVEL OF EVIDENCE

Level 4.

TECHNICAL EFFICACY

Stage 2. J. Magn. Reson. Imaging 2020;52:897-904.

Role of Frozen Section in Surgical Management of Ovarian Neoplasm

Objective:

Cancers of the adnexae, including ovarian and fallopian tube, constitute the eighth most common cancers among women worldwide. Surgery remains the cornerstone in the management of ovarian cancer. Intraoperative frozen section diagnosis of ovarian tumors is widely used in making this distinction and to decide the course of surgery. Therefore, the accuracy of this technique is very important. The aim was to determine the overall accuracy, sensitivity, specificity, and predictive values of frozen section for ovarian tumors and to evaluate the role of frozen section in the surgical management of ovarian tumors.

Materials and Methods:

This was a descriptive longitudinal study conducted in the gynecology department of a tertiary care hospital. During the 1 ½ year period of data collection, frozen section was performed among 60 cases of ovarian neoplasms. The overall accuracy, sensitivity, specificity and predictive values of frozen section for benign, borderline and malignant categories of ovarian tumors were studied.

Results:

Out of the 60 patients of ovarian tumors, frozen section diagnosis showed that 43 (71.7%) tumors were benign, 11 (18.3%) were malignant and 6 (10%) were of borderline nature. Final histopathological diagnosis showed that 45 (75%) tumors were benign, 11 (18.3%) were malignant and 4 (6.7%) were borderline. Frozen section for benign tumors had 95% sensitivity, 100% specificity, 100% positive predictive value (PPV) and 88% negative predictive value (NPV). Malignant tumors had 90% sensitivity, 97% specificity, 90% PPV and 97% NPV with frozen section. However, frozen section had low sensitivity (75%) and PPV (50%) for borderline tumors. Specificity was 94% and NPV 98% in this group of tumors.

Conclusion:

Frozen section was found to be an accurate and useful modality in the intraoperative evaluation of patients with ovarian neoplasm. The results can help to decide the type and extent of surgery.

Systematic Review of the Use of Telepathology During Intraoperative Consultation

OBJECTIVE

To compare studies that used telepathology systems vs conventional microscopy for intraoperative consultation (frozen-section) diagnosis.

METHODS

A total of 56 telepathology studies with 13,996 cases in aggregate were identified through database searches.

RESULTS

The concordance of telepathology with the reference standard was generally excellent, with a weighted mean of 96.9%. In comparison, we identified seven studies using conventional intraoperative consultation that showed a weighted mean concordance of 98.3%. Evaluation of the risk of bias showed that most of these studies were low risk.

CONCLUSIONS

Despite limitations such as variation in reporting and publication bias, this systematic review provides strong support for the safety of using telepathology for intraoperative consultations.

Malignant Lymphoma of the Ovary: A Diagnostic Pitfall of Intraoperative Consultation

Primary ovarian lymphomas are rare, but can potentially evoke diagnostic problems. We present a case of ovarian lymphoma, in which an ambiguous intraoperative pathologic report led to overtreatment (unnecessary surgery). A 73-yr-old woman with fatigue and low-grade fever was diagnosed as having a left ovarian tumor by imaging modalities. Exploratory laparotomy was carried out to confirm the diagnosis. The frozen tissue sections of the ovarian tumor showed condensed proliferation of atypical round cells accompanied with a few small lymphocytes. The pathologists could not determine whether this tumor was a lymphoma or another malignancy (eg, dysgerminoma). Hence, they reported it to gynecologists who operated as simply a malignant tumor in order to evade misdiagnosis. On the basis of the inconclusive pathologic report, the gynecologists decided to change the planned laparotomy to total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph node dissection. A postoperative paraffin section-based pathologic diagnosis was diffuse large B-cell lymphoma of the ovary, which basically does not require surgical treatments. Subsequently, chemotherapy for B-cell lymphoma was initiated, and no lymphoma recurrence has been reported to date. A more robust preoperative discussion between the gynecologists and the pathologists might have avoided the overtreatment.

The Evaluation of Intra-Operative Frozen Section Diagnosis Accuracy of Ovarian Tumors; Old Fashioned Not Out of Fashion

Background:

The accuracy of intra-operative decision in confirming ovarian tumor malignancy during the operation is vital. Frozen sections are an important intra-operative tool to determine the provisional diagnosis and appropriate treatment of a tumor.

Study design:

All records of diagnosed ovarian tumor patients who underwent exploratory laparotomy with intra-operative frozen sections request at Bhumibol Adulyadej Hospital (BAH) between January 2016 and June 2018 were reviewed.

Main outcome measures:

Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of intra-operative frozen and permanent sections were evaluated.

