Histological discrimination of malignancy in mucinous ovarian tumours

The management of borderline epithelial tumors of the ovary

The histopathological diagnosis and treatment of borderline epithelial tumors of the ovary (BTO) still pose problems to both pathologists and gynecologists. BTO is a disease of younger, fertile females and generally has an excellent prognosis. A minority of patients, however, succumb to this disease. A review of the literature is given addressing aspects of epidemiology, histology, treatment and prognosis, resulting in a proposal for the management of serous and mucinous borderline tumors of the ovary.

Prognostic factors in well-differentiated early-stage epithelial ovarian cancer

BACKGROUND

The prognosis of patients with early ovarian cancer is good as compared with that of patients with advanced disease. However, there are no methods for predicting prognosis of early ovarian cancer, on which treatment decisions can be based.

METHODS

The prognostic significance of DNA flow cytometric and morphometric analysis was evaluated in 64 surgically treated patients with well-differentiated early-stage (International Federation of Gynecology and Obstetrics [FIGO] Stage IA, IB, IC, and IIA) epithelial ovarian cancer. The extent of the well-defined staging procedure was assessed strictly in every patient.

RESULTS

Only five patients died of recurrent ovarian cancer; all of these patients belonged to the inaccurately staged group. No significant relationship was found between clinicopathologic characteristics, such as menopausal status, FIGO stage, histologic cell type, and 5-year disease-free survival rate. Forty-two of the tumors had a mitotic activity index (MAI) of less than 30, and 43 of the tumors showed a volume percentage epithelium (VPE) of less than 65. Neither as a single parameter nor in combination did MAI and VPE correlate significantly with disease-free survival. Thirty-two tumors (50%) were DNA diploid, 15 were considered wide-CV-diploid, and 17 were aneuploid. Nearly 90% of the tumors showed DNA indices (DI) of 1.40 or less. The 5-year disease-free survival rate was significantly lower (61%) for patients with DI greater than 1.40 than for those with DI of 1.40 or less (96%) (P < 0.005). From the total number of five patients who died of their disease, three had tumors with DI in the tetraploid range.

Possibilities and progress of quantitative pathological examination of ovarian tumours

Morphometric and flow DNA-cytometric analysis of ovarian tumours of the common epithelial type has an important and strong additional prognostic impact, which is stage-independent, and more important than subjective grade. In stage I cancers, combined morphometric analysis and DNA index assessed with flow-cytometry can indicate a subgroup of patients with an especially poor prognosis. In stage III and IV cancers, morphometric features exceed the prognostic value of cellular DNA content, as far as they allow selection of a small subset of patients with an excellent prognosis. These results indicate that quantitative pathological examination is of essential importance for therapeutic decision-making both in early and late ovarian cancer patients, and therefore should be carried out as a routine procedure in women with this disease.

Observer variation in histologic classification of malignant and borderline ovarian tumors

Eight hundred sixty-nine primary malignant or borderline ovarian tumors reported to the Norwegian Cancer Registry were reviewed. The histologic slides were randomly distributed to six observers and classified according to the World Health Organization classification of ovarian tumors. By rotation of slides, each tumor was successively reviewed by three observers. Each observer was given approximately 40 duplicates of slides he or she had typed before, mixed in with the slides for the third review. A contracted version of the classification with 27 entries was used in the analysis. Mean intraobserver reproducibility was 62% (kappa, 0.53), varying from 50% to 75% (kappa, 0.34 to 0.70) for the individual observers. The mean rate of agreement between two observers was 56% (kappa, 0.46), varying from 46% to 65% for the individual pairs of observers. The rate of full agreement among three observers was 41%. The most common disagreements were between different specific types of carcinoma, between undifferentiated and differentiated carcinoma, between borderline and malignant tumors, between unclassified and classified carcinoma, and between mixed and pure types of carcinoma. Very low reproducibility was obtained for mixed and unclassified carcinoma.

Ovarian epithelial tumors of borderline malignancy. A clinical and pathologic study of 109 cases

