iPad Annotation of 3D Surgical Models Using Procreate®: Novel Documentation of Supplemental Margins.

We present a novel, efficient approach to demonstrating supplemental margins during oncologic resection. Surgeons and pathologists annotated 10 virtual models of surgical defects and resection specimens in 3D using an iPad-based application, Procreate®. Incorporating this method into the surgical workflow can improve interdepartmental communication and provide visual documentation of surgical steps taken to address at-risk margins. Laryngoscope, 2023.

Precision medicine in neurosurgery: The evolving role of theranostics.

Theranostics in neurosurgery is a rapidly advancing field of precision medicine that combines diagnostic and therapeutic modalities to optimize patient outcomes. This approach has the potential to provide real-time feedback during therapy and diagnose a condition while simultaneously providing treatment. One such form of theranostics is focused ultrasound, which has been found to be effective in inducing neuroablation and neuromodulation and improving the efficacy of chemotherapy drugs by disrupting the blood-brain barrier. Targeted radionuclide therapy, which pairs positron emission tomography tracers with therapeutic effects and imaging modalities, is another promising form of theranostics for neurosurgery. Automated pathology analysis is yet another form of theranostics that can provide real-time feedback during the surgical resection of tumors. Electrical stimulation has also shown promise in optimizing therapies for patients with cerebral palsy. Overall, theranostics is a cost-effective way to optimize medical care for patients in neurosurgery. It is a relatively new field, but the advancements made so far show great promise for improving patient outcomes.

Intraoperative three-dimensional scanning of head and neck surgical defects: Enhanced communication and documentation of harvested supplemental margins.

BACKGROUND: We have demonstrated the effectiveness of 3D resection specimen scanning for communicating margin results. We now address the corresponding surgical defect by debuting 3D defect models, which allow for accurate annotations of harvested supplemental margins. METHODS: Surgical defects were rendered into 3D models, which were annotated to document the precise location of harvested supplemental margins. 3D defect scans were also compared with routine 2D photography and were analyzed for quality, clarity, and the time required to complete the scan. RESULTS: Forty defects were scanned from procedures including segmental mandibulectomy, maxillectomy, and laryngopharyngectomy. Average duration of defect scan was 6 min, 45 s. In six of ten 2D photographs, the surgeon was unable to precisely annotate the extent of at least one supplemental margin. CONCLUSION: 3D defect scanning offers advantages in that this technique enables documentation of the precise location and breadth of supplemental margins harvested to address margins at-risk.

Frozen Section Analysis in Head and Neck Surgical Pathology: A Narrative Review of the Past, Present, and Future of Intraoperative Pathologic Consultation.

Frozen section has remained the diagnostic gold standard for intraoperative pathological evaluation of surgical margins for head and neck specimens. While achieving tumor-free margins is of utmost importance to all head and neck surgeons, in practice, there are numerous debates and a lack of standardization for the role and method of intraoperative pathologic consultation. This review serves as a summary guide to the historical and contemporary practice of frozen section analysis and margin mapping in head and neck cancer. In addition, this review discusses current challenges in head and neck surgical pathology, and introduces 3D scanning as a groundbreaking technology to bypass many of the pitfalls in the current frozen section workflow. The ultimate goal for all head and neck pathologists and surgeons should be to modernize practices and take advantage of new technology, such as virtual 3D specimen mapping techniques, that improves the workflow for intraoperative frozen section analysis.

Patterns of Major Frozen Section Interpretation Error: An In-Depth Analysis From a Complex Academic Surgical Pathology Practice.

OBJECTIVES: To establish baseline error rates due to misinterpretation and to identify scenarios in which major errors were most common and potentially preventable. METHODS: Our database was queried over a 3-year period for major discrepancies due to misinterpretation. These were stratified by histomorphologic setting, service, availability/type of prior material, and years of experience and subspecialization of the interpreting pathologist. RESULTS: The overall discordance rate between frozen section (FS) and final diagnoses was 2.9% (199/6,910). Seventy-two errors were due to interpretation, of which 34 (47.2%) were major. Major error rates were highest on the gastrointestinal and thoracic services. Of major discrepancies, 82.4% were rendered in subdisciplines outside those of the FS pathologist. Pathologists with fewer than 10 years' experience made more errors than those with more experience (55.9% vs 23.5%, P = .006). Major error rates were greater for cases without previous material compared to those with a prior glass slide (47.1% vs 17.6%, P = .009). Common histomorphologic scenarios in which disagreements were made involved discriminating mesothelial cells from carcinoma (20.6%) and accurately recognizing squamous carcinoma/severe dysplasia (17.6%). CONCLUSIONS: To improve performance and decrease future misdiagnoses, monitoring discordances should be a continuous component of surgical pathology quality assurance programs.

