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

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.

Fast detection, a precise and sensitive diagnostic agent for breast cancer

Background

Breast cancer targeting diagnostic agent with effective imaging ability is important in guiding plan formulation, prediction, and curative effect evaluation of tumors in clinic. A tumor-targeting nanoprobe based on the functional and programmable Liquid–Liquid phase separation of AS1411 promoted by Ru(II) complex RuPEP may develop into a potential phosphorescence probe to detect breast cancer cells, where AS1411 act as a tumor-targeting guidance moiety to distinguish tumor cells from normal cells and RuPEP act as a light-emitting element to highlight breast cancer cells.

Methods

Here we designed and constructed a nanoprobe AS1411@RuPEP, and the physicochemical and biochemical properties were characterized by TEM, AFM and EDS. The breast cancer targeting diagnostic capacity was evaluated by normal/tumor cell co-culture assay, tumor cells targeting tracking in xenograft model and cancerous area selectively distinguishing in human patient tissue.

Results

Further studies indicated that the nanoprobe exhibits excellent tumor-targeting imaging ability in vitro and in vivo by effectively recognize the over-expressed nucleolin (NCL) on the breast cancer cells membrane. Intriguingly, we discovered that the selectively enrichment of nanoprobe particles in tumor cells is related to ATP-dependent NCL transport processes that rely on the AS1411 component of nanoprobe to recognize NCL. Furthermore, preferential accumulation of nanoprobe is clearly differentiating the human breast cancer tissue surrounding non-cancerous tissue in histological analysis.

Conclusion

This study produce a potent nanoprobe can be used as a convenient tool to highlight and distinguish tumor cells in vivo, and indicate the tumorous grading and staging in human breast cancer patient pathological section, which provides an effective way for breast cancer diagnostic imaging by targeting recognize NCL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13046-022-02393-3.

A Quantitative and Qualitative Assessment of Frozen Section Diagnosis Accuracy and Deferral Rate Across Organ Systems

OBJECTIVES

Monitoring of frozen section diagnostic performance provides an important quality improvement measure.

METHODS

Surgical specimens involving a frozen section diagnosis over a 3-year period were retrospectively reviewed. Glass slides were reviewed on cases with discordance. Discordance and deferral rates were calculated.

RESULTS

Of 3,675 frozen section diagnoses included, 96 (2.7%) were discordant with the final diagnosis. Additionally, 114 frozen section diagnoses (3.1%) were deferred. The organ-specific discordance rates were lowest in breast and genitourinary specimens and highest for pancreas, lymph node, and gynecologic specimens. Deferral rates were highest in musculoskeletal, breast, and hepatobiliary cases and lowest in thyroid, parathyroid, and neuropathology cases. Discordance was explained by block-sampling error (45%), specimen-sampling error (27%), or interpretation error (27%). Discordant frozen section diagnoses from gynecologic specimens were responsible for 81% of specimen-sampling errors; frozen section diagnoses of lymph nodes, head and neck, and pancreas were responsible for 54% of interpretation errors; 51% of block-sampling errors involved lymph node evaluation for metastatic carcinoma.

CONCLUSIONS

Careful gross evaluation and microscopic examination of multiple levels should minimize specimen-sampling error and block-sampling error, respectively. Periodic review of accuracy and deferral rates may help reduce errors and improve the overall performance of this essential procedure.

MRI of Borderline Epithelial Ovarian Tumors: Pathologic Correlation and Diagnostic Challenges

Borderline epithelial ovarian tumors are a distinct pathologic entity characterized by increased epithelial proliferation and nuclear atypia, but without frank stromal invasion. Borderline tumor (BT) is now considered to represent an intermediate phase in the stepwise progression from benign to malignant ovarian epithelial tumor. Since BTs commonly manifest at early stages in women of reproductive age and are associated with a good prognosis, making the correct diagnosis is important in determining whether a patient is a candidate for fertility-sparing surgery. There are six histologic BT subtypes (serous, mucinous, seromucinous, endometrioid, clear cell, and Brenner), and each has different MRI features, reflecting their unique histologic architectures. Radiologists should be aware of the MRI features that can suggest BTs. These features include a hyperintense papillary architecture with hypointense internal branching, which can be observed with serous and seromucinous BTs on T2-weighted images; aggregates of microcysts that have hypointensity on T2-weighted images and reticular enhancement on contrast-enhanced T2-weighted images, which can be seen with mucinous BTs; and moderately high signal intensity on diffusion-weighted images along with relatively high apparent diffusion coefficient values, which can be observed regardless of the histologic subtype. Nevertheless, because the imaging features of BTs overlap with those of many benign lesions (eg, cystadenoma and cystadenofibroma, decidualized endometriosis, and polypoid endometriosis) and malignant tumors (ovarian cancers and metastases), histologic confirmation is required for the final diagnosis. Special emphasis is placed on the MRI features of BTs, pathologic correlation, and the challenges related to diagnosis. ^©RSNA, 2022.

