Distribution and case-fatality ratios by cell-type for ovarian carcinomas: A 22-year series of 562 patients with uniform current histological classification

Clinical Decision Support for Ovarian Carcinoma Subtype Classification: A Pilot Observer Study With Pathology Trainees

CONTEXT.—

Clinical decision support (CDS) systems could assist less experienced pathologists with certain diagnostic tasks for which subspecialty training or extensive experience is typically needed. The effect of decision support on pathologist performance for such diagnostic tasks has not been examined.

OBJECTIVE.—

To examine the impact of a CDS tool for the classification of ovarian carcinoma subtypes by pathology trainees in a pilot observer study using digital pathology.

DESIGN.—

Histologic review on 90 whole slide images from 75 ovarian cancer patients was conducted by 6 pathology residents using: (1) unaided review of whole slide images, and (2) aided review, where in addition to whole slide images observers used a CDS tool that provided information about the presence of 8 histologic features important for subtype classification that were identified previously by an expert in gynecologic pathology. The reference standard of ovarian subtype consisted of majority consensus from a panel of 3 gynecologic pathology experts.

RESULTS.—

Aided review improved pairwise concordance with the reference standard for 5 of 6 observers by 3.3% to 17.8% (for 2 observers, increase was statistically significant) and mean interobserver agreement by 9.2% (not statistically significant). Observers benefited the most when the CDS tool prompted them to look for missed histologic features that were definitive for a certain subtype. Observer performance varied widely across cases with unanimous and nonunanimous reference classification, supporting the need for balancing data sets in terms of case difficulty.

CONCLUSIONS.—

Findings showed the potential of CDS systems to close the knowledge gap between pathologists for complex diagnostic tasks.

Selection of Representative Histologic Slides in Interobserver Reproducibility Studies: Insights from Expert Review for Ovarian Carcinoma Subtype Classification

BACKGROUND

Observer studies in pathology often utilize a limited number of representative slides per case, selected and reported in a nonstandardized manner. Reference diagnoses are commonly assumed to be generalizable to all slides of a case. We examined these issues in the context of pathologist concordance for histologic subtype classification of ovarian carcinomas (OCs).

MATERIALS AND METHODS

A cohort of 114 OCs consisting of 72 cases with a single representative slide (Group 1) and 42 cases with multiple representative slides (148 slides, 2-6 sections per case, Group 2) was independently reviewed by three experts in gynecologic pathology (case-based review). In a follow-up study, each individual slide was independently reviewed in a randomized order by the same pathologists (section-based review).

RESULTS

Average interobserver concordance varied from 100% for Group 1 to 64.3% for Group 2 (86.8% across all cases). Across Group 2, 19 cases (45.2%) had at least one slide classified as a different subtype than the subtype assigned from case-based review, demonstrating the impact of intratumoral heterogeneity. Section-based concordance across individual sections from Group 2 was comparable to case-based concordance for those cases indicating diagnostic challenges at the individual section level. Findings demonstrate the increased diagnostic complexity of heterogeneous tumors that require multiple section sampling and its impact on pathologist performance.

CONCLUSIONS

The proportion of cases with multiple representative slides in cohorts used in validation studies, such as those conducted to evaluate artificial intelligence/machine learning tools, can influence diagnostic performance, and if not accounted for, can cause disparities between research and real-world observations and between research studies. Case selection in validation studies should account for tumor heterogeneity to create balanced datasets in terms of diagnostic complexity.

A prognostic system for epithelial ovarian carcinomas using machine learning

Introduction

Integrating additional factors into the International Federation of Gynecology and Obstetrics (FIGO) staging system is needed for accurate patient classification and survival prediction. In this study, we tested machine learning as a novel tool for incorporating additional prognostic parameters into the conventional FIGO staging system for stratifying patients with epithelial ovarian carcinomas and evaluating their survival.