Validation and implementation of Aperio LV1 remote live view telepathology system for intraoperative frozen section diagnosis.

Introduction: Telepathology (TP) allows for remote slide review with performance comparable to traditional light microscopy. Use of TP in the intraoperative setting allows for faster turnaround and greater user convenience by obviating the physical presence of the attending pathologist. We sought to perform a practical validation of an intraoperative TP system using the Leica Aperio LV1 scanner in tandem with Zoom teleconferencing software. Methods: A validation was performed in accordance with recommendations from CAP/ASCP, using a retrospectively identified sample of surgical pathology cases with a 1 year washout period. Only cases with frozen-final concordance were included. Validators underwent training in the operation of the instrument and conferencing interface, then reviewed the blinded slide set annotated with clinical information. Validator diagnoses were compared to original diagnoses for concordance. Results: 60 slides were chosen for inclusion. 8 validators completed the slide review, each requiring 2 h. The validation was completed in 2 weeks. Overall concordance was 96.4%. Intraobserver concordance was 97.3%. No major technical hurdles were encountered. Conclusion: Validation of the intraoperative TP system was completed rapidly and with high concordance, comparable to traditional light microscopy. Institutional teleconferencing implementation driven by the COVID pandemic facilitated ease of adoption.

To Freeze or Not to Freeze? Recommendations for Intraoperative Examination and Gross Prosection of Thyroid Glands.

The use of intraoperative consultation for indeterminate thyroid lesions is not advocated but is still requested by some surgeons. Obscured cytomorphology and nonrepresentative sampling limit the specificity of intraoperative assessment. Formalin fixation of thyroid glands before sectioning also minimizes artifacts introduced by fresh sectioning. Inking of thyroid may vary based on institutional preferences and information desired by clinical teams. Sectioning may occur in the conventional transverse method or the modified transverse vertical method to more thoroughly evaluate the lesion's periphery. Gross examination of thyroid lesions should always consider possible high-grade features, such as necrosis or extrathyroidal extension.

Utilizing 3D head and neck specimen scanning for intraoperative margin discussions: Proof of concept of our novel approach.

BACKGROUND: The current standard of documenting and communicating frozen section margin results is inefficient. We present a novel method of generating 3D digital models of gross tumor specimens to more clearly visualize histopathological margin results. METHODS: Fifty-five head and neck specimens were scanned and virtually "inked" using 3D software. These 3D specimen maps were displayed in the operating room to provide the surgeon with a real-time specimen-to-defect relationship by which further resections could be guided. RESULTS: Margin results were reported within an average of 34 min using the proposed workflow. The scanner rendered accurate models of specimens that exceeded 3.0 × 3.0 × 3.0 cm. Critical specimen features to consider were size, color, textural complexity, and the presence of discernible anatomic landmarks. CONCLUSIONS: Optical 3D scanning technology can improve the quality of head and neck margin documentation and the efficiency with which results are communicated between the pathologist and surgeon.

Usefulness of intraoperative rapid immunohistochemistry in the surgical treatment of brain tumors.

