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
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.
- No
- Non-routine fixation (not formalin), describe.
- Yes
- Special studies required, describe.
- Ensure samples are taken prior to fixation.
- 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 Inspection
Orientate and identify the anatomical features of the specimen.
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
- 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 ovary1
Specimen integrity
- Fallopian tube serosa
- Intact
- Ruptured, describe
- Fragmented
- Ovary capsule1
- 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 dimensions1
- 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
Dissection
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 Inspection
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)
Cystic component
Describe the cystic component of the specimen.
Type of cyst
Cyst contents1,7
- Blood-filled/blood-stained7
- Clear/watery/serous7
- Mucoid/gelatinous7
- Hair/sebum/teeth (teratoma)7
Cyst internal surface abnormalities
- Absent
- Present (e.g. papillary excrescences)
- Describe appearance
- Number
- Range of sizes (mm)
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)
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.
Processing
Dissect the specimen further and submit sections for processing according to the diagram provided.
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 tumours7
- 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 blocks1
*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.12,13See illustrations in protocol for ovary and fallopian tube in a benign setting.
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 uninvolved1
- Appendix (received separately), submit all tissue, see appendix protocol for more detail
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.1 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
| 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 |
|
| 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 |
|
| 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.
References
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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.
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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.
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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.
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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.
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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.
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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.