Is intraoperative frozen examination sufficiently reliable for ovarian tumors: 11 years experience at a single center

Objectives: To demonstrate the safety of intraoperative frozen section (IFS) examination in epithelial, borderline, sex-cord stromal (SCST), and germ-cell (GCT) ovarian tumors and to report causes of misdiagnosis in IFS. Materials and Methods: Six hundred forty-nine patients with ovarian masses who underwent IFS examination between January 2006 and December 2016 were evaluated retrospectively. The cases were grouped as benign, malignant, borderline, and deferred according to the IFS outcome. Cases that were deferred to permanent section were excluded from the study. According to the permanent paraffin section (PPS) results, epithelial ovarian tumor (EOT), borderline ovarian tumor (BOT), SCST, and GCT subgroups were formed in addition to benign, malignant, and borderline groupings. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the IFS were calculated for each group. Univariate and multivariate analyses were performed to identify the causes of misdiagnosis in IFS. Results: The IFS results were malignant, benign, and borderline in 130, 429, and 58 cases; respectively. According to PPS outcome, 143 patients were diagnosed as malignant, 423 were benign, and 51 were borderline. Four-hundred and nine (75.74%) cases were epithelial, 70 (12.96%) cases were GCT, and 61 (11.29%) cases were in the SCST subgroup. Sensitivity, specificity, PPV, and NPV of IFS were 97.89%, 99.60%, 98.94%, and 99.20% in EOT, 66.67%, 95.38%, 40.0%, and 98.41% in GCT, 78.57%, 100%, 100%, and 94.0% in SCST, 78.43%, 96.82%, 68.97%, and 98.03% in borderline tumors, respectively. The most important factors causing misdiagnosis in IFS were mucinous and borderline histology (p = 0.016,OR=2.54; p = 0.001, OR = 5.74) and tumor size larger than 10 cm (p = 0.017, OR = 2.45). Conclusions: IFS examination is an effective and reliable method for intraoperative management of ovarian tumors despite some limitations in large tumors (> 10 cm), particularly in tumors of mucinous, teratoma, and borderline histology when evaluated by non-gynecopathologists.

[1] Morton R., Anderson L., Carter J., Pather S., Saidi S.A.: “Intraoperative frozen section of ovarian tumors: A 6-year review of performance and potential pitfalls in an Australian tertiary referral center’’. Int. J. Gynecol. Cancer, 2017, 27, 17.

[2] Subbian A., Devi U.K., Bafna U.D.: “Accuracy rate of frozen section studies in ovarian cancers: A regional cancer institute experience’’. Ind. J. Cancer, 2013, 50, 302.

[3] Acıkalın A., Torun G., Bagır E., Bayram F., Zeren H., Gulec U., et al.: “İntraopertaive frozen section in ovarian neoplasms; a tertiary center experience’’. Turk. Patoloji. Derg., 2014, 30, 184.

[4] Tempfer C.B., Polterauer S., Bentz E.K., Reinthaller A., Hefler L.A.: “Accuracy of intraoperative frozen section analysis in borderline tumors of the ovary: a retrospective analysis of 96 cases and review of the literature’’. Gynecol. Oncol., 2007, 107, 248.

[5] Tangjıtgamol S., Jesadapatrakul S., Manusurivithaya S., Sheanakul C.: “Accuracy of frozen section in diagnosis of ovarian mass’’. Int. J. Gynecol. Cancer, 2004, 14, 212.

[6] Malipatil R., Crasta J.: “How accurate is intraoperative frozen section in the diagnosis of ovarian tumors?’’. J. Obstet. Gynaecol. Res., 2013, 39, 710.

[7] Hashmi A.A., Naz S., Edhi M.M., Faridi N., Hussain S.D., Mumtaz S., et al.: “Accuracy of intraoperative frozen section for the evaluation of ovarian neoplasms: an institutional experience’’. World J. Surg. Oncol., 2016, 14, 91.

[8] Slavutin L., Rotterdam H.: “Frozen section diagnosis of serous epithelial tumors of the ovary’’. Am. J. Diag. Gynecol Obstet., 1979, 1, 89.

[9] Hamed F., Badia J., Chuagui D., Wild R., Barrena N., Oyarzun E., et al.: “Role of frozen section biopsy in the diagnosis of adnexal neoplasms’’. Rev. Chil. Obstet. Ginecol., 1993, 58, 361.

[10] Cuello M., Galleguillos G., Zarate C., Cordova M., Branes J., Chuaquri R., et al.: “Frozen section biopsy in ovarian neoplasm diagnosis. Diagnostic correlation according to diameter and weight in tumors of epithelial origin’’. Rev. Med. Chil., 1999, 127, 1199.

[11] Jacobs I., Menon U.: “The sine qua non of discovering novel biomarkers for early detection of ovarian cancer: carefully selected preclinical samples’’. Cancer Prev. Res., 2011, 4, 299.

