Ovarian intestinal type mucinous borderline tumors: are we ready for a nomenclature change?

At a National Cancer Institute-sponsored workshop it was proposed that the borderline category of ovarian intestinal-type mucinous tumors (OInMTs) could be eliminated if the apparent benign behavior of these tumors could be confirmed. We reviewed 33 cases of borderline OInMT, with either optimal or adequate sampling and with at least 5 years of follow-up, to investigate their behavior. Optimal sampling and adequate sampling were defined as at least 1 section per centimeter of maximum tumor dimension and at least 1 section per 2 cm of maximum tumor dimension, respectively. The patients' age ranged from 16 to 89 years (mean 49 yr). Tumor size ranged from 8 to 39 cm (mean 20 cm). The sampling of the ovarian tumor was optimal in 28 cases and adequate in 5 cases. The patients were treated surgically as follows: cystectomy (1), unilateral oophorectomy or unilateral salpingo-oophorectomy with or without total abdominal hysterectomy (13), and bilateral salpingo-oophorectomy with or without total abdominal hysterectomy (19). Complete or partial staging was obtained in 26 patients. All of them had Federation of Gynecology and Obstetrics stage I disease. Thirty-one patients with a follow-up ranging from 5 to 18 years (mean 10 yr) had no recurrences. Two patients had recurrences 12 and 14 months after their initial surgery. The first patient underwent a left salpingo-oophorectomy and limited staging for a borderline OInMT adherent to the ileum and sigmoid. The tumor was incompletely removed and recurred in the pelvis 1 year later. It was again incompletely excised. Ten months later, the tumor re-recurred in the pelvis and could only be drained because of the patient's advanced age and her poor medical status. She died of other causes 5 years later. The second patient with recurrent tumor had undergone a cystectomy and full staging for a borderline OInMT. Fourteen months later, she developed a recurrence in the residual ovary. She underwent a right salpingo-oophorectomy and total abdominal hysterectomy and has been without evidence of disease for 11 years. In this study of 33 Federation of Gynecology and Obstetrics stage I borderline OInMTs that were optimally or adequately sampled to exclude intraepithelial carcinoma, microinvasion, or invasive carcinoma, there were only 2 cases with recurrence, secondary to incomplete excision or cystectomy, and no deaths from disease. However, borderline OInMTs are usually large and heterogeneous, and the standard sampling protocol for them is not evidence based. As indicated by one of our consultation cases, there remains the potential for a sampling artifact in which a focus of carcinoma is missed. Caution dictates retaining the current nomenclature to ensure the follow-up of patients affected by this disease until uncertainty regarding the extent of sampling needed to exclude the presence of carcinoma is resolved.

Uterine artery embolization of leiomyomas with trisacryl gelatin microspheres (TGM): pathologic features and comparison with polyvinyl alcohol emboli.

In recent years, uterine artery embolization (UAE) has gained popularity as an alternative to surgery for the treatment of symptomatic uterine leiomyomas. Polyvinyl alcohol (PVA) particles have been the principal agent used for UAE. Recently, trisacryl gelatin microspheres (TGM) have been advocated as a preferable occlusive material for UAE. It is the first embolic agent to be cleared specifically by the United States Food and Drug Administration for this use. To date, information on the tissue effects, distribution, and morphology of UAE with TGM in resected human organs is very limited. Herein, we document the pathologic findings in a 46-year-old woman who underwent hysterectomy and bilateral salpingo-oophorectomy and omentectomy for metastatic colonic adenocarcinoma 19 months after UAE with TGM (microsphere size = 500-700 micron) for uterine leiomyomas. Histologically, a submucosal leiomyoma and an intramural uterine leiomyoma showed massive coagulative necrosis of the infarct-type with a peripheral zone of hyalinized fibrous tissue. Aggregates of TGM were within the necrotic leiomyomas and throughout the myometrium. Non-targeted extrauterine sites also contained TGM, including the paracervical soft tissue and the mesosalpinx as well as the ovaries and omentum where they were adjacent to metastatic colonic carcinoma. Other than the myomas, none of the embolized organs showed ischemic necrosis. Although some TGM were intravascular, most were extravascular. Typically, the microspheres were adjacent to muscular arteries from which they appeared to have been extruded following localized dissolution of the arterial wall. A thin rim of foreign body-type giant cells and mononuclear macrophages surrounded many of the TGM and focally involved the arterial wall. No vascular thrombosis was seen. TGM are believed to have advantages over PVA emboli for UAE. Hence, additional examples of surgical specimens following treatment of leiomyomas with TGM can be expected. Pathologists should be aware of the morphology of TGM in resected genital tract tissues. Although TGM are easily distinguished from embolic PVA particles, they may be mistaken for PVA microspheres if not carefully studied. Elastic stains are useful in the differential diagnosis of embolic agents.