Material and methods

Cancer‐specific survival data for epithelial ovarian carcinomas were extracted from the Surveillance, Epidemiology, and End Results (SEER) program. Two datasets were constructed based upon the year of diagnosis. Dataset 1 (39 514 cases) was limited to primary tumor (T), regional lymph nodes (N) and distant metastasis (M). Dataset 2 (25 291 cases) included additional parameters of age at diagnosis (A) and histologic type and grade (H). The Ensemble Algorithm for Clustering Cancer Data (EACCD) was applied to generate prognostic groups with depiction in dendrograms. C‐indices provided dendrogram cutoffs and comparisons of prediction accuracy.

Results

Dataset 1 was stratified into nine epithelial ovarian carcinoma prognostic groups, contrasting with 10 groups from FIGO methodology. The EACCD grouping had a slightly higher accuracy in survival prediction than FIGO staging (C‐index = 0.7391 vs 0.7371, increase in C‐index = 0.0020, 95% confidence interval [CI] 0.0012–0.0027, p = 1.8 × 10⁻⁷). Nevertheless, there remained a strong inter‐system association between EACCD and FIGO (rank correlation = 0.9480, p = 6.1 × 10⁻¹⁵). Analysis of Dataset 2 demonstrated that A and H could be smoothly integrated with the T, N and M criteria. Survival data were stratified into nine prognostic groups with an even higher prediction accuracy (C‐index = 0.7605) than when using only T, N and M.

Conclusions

EACCD was successfully applied to integrate A and H with T, N and M for stratification and survival prediction of epithelial ovarian carcinoma patients. Additional factors could be advantageously incorporated to test the prognostic impact of emerging diagnostic or therapeutic advances.

Pathologist Concordance for Ovarian Carcinoma Subtype Classification and Identification of Relevant Histologic Features Using Microscope and Whole Slide Imaging: A Multisite Observer Study

CONTEXT.—

Despite several studies focusing on the validation of whole slide imaging (WSI) across organ systems or subspecialties, the use of WSI for specific primary diagnosis tasks has been underexamined.

OBJECTIVE.—

To assess pathologist performance for the histologic subtyping of individual sections of ovarian carcinomas using the light microscope and WSI.

DESIGN.—

A panel of 3 experienced gynecologic pathologists provided reference subtype diagnoses for 212 histologic sections from 109 ovarian carcinomas based on optical microscopy review. Two additional attending pathologists provided diagnoses and also identified the presence of a set of 8 histologic features important for ovarian tumor subtyping. Two experienced gynecologic pathologists and 2 fellows reviewed the corresponding WSI images for subtype classification and feature identification.

RESULTS.—

Across pathologists specialized in gynecologic pathology, concordance with the reference diagnosis for the 5 major ovarian carcinoma subtypes was significantly higher for a pathologist reading on microscope than each of 2 pathologists reading on WSI. Differences were primarily due to more frequent classification of mucinous carcinomas as endometrioid with WSI. Pathologists had generally low agreement in identifying histologic features important to ovarian tumor subtype classification, with either optical microscopy or WSI. This result suggests the need for refined histologic criteria for identifying such features. Interobserver agreement was particularly low for identifying intracytoplasmic mucin with WSI. Inconsistencies in evaluating nuclear atypia and mitoses with WSI were also observed.

CONCLUSIONS.—

Further research is needed to specify the reasons for these diagnostic challenges and to inform users and manufacturers of WSI technology.

Ovarian Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States and is the country's fifth most common cause of cancer mortality in women. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. These NCCN Guidelines discuss cancers originating in the ovary, fallopian tube, or peritoneum, as these are all managed in a similar manner. Most of the recommendations are based on data from patients with the most common subtypes─high-grade serous and grade 2/3 endometrioid. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. This manuscript focuses on certain aspects of primary treatment, including primary surgery, adjuvant therapy, and maintenance therapy options (including PARP inhibitors) after completion of first-line chemotherapy.

High-grade Pelvic Serous Carcinoma Within the Fallopian Tube Lumen: Real or Artifact?