In the treatment of primary central nervous system lymphoma (PCNSL), intraoperative rapid pathological diagnosis can dramatically change the surgical strategy, and more accurate diagnostic methods are required. In April 2020, we adopted intraoperative rapid immunohistochemistry (IHC) in addition to conventional rapid intraoperative diagnosis based on morphological assessment, mainly for patients with PCNSL. Here, we investigate the usefulness and significance of intraoperative rapid IHC based on our initial experience. We performed intraoperative rapid IHC using antibodies for cluster of differentiation (CD)20, CD3, leukocyte common antigen (LCA) and glial fibrillary acidic protein (GFAP) using enzyme-labeled antibody methods in 25 patients, including PCNSL patients, from April 2020 to July 2022. We examined the utility of this approach in determining treatment strategies for brain tumors. Postoperative final pathological diagnoses from paraffin-embedded sections were as follows: diffuse large B-cell lymphoma, 16 cases; glioblastoma, six cases; pilocytic astrocytoma, one case; adenocarcinoma, one case; and inflammatory disorder, one case. The entire process took 32 min and staining for CD20, CD3, LCA, and GFAP was comparable to that using paraffin-embedded sections. In all cases, the results of intraoperative rapid IHC were consistent with final pathological diagnoses from paraffin-embedded sections. In addition, in two cases, the results of conventional intraoperative rapid pathological diagnosis based on morphological assessments using frozen sections were drastically changed by adding intraoperative rapid IHC. Intraoperative rapid IHC contributes to deciding appropriate treatment strategies and facilitating early initiation of chemotherapy for PCNSL. This may allow new therapeutic strategies not only for PCNSL but also for other brain tumors.

A retrospective analysis of the diagnostic accuracy and technical quality of frozen sections in detecting hepatobiliary lesions.

INTRODUCTION: Pathological consultation on intraoperative frozen sections plays a crucial role in the management of patients undergoing surgical therapy, and is also a key indicator for quality assurance in anatomical pathology. This study aimed to evaluate the diagnostic accuracy and technical quality of frozen sections in detecting hepatobiliary lesions with malignant potential. PATIENTS AND METHODS: A retrospective database review was performed for 1208 cases intraoperative pathology consultation who underwent hepatobiliary lesions resection at our institution from 2016 to 2020. The intraoperative consultation cases during a 5-year period were reviewed and analyzed, including the measurement of the diagnostic accuracy and turnaround time of frozen sections, the reasons for discrepancies, and the rates of discordance and deferral. RESULTS: In this study, we confirmed that the overall accuracy, sensitivity and specificity were 95.3 %, 96.3 % and 96.6 %, respectively, in distinguishing benign from malignant lesions. The rates of deferred and discordant diagnoses were 2.57 % and 2.2 %, respectively. The overall frozen section turnaround time was 22.1 min. The most common cause of deferred and discordant was poor section quality, the lesion of bile duct margin on the frozen section, misinterpretation of difficult and complicated cases, etc. CONCLUSIONS: This study confirms that the intraoperative frozen sections can serve as a rapid, accurate and robust method for the pathological diagnosis of suspected hepatobiliary lesions. However, it should be noted that some poor technical problems, pathological assessment of tumor margin and difficult cases are the most frequently causes of deferred and discordant interpretations.

Frozen section telepathology service: Efficiency and benefits of an e-health policy in South Tyrol.

Objective/Background: Telepathology has been widely adopted to allow intraoperative pathology examinations to be performed remotely and for obtaining second opinion teleconsultation. In the Italian northern region of South Tyrol, the widespread geographical distances and consequent cost for the health system of having a travelling pathologist cover intraoperative consultations in peripheral hospitals was a key driver for the implementation of a telepathology system. Methods: In 2010, four Menarini D-Sight whole slide scanners to digitize entire pathology slides were placed in the peripheral hospitals of Merano, Bressanone, Brunico, and in the hub hospital of Bolzano. Digital workstations were also installed to allow pathologists to remotely perform intraoperative consultations with digital slides. This study reviews the outcome after 12 years of telepathology for this intended clinical use. Results: After an initial validation phase with 100 cases which yielded a sensitivity of 65% (CI 43-84%) and specificity of 100% (CI 95-100%), there were 2058 intraoperative consultations handled by telepathology. The cases evaluated were mainly breast sentinel lymph nodes, followed by urological, gynecological and general surgical pathology frozen section specimens. There were no false-positive cases and 165 (8%) false-negative cases, yielding an overall sensitivity and specificity of 65% (CI 61-69%) and 100% (CI 99-100%), respectively. Conclusion: Telepathology is reliable for remote intraoperative diagnosis and, despite technical issues and initial acquaintance issues, proved beneficial for patient care in satellite hospitals, improved standardization, promoted innovation, and resulted in cost savings for the health system.

Intraoperative confocal laser endomicroscopy for brain tumors - potential and challenges from a neuropathological perspective.