Characteristics Patients with Borderline Ovarian Tumor at Sanglah General Hospital: From Pre- to Post-operative Approach

BACKGROUND: Specific epidemiology data of borderline ovarian tumor (BOT) might be beneficial for the early diagnosis of BOT. The scarcity of BOT epidemiological data in Indonesia urged the writer to study further. AIM: The objectives of the study were to obtain the characteristics of BOT patients in Sanglah General Hospital between 2018 and 2019 according to sociodemographic, hormonal, clinical, and patient outcome factors. METHODOLOGY: This is a descriptive retrospective study. Data were obtained from patient’s medical records at medical records installation Sanglah General Hospital between March 2020 and July 2020. Descriptive data collected from medical records were analyzed using Microsoft Excel 2010 and presented in tables and narrative form. RESULTS: From sociodemographic factors, we found that majority of BOT patients were >40 years old, multiparous women, married, low educated, housewives, and had normal BMI. From hormonal factors, we found that experienced menarche between 11 and 15 years old, most of the patients were already menopause, did not use any contraception. From clinical factors, we found that many were referral cases, with abdominal pain as the main complaint, varied CA 125 and risk of malignancy index levels, unilateral mass, suspected with malignant ovarian cyst when being diagnosed earlier. From patient outcome factors, we found that the majority underwent definitive surgery with no post-operative CA 125 level, no malignant cells on cytology examination, borderline mucinous type in both frozen section and paraffin block examination, and followed up after surgery. CONCLUSIONS: Clinicians could use these characteristics as a reference in diagnosing a patient who fits the profile.

Comparison of Frozen and Permanent Section Diagnosis in Ovarian Neoplasms: Analysis of Factors Affecting Accuracy

Ovarian cancer is the seventh most common form of cancer among women worldwide. The aim of the study was to determine the accuracy of a frozen section and the factors affecting the accuracy of frozen diagnosis of ovarian neoplasms. This retrospective, cross-sectional study was conducted on 401 patients with ovarian masses with frozen section diagnosis in Shahid Faghihi Hospital affiliated to Shiraz University of Medical Sciences between 2014 and 2018. Each ovarian tumor sample was evaluated for histopathologic diagnosis using frozen and paraffin-embedded sections, which were reviewed by an expert gynecologic pathologist. Accuracy and diagnostic values were estimated by comparing the results of the 2 techniques, using the paraffin section as the gold standard. The overall accuracy of the frozen section was 94.5%. Its sensitivity was 85.3% for malignant, 88.2% for borderline, and 99.6% for benign tumors. Its specificity was also 99.7% for malignant, 98.0% for borderline, and 90.9% for benign tumors. The positive predictive value was 98.9% for malignant, 86.5% for borderline, and 94.6% for benign tumors. Most false negatives occurred in mucinous and borderline tumors. The sensitivity of malignant tumors of germ cell and sex cord-stromal cell types were 64.3% and 95.5%, respectively. The specificity of germ cell and sex-cord stromal tumors were 100% and 93.8%, respectively. Frozen section seems to be a precise technique for histopathologic diagnosis of ovarian tumors. However, borderline and mucinous tumors are the most problematic issues during frozen section diagnosis and malignant germ cell tumors have the lowest sensitivity.

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.

Rapid brain structure and tumour margin detection on whole frozen tissue sections by fast multiphotometric mid-infrared scanning

Frozen section analysis is a frequently used method for examination of tissue samples, especially for tumour detection. In the majority of cases, the aim is to identify characteristic tissue morphologies or tumour margins. Depending on the type of tissue, a high number of misdiagnoses are associated with this process. In this work, a fast spectroscopic measurement device and workflow was developed that significantly improves the speed of whole frozen tissue section analyses and provides sufficient information to visualize tissue structures and tumour margins, dependent on their lipid and protein molecular vibrations. That optical and non-destructive method is based on selected wavenumbers in the mid-infrared (MIR) range. We present a measuring system that substantially outperforms a commercially available Fourier Transform Infrared (FT-IR) Imaging system, since it enables acquisition of reduced spectral information at a scan field of 1 cm² in 3 s, with a spatial resolution of 20 µm. This allows fast visualization of segmented structure areas with little computational effort. For the first time, this multiphotometric MIR system is applied to biomedical tissue sections. We are referencing our novel MIR scanner on cryopreserved murine sagittal and coronal brain sections, especially focusing on the hippocampus, and show its usability for rapid identification of primary hepatocellular carcinoma (HCC) in mouse liver.

Factors associated with the inconsistent diagnosis between frozen section and permanent pathologic examination in borderline ovarian tumors

AIM

The predictive accuracy of frozen sections for borderline ovarian tumors (BOTs) is suboptimal. The aim of this study was to determine the diagnostic accuracy of BOTs and factors associated with an upgrade to a permanent pathological diagnosis of invasive carcinoma in patients diagnosed with BOTs by frozen section.

