Download Biopsia intraoperatoria de cancer de ovario

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
[email protected]