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ORIGINAL ARTICLE
Year : 2013  |  Volume : 50  |  Issue : 4  |  Page : 302-305
 

Accuracy rate of frozen section studies in ovarian cancers: A regional cancer institute experience


Department of Gynecologic Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India

Date of Web Publication24-Dec-2013

Correspondence Address:
A Subbian
Department of Gynecologic Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.123599

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 » Abstract 

Background: Frozen section is a valuable diagnostic procedure in the categorization of ovarian tumors as benign, borderline and malignant. Thus, it guides in tailoring surgical therapy, particularly in young women. Aim: This study was undertaken to determine the accuracy of frozen section in ovarian neoplasms. Materials and Methods: A retrospective analysis was done of intraoperative frozen sections for suspected ovarian neoplasms. The frozen and permanent section reports were compared and overall accuracy, sensitivity, specificity, positive and negative predictive values were determined. Results: The study included 135 patients and the overall accuracy of frozen section in determining malignancy was 84.25%. Twenty cases were incorrectly diagnosed, of which 16 cases were under-diagnosed and four were over-diagnosed. With respect to malignant potential, the sensitivity for malignant tumors was highest (91.5%) with specificity of 98.2%. For benign tumors, the sensitivity and specificity were 90.4% and 82.6%, respectively. Borderline tumors had the lowest sensitivity of 31.2% with specificity of 94%. Sensitivity for benign, borderline and malignant tumors in the non-mucinous group was 91.3%, 60% and 95% respectively, whereas the sensitivity was 75%, 18% and 57%, respectively, for mucinous tumors revealing low sensitivity in borderline, mucinous tumors. The low sensitivity rates were due to restriction in the sampling of an adequate number of bits in the large sized tumors. Conclusion: The present study concurs that frozen section is an accurate test for diagnosis of benign and malignant tumors. However, accuracy rates for borderline and mucinous tumors are low.


Keywords: Frozen section, ovarian cancer


How to cite this article:
Subbian A, Devi U K, Bafna U D. Accuracy rate of frozen section studies in ovarian cancers: A regional cancer institute experience. Indian J Cancer 2013;50:302-5

How to cite this URL:
Subbian A, Devi U K, Bafna U D. Accuracy rate of frozen section studies in ovarian cancers: A regional cancer institute experience. Indian J Cancer [serial online] 2013 [cited 2020 Oct 22];50:302-5. Available from: https://www.indianjcancer.com/text.asp?2013/50/4/302/123599



 » Introduction Top


Ovarian malignancy is a leading cause of mortality among women with gynecological cancers. Most cases are diagnosed in late stages and require aggressive surgical management. However, in certain situations, such as, early stages of epithelial cancers, borderline tumors and germ cell tumors, a conservative approach may be followed. This applies especially to germ cell tumors as most of these patients are in the reproductive age group, and germ cell tumors are the most chemo- responsive. In these situations, intraoperative diagnosis is crucial in planning appropriate surgical management. Frozen section has been a valuable intraoperative diagnostic procedure that aids in the categorization of tumors as benign, borderline and malignant, and thus guides in tailoring the extent of surgical therapy, particularly in patients requiring fertility preservation. Accuracy of frozen section has been quoted by several studies to be fairly high, and this ranges from 73% to 98% in determining the status of malignancy [1],[2],[3] The accuracy rates have consistently improved over the past decades, thus mirroring improvements in this technique. This study was undertaken to determine its accuracy in relation to the status of malignancy in our setting.


 » Materials and Methods Top


A retrospective analysis was performed by reviewing reports of frozen section and paraffin block diagnoses of patients undergoing surgery as primary line of therapy for suspected ovarian neoplasms, from March 2004 to January 2006. All the frozen section diagnoses were made by a team of expert onco-pathologists at the institute. Before sectioning, gross examination of the tumor was carried out and frozen section samples were taken from solid or suspicious areas. The number of bits sampled varied from one to three (average of two). The frozen section and the permanent section reports of each patient were compared. The frozen section results were divided into the following groups: Deferred, benign, borderline and malignant. Reports mentioned as 'suggestive of', 'suspicious of' or 'compatible with' were included in the diagnoses mentioned. The overall accuracy, sensitivity, specificity, positive and negative predictive values of the frozen section diagnoses were determined according to the status of malignancy. Statistical evaluation was also done with respect to the histological type of the tumors (mucinous and non-mucinous).