METHODS

We conducted a retrospective study between 2011 and 2018 at Kaohsiung Chang Gung Memorial Hospital (KCGMH). Two hundred and twenty-five records of eligible patients with a diagnosis of BOT by frozen section or permanent diagnosis were reviewed. Positive predictive value and the diagnostic accuracy of frozen sections were calculated. Univariate and multivariate analyses were used to determine the clinicopathological factors associated with an upgrade of the diagnosis from a borderline tumor to malignancy.

RESULTS

The agreement between frozen section and permanent pathological diagnoses was 63.1%, and the positive predictive value was 72.1%. The multivariate analysis revealed that CA-125 level > 136 U/mL (odds ratio [OR] = 2.96, 95% confidence interval [CI] = 1.3-6.9; p = 0.012), and tumor histologic type (clear cell/endometrioid vs. mucinous; OR:32.8, 95% CI = 6.9-154.8, p < 0.001; clear cell/endometrioid vs. serous: OR 48.1, 95% CI = 8.8-261.8, p < 0.001) were independent risk factors for an upgrade of the permanent diagnosis from a BOT to ovarian carcinoma.

CONCLUSION

An elevated CA-125 level (over 136 U/mL) and tumor histologic type (clear cell and endometrioid subtypes) were associated with an upgrade in the diagnosis of ovarian tumor from a BOT on frozen section to a permanent diagnosis of malignancy.

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.

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).

Surgery of Benign Ovarian Masses by a Gynecological Cancer Surgeon: A Cohort Study in a Tertiary Cancer Centre

Objectives This study aimed to evaluate diagnostic performance in characterising ovarian masses by our gynaecological oncology multidisciplinary team meeting (MDM). Surgical outcome and overall impact on patients and healthcare service were also assessed. Methods This was a prospective cohort study of all women with adnexal masses presenting to the gynaecological oncology MDM at a central London tertiary cancer centre between February 2017 and February 2018. The multidisciplinary team (MDT) outcome, imaging details, subjective opinion, tumour markers, surgical details, and final histological diagnosis were collected. Diagnostic performance was also determined. Results There were 200 eligible patients in the study period. MDM imaging review demonstrated a sensitivity of 98.4% (95% CI: 94.3% to 99.8%) and a specificity of 52% (95% CI: 40.2% to 63.7%). Thirty-five cases were false positive, either presumed invasive cancers (51%) or borderline tumours (49%). The most common histological types were serous (37%) and mucinous (31%) cystadenomas. A retrospective application of the International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model suggests a potential reduction in false-positive rates (17%). Among the false-positive cases, there was no postoperative (90 days) mortality and postoperative morbidity was 14% with only grade 2 (CD2) complications according to Clavien and Dindo's CD classification. Conclusion An MDT has high sensitivity but low specificity when characterising ovarian masses referred with possible ovarian cancer to the tertiary centre. False-positive values in ovarian cancers are an important indicator of over-treatment. More research is required to assess other methods, such as the IOTA ADNEX model, to reduce the false-positive value.

Effect of tumor size on the accuracy of frozen section in the evaluation of mucinous borderline ovarian tumors

OBJECTIVE

This study aims to evaluate the accuracy of frozen section (FS) in mucinous borderline ovarian tumors (BOTs) and to examine the factors associated with misdiagnosis.

METHODS

In this retrospective study, cases diagnosed as mucinous BOTs by FS or final pathologic (FP) results were studied. The results of FS and FP were compared, and the factors associated with misdiagnosis were analyzed.

RESULTS

Seventy-nine cases were examined. The median tumor diameter was 16 (6-50) cm, and 89.9 % of cases had tumors ≥10 cm. The overall agreement ratio between FS and FP was 79.7 %. Over-diagnosis and under-diagnosis rates were 3.8 % and 16.5 %, respectively. The sensitivity and positive predictive values were both 88.7 %. None of the underdiagnosed patients (13 cases) had recurrence during the 100-month median follow-up (9-222). Misdiagnosis was more common in tumors <10 cm (p = 0.025). The under-diagnosis rate for tumors <10 cm was 30.8 %. Tumor size <10 cm was significantly associated with misdiagnosis in univariate and multivariate analyses (Odds ratio {OR} 4.92, 95 % Confidence Interval {CI} (1.08-22.45) p = 0.040; OR 5.17, 95 % CI (1.07-25.05) p = 0.041, respectively). Laterality and preoperative CA 125 levels were not associated with misdiagnosis.

CONCLUSION

Tumor size <10 cm is associated with misdiagnosis in mucinous BOTs. Laterality and CA 125 levels do not affect diagnostic accuracy. The evaluation of FS by gynecologic pathologists can help to increase the accuracy of FS.