Yeungnam Univ J Med.  2019 Sep;36(3):163-182. 10.12701/yujm.2019.00227.

Intraoperative consultation for ovarian tumors

• Kim I

• KMID: 2460185
• DOI: http://doi.org/10.12701/yujm.2019.00227

Abstract

The primary function of intraoperative frozen consultation is to provide an as accurate and prompt diagnosis as possible during surgery and to guide the surgeon in further management. However, the evaluation of frozen section (FS) is sometimes difficult because of suboptimal tissue quality and frozen artifacts compared with routinely processed tissue section. The pathologist responsible for the FS diagnosis requires experience and good judgment. Ovarian tumors are a heterogeneous group of tumors including primary surface epithelial tumors, germ cell tumors and sex cord-stromal tumors, secondary tumors, and other groups of tumors of uncertain histogenesis or nonspecific stroma. Intraoperative FS is a very important and reliable tool that guides the surgical management of ovarian tumors. In this review, the diagnostic key points for the pathologist and the implication of the FS diagnosis on the operator's decisions are discussed.

Keyword

Frozen section; Intraoperative consultation; Ovarian tumors

MeSH Terms

Artifacts
Diagnosis
Frozen Sections
Judgment
Neoplasms, Germ Cell and Embryonal
Sex Cord-Gonadal Stromal Tumors

Figure

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  Fig. 1. On frozen section, the multilocular cyst is lined by single layer of tall columnar cells (A), but the epithelial cells are stratified and show papillary growth indicating mucinous borderline tumor on permanent section (B).

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  Fig. 2. On frozen section, the tumor was diagnosed as mucinous borderline tumor (A), but permanent histologic section shows expansile type of mucinous carcinoma (B).

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  Fig. 3. Two patterns of invasion in mucinous carcinoma: expansile (A) and infiltrative (B).

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  Fig. 4. Goss finding of mucinous carcinoma is cystic, with polypoid mass (A). On section, the solid mass is sponge-like with hemorrhage and necrosis (B). The cystic area is mucinous borderline tumor (C), but solid portion is mucinous carcinoma (D).

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  Fig. 5. Mucinous borderline tumor shows mural nodule composed of anaplastic carcinoma.

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  Fig. 6. Serous borderline tumor on frozen section (A) and on permanent section (B). Epithelial proliferation is characterized by hierarchical branching papillae with budding and tufting, and stratification of the cells.

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  Fig. 7. High grade serous carcinoma shows solid and complex glandular growth patterns and psammomatous calcification on frozen section (A), and slit-like spaces of tumor cells with marked nuclear atypia (B).

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  Fig. 8. Endometrioid adenocarcinoma shows confluent, back-to back glandular proliferation with loss of intervening stroma (A), and squamous component (B).

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  Fig. 9. Clear cell carcinoma may have a solid cut surface (A) or may show a predominantly cystic appearance with intraluminal solid growth (B). On frozen section, the tumor has solid and papillary growth patterns and psammomatous calcification (C). The tumor cells are large and pleomorphic. Hyaline bodies are found (D).

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  Fig. 10. Seromucinous borderline tumor is grossly cystic and shows intraluminal papillary growth (A). Histologically papillary growth is similar to serous borderline tumor (B). Frozen (C) and permanent (D) sections show complex glands composed of serous and mucin-secreting cells infiltrated with neutrophils.

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  Fig. 11. Cut surface of fibroma is solid, firm, tan white and yellow (A). Histologically, the tumor is hypercellular and hypocellular with interlacing fascicles of spindle tumor cells (B).

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  Fig. 12. Adult granulosa cell tumor typically shows microfollicular pattern with Call-Exner bodies (A), and the tumor cells are oval and have angular nucleus with groove (B). Metastatic atypical carcinoid may show microfollicular structure, but the nuclei of the tumor cells are different from those of granulosa cell tumor.

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  Fig. 13. Sertoli-Leydig cell tumor (A) has sex cord component similar to adult granulosa cell tumor (B), but Leydig cell component is present in Sertoli-Leydig cell tumor (circle in A).

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  Fig. 14. Immature teratoma shows primitive neuroepithelial component, in addition to immature epithelial and mesenchymal tissues including immature cartilage (A), whereas carcinosarcoma is composed of carcinomatous (B, left) and sarcomatous components with malignant-looking cartilage (B, right).

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  Fig. 15. Dysgerminoma shows pale gray, solid, and lobulated cut surface (A), and histologically is characterized by sheets of large polygonal cells separated by fibrous septa with infiltration of lymphocytes on frozen section (B). Malignant lymphoma shows homogeneous, fish flesh cut surface (C), and diffuse infiltration of large lymphoid cells (D).

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  Fig. 16. Yolk sac tumor shows reticular, alveolar and papillary growth patterns (A). The tumor cells are large, pleomorphic and contain hyaline globules (B).

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  Fig. 17. Choriocarcinoma shows extensive hemorrhagic necrosis (A). Viable tumor nest is composed of two cell pattern of cytotrophoblasts and syncytiotrophoblasts (B).

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  Fig. 18. Multilocular cystic metastasis from colon cancer with multifocal yellow necrotic foci (A). Garland pattern with central necrosis simulates endometrioid carcinoma on frozen section (B).

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  Fig. 19. Metastatic signet ring cell carcinoma involving both ovaries (A). Fibrous stroma is infiltrated with nests and cords of small tumor cells on frozen section (B).

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  Fig. 20. Mucinous borderline tumor showing multilocular cysts filled with yellow, gelatinous material (A). Histologically, mucinous tumor represents benign (B) and borderline (C) areas and extensive pseudomyxoma ovarii. The association with mature teratoma indicates ovarian origin than appendiceal metastasis (D).

Reference

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