Result:

A total of 150 cases were recruited in this study. The mean age was 45.4 years. The number of benign, borderline and malignant ovarian tumors in this study were 97, 9 and 44 cases, respectively. The overall accuracy was 93.3%. Percentage of accuracy, sensitivity, specificity, PPV and NPV for benign, borderline and malignancy were 98.0/94.7/94.0, 100/88.9/79.6, 94.3/95.0/100, 97.0/55.3/100 and 100/99.3/92.2, respectively.

Conclusion:

The frozen section results yielded accurate diagnosis for rapid intraoperative evaluation of ovarian tumors. Its high accuracy allows for an appropriate surgical plan to be made in a timely manner. Large sizes and suspected mucinous borderline ovarian tumors reduced accuracy factors of frozen sections.

Diagnostic Accuracy of Frozen Section and Its Influence on Intraoperative Management of Indeterminate Epithelial Ovarian Tumors

The objective of this study is to determine the diagnostic accuracy of frozen section in detecting epithelial ovarian tumor histological types and its effect on management. A retrospective review was done of all patients who had an intraoperative frozen section for an indeterminate ovarian tumor over a six-year period. The reference standard was final histology. The validity indices for frozen section in diagnosing benign, borderline, and malignant lesions were determined. One hundred thirty-five intraoperative frozen section-diagnosed epithelial ovarian tumors were reviewed. The mean age was 44.9 ± 14.2 years, the median parity was 2, and 57% (77/135) of patients were post-menopausal. The commonest histological subtype was mucinous 48.1% (65/135) on frozen section and 46.7% (63/135) on final histology. The overall concordance rate of frozen section to final histology was 81.5% (ƙ = 0.719, p = 0.0001). The accuracy, sensitivity, specificity, and positive predictive value of frozen section to diagnose benign lesions were 86.7%, 85.7%, 97.2%, and 79.2% respectively. In borderline tumors, the diagnostic test characteristics were 88.1%, 81.2%, 90.3%, and 72.2%. For malignant lesions, these values were 88.1%, 77.8%, 95.1%, and 91.3% respectively. The odds ratios for frozen section being correct were 40.9 (95% CI 14.8-113.5) for benign lesions, 40.3 (95% CI 13.4-121.3) for borderline tumors, and 67.4 (95% CI 20.5-222.0) for malignancy. Over-treatment or under-treatment occurred in 19.3% of patients. Intraoperative frozen section is useful in situations where the nature of the ovarian tumor is uncertain. However, borderline ovarian tumors are more likely to be over-diagnosed. About a fifth of patients received inappropriate treatments based on the frozen section report.

Compatibility of the frozen section method in histopathological specimens for female pelvic masses with results for pathology and tumor markers

Background: Detection of pelvic masses is of great value for scheduling a proper treatment process and is an important factor for detection. Frozen section is a diagnostic method for the evaluation of pelvic tumors during surgery. The purpose of this study was to measure the compatibility of the frozen section method for histopathological specimens of female pelvic masses with pathologic results of tumor markers.

Methods: This retrospective study was performed on 188 female pelvic mass specimens during 2014-2016. Medical files for all patients with injury of female genital system who had undergone frozen section surgery was compared with the results of pathology and tumor marker tests. SPSS version 19 was used for statistical analysis. The results were analyzed by Kappa test.

Results: Based on the final pathology of the 188 specimens, 150 (79.8%) were benign, 8 (4.2%) intermediate, and 30 (16%) malignant. Sensitivity, specificity, and validity of frozen section in benign tumors were calculated as follow: 96.7 Confidence Interval (CI95% : 92.6–98.9%), 97 (CI95%: 84.7–99.9%), and 96.8%; in intermediate tumors, the respective numbers were: 71.4 (CI95% :29–96.3%), 98.3 (CI95% :95, 2–99%, 7%), and 97.3%; and in the malignant tumors the numbers were: 96.3 (CI95% :81.9–99%), 97.4 (CI95% :93. 4–99.3%), and 97.2%. Positive and negative predictive values were calculated as follow: 99.3 (CI95% :96.3–99.9%) and 86.8% (CI95% :71.9–95.6%) in benign tumors; 62.5 (CI95% :24.5–91.5%) and 98.9% (CI95% :96–99.9%) in intermediate tumors; and 86.7 (CI95% :69.3–96.2%) and 99.3% (CI95% :96.3–99.9%) in malignant tumors.

Conclusion: The results of this study showed that the frozen section method has managed to keep its value and place among all diagnostic methods regarding pelvic masses to an acceptable extent. Except for the intermediate tumors, the frozen section method showed great accuracy in dealing with pelvic masses.

[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.

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.

A case report of an incidental Brenner tumor found after resection of a large ovarian mucinous neoplasm

INTRODUCTION

Brenner Tumors are rare adenofibromas that are most commonly benign and discovered in post-menopausal women.