One hundred nine cases of ovarian tumors of low malignant potential (borderline tumors) diagnosed at Stanford University Medical Center from 1958 to 1982 were reviewed. The patients ranged in age from 10 to 79 years (mean, 40.5 years). The histologic types and corresponding stages of these neoplasms were 73 serous (Stage IA: 35 patients; Stage IB+C: 16 patients; stage II: 8 patients; Stage III: 14 patients), 30 mucinous (Stage IA: 27 patients; Stage IB+C: 3 patients), and 6 mixed seromucinous (all Stage IA). Borderline endometrioid, clear cell, and Brenner tumors were excluded. Follow-up information from 3 to 27 years from the time of initial diagnosis (mean, 7.6 years; median, 7.1 years) revealed that 89 patients are alive without further evidence of neoplasm, and three patients died of unrelated disease without recurrent tumor. Seventeen patients have developed persistent or recurrent neoplasms in the contralateral ovary (six patients) and/or elsewhere within the peritoneal cavity (15 patients) at 5 to 226 months (mean, 61 months) after the initial excision. All of the second neoplasms were borderline serous or seromucinous tumors histologically identical to the original tumor; none of the borderline mucinous tumors recurred. Patients who initially had Stage III borderline serous tumors developed persistent or recurrent neoplasms more commonly (64%) than did patients with lower stage tumors (12%). No correlation was found between the development of a subsequent serous neoplasm and patient age, the primary tumor size, or any single histologic feature. Following treatment of the subsequent neoplasms, 13 patients are free of neoplasm, one patient is alive with tumor, one patient has died of intercurrent disease with tumor, and two patients have died with widespread abdominal tumor 53 and 232 months after their initial diagnosis. These findings confirm the excellent prognosis for patients with borderline serous tumors, despite involvement of the peritoneal cavity and the development of recrudescent tumor, although long-term follow-up is indicated. Mucinous borderline tumors, as defined by published criteria, almost invariably present as localized (low-stage) tumors and, in our experience, do not recur when confined to the ovary.

The outlook for women with borderline epithelial tumours of the ovary

Seventy-two women with borderline epithelial tumours of the ovary have been followed up for between 3 and 9 years. Patients with disease confined to one or both ovaries had a good prognosis, irrespective of histological type. When extra-ovarian spread was present at the time of diagnosis, neither the histological type nor the amount of residual tumour predicted the long-term outcome in individual patients.

Mucinous tumors of the ovary. A clinicopathologic study of 70 cases

Seventy cases of mucinous ovarian tumor were reviewed. All patients were followed for a minimum of 5 years. Clinicopathologically, three groups were defined: (1) mucinous cystadenoma, which demonstrated no nuclear stratification and no stromal invasion (15 cases); (2) mucinous tumor of uncertain malignant potential, which was characterized by nuclear stratification of two to three layers and no stromal invasion (21 cases); and (3) mucinous carcinoma, which showed stromal invasion and/or nuclear stratification in excess of three layers (34 cases; 15 with invasion, 19 without). All patients with mucinous cystadenomas remained tumor-free after initial surgery. Two patients with mucinous tumors of uncertain malignant potential died of tumor at 55 and 72 months, respectively, whereas 18 with mucinous carcinomas died after intervals ranging from 2 to 71 months. All mucinous tumors of uncertain malignant potential were Stage I at presentation. Twenty-one mucinous carcinomas were Stage I (six tumor deaths), one was Stage II (tumor death), ten were Stage III (nine tumor deaths), one was Stage IV (tumor death), and one was of uncertain stage (tumor death). Patients with mucinous carcinomas having stromal invasion demonstrated poorer survival (10 of 15 dead) than those with mucinous carcinomas lacking this finding (8 of 19 dead); however, stromal invasion was related to higher stage (5 with invasion Stage I; 16 without invasion Stage I).

Image processing for mitoses in sections of breast cancer: a feasibility study

This paper describes an image analysis technique for the counting of nuclei in mitosis in tissue sections. Five experienced pathologists scored mitoses in photographs of preselected areas of tissue sections of the breast. Objects consistently labelled as mitotic cells by all five pathologists were considered "mitoses" in the analysis. In total, there were 45 mitotic nuclei, 68 possible mitotic nuclei and 1,172 nonmitotic nuclei. The image analysis procedure was designed to give priority to a low false negative rate, i.e., misclassification of mitoses. The procedure consists of three steps: 1. Segmentation of the image. 2. Reduction of the number of nonmitotic nuclei by using feature values based on the brightness histogram of the objects. 3. Fully automatic classification of the remaining objects using contour features. The objects remaining after the first two steps were visualized in a composite display for interactive evaluation: 10% of the mitotic nuclei were missed, and 85% of the nonmitotic nuclei were eliminated. The result of the fully automatic procedure described in this paper is rather disappointing and gave a loss of 37% of the mitoses while 5% of the nonmitotic nuclei remained.

Ovarian epithelial tumors in Thai women: a histological analysis of 291 cases

A semiquantitative histological analysis on 291 epithelial tumors of the ovary in Thai women was done to assess the association between stromal invasion and a number of other histological features. Cribriform pattern, back-to-back growth, and epithelial stratification deeper than three cells were significantly related with stromal invasion in all types of ovarian epithelial tumors combined as well as in mucinous tumors alone. This finding suggests that the three histological characteristics serve as additional criteria of malignancy when unequivocal stromal invasion cannot be demonstrated. Histological classification of ovarian epithelial tumors in Thai women, together with age distribution, laterality, extraovarian spread, and some associated pathology, are presented and discussed.