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Biopsia Intraoperatoria en Cáncer de Ovario Diego Häbich, MD, PhD Especialista en Ginecología Oncológica y Oncología Clínica. Jefe de Ginecología Oncológica Hospital Alemán – Buenos Aires Introducción – Masa Anexial El hallazgo de una masa anexial (ovarica, tubaria o de tejidos circundantes) es un problema frecuente. Se calcula un riesgo de 5 a 10% a lo largo de la vida de requerir una cirugia por masa anexial. Puede hallarse una masa anexial en mujeres de cualquier edad, e histologicamente existe una gran variedad de tumores. El manejo depende de las caracteristicas de la masa, la urgencia en la presentación y el grado de sospecha de malignidad Introducción – Masa Anexial Cirugía de Estadificación sin histología confirmada? Cirugía de Diagnostico Diferido Cirugía con estudio por congelación Masa Anexial ¿Que esperar de la biopsia por congelación? ¿Que limitaciones presenta la biopsia por congelación? ¿Que esperar de la biopsia por congelación? Int J Gynecol Cancer. 2004 Mar-Apr;14(2):212-9. En 212 of casos sensibilidad para patología Accuracy frozenla section in diagnosis of ovarian mass. benigna fue 99,1%, de 90,9% para malignidad, pero para tumor borderline fue de 50% Tangjitgamol S(1), Jesadapatrakul S, Manusirivithaya S, Sheanakul C. To determine the accuracy of frozen section according to the status of malignancy and the histologic cell type, we reviewed the frozen and permanent pathologic Las mayores dificultades de diagnostico seThe presentaron reports of 212 resected ovarian masses in our hospital. accuracy, en tumores gran tamaño, mucinosos o negative borderline sensitivity, specificity, positive, and predictive value of frozen section were studied. The overall accuracy to determine the status of malignancy was 90.9%. Sensitivity of the test was highest in the benign groups at 99.1% and lowest in the borderline groups at 50%. All inaccurate diagnoses were in the common epithelial groups. Problems in diagnosis of mucinous tumors and borderline tumors were striking. The accuracy of the test for histologic diagnosis was 91.9%. Most cases of the incorrect diagnosis (81.3%) were common epithelial tumors. In conclusion, the accuracy of frozen section in the diagnosis of ovarian mass was generally high with a few exceptions in large tumors, mucinous, or borderline tumors that yielded lower accuracy, sensitivity, specificity, and positive predictive value. We encourage both the surgeons and the pathologists to be cautious of these limitations. Additional number of frozen section taken for a mass larger than 10 cm may minimize the error in large tumors to some extent. de ¿Que esperar de la biopsia por congelación? ¿Que limitaciones presenta la biopsia por congelación? Un metodo confiable, pero requiere gran comunicación en el equipo ¿Que esperar de la biopsia por congelación? Gynecol Oncol. 2005 May;97(2):395-9. En 617 casos el diagnostico fue correcto en 97% de ellos. El 18,3% The accuracy of frozen (intraoperative consultation) the diagnosis6,2% of fueron lesiones no section neoplásicas, 56,1% lesionesinbenignas, ovarian masses. tumores tumores malignos. Ilvan S(1), borderline RamazanogluyR,19,4% Ulker Akyildiz E, Calay Z, Bese T, Oruc N. OBJECTIVE: Frozen section is an important and helpful adjunct in the intraoperative diagnosis of ovarian tumors. This retrospective study was undertaken to determine the accuracy of frozen La sensibilidad de 100% tumores y de 87% para section diagnosis offue ovarian masses para and the reasons ofbenignos discordance. tumores borderline y malignos. METHODS: From January 1995 to December 2003, 1494 ovarian specimens were received for histopathological evaluation, and 617 of them were submitted for frozen section examination. RESULTS.: The final paraffin section diagnoses of these 617 cases were a nonneoplastic lesion in 18.3% of the cases, benign tumor in 56.1%, borderline tumor in 6.2%, and malignant tumor in 19.4%. The overall accuracy was 97%. Twenty-one cases were incorrectly diagnosed by frozen section. All of them were false negatives. There were no deferred cases. The majority of the cases La mayor dificultad la presentaron los tumores mucinosos