Ovary and fallopian tube -malignant setting

Background

Ovaries and fallopian tubes may be removed for the treatment of neoplastic disease. 1-13 Where mucinous ovarian tumours are suspected, appendix may also be removed. 1 Omentum and peritoneal biopsies are also commonly received with ovarian tumour specimens. 1 

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Prophylactic oophorectomy and salpingectomy may be undertaken where there is a family history of ovarian, breast or fallopian tube cancer or in patients with a BRCA1 or 2 mutations. 6,7 Occult cancer is present in a small number of these specimens and is often difficult to detect macroscopically. 8,13

Endometriosis can affect the ovaries and be a predisposing factor in the development of ovarian cancer. 2-5

When a tumour involves both the ovary and the fallopian tube, it may be difficult or even impossible to determine the primary site of the tumour. A diagnosis of primary tubal carcinoma is typically not associated with significant gynaecological tumour of the same phenotype elsewhere. In most cases the bulk of the tumour can be macroscopically identified within one organ, which is almost always the ovary. Although the convention is to designate these tumours as primary ovarian carcinomas, there is evidence that at some may arise primarily in the fallopian tube. 10

Ovaries, omentum and other gynaecological tissues may also be resected due to the presence of primary peritoneal tumours. 1 The ovaries will be normal in size (or only enlarged by a benign process), with tumour involvement confined to the ovarian surface without stromal invasion (or with minimal stromal involvement up to 5 x 5 mm in size). The tumour will involve extraovarian sites to a greater extent than the ovarian surface. 1

Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

Fresh tissue received
  • No
    • Non-routine fixation (not formalin), describe.
  • Yes
    • Special studies required, describe.
    • Ensure samples are taken prior to fixation.
Intraoperative consultation
  • Not performed
  • Performed, describe type and result
    • Frozen section
    • Imprints
    • Other, describe

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

External InspectionBack to top


Orientate and identify the anatomical features of the specimen.

Orientation markers

Record additional orientation or designation provided by operating clinician:

  • Absent
  • Present
    • Method of designation (e.g. suture, incision)
    • Featured denoted

Photograph the intact specimen if required.

Describe the following features of the specimen:

Operative procedure

Record as stated by the clinician

Options
  • Oophorectomy
  • Salpingo-oophorectomy
  • Peritoneal resection
  • Omentectomy
  • Total hysterectomy with bilateral salpingo-oophorectomy
  • Other, describe

Specimen laterality

  • Left
  • Right
  • Bilateral
  • Unspecified

Specimen type

Describe the anatomical components present.

  • Ovary, right/left
  • Fallopian tube, right/left
  • Omentum
  • Peritoneal biopsies
  • Lymph nodes

Specimen weight (g)

  • Weight of each affected/involved ovary 1

Specimen integrity

  • Fallopian tube serosa
    • Intact
    • Ruptured, describe
    • Fragmented
  • Ovary capsule 1
    • Intact
    • Ruptured, describe
    • Fragmented/morcellated
  • Other, describe

Specimen dimensions (mm) and description

  • Fallopian tube, in two dimensions, length x maximum diameter if macroscopically normal. If abnormal, record in three dimensions.
    • Fimbriae -present or not identified
  • Ovary, in three dimensions 1
    • Tumour on surface -absent or present. If present, record the number of tumours and the size of each in two dimensions
  • Omentum, in three dimensions
  • Uterus, see protocols for uterus
  • Other, describe and refer to relevant protocol for more information

DissectionBack to top


Paint the relevant surgical margins with ink if required and record the colours applied. In most circumstances the ovarian surface does not require painting with ink. 9 However  if surface abnormalities are present, painting these areas of possible  tumour may assist with microscopic determination of surface involvement. 1

Serially section the ovary sagitally through its full thickness at 3-4mm intervals. 9 Examine the cut surface for abnormalities and heterogeneous areas.

After opening the specimen may require longer fixation in larger quantity of formalin.