Tumor cells are occasionally observed in the lumen in histologic sections of the fallopian tube from women with gynecologic cancer. There is some evidence that this finding may be important in endometrial cancer, but its significance is unknown in women with extrauterine pelvic serous carcinomas (tubo-ovarian high-grade serous carcinoma). Fallopian tube sections from 213 women with extrauterine pelvic serous carcinoma were reviewed, and luminal tumor cells were correlated with clinical and pathologic features. Intraluminal tumor cells were found in 84 patients (39%). The presence or absence of luminal tumor cells correlated significantly with serous tubal intraepithelial carcinoma (52% and 33%, respectively, P=0.004), tubal lymphatic invasion (32% and 12%, respectively, P=0.0002), and number of tube sections reviewed (6.6 and 4.9 for lumen-positive and lumen-negative cases, respectively, P=0.0056). There was no correlation with the presence of ascites, peritoneal cytopathologic findings, lymph node metastases, or FIGO stage. In the setting of pelvic serous carcinoma, a substantial portion of fallopian tube tissue is often distorted, fibrotic, and difficult to identify. Since the identification of luminal tumor cells, serous tubal intraepithelial carcinoma and tubal lymphatic invasion all depend on identification of fallopian tube tissue, these correlates with luminal tumor cells could be a result of a higher likelihood of their observation when tubal tissue can be more readily identified and may not necessarily reflect a biologically important phenomenon. It remains unclear whether and in what proportion this finding reflects an artifact of specimen handling.

Maximal cytoreduction is related to improved disease-free survival in low-grade ovarian serous carcinoma

Objective:

To evaluate the factors predicting oncologic outcomes in low-grade ovarian serous carcinoma (LGOSC).

Methods:

Seventy patients with LGOSC were included in the study. According to the residual disease present at the end of the initial cytoreductive surgery (CRS), surgical outcomes are defined as follows: maximal CRS for absence of macroscopic residual tumors, optimal CRS for macroscopic residual tumors with diameters ranging from 0.1 to ⩽1 cm diameter, and suboptimal CRS for macroscopic residual tumors measuring >1 cm in diameter.

Results:

Five-year disease-free survival (DFS) and cancer-specific survival (CSS) were 61% and 83%, respectively. Surgical outcomes were suboptimal in 3 (4.3%) patients, optimal in 8 (11.4%) patients, and maximal in 59 (84.3%) patients. Stage and surgical outcomes were related to DFS ( p < 0.05). Compared with maximal CRS, the presence of residual tumors (suboptimal and optimal debulking) was related to threefold increased risk of disease failure (recurrence or progression) (hazard ratio [95% confidence interval] 3.00 [1.27–7.09]; P=0.012). CSS was associated with disease stage alone ( P=0.03). Advanced stage was related with lower DFS and CSS.

Conclusions:

Maximal CRS facilitates an improvement in DFS. Achieving no residual disease after the completion of surgery should be a cornerstone of LGOSC management.

Lymphatic Invasion in the Fallopian Tube is a Late Event in the Progression of Pelvic Serous Carcinoma and Correlates With Distant Metastasis

The majority of extrauterine high-grade serous carcinomas are believed to arise in the fallopian tube as serous tubal intraepithelial carcinomas. The primary mode of metastasis is intraperitoneal, and patients usually present with peritoneal carcinomatosis. Although the tubes have a rich lymphatic network, tubal lymphatic invasion is observed in only a minority of cases. Fallopian tube sections from 222 patients with advanced stage high-grade extrauterine serous carcinoma were reviewed and lymphatic invasion within the lamina propria and myosalpinx were assessed. Seventeen patients were FIGO stage II, 162 stage III, and 43 stage IV. Tubal lymphatic invasion was identified in 44 cases (19.7%). Among the cases with lymphatic invasion, nonfimbrial lamina propria, fimbrial lamina propria, and myosalpingeal lymphatic invasion were present in 23 (52%), 21 (48%), and 21 (48%), respectively. Among cases with lymphatic invasion, 16 (36%) were FIGO stage IV, while among cases without lymphatic invasion, 27 (15%) were stage IV (P=0.0014, χ). In summary, in women with advanced stage high-grade extrauterine serous carcinoma, lymphatic invasion in the fallopian tube is uncommon, and is more than twice as likely to be associated with distant metastases as compared with those without tubal lymphatic invasion.

