Case Report - (2023) Volume 9, Issue 4
Intaroperative frozen section is a widely used and important aspect of surgical pathology in dealing with ovarian masses and guides the oncologist in planning optimal treatment protocols and strategies. There are limited data regarding the diagnostic accuracy of frozen section in specific subtypes of ovarian neoplasia. Intraoperative cytology has been in vogue and can be used as a reliable and rapid alternative procedure to arrive at a preliminary rapid diagnosis. This manuscript elucidates and details the intraoperative scrape cytological features of ovarian clear cell carcinoma which permits correct, rapid diagnosis and thereby facilitates optimal surgical management. The cytological analysis of scraping samples of ovarian tumours can make a precise intraoperative cytological diagnosis in most cases of CCC of the ovary and has a complementary role in the intraoperative assessment of ovarian neoplasia and provides a more specific diagnosis in cases of ovarian clear cell carcinomas.
Intraoperative scrape cytology is a rapid reliable, cost-effective and good complementary method to traditional frozen sections to arrive at a preliminary rapid diagnosis, especially in resource-poor settings and aids in arriving at a specific diagnosis in certain situations and helps in further surgical management.
Ovarian tumour • Scrape cytology • Intraoperative • Clear cell carcinoma • Cytodoagnosis
Ovarian cancer is ranked the eighth most common cancer diagnosis and cause of cancer death in women worldwide and is estimated to be the third most common cancer with the leading cause of cancer death in Indian women [1]. The major types of malignant epithelial ovarian tumours are classified as serous carcinoma, mucinous adenocarcinoma, endometrioid carcinoma, clear cell carcinoma, transitional carcinoma, squamous carcinoma, undifferentiated carcinoma and mixed carcinoma. Morphology still remains the mainstay in diagnosis along with immunohistochemistry is of value in supporting the diagnosis [2,3]. Each specific tumour subtype is associated with distinct clinical and prognostic features and has specific molecular targets for planning therapy.
Clear Cell Carcinoma (CCC) is a well-defined distinct subtype of ovarian carcinoma and accounts for about 7% of ovarian cancers [4,5]. The age ranges from 19 years to 82 years with a mean age of 53.1 years and about 50% to 70% are associated with endometriosis [6-8]. The most common presentation is with a unilateral sizable pelvic mass and a mild to moderate increase in serum CA-125 levels (usually <200 U/mL). A higher rate of venous thromboembolic events and paraneoplastic hypercalcemia have been documented in CCC than their counterparts with other histotypes [9-12]. A family history of ovarian cancer in a first-degree relative and a history of Lynch syndrome has been associated with an increased risk of CCC.
Intraoperative consultation is a very important aspect of surgical pathology in dealing with ovarian masses and guides the oncologist in further treatment strategies and protocols. Traditionally frozen sections are employed for intraoperative assessment of ovarian masses primarily to establish or confirm malignancy which may further require staging and debulking procedures and preferentially subtype the malignancy. Intraoperative cytology has been in vogue and can be used as a reliable and rapid alternative procedure to arrive at a preliminary rapid diagnosis, especially in resource-poor settings where cryosections are not available [13-18]. Herein in this manuscript, we elucidate and detail the intra-operative scrape cytological features of ovarian clear cell carcinoma which permits correct, rapid diagnosis and thereby facilitates optimal surgical management.
A thirty-seven years nulliparous woman presented with abdominal pain for three months duration. Computed Tomography (CT) scan of the abdomen/pelvis revealed a well-defined unilocular large cystic lesion with peripherally enhancing solid component arising from the right adnexa noted in hypogastrium, right iliac fossa, left iliac fossa, bilateral lumbar and umbilical regions. No evidence of septations or calcifications. The cystic lesion is seen abutting the abdominal aorta, right common iliac artery, external iliac artery, and right psoas and displacing bowel loops superiorly and laterally. The lesion is seen compressing the right distal ureter causing moderate upstream hydroureteronephrosis. Intra-operative frozen consultation was raised of the right adnexal solid cystic mass measuring 17 cm x 17 cm, on section yielded 150 ml of greenish yellow serous fluid with internal foci of yellow to grey-white to hemorrhagic solid areas and papillary excrescences(Figures 1 A and 1 B).
