Sabato 27 ottobre 2012 - Pacini Editore

RElaziONi
nuove teorie di patogenesi: l’impatto sulle
nostre diagnosi
L. Resta
Paper not received
I tumori ovarici borderline
M. De Nictolis
Azienda Ospedaliera Marche Nord
I tumori ovarici borderline più frequenti e meglio conosciuti
sono i tumori sierosi e quelli mucinosi con epitelio intestinale.
I borderline sierosi hanno caratteristiche morfologiche e molecolari
ben definite. La prognosi è in genere ottima e solo le
forme associate ad impianti invasivi mostrano un comportamento
biologico aggressivo. Nell’ambito di un tumore sieroso
borderline si possono sviluppare aree di carcinoma sieroso di
basso grado in situ (carcinoma micropapillare con il pattern
della “medusa”) o carcinomi sierosi di basso grado invasivi,
che più raramente possono comparire de novo.
I tumori mucinosi borderline sono neoplasie di grandi dimensioni,
tipicamente polimorfe. Aree morfologicamente
benigne si alternano con aree borderline; in alcuni casi l’epitelio
è atipico realizzando aspetti di carcinoma intraepiteliale;
quando l’atipia citologica si associa ad un pattern di crescita
complesso si parla di carcinoma mucinoso di tipo espansivo.
In rari casi il carcinoma mucinoso infiltra in modo distruttivo
lo stroma alla stregua di un carcinoma del colon realizzandosi
il quadro di un carcinoma mucinoso infiltrante. Il fattore prognostico
principale di queste lesioni è lo stadio; le forme infiltrative
in stadio avanzato sono in pratica le uniche in grado di
progredire rapidamente e sono insensibili alla chemioterapia
abitualmente utilizzata per i carcinomi ovarici. Un’accurata
diagnosi di queste complesse neoplasie è alla base della prognosi,
della terapia e degli studi molecolari.
The frozen section in ovarian pathology
G.F. Zannoni
Istituto di Anatomia Patologica, Policlinico A. Gemelli, Università
Cattolica del Sacro Cuore
Frozen sections (FS) of ovarian tumors are the most common
ones seen in gynecological pathology, accounting for the largest
number of discrepancies between the intraoperative and
the final diagnosis. In this context these FS should only be
requested if the result will influence the surgical procedure.
The most common scenario is that of an adnexal mass with
clinical and radiological features that suggest a non benign
tumor. The differential diagnosis between a borderline tumor
and an ovarian carcinoma may be difficult.
Most of the mistakes at the time of frozen section are due
to either poor quality of the frozen section slide or sampling
Venerdì, 26 ottobre 2012
Sala Botticelli – 08.30-10.30
Patologia Ginecologica 1
Patologia dell’ovaio
Moderatori: Luigi Resta (Bari), Gian Franco Zannoni (Roma)
223
error. Poor quality can be caused by problems on the frozen
section, fixation or staining.
A common problem is the finding of a solid tumor on the FS
that cannot be classified under any of the common ovarian epithelial
types. Features that favor a serous carcinoma include:
presence of isolated large nuclei more than two time larger
than the average (averaging 15-16 microns): multinucleated
tumor cells (defined as having more than 2 nuclei); macronucleoli
(defined as measuring at least 3 microns); psammomatous
calcifications; and lack of uniformity in size of the nuclei.
Sampling errors are more commonly seen in mucinous tumors
due to their heterogeneity. Once tumor is identified as mucinous,
it is better submit 2 or 3 frozen sections from grossly
different areas. It is useful keep in mind that mucinous carcinomas
are very rare and, as a rule, they contain less mucin that
in the bening or borderline ones. Most tumor that look infiltrative
and have abundant mucin are metastases. Most common
sites being appendix, pancreatic-biliary, large intestine and
cervix. The presence of large pools of mucin either within the
ovarian parenchyma or on the ovarian surface should prompt
a possible diagnosis of metastatic appendical carcinoma
(pseudomyxoma peritonei type). Some of these cases may be
metastatic but have a grossly normal appendix. Nevertheless,
in these cases an appendectomy should be performed to rule
out this possibility.
The differential diagnosis between a primary ovarian carcinoma
and a metastasis can be challenging at the time of FS.
The gross appearance of the tumor can also help. Bilaterality
and the presence of deposits of tumor of the ovarian surface
favor metastases. If the tumor has endometrioid features, features
that favor a primary tumor of the ovary include: an adenofibroma
component, endometriosis, squamous or morular
metaplasia, a sertoliform component (sex-cord like areas), and
a spindle cell component. Features that favor metastasis in endometrioid
like tumors include: extensive necrosis, extensive
desmoplasia, cribriforming with central dirty necrosiss, segmental
distruction of the glands and diffuse lynphovascular
involvement. Metastatic tumors that can have endometrioidlike
feautures include colon, endometrium, gallbladder, bile
ducts and cervix.
In one personal study we analyzed the impact of a specialized
pathologist on the accuracy of frozen section analysis for adnexal
masses.We included women who underwent frozen section
diagnosis for adnexal mass surgery. A specialized and a
general pathologist read the sections. We calculated sensitivity,
specificity, positive and negative predictive values, and accuracy
for the whole series, as well as for the specialized and
general pathologist groups. We included 325 patients; in 103
patients (31.7%), frozen section diagnosis was performed by
the specialized and in 222 (68.3%), by the general pathologist.
There was a significant difference in terms of correspondence
between the specialized and the general pathologist groups(P
¼ 0.024). We registered four overdiagnoses (both performed