 » Results Top


The study included 135 patients who had undergone frozen section for ovarian masses. The mean age of the patients was 43.7 years (range 13-86 years). Diagnosis by frozen section was deferred in eight patients as opinion was not possible due to absence of discrete lining. Out of the remaining 127 patients, non-neoplastic conditions were diagnosed in 10 patients. The final histopathological diagnoses were benign in 51 patients (40.15%), borderline in 16 (12.6%) and malignant in 60 (47.24%) patients. Histologically, the commonest tumor type was epithelial. Six tumors (4.7%) were metastatic to the ovary, with two tumors of unknown primary, and the remaining from the uterus (n = 1), appendix (n = 2) and gastrointestinal stromal tumor (n = 1). Distribution of the tumors according to histology is given in [Table 1].
Table 1: Distribution of tumors by histology according to paraffin diagnosis as seen in the study (n=127)

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Statistical analysis included 117 patients after excluding the eight deferred cases and the ten patients diagnosed with non-neoplastic conditions, as our intent was in analyzing its value in categorizing ovarian tumors. Overall accuracy of frozen section in determining the status of malignancy was 84.25%. Twenty cases were incorrectly diagnosed, of which 16 cases were under-diagnosed (false negatives) and 4 were over-diagnosed (false positives). Of the 16 cases which were under-diagnosed, three cases were of serous type and the remaining 13 were mucinous. Two of the three serous tumors were borderline wrongly classified as benign, and one was a low grade malignant tumor which was diagnosed as borderline by frozen section. Of the 13 mucinous tumors, 11 cases were wrongly classified as benign. Out of these, nine tumors were finally found to be borderline and two were found to be low grade malignancies. The remaining two mucinous tumors were low grade malignancies which were wrongly classified as borderline tumors.

In the group of discordant diagnoses, all but one patient were managed adequately. Four cases were over diagnosed-one was a benign serous tumor and two were benign mucinous tumors which were wrongly diagnosed as borderline. One patient was diagnosed as "possibly malignant" by frozen section, but was diagnosed as endometriosis on paraffin section. This was a 32 year old multipara, who presented with complaints of pain abdomen, not related to menstruation. The patient had regular cycles and physical examination revealed a firm-hard mass measuring 10 × 10 × 10 cm posterior to the uterus with restricted mobility. Ultrasound scan showed a solid-cystic lesion in the right adnexal region measuring 8.1 × 5.2 × 6.8 cm with lobulated margins and internal septations. Uterus and left ovary were imaged and found normal. Laparotomy revealed a 8 × 8 × 5 cm mass in the pouch of Douglas adherent to uterus, appendix, right ovary, fimbrial end of right tube and small bowel loops. The other ovary and upper abdomen appeared normal. Since frozen section of the mass was 'suspicious of carcinoma' it was decided to perform a total hysterectomy and bilateral oophorectomy with complete surgical staging (which included omentectomy and pelvic node dissection). This was overtreatment when the final report confirmed endometriosis.

With respect to the malignant potential, the sensitivity for malignant tumors was highest (91.5%) and the specificity was 98.2%. For benign tumors, the sensitivity and specificity were 90.4% and 82.6%, respectively. Borderline tumors had the lowest sensitivity of 31.2% and a specificity of 94%. The statistical values for these three groups are listed in [Table 2]. The accuracy rate regarding the histological type was 89.5% for serous tumors and 48.2% for mucinous tumors. Accuracy for germ cell tumors and sex-cord stromal tumors was 100% and 85%, respectively. Accuracy of frozen section for determining the status of malignancy in mucinous and non-mucinous tumors groups was compared. Sensitivity for benign, borderline and malignant tumors in the non-mucinous group was 91.3%, 60% and 95% respectively, whereas the sensitivity was 75%, 18% and 57%, respectively, for mucinous tumors. The sensitivity was thus low in the borderline and mucinous groups. The statistical values comparing the two groups are listed in [Table 3].
Table 2: Diagnostic value of frozen section according to the status of malignancy as seen in the study