y borderline of disagreement were mucinous and borderline tumors. The sensitivity for benign, borderline, and malignant tumors were 100%, 87%, and 87%, respectively. The specificity for benign tumors was 97%; for borderline tumors 98%; and for malignant tumors 100%. CONCLUSION: Our data confirm that frozen section diagnosis is a reliable method for the surgical management of patients with an ovarian mass. However, diagnostic problems can occur in Mencionan como punto clave errores la comunicación mucinous and borderline tumors duringpara frozendisminuir section examination. The clinicians and pathologists must beelaware of the pitfalls of this method; therefore, a good communication established entre patólogo y el cirujano between them is necessary to obtain more accurate results and to minimize the number of deferred cases. ¿Que esperar de la biopsia por congelación? ¿Que limitaciones presenta la biopsia por congelación? Un metodo confiable, pero requiere gran comunicación en el equipo Los tumores borderline / histologia no seroso: dificultades . ¿Que esperar de la biopsia por congelación? Obstet Gynecol. 2000 Jun;95(6 Pt 1):839-43. En 140 casos de tumor borderline, 80 eran serosos, 47 mucinosos, Borderline tumors of the ovary: correlation of frozen and permanent histopathologic diagnosis. 11mixtos y N, 2 Duska endometroides. Houck K, Nikrui L, Chang Y, Fuller AF, Bell D, Goodman A. OBJECTIVE: To evaluate the correlation between the diagnosis of borderline tumor of the ovary by frozen and permanent pathology. METHODS: All pathology reports with diagnoses of borderline tumor of the ovary between 1980 and El tamaño promedio fueHospital de 13,7cm, 10,2Univariate cm paraandserosos, 20,1 cm 1998 at Massachusetts General were reviewed. multivariable logistic regression models were constructed for patient age, tumor size, histology, presence of bilateral or para mucinosos. extraovarian disease, and concurrent diagnosis of endometriosis or endosalpingiosis. RESULTS: We reviewed 140 cases. The average age of patients was 52.3 years. Eighty tumors were serous, 47 mucinous, 11 mixed, and two endometrioid. The mean diameter overall was 13.7 cm (range 1-70 cm), 10.2 cm for serous, and 20.1 cm for mucinous. Diagnoses of borderline tumors by frozen and pathology were fue consistent in 60%en of cases. Frozen La concordancia con lapermanent histología diferida de 60%, 10,7% de los section interpreted a benign lesion as malignant (overdiagnosed) in 10.7% of cases, and interpreted a casos hubo sobrediagnostico y subdiagnostico malignant lesion as benign (underdiagnosed) in 29.3%. No variableen was29,3%. a significant predicator of overdiagnosis. In univariate analysis, underdiagnosis was more likely for other types of tumors than serous (P <.001), tumors larger than 20 cm (P =.039), and tumors confined to the ovaries (P =. 009). When all variables were included in a multiple regression model, only histology was a significant predictor of underdiagnosis (P =.039). CONCLUSION: Frozen or permanent pathology reports of diagnoses of borderline tumor were No se encontró ningún predictor significativo de sobrediagnostico. consistent 60% of the time, whereas the positive predictive value of borderline by frozen section was 89.3%. Tumors other than serous are more likely to be misinterpreted. ¿Que esperar de la biopsia por congelación? ¿Que limitaciones presenta la biopsia por congelación? Un metodo confiable, pero requiere gran comunicación en el equipo Mas evidencia de sobre y subdiagnostico Los tumores borderline / histologia no seroso: dificultades . ¿Que esperar de la biopsia por congelación? Gynecol Oncol. 