Confocal laser endomicroscopy (CLE) represents a new non-invasive in vivo imaging technique that holds considerable promise in neurosurgery and neuropathology. CLE is based on the principle of optical sectioning which uses pinholes placed in the light path to selectively image photons of a specific focal plane by filtering out photons above and below the focal plane. Potential indications of CLE in neurosurgery and neuropathology include intraoperative tumor diagnosis and staging as well as assessment of tumor resection margins notably in the case of diffusely infiltrating gliomas. CLE-based tumor analysis in near-real time may also have a significant impact on future tumor resection strategies. We here discuss the technical features of CLE, its potential for wide-field imaging, its role in comparison to established histological techniques for intraoperative tumor assessment and its position in digital pathology and telepathology. Based on our group's experience with a commercially available confocal laser endomicroscope (ZEISS CONVIVO), we critically address the current state of intraoperative CLE in brain tumor surgery, the applicability of classical histological criteria and the strategies required to further improve the diagnostic accuracy of CLE. We finally discuss how a widespread use of CLE in neurosurgery may modify the role of neuropathologists in intraoperative consultation, generating both new opportunities and new challenges.

Five-year review of intraoperative pathology consultation in a single institution.

Intraoperative pathology consultation plays an important role in the management of surgical patients and is also a measure for quality control in surgical pathology. A retrospective study was conducted to review intraoperative consultation during a 5-year period at a single institution. There were 19,145 intraoperative pathology consultation cases, including 19,026 concordant cases, 71 (<1%) frozen discordant cases, 11 (<1%) gross discordant cases, and 37 (<1%) deferred cases. Among frozen discordant cases, the most common cause for discordance was histologic sampling error (52.1%), followed by misinterpretation (42.3%). The most common major (clinically significant) frozen discordance was histologic sampling error for skin margins (32.4%), followed by histologic sampling error for lymph node metastasis (13.5%). Although our discordant rate (0.43%) was lower than that in previously reported studies (2%-8%), our major discordant rate was relatively high (50%). This review suggests that deeper sectioning of the blocks could improve the quality of our intraoperative consultations.

Quality assurance review: Intra-operative evaluation of sentinel lymph nodes in breast cancer.

BACKGROUND: Intraoperative consultation (IOC) of axillary sentinel lymph node (SLN) biopsy continues to play a role in selected breast cancer patients. The reported sensitivity rates for intraoperative SLN evaluation in breast cancer range from 47% to 80%. We study a center where the majority of SLN IOC is performed by imprint cytology, and a protocol was established to limit microscopic examination to three slides for a reporting TAT goal of 30 min. METHODS: Approval to conduct this study was obtained from the REB. A retrospective review was performed on all consecutive SLN cases sent for IOC. Reported IOC assessments of all cases were compared with the final pathology. RESULTS: Of 164 patients, there were 22 (13%) false negative IOC events, including 15 missed macro-metastasis and 7 missed micro-metastasis. The overall sensitivity for touch imprint in detecting SLNs macro-metastasis was 70.9%. Reporting total turnaround time was on average 3 min longer, whereas sensitivity and specificity were not significantly different in the two protocol periods. CONCLUSION: Implementation of an IOC policy for a maximum of three slides for imprint cytology did not result in a significant impact on the sensitivity, specificity, or total turnaround time for SLN in breast cancer patients. False negative IOC events were mainly due to sampling error. Quality review was made difficult by limited documentation related to the gross handling of the specimens at IOC. System factors identified include insufficient space for the IOC report on the pathology requisition, and the lack of clearly communicated expectations for documentation.

Imprint cytology: Invaluable technique to evaluate fresh specimens received in the pathology department for lymphoma workup.

At the time of intraoperative consultation, cytologic preparations including smears and imprints can be used in combination with frozen sections to increase diagnostic yield; however, these simple and rapid techniques are not adopted by all pathologists and their use varies considerably between institutions. In patients under investigation for suspected lymphoma, optimal triaging of tissue received fresh in pathology for lymphoma workup is paramount to maximize the odds of obtaining an accurate and clinically meaningful diagnosis and to avoid the need for additional procedures and delays in management, particularly in the current context in which core biopsies have become common practice as a first attempt to attain this goal. Imprint cytology is invaluable in this regard, also as these patients may not have a lymphoma but rather one of its clinical mimics. Herein, imprint cytology is used to approach fresh specimens received intraoperatively for lymphoma workup. More specifically, how these specimens are triaged for ancillary studies, such as flow cytometry, florescence in situ hybridization, or molecular analyses based on an interpretation of the touch imprints, is described. Detailed imprint cytological findings of typical benign and malignant lymphoid and nonlymphoid lesions are discussed and illustrated.