Immunohistochemical Characterization Improves the Reproducibility of the Histological Diagnosis of Ovarian Carcinoma

Background: Ovarian cancer is the leading cause of gynecologic cancer-related death. Histological assessment remains the standard clue for the diagnosis of ovarian carcinoma. Misinterpretation and inconsistent application of histological criteria may lead to significant interobserver variability and poor reproducibility of the diagnosis. In this study, we investigated the discrepancy in histological diagnosis and the significance of a designed panel of immunohistochemical markers for the improvement of the diagnostic reproducibility of ovarian carcinomas. Methods: We performed a retrospective study on 74 ovarian carcinomas. All tumor slides were independently reviewed by two pathologists. The results for seven available immunomarkers as p53, WT-1, p16INK4A, CK7, CK20, and estrogen and progesterone receptors were determined for all cases by immunohistochemistry. Results: The histological diagnosis review performed using standard histology showed a concordance of diagnoses in 86% of cases with Cohen’s kappa of 0.80. Immunohistochemical results increased significantly the diagnosis reproducibility with a concordance of 91% and a Cohen’s kappa of 0.86 (P = 0.001). Conclusion: Although the histological diagnosis remains reliable, the use of a designed panel of immunohistochemical markers improves significantly the interobserver concordance and the classification accuracy of ovarian carcinomas.

Adopting a Uniform Approach to Site Assignment in Tubo-Ovarian High-Grade Serous Carcinoma: The Time has Come

There is currently sufficient evidence that nonuterine high-grade serous carcinoma (HGSC) originates in the fallopian tube in the majority of cases, but this is not uniformly reflected in our diagnostic terminology. This is because there remains wide variation in awareness and acceptance of this evidence, which conflicts with traditional views on origin. Accurate disease classification is fundamental to routine clinical practice and research, particularly at a time when exciting new approaches to therapy, early detection, and prevention are appearing on the horizon. We feel the time has come to minimize individual and institutional variations in practice, and agree on an evidence-based approach to uniform terminology and primary site assignment. In this paper we put forward a proposal for a unified approach based on published research evidence and discuss the reasons why it is vital to agree on a uniform protocol. We propose the term "Tubo-ovarian HGSC" in preference to "pelvic" or "Müllerian," as it accurately reflects the origin of this disease in the vast majority of cases, and is unambiguous, distinguishing it clearly from uterine serous carcinoma and ovarian low-grade serous carcinomas. A detailed protocol for primary site assignment is presented for different scenarios, which is easy to follow and has been developed with a view to promoting a uniform approach worldwide.

18F-FDG PET/CT as predictor of tumour biology and prognosis in epithelial ovarian carcinoma

OBJECTIVE

To investigate the relationship between maximum standardised uptake value (SUVmax) of ovarian lesions and histopathology subtypes, and their involvement in the response and prognosis of patients with epithelial ovarian carcinoma (EOC).

MATERIAL AND METHODS

A retrospective analysis of 31 patients with EOC and ¹⁸F-FDG-PET/CT before treatment, including an assessment of the SUVmax of ovarian lesion. Histopathological diagnosis and follow-up was performed. A study was made on the relationship between the SUVmax and histological type (type I and II) and tumour stage, as well as the role of various parameters (SUVmax, histology, stage) on the patient outcomes (complete response [CR], overall survival [OS], disease-free survival [DFS], and disease-free [DF] status, at 12 and 24 months).

RESULTS

The medium SUVmax in type I lesions was lower than in type II (6.3 and 9.3, respectively; P=.03). A 7.1 cut-off was set for SUVmax in order to identify type II EOC (sensitivity: 77.8%, specificity: 69.2%; AUC=0.748; P=.02). No significant relationship was found between tumour stage and SUVmax. CR was more common in early stages; relative risk (RR) of 1.64; P=.003, as well as in type I tumours and a lower SUVmax. Tumour stage was decisive in DFS (P=.04), LE24m (0.07) and OS (P=.08). Longer DFS and a higher percentage of DF 24m were observed in type I tumours (RR: 1.32; P=.26).