Figure 1: Gross picture showing a solid cystic lesion with solid component composed of gray white to yellowish to pale haemorrhagic nodules and papillary configurations studding the inner surface of cyst (A,B).
The scrape cytology smears from the solid yellow-grey-white non-necrotic areas were prepared and stained with rapid H and E and Ultrafast Giemsa stain [19]. The rapid H and E stained cellular smears showed a predominant pattern of large neoplastic cells in papillary clusters with fibrovascular core, sheet-like arrangements, cell balls and glandular structures with focal hobnailing of cells (Figure 2).
Figure 2: Microphotographs showing distinct arrangement of neoplastic cells as (A) Papillary custers with distinct central fibrovascular core (B) Hobnailing of tumor cells over vascular fragment (C and D) Sheets,clusters and acinar/glandular arrangement (Rapid H &E,x100).
The cells were large polygonal to round with an abundance of cytoplasm, and predominant clear cells varied from moderate to high amounts with sudden anisonucleosis. A very prominent central nucleolus was a characteristic finding with a contrasting typical low mitotic rate. Pale globoid extracellular eosinophilic hyaline material was seen surrounded by neoplastic cells (Figure 3).
Figure 3: (A) High power shows large polygonal to round with abundance of pale cytoplasm, with vesicular nulcei and sudden anisonucleosis. (B) A characteritic finding of prominent central nucleoli and pale globoid extracellular eosinophilic hyaline material seen surrounded by neoplastic cells. (Rapid H&E,x400).
With ultrafast Giemsa stained smears, the neoplastic cells were essentially arranged as papillary clusters, dyshesive sheets, and clusters and dispersed singly (Figure 4).
Figure 4: The neoplastic cells were essentially arranged as papillary clusters with hobnailing (A,B), dyshesive sheets ,clusters and dispersed singly (C,D)(Ultrafast Giemsa, x100).
The cells were large round to polygonal cells measuring around 30 μm with abundant delicate to frail cytoplasm with distinct fine cytoplasmic vacuolations and some with foamy to clear cytoplasm (Figure 5 A and 5 B). The nuclei were variable with foci of sudden anisonucleosis, round to oval, with a distinct nuclear border and with very prominent inclusion like nucleoli (Figure 5 C). Occasional cells showed the presence of intracytoplasmic round to fragmented eosinophilic hyaline inclusions stained pink, within the cytoplasm (Figure 5 D, and 5 E).
Figure 5: The neoplastic cells were large round to polygonal cells measuring around 30 μm with abundant delicate to frail cytoplasm with distinct fine cytoplasmic vacoulations and some with foamy to clear cytoplasm.).The nuclei are enlarged, homogenous with sudden anisonucleosis and some with prominent nucleoli. (A,B,C Ultrafast Giemsa stain, x 100) show pResence of intracytoplasmic round to fragmented eosinophilic hyaline inclusions stained pink, within the cytoplasm (D,E, Ultrafast Giemsa stain, x 100).
An extensive search showed no intranuclear pseudo inclusions. The most striking at low power was the abundance of eosinophilic, hyaline, extra- cellular, globular basement membrane-like material, seen predominantly within the papillary cores, and sheets and located centrally within the acinar/glandular formation with classical “Raspberry bodies” (Figure 6). The abundant large extracellular rounded magenta pink globules were of variable sizes ranging from 40 μm to 50 μm in diameter with smooth well-defined spherical outlines. Some of the spherical globules were circumferentially encircled by single to bilayered row of tumor cells. Other patterns of hyaline globules which were observed were branching ribbon-like stromal fragments, and strings with rosary-beads appearance forming the classic raspberry bodies. The background showed many naked nuclei with predominantly mucinous and granular necrotic debris.
Figure 6: The very characteristic extracellular abundance of eosinophilic, hyaline, extra- cellular, globular basement membrane like material within the papillary cores ,sheets and located centrally within the acinar/glandular formation with classical “Raspberry bodies”.