The usefulness of intraoperative consultation for the diagnosis of borderline ovarian tumors.

BACKGROUND: Borderline ovarian tumors (BTs) must be recognized during the surgery by intraoperative consultation (IOC) to guide surgical treatment; however, this diagnosis can be imprecise. Therefore, this study aimed to evaluate the diagnostic accuracy of IOC for the diagnosis of BT. METHODS: A retrospective cohort study was carried out including all women diagnosed with a pelvic tumor consecutively surgically treated from 2005 to 2015 with IOC. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LR) for the IOC and BTs. RESULTS: A total of 758 patients were enrolled, the median age was 44 years, the median tumor size was 11.8 cm, and the median CA-125 levels were 45.65 U/µL. After IOC, 458 (64.1%) cases were diagnosed as benign, 111 (14.7%) as BT, and 161 (21.2%) as malignant. The definitive diagnosis was a benign tumor in 448 (59.1%) cases, BT in 110 (14.5%), and 200 (26.4%) cases were malignant. The diagnostic accuracy of the IOC for BT diagnosis was 89.8% (sensitivity =65.5%, specificity =93.9%). The diagnosis performance of IOC for the diagnosis between BT and benign tumors (n=546) had a sensitivity of 69.9%, a specificity of 98.4%, and a diagnostic accuracy of 84%; meanwhile for the diagnosis between BT and malignant tumors (n=242) IOC had a sensitivity of 92.3%, a specificity of 81.7%, and a diagnostic accuracy of 87%. CONCLUSIONS: For practitioners, knowing the accuracy and limitations of the IOC for BT enables the better selection of cases to perform a complete staging surgery.

Acute Invasive Fungal Sinusitis: A 30-Year Review of Pathology Practice and Possible Utility of the DiffQuik® Stain.

Acute invasive fungal rhinosinusitis (AIFRS) is a fulminant disease with a high mortality rate. Here, we review the clinical and pathologic features of AIFRS over a 30-year period at a tertiary-care academic center focusing on diagnostic practice, especially the use of intra-operative consultation (IOC). A 1-year trial of intraoperative staining with DiffQuik® (DQ) was also assessed. There were 202 cases from 104 patients with AIFRS. The incidence of AIFRS increased over time (6.8 per year in the past decade versus 1.9 before 2009) as did the number of IOCs per case (2.4 per case in the past decade versus 0.6 before 2009). Disagreement between final diagnosis and IOC was seen in 8.3 % of patients, and the block-by-block error rate was 14.9 %. Fusarium was the most common fungus identified. An attempt to categorize the fungal organism based on histopathology was performed in 85.6 % of patients, with 91 % agreement with microbial cultures or PCR. Fungal hyphae were subjectively easier to identify on DQ stained cryostat sections compared to on routine hematoxylin and eosin stained sections and hyphae were identified in all 5 blocks in which organisms were present. The increasing incidence of AIFRS and expanding use of IOC indicate a need to improve and standardize the diagnostic protocol. The use of DQ as visual aid in IOC for AIFRS may be useful.

Intraoperative consultation in the diagnosis of posterior fossa brain tumors following the 2016 WHO update.

OBJECTIVE: Intraoperative crush/squash smear or frozen section consultation is routinely performed at several centers and offers rapid onsite assessment of tumor type and provides invaluable information to the neurosurgeons. The WHO classification of central nervous system neoplasms underwent a paradigm shift in 2016 with the incorporation of molecular data with the morphological features, such that several new entities came to be distinctly defined. With this paper, we present our experience at intraoperative consultation of brain tumors arising in posterior fossa and aim to apprise the pathologists with the spectrum of cytomorphologic appearances that can occur during such consultation and highlight the diagnostic dilemmas and pitfalls encountered in this setting. METHODS: This is a retrospective observational study illustrating the salient morphological features of commonly encountered brain tumors arising in the posterior fossa (prototype example of each type) reported at our institute over a period of seven years. Both squash smears and rapid snap frozen section were prepared and stained with Toluidine blue and rapid hematoxylin and eosin (H&E) stains. RESULTS AND CONCLUSIONS: While the majority of tumors at this location comprise of pilocytic astrocytoma, ependymoma, and medulloblastoma, some rare examples may also arise; common differentials must be considered and prudently excluded to arrive at the diagnosis which is crucial in guiding the neurosurgeon. Both squash smears and rapid frozen section should be prepared and complement each other for rapid on-site evaluation.

