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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 limitaciones presenta la biopsia por congelación?
¿Que esperar de la biopsia por congelación?
Int J Gynecol Cancer. 2004 Mar-Apr;14(2):212-9.
Accuracy of frozen section in diagnosis of ovarian mass.
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
reports of 212 resected ovarian masses in our hospital. The accuracy,
sensitivity, specificity, positive, and negative 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.
¿Que esperar de la biopsia por congelación?
En 212 casos la sensibilidad para patología benigna fue 99,1%, de
90,9% para malignidad, pero para tumor borderline fue de 50%
Las mayores dificultades de diagnostico se presentaron en tumores de
gran tamaño, mucinosos o borderline
Un metodo confiable, pero requiere gran comunicación en el equipo
¿Que limitaciones presenta la biopsia por congelación?
¿Que esperar de la biopsia por congelación?
Gynecol Oncol. 2005 May;97(2):395-9.
The accuracy of frozen section (intraoperative consultation) in the diagnosis of
ovarian masses.
Ilvan S(1), Ramazanoglu R, 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
section diagnosis of ovarian masses and the reasons of discordance.
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
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
mucinous and borderline tumors during frozen section examination. The clinicians and pathologists
must be aware of the pitfalls of this method; therefore, a good communication established
between them is necessary to obtain more accurate results and to minimize the number of
deferred cases.
¿Que esperar de la biopsia por congelación?
En 617 casos el diagnostico fue correcto en 97% de ellos. El 18,3%
fueron lesiones no neoplásicas, 56,1% lesiones benignas, 6,2%
tumores borderline y 19,4% tumores malignos.
La sensibilidad fue de 100% para tumores benignos y de 87% para
tumores borderline y malignos.
La mayor dificultad la presentaron los tumores mucinosos y borderline
Mencionan como punto clave para disminuir errores la comunicación
entre el patólogo y el cirujano
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
Obstet Gynecol. 2000 Jun;95(6 Pt 1):839-43.
Borderline tumors of the ovary: correlation of frozen and permanent histopathologic diagnosis.
Houck K, Nikrui N, Duska 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
1998 at Massachusetts General Hospital were reviewed. Univariate and multivariable logistic
regression models were constructed for patient age, tumor size, histology, presence of bilateral or
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 permanent pathology were consistent in 60% of cases. Frozen
section interpreted a benign lesion as malignant (overdiagnosed) in 10.7% of cases, and interpreted a
malignant lesion as benign (underdiagnosed) in 29.3%. No variable was 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
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?
En 140 casos de tumor borderline, 80 eran serosos, 47 mucinosos,
11mixtos y 2 endometroides.
El tamaño promedio fue de 13,7cm, 10,2 cm para serosos, 20,1 cm
para mucinosos.
La concordancia con la histología diferida fue de 60%, en 10,7% de los
casos hubo sobrediagnostico y subdiagnostico en 29,3%.
No se encontró ningún predictor significativo de sobrediagnostico.
Mas evidencia de sobre y subdiagnostico
Los tumores borderline / histologia no seroso: dificultades .
¿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. 2007 Nov;107(2):248-52. Epub 2007 Jul 12.
Accuracy of intraoperative frozen section analysis in borderline tumors of the
ovary: a retrospective analysis of 96 cases and review of the literature.
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).
METHODS: Retrospective analysis at the Department of Obstetrics and Gynecology, University of
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%,
respectively. Underdiagnosis and overdiagnosis occurred in 27/96 (28%) and 0/96 (0%) patients,
respectively. In a univariate and multivariate analysis, tumor diameter, but not patient age, tumor
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 an overall sensitivity and PPV of 71.1% and 84.3%, respectively. Overdiagnosis and
underdiagnosis were identified in 21/317 (6.6%) and in 97/317 (30.6%) cases, respectively.
CONCLUSION: Intraoperative frozen section diagnosis of BTO has a low sensitivity and PPV and
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?
En 96 casos de tumor borderline la concordancia con la histología
diferida fue de 71,9%, con una sensibilidad de 75% y un VPP de 94,5%
El subdiagnostico ocurrió en 28% de los casos y no hubo
sobrediagnostico.
Los predictores de subdiagnostico fueron el tamaño, la bilateralidad y la
presencia concurrente de endometriosis principalmente.
En la revisión bibliográfica encuentran sobrediagnostico de 6,6% y
subdiagnostico de 30,6% de los casos.
Mas evidencia de sobre y subdiagnostico
Los tumores borderline / histologia no seroso: dificultades .
¿Que limitaciones presenta la biopsia por congelación?
Un metodo confiable, pero requiere gran comunicación en el equipo
¿Que esperar de la biopsia por congelación?
Evidencia de Metaanálisis
¿Que esperar de la biopsia por congelación?
Mas evidencia de sobre y subdiagnostico
Los tumores borderline / histologia no seroso: dificultades .
¿Que limitaciones presenta la biopsia por congelación?
Un metodo confiable, pero requiere gran comunicación en el equipo
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
Cirugía con estudio por congelación
Masa Anexial
Oportuna derivación a centros especializados ante
la sospecha de malignidad