Internal InspectionBack to top


Describe the cut surface appearance including the following items:

Ovary

Solid component

  • Not identifed
  • Present, describe
    • Texture e.g. whorled, necrotic
    • Consistency e.g. soft, firm, gritty
    • Colour

Tumour size (mm)

  • In three dimensions

Cystic component

Describe the cystic component of the specimen.

Type of cyst

  • Unilocular
  • Multilocular

Cyst contents1,7

  • Blood-filled/blood-stained 7
  • Clear/watery/serous 7
  • Mucoid/gelatinous 7
  • Hair/sebum/teeth (teratoma) 7

Cyst internal surface abnormalities

  • Absent
  • Present (e.g. papillary excrescences)
    • Describe appearance
    • Number
    • Range of sizes (mm)
More detail

Cysts may be physiological (sometimes up to 20mm in diameter), an indication of polycystic disease (multiple small subcapsular cysts) or endometriosis. Cysts with complex internal structures, solid or papillary areas are likely to represent neoplastic disease. 7

Tumour involvement of other organs (more than one may apply)

  • Fallopian tube
  • Uterus, specify location
  • Omentum
  • Peritoneum, specify
  • Other, specify

Omental involvement by tumour (if applicable)

  • Uninvolved
  • Involved
    • Number of metastatic deposits, if present and/or approximate area (%) of specimen involved by tumour
    • Maximum dimension of largest metastatic deposit (mm)
Lymph nodes (if applicable)

Retrieved from resection specimen

  • Describe site(s)
  • Number retrieved

Separately submitted

  • For each specimen container, record specimen number and designation
  • Collective size of tissue in three dimensions (mm)
  • Number of grossly identified lymph nodes submitted
  • Maximum diameter of each (mm)

Photograph the dissected specimen, if required.

Note any photographs taken, diagrams recorded and markings used for identification.

ProcessingBack to top


Dissect the specimen further and submit sections for processing according to the diagram provided.

Ovary/fallopian tube with neoplasia

Submit representative sections:

  • Entire tumour if small. Otherwise, one section for every 10mm of maximum tumour dimension focussing on:
    • Sections demonstrating relationship with the capsule
    • Unusual or heterogeneous areas including yellow areas of fibrous tumours 7
    • Include thin walled areas of cysts, but thoroughly sample solid and papillary areas. 1 Include sections from breaches of the capsule, adhesions and areas of tumour infiltration particularly if close to the external surface.
  • The Bethesda 2004 Workshop for Borderline tumours recommends at least one block per cm of max. dimension for neoplasms <10cm and two blocks per cm for larger tumours. 11
  • Always include an area of normal ovary and fallopian tube including the soft tissue between the ovary and tube. 1,9
  • Other tissues present, representative sections demonstrating any suspected invasion if present
  • Fallopian tube(s)* 
  • Appendix (received separately), submit all tissue, see appendix protocol for more detail
  • Omentum (if macroscopically uninvolved), four to six blocks 1

*Fallopian tube has been proposed as the origin of many ovarian tumours therefore thorough sampling including longitudinal sections of the fimbrial end (SEE-FIM protocol) may be appropriate particularly in serous carcinoma.12,13 See illustrations in protocol for ovary and fallopian tube in a benign setting.

Primary peritoneal tumours

Submit representative sections:

  • Tumour, four representative sections should suffice or entire tumour if small.
  • Ovary and fallopian tubes may need to be submitted in their entirety to exclude ovarian/fallopian tube origin. If cystic, representative sections of any suspicious areas should be submitted to establish the nature of the cyst.
  • Other tissues, if present, representative sections demonstrating any suspected invasion 
  • Omentum, four to six blocks if macroscopically uninvolved 1
  • Appendix (received separately), submit all tissue, see appendix protocol for more detail
Mucinous tumours

Mucinous tumours require careful sampling of solid and heterogeneous areas as benign and malignant areas may be intermingled. 1

Mucinous tumours of the appendix and ovary can occur (particularly pseudomyxoma peritonei) where the appendix is the primary tumour site. In these cases, all sections of the appendix should be submitted for processing as tumour may not be macroscopically apparent.See appendix protocol for more detail.