The extracellular basement membrane material was more appreciable in Giemsa stained smears and appeared a bright magenta-pink color. In H and E smears, the delicate abundant cytoplasm showed cytoplasmic vacuolation. The nuclei were round and predominantly regular with smooth and regular nuclear contours, fine chromatin and prominent inclusion-like nucleoli. The extracellular basement membrane material was also appreciated well in H and E smears, though not as bright and prominent as that of Giemsa stain. They appeared as dense pale grey globules seen between the neoplastic cellular sheets, extracellular globoid structures lying freely without neoplastic cells, as well as a string of beads with constricted appearance. Mitotic figures and karyorrhectic debris were infrequent.
The frozen sections showed predominantly the classical tubulocystic pattern comprising large ectatic cysts to small, round, nonspecific glandular structures and very focal papillary architecture with characteristic hobnailing of lesional cells (Figures 7 A and B). The predominant patterned tubulocystic units were lined by round to flat cells with minimal to abundant pale eosinophilic to clear vacuolated cytoplasm and hobnailing of tumour cells with large hyperchromatic nuclei with characteristic hyaline globules (Figures 7 C and D).
Figure 7: Frozen sections showing the characteristic tubulocystic and glandular pattern of tumor cells (H&E,A x 40,B x 100). The tubulocystic units lined by round to flat cells with minimal to adundant pale eosinophilic to clear vacuolated cytoplasm and hobnailing of tumor cells with large hyperchromatic nuclei with characteristic hyaline globules (H&E,Cx100,Dx100).
The papillae are rounded and focally cystic without hierarchical branching. The characteristic hyaline globules were not obviously evident under low power in frozen sections, however, observed on close high power examination with evidence of stromal hyalinization and stromal infiltration by neoplastic cells. The routine paraffin-embedded sections also showed similar characteristic tubulocystic and glandular patterns with the hobnailing of tumour cells and an abundance of hyaline globules (Figure 8).
Figure 8: Paraffin sections showing the characteristic tubulocystic and complex glandular pattern of tumor cells with hobnailing of lining neoplastic cells (H&E,A;x40,B;x100,Cx;100). The variably sized ectatic tubulocystic units lined by round to flat cells with minimal cytoplasm with enlarged hyperchromatic nuclei and abundance of characteristic hyaline globules (H&E,D;x100,E;x100). Areas showing large polygonal cells with abundant clear cytoplasm with central to eccenteric hyperchormatic nuclei and minimal pleomorphism. (H&E,F;x100).
Intraoperative scrape cytological examination has been in vogue and has shown comparable accuracy in the diagnosis of ovarian mass lesions to that of traditional frozen section diagnosis [20-22]. In resource-poor setting the intraoperative cytodiagnosis has been considered as an initial modality of evaluation where cryosections are not available or in limited usage only for difficult cases [23].
Ovarian clear cell carcinomas are one of the most common tumours which are misdiagnosed in intra-op evaluation as many tumours enter the differential diagnosis. The most important ones considered are primary and metastatic tumours with predominant clear cells like serous and endometrioid carcinomas, yolk sac tumours, Krukenberg tumours, and ovarian dysgerminomas. Ovarian clear cell carcinomas exhibit characteristic and unique cytological features distinct from other ovarian tumours which can be highlighted by scrape smear cytological preparations and can be considered as an adjunct to cryosections and aids as a complementary tool while intraoperative evaluation of ovarian masses.
The case report highlights the distinct advantages of scrape smear cytology during the intraoperative evaluation of ovarian masses with the elucidation of cytomorphology of clear cell carcinoma. The distinct advantages of scrape cytology are smears are available within minutes of sample reception and in settings of benign conditions, a correlation of macroscopic with smear cytology is sufficient to be confident of the diagnosis; when multiple lesions are present, a smear correlation from the various sites can be sufficient to comment on tumour metastasis and prevents many cryosections and finally even with good technical expertise, cryosections can be suboptimal sometimes owing to tumour characteristics like necrosis and friable tissue and ice crystal artefacts. With the request of Intra op evaluation, the protocol we follow is the initial scrape cytological preparation followed by cryosections as the smears are available within minutes before the routine cryo sections are available for evaluation and reporting is done based on combined analysis of both techniques in correlation with macroscopic /gross details of the mass lesion.