PRESENTATION OF CASE

This is a case report of a 57-year-old female with three months of progressively worsening abdominal pain due to a large abdominal mass discovered on CT scan. Surgical removal of the mass revealed a giant mucinous tumor of the ovary with an associated Brenner tumor that was discovered incidentally.

DISCUSSION

Although the Brenner tumor was accurately identified in the intraoperative frozen section evaluation, the mucinous tumor was underdiagnosed by frozen section as benign when permanent section revealed borderline mucinous cystadenoma. This finding did not change the treatment course for this particular patient as she had expressed personal preference for total abdominal hysterectomy. However, underdiagnosis of frozen sections of ovarian tumors is not rare. It is unclear whether an associated Brenner tumor increases malignancy potential.

CONCLUSION

Further investigation is required to determine whether associated Brenner tumors found during frozen section are more highly associated with malignancy and could therefore change intraoperative and overall decision making.

Diagnostic accuracy of touch imprint cytology for head and neck malignancies: a useful intra-operative tool in resource limited countries

Background

Intraoperative consultation is an important tool for the evaluation of the upper aerodigestive tract (UAT) malignancies. Although frozen section analysis is a preferred method of intra-operative consultation, however in resource limited countries like Pakistan, this facility is not available in most institutes; therefore, we aimed to evaluate the diagnostic accuracy of touch imprint cytology for UAT malignancies using histopathology of the same tissue as gold standard.

Methods

The study involved 70 cases of UAT lesions operated during the study period. Intraoperatively, after obtaining the fresh biopsy specimen and prior to placing them in fixative, each specimen was imprinted on 4-6 glass slides, fixed immediately in 95% alcohol and stained with Hematoxylin and Eosin stain. After completion of the cytological procedure, the surgical biopsy specimen was processed. The slides of both touch Imprint cytology and histopathology were examined by two consultant histopathologists.

Results

The result of touch imprint cytology showed that touch imprint cytology was diagnostic in 68 cases (97.1%), 55 (78.6%) being malignant, 2 cases (2.9%) were suspicious for malignancy, 11 cases (15.7%) were negative for malignancy while 2 cases (2.9%) were false negative. Amongst the 70 cases, 55 cases (78.6%) were malignant showing squamous cell carcinoma in 49 cases (70%), adenoid cystic carcinoma in 2 cases (2.9%), non-Hodgkin lymphoma 2 cases (2.9%), Mucoepidermoid carcinoma 1 case (1.4%), spindle cell sarcoma in 1 case (1.4%). Two cases (2.9%) were suspicious of malignancy showing atypical squamoid cells on touch imprint cytology, while 13 cases (18.6%) were negative for malignancy, which also included 2 false negative cases. The overall diagnostic accuracy of touch imprint cytology came out to be 96.7% with a sensitivity and specificity of 96 and 100%, respectively while PPV and NPV of touch imprint cytology was found to be 100 and 84%, respectively.

Conclusion

Our experience in this study has demonstrated that touch imprint cytology provides reliable specific diagnoses and can be used as an adjunct to histopathology, particularly in developing countries, where the facility of frozen section is often not available, since a rapid preliminary diagnosis may help in the surgical management planning.

Malignant Brenner tumor of the ovary: Review and case report

Ovarian neoplasms are a heterogeneous group of tumors with varying incidence in the general population. The most common are the surface epithelial tumors which include transitional cell tumors. Transitional cell tumors include both transitional cell carcinoma and Brenner tumor. The vast majority of Brenner tumors are benign, often incidental findings; however, malignant Brenner tumors (MBT) do occasionally occur. MBT present similarly to other ovarian neoplasms with abdominal pain and bulk symptoms. On imaging, these tumors demonstrate nonspecific findings. Microscopically, they demonstrate areas of conventional benign Brenner tumor juxtaposed with regions of frank malignancy showing marked cytologic atypia and infiltration. There is no consistent tumor marker for these tumors, but CA-125, CA 72-4 and SCC have been reported in singular instances. Tumors express several immunohistochemical markers of urothelial differentiation including uroplakin III, thrombomodulin, GATA3, p63, as well as cytokeratin 7. The primary treatment modality is surgical excision. Due to their rarity, the precise role and regimen of adjuvant chemo-radiation therapy for MBT has not been established. We herein review a case of MBT with emphasis on primary treatment and treatment of recurrent disease, including the use of adjuvant pelvic radiation, discuss the current state of the literature and standards of practice regarding this malignancy.

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Histologic differentiation of MBT from TCC is critical for diagnosis.

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Surgical staging should be performed for all cases of MBT.

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The role of adjuvant strategies for MBT is poorly defined.