Frozen section diagnosis of borderline ovarian tumors with suspicious features of invasive cancer is a devil’s dilemma for the surgeon: A systematic review and meta‐analysis

Abstract

Introduction: Frozen section diagnoses of borderline ovarian tumors are not always straightforward and a borderline frozen section diagnosis with suspicious features of invasive carcinoma (reported as "at least borderline" or synonymous descriptions) presents us with the dilemma of whether or not to perform a full surgical staging procedure. By performing a systematic review and meta-analysis, the prevalence of straightforward borderline and "at least borderline" frozen section diagnoses, as well as proportion of patients with a final diagnosis of invasive carcinoma in these cases, were assessed and compared, as quantification of this dilemma may help us with the issue of this clinical decision. Material and methods: PubMed, EMBASE and Cochrane library databases were searched and studies discussing "at least borderline" frozen section diagnoses were included in the review. Numbers of specific frozen section diagnoses and subsequent final histological diagnoses were extracted and pooled analysis was performed to compare the proportion of patients diagnosed with invasive carcinoma following borderline and "at least borderline" frozen section diagnoses, presented as risk ratio and risk difference with 95% confidence intervals (95% CI). Results: Of 4940 screened records, eight studies were considered eligible for quantitative analysis. A total of 921 women was identified and 230 (25.0%) of these women were diagnosed with "at least borderline" ovarian tumor at the time of frozen section. Final histological diagnoses were reported in five studies, including 61 women with an "at least borderline" diagnosis and 290 women with a straightforward borderline frozen section diagnosis. Twenty-five of 61 women (41.0%) of the "at least borderline" group had invasive cancer at final diagnosis, compared with 28 of 290 women (9.7%) of the straightforward borderline frozen section group (risk difference −0.34, 95% CI −0.53 to −0.15; relative risk 0.25, 95% CI 0.13-0.50). Conclusions: Women diagnosed with "at least borderline" frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis when compared This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

The value of ultrasonography combined with carbohydrate antigen 125 and 19-9 detection in the diagnosis of borderline ovarian tumors and prediction of recurrence

“…Therefore, it is easier and more accurate to judge by the intraoperative frozen sections according to the preoperative indications. Patients’ general condition and ultrasonography features are also valuable in predicting the recurrence rate and can aid in the surgical approach selection, postoperative monitoring, and follow-up ( 20 ), minimizing the trauma caused by secondary surgery and reducing unnecessary recurrence and death caused by recurrence.…”

Factors associated with the involvement of lymph nodes in low‐grade serous ovarian cancer

“…Full staging surgery including lymphadenectomy might be considered in the initial surgery of those patients whose frozen section results were reported as "at least borderline" to prevent a second surgical procedure. 22 Misdiagnosis of an invasive ovarian cancer in the frozen section analysis with underdiagnosis as a borderline tumor, may influence the decision to perform lymphadenectomy. 23 Thus, these cases could be incompletely staged during primary surgery.…”

“…In a recent meta‐analysis, 41% of the women whose frozen section results were reported as “at least borderline” and 9.7% of the women whose frozen section results were reported as “straightforward borderline” tumor, were finally diagnosed with invasive cancer after histopathological evaluation of the paraffin sections. Full staging surgery including lymphadenectomy might be considered in the initial surgery of those patients whose frozen section results were reported as “at least borderline” to prevent a second surgical procedure 22 . Misdiagnosis of an invasive ovarian cancer in the frozen section analysis with underdiagnosis as a borderline tumor, may influence the decision to perform lymphadenectomy 23 .…”

The challenging management of borderline ovarian tumors (BOTs) in women of childbearing age

“…Frozen samples tend to under diagnose BOT as benign tumors in 25%–30% of cases, and improperly identify BOTs as carcinoma in 20%–30% of cases ( 24 , 25 ). More caution in the use of FS in BOTs is needed, especially in cases of bulky tumors, where the intraoperative histology may lead to misdiagnosis of some features (e.g., microinvasion, papillary variant,intraepithelial carcinoma, stromal microinvasion) ( 26 – 28 ).…”