Cytologic Features of Ventricular Tumors of the Central Nervous System: A Review with Emphasis on Diff-Quik Stained Smears.

BACKGROUND: Neoplasms from the ventricular system share a common location but have highly variable histogenesis. Many are slowly growing tumors that behave in a benign fashion. They can be classified as primary and secondary tumors. The most common primary tumors are ependymomas, subependymomas, subependymal giant cell astrocytomas, central neurocytomas, choroid plexus tumors, meningiomas, germinomas, pineal parenchymal tumors, papillary tumors of the pineal region, chordoid gliomas, rosette-forming glioneuronal tumors of the fourth ventricle, and craniopharyngiomas. Pilocytic astrocytomas, medulloblastomas, and atypical teratoid/rhabdoid tumors often show secondary involvement of the ventricular system. SUMMARY: Advances in neurosurgery have facilitated access to the ventricular system increasing the number of cases in which such tumors can be biopsied. In this context, cytology has been proven to be an extremely useful diagnostic tool during intraoperative pathologic consultations. Many ventricular tumors are infrequent, and the cytologic information available is limited. In this review, we describe the cytologic features of the uncommon ventricular tumors and report on unusual findings of the more common ones. For the cytologic evaluation of brain tumors, many neuropathologists prefer formalin fixation and hematoxylin and eosin staining. In this review, we highlight the cytologic findings as seen with Diff-Quik, a very popular staining method among cytopathologists. In fact, when pathologists are unfamiliar with cytology, it is common to request the assistance of cytopathologists during the evaluation of intraoperative procedures. Key Message: Ventricular tumors of the central nervous system comprise a group of heterogeneous tumors with very different cytologic features. The cytomorphology of these tumors, including rare entities, is often very characteristic, allowing a precise recognition during intraoperative pathologic consultations. Diff-Quik is a valuable staining method that can be used alone or as a complement to hematoxylin and eosin staining. Diff-Quik allows for clear visualization of the overall architecture, cytoplasmic details, and extracellular material.

Gross mucinous multinodular appearance aids in the identification of ovarian metastases in low-grade appendiceal mucinous neoplasms during intraoperative consultation.

Ovarian metastases of low-grade appendiceal mucinous neoplasms (LAMNs) show grossly abundant nodular mucous cells, with a gross mucinous multinodular appearance and a histological resemblance to primary ovarian mucinous tumors (POMTs). This study aimed to elucidate the utility of gross features including the gross mucinous multinodular appearance and available clinical information at the time of intraoperative consultation, in distinguishing the ovarian metastases of LAMNs from POMTs or the ovarian metastases of colorectal cancer (CRC). In total, 776 patients with primary ovarian tumor and 68 patients with ovarian metastases underwent intraoperative consultation during 1998-2018. Of the total cases, 4 ovarian metastases of LAMNs, 19 ovarian metastases of CRC, and 50 POMTs (36 borderline tumors and 14 carcinomas) were identified. The gross features including the gross mucinous multinodular appearance were analyzed based on the gross photographs obtained before formalin fixation and the available clinical information collected during intraoperative consultation. The analysis indicated that the ovarian metastases of LAMNs significantly presented with gross mucinous multinodular appearance (4/4 vs. 0/50, P < 0.0001), extraovarian disease (4/4 vs. 2/50, P < 0.0001), ovarian surface involvement (3/4 vs. 2/50, P = 0.0016), and abnormal appendix (4/4 vs. 0/50, P < 0.0001) as compared to POMT. Moreover, the gross mucinous multinodular appearance was a distinguishable feature between the ovarian metastases of LAMNs and ovarian metastases of CRC (4/4 vs. 0/19, P = 0.0001). Based on these results, we proposed an algorithm to diagnose ovarian tumors using the gross mucinous multinodular appearance. Thus, recognizing unique gross features including the gross mucinous multinodular appearance would be useful for both pathologists and surgeons to accurately diagnose ovarian metastases of LAMNs during intraoperative consultation.