CONCLUSIONS

SUVmax was related to EOC histology, so could predict the response and prognosis of these patients. No association was found between glycolytic activity of the primary tumor with the response and prognosis.

Expression of hypothalamic-pituitary-gonadal axis-related hormone receptors in low-grade serous ovarian cancer (LGSC)

Background

The aim of our study was to investigate the clinical features and expression levels of hypothalamic-pituitary-gonadal axis-related hormone receptors in low-grade serous ovarian cancer (LGSC).

Methods

We retrospectively investigated the clinical features of 26 consecutive patients with LGSC who underwent primary staging or debulking surgery between April 2005 and June 2013 in our center; concomitant primary high-grade serous ovarian cancer (HGSC) patients were randomly selected at a 2:1 ratio for comparison. Tissue microarrays were constructed from the LGSC and HGSC specimens, and the expression levels of six hormone receptors in the hypothalamic pituitary-gonadal axis were analyzed by immunohistochemistry.

Results

The median (range) age of patients with LGSC was 54 (27–77) years. According to the FIGO staging system, the cases were distributed as follows: stage I, 6 (23.1%); stage II, 0 (0%); stage III, 19 (73.1%); and stage IV, 1 (3.8%). The 2-year and 5-year overall survival rates for LGSC were 91.8% and 67.5%, respectively. The expression levels of the hormone receptors were as follows: ER, 80.8%; PR, 34.6%; AR, 53.8%; FSHR, 84.0%; LHR, 65.4%; and GnRHR, 100%. Hormone receptor-positive patients had a better prognosis compared with hormone receptor-negative patients, but the difference was not significant.

Conclusions

Our study presented a higher overall survival rate and distinctive hormone receptor expression levels of LGSC patients compared with the HGSC cohort. Patients with positive hormone receptor expression tended to have a better prognosis than the corresponding hormone receptor negative patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13048-016-0300-5) contains supplementary material, which is available to authorized users.

Downregulation of SASH1 correlates with tumor progression and poor prognosis in ovarian carcinoma

SAM- and SH3-domain containing 1 (SASH1) is a recently identified tumor suppressor gene that is required in the tumorigenesis of breast and other solid carcinomas. The SASH1 protein contains SH3 and SAM domains, indicating that it may serve an important role in intracellular signal transduction. The purpose of the present study was to investigate the expression of SASH1 in ovarian carcinoma and the correlation between its expression with clinical pathological features and clinical significance, and the effect of SASH1 on cell proliferation, apoptosis and migration of ovarian SKOV3 cells. The human ovarian carcinoma tissues and adjacent normal tissues were collected following surgery. Reverse transcription-quantitative polymerase chain reaction and western blot analysis were used to detect the expression levels of SASH1 mRNA and protein, respectively. The expression levels of SASH1 mRNA and protein in ovarian carcinoma tissues were significantly lower than that observed in adjacent normal tissues (P<0.05). The expression levels of SASH1 in samples from patients without lymph nodes metastasis and patients with early FIGO stage was lower than those with lymph nodes metastasis and patients with advanced FIGO stage (P<0.05). Flow cytometry analysis and Transwell invasion chamber experiments were used to investigate the effect of SASH1 on the cell proliferation, apoptosis and migration of SKOV3 cells. The recombinant plasmid pcDNA3.1-SASH1 was constructed and transfected into SKOV3 cells. In addition, the SKOV3 cells in the pcDNA3.1-SASH1 group exhibited significantly reduced cell growth, proliferation, and migration ability compared to the empty vector group and normal group (P<0.01). There were a greater number of apoptotic cells in the pcDNA3.1-SASH1 group compared to the empty vector group and normal group (P<0.01). Taken together, these results indicated that SASH1 may be a tumor suppressor gene in ovarian carcinoma, and SASH1 expression inhibited growth, proliferation and migration, and enhanced apoptosis of SKOV3 cells.