Evidence-Based Recommendations for Intra-Operative Pathologic Evaluation of Risk Reducing Salpingo-Oophorectomies from Women with BRCA Mutations
AN Mackey, LM Chen, CB Powell, B Crawford, CJ Zaloudek, JT Rabban. UCSF, San Francisco, CA
Background: Occult cancer can be detected in up to 15% of risk-reducing salpingo-oophorectomies (RRSO) in women with BRCA mutations. Occult cancer is often microscopic. The role of intra-operative pathologic evaluation of RRSO remains undefined. While intra-operative cancer diagnosis allows for immediate surgical staging, there is a risk that a small cancer is cut away during frozen section (FS) preparation. Correlation of intra-operative gross and FS findings with those of the permanent slides has not been studied. We report this correlation in RRSO of 112 BRCA patients and we propose an algorithm for intra-operative evaluation.
Design: Intra-operative gross and FS findings in RRSO from 112 BRCA patients were retrospectively reviewed. Intra-operative decision to evaluate RRSO by gross exam or FS was made on an ad-hoc basis. A standardized algorithm was not used. For permanent sections, RRSO were sectioned at 2 to 3 mm intervals and entirely embedded. Tubal fimbriae were sectioned parallel to the fimbriae.
Results: Occult cancer was detected in permanent slides of 9/112 RRSO (5 in tube, 2 in ovary, 2 in tube and ovary), of which only 1 was diagnosed intraoperatively. Gross abnormalities were seen in 77/112 RRSO: ovarian cysts, 46%; paratubal cysts, 27%; ovarian nodules, 14%; tubal nodules, 7%. Intra-operative exam was performed in 48/112 RRSO; FS was performed in 19/48. Gross findings were seen in 8/9 occult cancers: ovarian cysts (n=3, up to 6 cm), paratubal cysts (n=2, up to 0.7 cm), ovarian nodule (n=2, 1.1 to 3 cm), tubal nodule (n=2, 0.9 to 1.2 cm). Among 9 occult cancers, FS was performed on 1 case with ovarian cysts, 1 with a paratubal cyst, and 1 with an ovarian nodule. The cyst FS were benign but permanent slides of fimbriae revealed occult carcinoma (0.15 to 0.2 cm). The ovarian nodule FS was malignant. Of 6 occult cancers without FS, all cases with nodules corresponded to cancer but none of the cysts did; in the latter, cancer was in fimbriae or ovary (0.1 to 0.2 cm). Among 82 RRSO with gross cysts, none were malignant. Among 24 RRSO with gross nodules, 4 (17%) were malignant.
Conclusions: Cancer in RRSO presents as a nodule or as a microscopic finding but not as a cyst. There is no role for frozen section of RRSO unless a nodule is visible. Otherwise, fixation, thin sectioning and total tissue embedding is the optimal method to detect occult cancer.
Tuesday, March 10, 2009 1:00 PM
Poster Session IV # 179, Tuesday Afternoon