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Table 3: Diagnostic value of frozen section in mucinous and Non-mucinous groups as seen in the study

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 » Discussion Top


Intraoperative diagnosis of the status of malignancy of ovarian tumors by frozen section is very important as it aids in determining the extent of surgery. This is very valuable especially in young women who desire fertility conservation and in cases of borderline tumors, metastatic tumors or in certain cases of endometriosis which are hard to differentiate from malignancy. The accuracy of frozen section examination should therefore be evaluated in order to consider this diagnostic tool to be dependable. In our study, the overall accuracy rate was 84.25%, which is comparable to those quoted in previous studies which range from 73.7% to 98.7%. [1],[2],[3],[5],[6],[7],[8],[9] [Table 4] summarizes the statistical details quoted in these previous studies.

In our study, 20 cases were incorrectly diagnosed. Of these, 16 cases were under diagnosed and 4 were over diagnosed. The overall false negative rate in our study was 13.6%, and the false positive rate was 0.3%, and this was consistent with other studies where false positive rates ranged from 0-1%. [6],[10],[11],[12],[17] With regard to sensitivity of frozen section with relation to the status of malignancy, most studies quote rates of >90% for benign and malignant tumors. [2],[6],[9],[10],[11],[12],[17] In our study, we found comparable sensitivity rates of 90.4% and 91.5% for benign and malignant tumors, respectively.
Table 4: Accuracy rates of frozen section for ovarian tumors as seen in the study

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However, in contrast to these two groups of tumors, the sensitivity of borderline tumors in most studies have been found to be low, although a considerable improvement in the sensitivity rates have been noted in recent years. Most studies show sensitivity rates ranging from 44.4% to 77.2%, [1],[6],[9],[12],[13],[14] and in our study the rate was 31.1%. The low sensitivity rate observed in our study was due to the high rates of false negatives (68.7%) observed, especially in the mucinous tumors. The sensitivity rates for borderline tumors was 18% in the mucinous tumors (n = 11) as compared to 60% in the non mucinous group (n = 5). This has been consistently observed by several authors who quote low sensitivity rates in borderline tumors which is mainly due to mucinous tumors. [4],[6] In our study, of the 20 incorrectly diagnosed cases, 15 were mucinous tumors and only four were serous and one was a case of endometriosis. Nigrisoli [8] found that adequate sampling may be difficult in mucinous tumors due to their larger average size compared to serous tumors. In the present study, we found that the mean maximal tumor dimension of the mucinous tumors was 24.8 cm (range 10-45 cm) as compared to 14.4 cm (range 7-30 cm) in the serous tumors. We found that the reasons for low sensitivity in mucinous tumors were larger tumor size making sampling inadequate at the time of frozen section. Inaccurate diagnoses also arises since mucinous tumors frequently contain benign, borderline and malignant components in different areas of the same tumor, in contrast to the more uniform serous tumors. [4]

In addition, reduced sensitivity may also be due to insufficient tumor removal at the time of surgery and inexperience of pathologists. [9] Since pathologists in our institution are experienced and reliable in gynecological pathology and care is taken by the surgical team to send the whole tumor for frozen section examination, we concluded that technical problems in the form of sampling only a limited number of bits might be the cause for the low sensitivity rates noted in borderline tumors, and mucinous tumors in the current study. Hence, although no consensus has been reached regarding the role of surgical staging and adjuvant therapy in borderline tumors, it becomes imperative to keep in mind that borderline tumors diagnosed by frozen section may be potentially invasive, and hence treatment has to be tailored accordingly.


 » Conclusion Top


The present study concludes that intraoperative frozen section appears to be an accurate test for diagnosis of benign and malignant tumors and has important implications in deciding the extent of surgery. However, accuracy rates for borderline and mucinous tumors are low and therefore appropriate caution should be exercised when deciding the extent of surgery in these clinical scenarios.