The typical papillary clusters, poorly cohesive sheets and acinar formations of the neoplastic cells with High NC ratio, regular nuclear borders and moderate sudden anisonucleosis with distinct cytoplasmic fine vacuolations and the most characteristic extracellular bright magenta-colored hyaline globules forming characteristic Rasberry bodies are almost typical and unique cytological findings in a classic clear cell carcinoma of ovary. These spheroid hyaline globules encircled by neoplastic cells were first described in an ascitic fluid by Nishida [24]. In FNAC preparations from ovarian CCC, detailed descriptions of raspberry bodies were proposed by Heffernan and Ito who postulated that these unique structures were characteristic of CCC [25,26]. This hyaline, globular, eosinophilic, extracellular substance and raspberry bodies were found in 12 of 14 imprint/scrape samples of the tumour in a study done by Vrdoljak and were considered as highly characteristic features for cytodiagnosis of Cin addition to intracytoplasmic eosinophilic inclusions [27]. The Rasberry bodies are formed by central core homogenous bright magenta basement membrane pink hyaline globule material secreted by neoplastic cells with complete/incomplete circumferential lining by one to two layers of neoplastic cells with scalloping borders and vacuolations of cytoplasm. These bodies have a characteristic similarity to the extracellular hyaline globules formed characteristically in adenoid cystic carcinomas of salivary origin. These raspberry bodies can be found in the effusion and exfoliative material, as well as in metastatic deposits which provides a clue in the identification of the primary subtype.
The other fewer characteristics of cytologycal findings include prominent clear cells, papillary, glandular, sheets/ball-like arrangement of neoplastic cells with moderate nuclear pleomorphism are non-specific findings and can be considered in making a diagnosis of malignancy rather than any specific subtype. The distinct hobnailing of tumour cells is also seen in only 50% of cases and an inconstant finding in the differential diagnosis of ovarian neoplasms.
The typical diagnostic hallmarks of ovarian clear cell carcinomas include the characteristic architecture of epithelial cells exhibiting tubulocystic, papillary, and solid patterns with the papillary pattern most common. The papillae are typically round and small with central fibrous to hyalinised stroma surrounded by tumour cells without hierarchical branching. More than 90% show at least focal clear cell areas with hobnailing of nuclei. Nuclear pleomorphism is mild to moderate in the majority of cases, with only 40% showing severe anaplasia or increased mitotic activity >6/ 10 hph.
Though frozen sections can give a better architectural evaluation of ovarian masses, the cytological scrape preparations which provide better cellular, nuclear details and extracellular stromal details can on many occasions be superior to frozen which can be suboptimal due to frozen artifcats, necrosis, calcifications and other technical factors. The characteristic cytologic findings of OCCC, including the presence of abundant extracellular hyaline material, and cytologic examination of scrape preparations have been recommended as a valuable adjunct and a necessary complementary tool in the intraoperative assessment of ovarian tumours.
Ovarian scrape cytological evaluation is an extremely simple, rapid and inexpensive adjunct technique for intraoperative consultation of ovarian lesion. The most distinct cytological features of an ovarian clear cell carcinoma are hyaline globules, eosinophilic, extracellular substance, intracytoplasmic eosinophilic inclusions and the characteristic Raspberry body. Combined analysis and interpretation of gross features with intraoperative scrape cytology and frozen sections will increase the diagnostic accuracy during intraoperative frozen consulation and can guide the oncologists in planning further optimal treatment strategies and protocols.
Citation: Bala D, Appasani S, Nandyala R and Prayaga A.K. Intraoperative Scrape Cytology of Ovarian Clear Cell Carcinoma. Oncol Cancer Case Rep. 2023, 9(4), 001-004
Received: 10-Jul-2023, Manuscript No. OCCRS-23-105377; Editor assigned: 13-Jul-2023, Pre QC No. OCCRS-23-105377(PQ); Reviewed: 21-Jul-2023, QC No. OCCRS-23-105377(Q); Revised: 24-Jul-2023, Manuscript No. OCCRS-23-105377(R); Published: 01-Aug-2023, DOI: 10.35248/23.9.3.1-2
Copyright: ©2023 Bala, D. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC-BY, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.