Microscopic extraovarian sex cord proliferations: an undescribed phenomenon.

AIMS: To report a previously undescribed phenomenon of incidentally detected microscopic proliferations of sex cord cells, often mimicking adult granulosa cell tumour or sex cord tumour with annular tubules, in extraovarian locations. METHODS AND RESULTS: The six cases were in patients aged 23-58 years. The proliferations were located in the fallopian tube in three cases, and in paraovarian connective tissues, the pelvic side wall, and appendiceal serosa (one case each). Microscopically, they were typically composed of well-demarcated nests of regular cells with round/ovoid vesicular nuclei, some containing grooves. Microfollicular and/or cribriform arrangements were present in three cases. In five cases, the sex cord lineage was confirmed by positive staining with inhibin and/or calretinin and other sex cord markers. FOXL2 mutation analysis was performed in one case, but was inconclusive. Bilateral oophorectomies and bilateral cystectomies were performed in three cases and one case respectively; there was no sex cord-stromal neoplasm in the removed ovaries. In the two cases in which the ovaries were not removed, imaging showed no suspicious features. Follow-up in four cases (11 months-6 years) has been uneventful. CONCLUSIONS: The pathogenesis of these microscopic extraovarian sex cord proliferations is unknown, but they may represent non-neoplastic proliferations of embryonic remnants.

A systematic review of papers examining the use of intraoperative frozen section in predicting the final diagnosis of ovarian lesions.

This systematic review assesses the accuracy of the frozen section classification of benign and borderline lesions or invasive carcinoma when compared with the final diagnosis on paraffin section. A Pubmed database search identified 18 retrospective cohort studies, published since 2005 that satisfied the criteria, on the critical appraisal sheet of the center for evidence-based medicine, The University of Oxford. The sensitivity, specificity, and negative and positive predictive values suggest that frozen section is more accurate at discriminating between benign lesions and invasive carcinoma than between benign and borderline or borderline lesions and invasive carcinoma and indicate a tendency to overcall benign tumors as borderline and borderline tumors as invasive malignancies. A narrative review of individual papers and abstracts suggests that this particular difficulty is encountered when dealing with clear cell carcinoma and mucinous lesions of all sorts. This may have greater importance in the future with the introduction of targeted chemotherapy requiring accurate typing to guide the use of genetic analysis. It would be beneficial if future researchers comparing the results of frozen section and paraffin sections presented their results in the context of preoperative assessment of the clinical and radiological findings or the intraoperative appearances of the tumor and abdominal cavity, which would allow the identification of those cases in which the frozen section allowed a refinement of the diagnoses made using these modalities.

Subspecialisation and despecialisation in anatomical pathology.

Subspecialisation in histopathology was anticipated to improve the quality of reporting, teaching and communication with the clinical team. Although there is little information available, there is a suggestion that subspecialised services are more expensive than services provided by general departments but are speedier, although even this improvement is now being compromised by requirements to doubly report some types of case. Departments considering adopting a subspecialist model should carefully consider the financial and organisational implications, and recognise that it is associated with reduced flexibility in case of vacancy or illness. Although individual pathologists report moving from subspecialist to more general practice with varying degrees of success (this was facilitated by general training, a brief period of subspecialisation, exposure to a general pool of straightforward cases from other specialities and a defined period of supervised retraining), there is no known example of an entire subspecialised department returning to provide a general service, and it is unclear as to how the difficulties likely to be encountered could be overcome. The original move to subspecialise was based on enthusiasm with little objective measurement of changes in cost or quality (or any input or output measure). Cost and quality associated with both general and subspecialist units are still poorly documented in the literature, and the need to establish baselines for these is a major challenge for pathologists. Further subspecialisation or any move to despecialise should be undertaken on the basis of such measures, which should be carefully monitored.

Is female adnexal tumour of probable wolffian origin a benign lesion? A systematic review of the English literature.