2007 Nov;107(2):248-52. Epub 2007 Jul 12. En 96ofcasos de tumor lainconcordancia Accuracy intraoperative frozen borderline section analysis borderline tumors con of thela histología ovary: a retrospective 96 cases review of the literature. diferida fue de analysis 71,9%,of con unaand sensibilidad de 75% y un VPP de 94,5% Tempfer CB, Polterauer S, Bentz EK, Reinthaller A, Hefler LA. OBJECTIVE: To assess the sensitivity and positive predictive value (PPV) of intraoperative frozen section diagnosis of borderline tumors of the ovary (BTO).de los casos y no hubo El subdiagnostico ocurrió en 28% METHODS: Retrospective analysis at the Department of Obstetrics and Gynecology, University of sobrediagnostico. Vienna, between 1995 and 2007 and review of the literature. Frozen section analysis and definitive histology reports were compared. Univariate and multivariate regression models were used to assess the influence of patient and tumor characteristics on the likelihood of underdiagnosis and overdiagnosis. RESULTS: Agreement between frozen section diagnosis and definitive histology was observed in 69/96 (71.9%) patients, yielding an overall sensitivity and a positive predictive value of 75.0% and 94.5%, Los predictores de subdiagnostico fueronin el tamaño, la0/96 bilateralidad respectively. Underdiagnosis and overdiagnosis occurred 27/96 (28%) and (0%) patients, y la respectively. In aconcurrente univariate and multivariate analysis, tumorprincipalmente. diameter, but not patient age, tumor presencia de endometriosis histology, tumor stage, presence of a bilateral tumor, serum CA-125 and concurrent presence of endometriosis was a predictor of underdiagnosis of frozen section analysis. We identified 29 studies investigating the accuracy of frozen section analysis of BTO. Three studies exclusively examined BTO in 140, 48 and 33 cases, respectively. Data of these three studies and the present study were pooled, yielding overall sensitivity and PPV of 71.1% and 84.3%, respectively. Overdiagnosis and y En laanrevisión bibliográfica encuentran sobrediagnostico de 6,6% underdiagnosis were identified in 21/317 (6.6%) and in 97/317 (30.6%) cases, respectively. subdiagnostico de 30,6% de losdiagnosis casos.of BTO has a low sensitivity and PPV and CONCLUSION: Intraoperative frozen section overdiagnosis and underdiagnosis are frequent. Surgical management based on intraoperative frozen section diagnosis should be used with caution. ¿Que esperar de la biopsia por congelación? ¿Que limitaciones presenta la biopsia por congelación? Un metodo confiable, pero requiere gran comunicación en el equipo Mas evidencia de sobre y subdiagnostico Los tumores borderline / histologia no seroso: dificultades . ¿Que esperar de la biopsia por congelación? ¿Que limitaciones presenta la biopsia por congelación? Un metodo confiable, pero requiere gran comunicación en el equipo Evidencia de Metaanálisis Mas evidencia de sobre y subdiagnostico Los tumores borderline / histologia no seroso: dificultades . Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses Cochrane Database of Systematic Reviews 1 MAR 2016 DOI: 10.1002/14651858.CD010360.pub2 Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses Cochrane Database of Systematic Reviews 1 MAR 2016 DOI: 10.1002/14651858.CD010360.pub2 Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses Cochrane Database of Systematic Reviews 1 MAR 2016 DOI: 10.1002/14651858.CD010360.pub2 Intraoperative frozen section analysis for the diagnosis of early stage ovarian cancer in suspicious pelvic masses Cochrane Database of Systematic Reviews 1 MAR 2016 DOI: 10.1002/14651858.CD010360.pub2 Conclusiones En una población hipotética de 1000 mujeres (290 con cáncer y 80 con tumor borderline de ovario) si la congelación informa cáncer: 261 tendrían correctamente el Dx de Cáncer y 706 correctamente ausencia de malignidad. Sin embargo 4 mujeres habrían sido falsos positivos y 29 falsos negativos. Si en la misma población consideramos congelación positiva cáncer/borderline 280 tendrían correctamente diagnostico de cáncer y 635 correctamente ausencia de malignidad. Sin embargo 75 pacientes hubieran recibido equivocadamente el Dx de Cáncer y 10 pacientes con cáncer no hubieran sido diagnosticadas Conclusiones El diagnostico de Tumor Borderline por congelación debe ser tomado con cautela, especialmente en tumores de gran tamaño y de histología no seroso. La decisión quirúrgica deberá ser especialmente cuidadosa en mujeres en edad reproductiva, ante la posibilidad de un sobretratamiento. Cirugía de Diagnostico Diferido Oportuna derivación a centros especializados ante la sospecha de malignidad Cirugía con estudio por congelación Masa Anexial Nuevos Casos por Año ~ 500.000 Muchas Gracias diegohabich@juncal1920.com