Submit all peritoneal biopsies whole (received separately) in separate cassettes and identify the site of each.

Submit all lymph nodes (received separately) and identify the site of each.


Record details of each cassette.

An illustrated block key similar to those provided below may be useful.

Block allocation key

Ovary/fallopian tube with neoplasia
Cassette id Site No. of pieces
A-D Tumour, one section per 10mm maximum diameter, demonstrating relationship with capsule  
E-G Cysts, solid-papillary areas, breaches of the capsule, adhesions and areas of possible tumour infiltration  
H Fallopian tube, residual ovary and other suspicious papillary areas  
I-L Omentum, representative sections  
Primary peritoneal tumours
Cassette id Site No. of pieces
A-F Tumour, one section per 10mm maximum diameter, demonstrating relationship with other tissues. If small submit all.  
G-H Ovary and fallopian tube, all sections  
I-L Omentum, representative sections  
Prophylactic/risk-reducing salpingo-oophorectomy
Cassette id Site No. of pieces
A-B Ovary, all sections  
C
Fallopian tube, fimbrial end, longitudinal sections
 
D
Fallopian tube, transverse sections
 
 
All tissue submitted
 

Acknowledgements

Drs Kerryn Ireland-Jenkin and Marsali Newman for their contribution in reviewing and editing this protocol.

ReferencesBack to top


  1. Wells M. Recent advances in endometriosis with emphasis on pathogenesis, molecular pathology, and neoplastic transformation. Int J Gynecol Pathol 2004;23(4):316-320.
  2. Van Gorp T, Amant F, Neven P, Vergote I and Moerman P. Endometriosis and the development of malignant tumours of the pelvis. A review of literature. Best Pract Res Clin Obstet Gynaecol 2004;18(2):349-371.
  3. Yoshikawa H, Jimbo H, Okada S, Matsumoto K, Onda T, Yasugi T and Taketani Y. Prevalence of endometriosis in ovarian cancer. Gynecol Obstet Invest 2000;50 Suppl 1:11-17.
  4. Sainz de la Cuesta R, Eichhorn JH, Rice LW, Fuller AF, Jr., Nikrui N and Goff BA. Histologic transformation of benign endometriosis to early epithelial ovarian cancer. Gynecol Oncol 1996;60(2):238-244.
  5. Leunen K, Legius E, Moerman P, Amant F, Neven P and Vergote I. Prophylactic salpingo-oophorectomy in 51 women with familial breast-ovarian cancer: importance of fallopian tube dysplasia. Int J Gynecol Cancer 2006;16(1):183-188.
  6. Brown L, Andrew A, Hirschowitz L and Millan D. Tissue pathways for gynaecological pathology, The Royal College of Pathologists, London, 2008.
  7. Gwin K, Wilcox R and Montag A. Insights into selected genetic diseases affecting the female reproductive tract and their implication for pathologic evaluation of gynecologic specimens. Arch Pathol Lab Med 2009;133(7):1041-1052.
  8. Heatley MK. Dissection and reporting of the organs of the female genital tract. J Clin Pathol. 2008;61(3):241-57.
  9. Crum CP, Drapkin R, Miron A, Ince TA, Muto M, Kindelberger DW, et al. The distal fallopian tube: a new model for pelvic serous carcinogenesis. Curr Opin Obstet Gynecol. 2007;19(1):3-9.

  10. Silverberg SG, Bell DA, Kurman RJ, Seidman JD, Prat J, Ronnett BM, et al. Borderline ovarian tumors: key points and workshop summary. Hum Pathol. 2004;35(8):910-7.

  11. Clarke BA, Crum CP, Nucci MR, Oiva E, Cooper K, For the Members of the Cancer Committee. Protocol for the Examination of Specimens From Patients With Carcinoma of the Fallopian Tube. College of American Pathologists, 2013.
  12. Lee Y, Medeiros F, Kindelberger D, Callahan MJ, Muto M, Crum CP. Advances in the recognition of tubal intraepithelial carcinoma: applications to cancer screening and the pathogenesis of ovarian cancer. Adv Anat Pathol. 2006;13(1):1-7.