 
 » References Top

1.Slavutin L, Rotterdam H. Frozen section diagnosis of serous epithelial tumors of the ovary. Am J Diag Gyn Obst 1979;1:89-92.  Back to cited text no. 1
    
2.Hamed F, Badia J, Chuagui D, Wild R, Barrena N, Oyarzún E, et al. Role of frozen section biopsy in the diagnosis of adnexal neoplasms. Rev Chil Obstet Ginecol 1993;58:361-4. Spanish  Back to cited text no. 2
    
3.Cuello M, Galleguillos G, Zarate C, Córdova M, Brañes J, Chuaqui 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;127:1199-205. Spanish  Back to cited text no. 3
    
4.Scurry JP, Sumithran E. An assessment of the value of frozen section in gynaecologic surgery. Pathology 1989;21:159-63.  Back to cited text no. 4
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5.Prey M, Vitale T, Martin S. Guidelines for practical utilization of intraoperative frozen sections. Arch Surg 1989;124:331-5.  Back to cited text no. 5
    
6.Twaalfhoven FC, Peters AA, Trimbos JB, Hermans J, Fleuren GJ. The accuracy of frozen section diagnosis of ovarian tumors. Gynecol Oncol 1991;41:189-92.  Back to cited text no. 6
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7.Souko S, Kamel M, Rocca M, el-Assi M, Hebeishy N, Sheir SH. The combined use of cytological imprint and frozen section in the intraoperative diagnosis of ovarian tumors. Int J Gynaecol Obstet 1990;31:43-6.  Back to cited text no. 7
    
8.Nigrisoli E, Gardini G. Quality control of intraoperative diagnosis: Annual review of 1480 frozen sections. Pathologica 1994;86:191-5. Italian  Back to cited text no. 8
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9.Gol M, Baloglu A, Yigit S, Dogan M, Aydin C, Yensel U. Accuracy of frozen section diagnosis in ovarian tumors: Is there a change in the course of time. Int J Gynecol Cancer 2003;13:593-7.  Back to cited text no. 9
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10.da Cunha Bastos A, Salvatore CA, Faria RM. Frozen section biopsy of ovarian neoplasms. Int J Gynaecol Obstet 1983;21:103-10.  Back to cited text no. 10
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11.Usubütün A, Altinok G, Küçükali T. The value of intraoperative consultation (frozen section) in the diagnosis of ovarian neoplasms. Acta Obstet Gynecol Scand 1998;77:1013-6.  Back to cited text no. 11
    
12.Pinto PB, Andrade LA, Derchain SF. Accuracy of intraoperative frozen section diagnosis of ovarian tumors. Gynecol Oncol 2001;81:230-2.  Back to cited text no. 12
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13.Spann CO, Kennedy JE, Musoke E. Intraoperative consultation of ovarian neoplasms. J Natl Med Assoc 1994;86:141-4.  Back to cited text no. 13
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14.Zhang GN. Accuracy of frozen section diagnosis of ovarian tumors. Zhonghua Fu Chan Ke Za Zhi 1993;28:601-3, 635. Chinese Obiakor I, Maiman M, Mittal K, Awobuluyi M, DiMaio T, Demopoulos R. The accuracy of frozen section in the diagnosis of ovarian neoplasms. Gynecol Oncol 1991;43:61-3.  Back to cited text no. 14
    
15.Ilvan S, Ramazanoglu R, Ulker Akyildiz E, Calay Z, Bese T, Oruc N. The accuracy of frozen section (intraoperative consultation) in the diagnosis of ovarian masses. Gynecol Oncol 2005;97:395-9.  Back to cited text no. 15
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16.Tangjitgamol S, Jesadapatrakul S, Manusirivithaya S, Sheanakul C. Accuracy of frozen section in the diagnosis of ovarian mass. Int J Gynecol Cancer 2004;14:212-9.  Back to cited text no. 16
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17.PG, Rubin RB, Nelson BE, Hunter RE, Reale FR. Accuracy of frozen-section (intraoperative consultation) diagnosis of ovarian tumors. Am J Obstet Gynecol 1994;171:823-6.  Back to cited text no. 17
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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