AIMS: To establish the prognosis associated with female adnexal tumour of probable wolffian origin (FATWO) and determine the frequency with which it behaves as a truly benign lesion. METHODS: Medline and Embase electronic databases were interrogated to identify 31 papers describing 63 patients with FATWO with follow up. RESULTS: Fifty (79%, CI 67.4-87.3%) were alive and well but seven patients had recurrent or residual disease (11.1%, CI 5.6-21.5%) and three had died of disease (4.8%, CI 1.6-13.1%). Stage (p = 0.0002) and differentiation (p = 0.0118) showed a significant association with outcome although atypia approached significance at the 5% level (p = 0.0658). One patient with a ruptured tumour had recurrent disease and one other had died of disease (p = 0.2278). There was no association between outcome and age (p = 0.6651), size (p = 0.1912), length of survival (p = 0.2351) tumour site, mitotic rate or necrosis (p = 0.5937, 0.4697 and 0.2016, respectively). CONCLUSION: On the basis of these findings, FATWO cannot be regarded as a benign lesion. These lesions may be confused with well differentiated gynaecological cancers and careful clinicopathological correlation with the extensive use of immunohistochemistry is encouraged to ensure that lesions such as extragonadal endometrioid adenocarcinoma is not confused with FATWO.

Comparison of the overall dimensions of large loop excision specimens of the cervix with the dimensions on histology.

AIMS: This study was carried out to establish whether the macroscopic/gross dimensions of a cone biopsy or large loop excision of the transformation zone specimen (LLETZ) were a reliable reflection of the microscopic measurements and whether any of these dimensions could be used to reliably predict whether the deep lateral stromal margin of the specimen was involved. This is because the transection of cervical crypts involved by cervical intraepithelial neoplasia is likely if the amount of tissue removed is said to be less than 4.8 mm when measured on the histological specimen. METHODS: Prior to sectioning using the standard method, the gross external dimensions of the specimens were recorded. These were compared with the length of the ectocervical surface, endocervical canal, and the deep stromal measurement, defined as the maximum perpendicular distance between the stromal resection edge at the deep lateral limit and the epithelial covered surface, on the microscopic slide. RESULTS: Although 94.6 (91.4-96.7)% of the specimens had a deep stromal measurement in excess of 4.8 mm, 21.1% of these had involved deep stromal margins while 27.3 (22.6-33)% of those with a stromal measurement less than 4.8 mm had involved deep margins (p = 0.9144). None of the gross dimensions correlated with the microscopic measurement of stromal depth. CONCLUSIONS: The current audit figures indicate that it is not possible to predict whether sufficient tissue has been removed simply from assessing the overall gross dimensions of the LLETZ specimen.

The effect of prior fixation on the distortion of uterine specimens opened after receipt in the pathology laboratory.

AIM: To establish whether a period of fixation in formalin before incision reduced distortion of intact uterine specimens. METHODS: A record was kept of the period between placing the intact specimen in formalin and incising the uterine corpus for 98 hysterectomy specimens. After fixation and at the time of cut up, the size of any gap that developed in the anterior uterine wall during the fixation period was measured. This was correlated with the period of fixation. RESULTS: There was a negative association between the period of prior fixation and size of gap (p=0.0009). The delay in opening the specimen was not associated with any compromise in histological assessment of the tumour but facilitated the assessment of prognostic dimensions. CONCLUSION: These findings indicate that the specimen should be placed in fixative as soon as possible after excision and before opening to ensure minimum distortion of the specimen.

The prevalence of Chlamydia trachomatis in fresh tissue specimens from patients with ectopic pregnancy or tubal factor infertility as determined by PCR and in-situ hybridisation.

The prevalence of chlamydial DNA determined by PCR and in-situ hybridisation (ISH) in fresh tissue specimens (endometrium, fallopian tube and ovary) was investigated in 33 women presenting with ectopic pregnancy (EP), 14 women with tubal factor infertility (TFI) and 50 control patients from the UK and the West Indies. In the UK EP group, chlamydial DNA was detected by PCR in 56% of patients; similar results were found in the Trinidad EP group (67%). In the TFI group, chlamydial DNA was detected in (71%) of patients by PCR. The detection of Chlamydia trachomatis DNA by ISH was highest in the TFI group (43%). Women presenting with EP and TFI showed evidence of previous or current genital C. trachomatis infection, underlining the importance of this microorganism in the development of these conditions. Importantly, chlamydial DNA could be detected in DNA preparations from the endometrium, fallopian tube and ovary of EP and TFI patients at the time of surgery.