[12] Kokka F., Singh N., Reynolds K., Oram D., Jeyerajah A., Hassan L., et al.: “The accuracy of frozen section diagnosis in apparent early ovarian cancer-results from a UK centre’’. Histopathology, 2009, 55, 756.

[13] Pinto PB, Andrade LA, Derchain S.F.: “Accuracy of intraoperative frozen section diagnosis of ovarian tumors’’. Gynecol.Oncol., 2001, 81, 230.

[14] Puls L., Heidtman E., Hunter J.E., Crane M., Stafford J.: “The accuracy of frozen section by tumor weight for ovarian epithelial neoplasms’’. Gynecol. Oncol., 1997, 67, 16.

[15] Basaran D., Salman C.M., Boyraz G., Selcuk I., Usubutun A., Ozgul N., et al.: “Accuracy of Intraoperative Frozen Section in the Evaluation of Patients with Adnexal Mass: Retrospective Analysis of 748 Cases with Multivariate Analysis’’. Pathol. Oncol. Res., 2015, 21, 113.

[16] Brun J.L., Cortez A., Rouzier R., Callard P., Bazot M., Uzan S., et al.: “Factors influencing the use and accuracy of frozen section diagnosis of epithelial ovarian tumors’’. Am. J. Obstet. Gynecol., 2008, 199, 244e1.

[17] Bige O., Demir A., Saygili U., Gode F., Uslu T., Koyuncuoglu M.: “Frozen section diagnosis of 578 ovarian tumors made by pathologists with and without expertise on gynecologic pathology’’. Gynecol. Oncol., 2011, 123, 43.

[18] Trillsch F., Mahner S., Ruetzel J., Harter P., Ewald-Riegler N., Jaenicke F., et al.: “Clinical management of borderline ovarian tumors’’. Expert Rev. Anticancer Ther., 2010, 10, 1115.

[19] Boran N., Cil A.P., Tulunay G., Ozturkoglu E., Koc S., Bulbul D., et al.: “Fertility and recurrence results of conservative surgery for borderline ovarian tumors’’. Gynecol. Oncol., 2005, 97, 845.

[20] Anastasiadis P.G., Romanidis K.N., Polichronidis A., Koutlaki N.G., Tamiolakis D., Simoopoulos K.: “The contribution of rapid intraoperative cytology to the improvement of ovarian cancer staging’’. Gynecol. Oncol., 2002, 86, 244.

[21] Baker P., Oliva E.: “A practical approach to intraoperative consultation in gynecological pathology’’. Int. J. Gynecol. Pathol., 2008, 27, 353.

[22] Desfeux P., Camette S., Chatellier G., Blanch B., Querleu D., Lecuru F.: “Impact of surgical approach on the management of macroscopic early ovarian borderline tumors’’. Gynecol. Oncol., 2005, 98, 390.

[23] Geomini P., Bremer G., Kruitwagen R., Mol B.W.: “Diagnostic accuracy of frozen section diagnosis of the adnexal mass: a meta-analysis’’. Gynecol. Oncol., 2005, 96, 1.

[24] Heatley M.K.: “A systemic review of papers examining the use of intraoperative frozen section in predicting the final diagnosis of ovarian lesions’’. Int. J. Gynecol. Pathol., 2012, 31, 111.

[25] Ilvan S., Ramazanoglu R., UlkerAkyıldiz E., Calay Z., Bese T., Oruc N.: “The accuracy of frozen section (intraoperative consultation) in the diagnosis of ovarian masses’’. Gynecol. Oncol., 2005, 97, 395.

[26] Akrivos N., Thomakos N., Sotiropoulou M., Rodolakis A., Antsaklis A.: “Intraoperative consultation in ovarian pathology’’. Gynecol. Obstet. Invest., 2010, 70, 193.

[27] Houck K., Nikrui N., Duska L., Chang Y., Fuller A.F., Bell D.: ‘‘Borderline tumors of the ovary: correlation of frozen and permanent histopathologic diagnosis’’. Obstet. Gynecol., 2000, 95, 839.

[28] Song T., Choi C.H., Kim H.J., Kim M.K., Kim T.J., Lee J.W., et al.: “Accuracy of frozen section diagnosis of borderline ovarian tumors’’. Gynecol. Oncol., 2011, 122, 127.

[29] Usubutun A., Altinok G., Kucukali T.: “The value of intraoperative consultation (frozen section) in the diagnosis of ovarian neoplasms’’. Acta Obstet. Gynecol. Scand., 1998, 77, 1013.

[30] Youngh R.H.: “From Krukenberg to today: The ever present problems posed by metastatic tumors in the ovary: part I. Historical perspective, general principles, mucinous tumors including the krukenberg tumor’’. Adv. Anat. Pathol., 2006, 13, 205.