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LETTER TO EDITOR  
Year : 2016  |  Volume : 59  |  Issue : 4  |  Page : 567-569
A pathologist's role in evaluation of postneoadjuvant chemotherapy epithelial ovarian carcinomas


Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India

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Date of Web Publication10-Oct-2016
 

How to cite this article:
Pradhan AP, Rekhi B, Menon S, Deodhar KK. A pathologist's role in evaluation of postneoadjuvant chemotherapy epithelial ovarian carcinomas. Indian J Pathol Microbiol 2016;59:567-9

How to cite this URL:
Pradhan AP, Rekhi B, Menon S, Deodhar KK. A pathologist's role in evaluation of postneoadjuvant chemotherapy epithelial ovarian carcinomas. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Jul 20];59:567-9. Available from: http://www.ijpmonline.org/text.asp?2016/59/4/567/191780


Editor,

Epithelial ovarian carcinomas (EOCs) are aggressive tumors, which often present with advanced stage disease. Hence, such cases have a relatively poorer prognosis and survival rate. The use of neoadjuvant chemotherapy (NACT), followed by tumor reduction surgery, also called as interval debulking surgery, is considered as an alternative therapeutic regimen for selected patients harboring advanced stage EOC. [1] Till date, several studies have attempted to draw an association between NACT and the histology of residual tumor, its grade, stage with the prognosis. A tumor regression grading (TRG) score which is widely used in cancers of gastrointestinal tract, has not been formulated for ovarian carcinomas, till date.

Our aims of this study were to assess the pathological outcome in cases of EOCs, post-NACT and to assess the uniformity of grossing techniques in post-NACT-treated specimens.

All pathology reports of "in-house" operated cases of carcinoma ovary of 1 year duration (January 2011-December 2011) were retrieved from the medical records of our institution. A total of 162 cases of total abdominal hysterectomy with bilateral salpingo-oophorectomy and omentectomy, post-NACT-treated EOC were retrieved.

In 1 year, 162 cases of EOC received NACT. Before the induction of therapy, majority of the patients had undergone ascitic fluid examination (111/162), or a biopsy (29/162) or a fine needle aspiration cytology diagnosis (10/162). The median age-group of these patients was 52 years, the mean being 51.04 years. The following table shows the post-NACT residual tumor status and histological subtyping [Table 1].
Table 1: Post neoadjuvant chemotherapy Ovarian carcinoma status (n=162)


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Among a total number of cases with residual tumors, serous adenocarcinomas formed the most frequent histopathological subtype (66.67%). Immunohistochemical (IHC) staining was performed in 16/162 cases, to further subtype the tumor (in post-NACT samples). Necrosis, inflammation, psammomatous calcification, foamy histiocytes, hemosiderin laden macrophages, and foreign body type giant cells constituted as therapy-related changes. Ovaries were submitted entirely in 48/162 cases (29.62%). Out of the 146 cases with residual tumor, 102 had omental metastasis. Out of the 16 cases with no residual tumor, five had omental metastasis. Residual tumor percentage was not offered in any of the reports. The follow-up of the patients was between 3 and 49 months with a mean average survival of 26.8 months.

In this study, there were 90.13% of cases which showed residual tumor on histopathology, whereas complete response was seen in 9.87% cases. As per established literature, chemotherapy induces morphological variations in the original tumor, which make it difficult or sometimes impossible to subtype the tumor. However, this should be attempted. [2] Many study results have shown histologic response to be a prognostic indicator. [1],[2],[3]

IHC staining was performed in 9% cases to subtype the tumor. Chemotherapy has many effects on the morphology of the tumor. A serous tumor with clear cell change can mimic a clear cell adenocarcinoma. [4] Wilms' tumor 1 (WT-1) may be a useful antibody marker, especially if IHC before NACT has not been performed. Futhermore, normal cells might appear bizarre and could cause confusion as to the presence of residual tumor. In such scenarios, IHC is a useful adjunct.

Optimal cytoreduction has been defined as residual tumor <1 cm. However, the Gynecologic Cancer Interstudy Group has changed this to complete resolution of all tumor. [5] Thus, 100% response or no residual tumor on microscopy is considered as good/complete response to therapy.

Currently, there is no unified TRG of ovarian/tubal/peritoneal high-grade carcinomas that have been treated with NACT. TRG scoring has been applied to cancers of the breast, stomach, esophagus, and colorectum as a prognostic tool. Few investigators evaluated the effect of NACT in advanced-stage EOC, in the form of correlation between response and survival. A recent study suggested applying the TRG score to the omental metastasis stating it to be superior than the one in the primary tumor site. [6] In our study, 5/16 cases which showed a complete response to therapy (no residual viable tumor in the primary ovarian site), also had omental metastasis. Thus, in future, a TRG score assessing the tumor presence at metastatic site as well rather than only the primary could prove more beneficial. The presence of omental metastasis is taken as pathological Stage III. Thus, in this series, 11 out of 162 had "complete response" (no residual tumor at the primary or secondary site).

While grossing the specimen of an ovarian tumor wherein NACT was administered, representative sections were given where the presence of tumor was evident on gross examination. Till date, no protocol is followed as to the sampling of ovary in such cases. However, the ovaries in our cases were submitted entirely when the tumor was not visible on gross examination; when size of the ovary was within 4 cm (maximum dimension) and before confirming the microscopic diagnosis of "nonresidual" tumor. This minimized the possibility of error in reporting the residual status of the disease. We also recommend that if residual tumor is seen in only one of the ovaries, the contralateral ovary must be submitted entirely as high-grade serous adenocarcinomas have the propensity to occur bilaterally. A larger study will be undertaken for further validating these observations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Samrao D, Wang D, Ough F, Lin YG, Liu S, Menesses T, et al. Histologic parameters predictive of disease outcome in women with advanced stage ovarian carcinoma treated with neoadjuvant chemotherapy. Transl Oncol 2012;5:469-74.  Back to cited text no. 1
[PUBMED]    
2.
McCluggage WG, Lyness RW, Atkinson RJ, Dobbs SP, Harley I, McClelland HR, et al. Morphological effects of chemotherapy on ovarian carcinoma. J Clin Pathol 2002;55:27-31.  Back to cited text no. 2
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3.
Khandakar B, Kumar L, Kumar S, Gupta SD, Kalaivani M, Iyer V, et al. Tumour morphology after neoadjuvant chemotherapy as a predictor of survival in serous ovarian cancer: An experience from a tertiary care centre in India. Malays J Pathol 2015;37:115-21.  Back to cited text no. 3
[PUBMED]    
4.
Chew I, Soslow RA, Park KJ. Morphologic changes in ovarian carcinoma after neoadjuvant chemotherapy: Report of a case showing extensive clear cell changes mimicking clear cell carcinoma. Int J Gynecol Pathol 2009;28:442-6.  Back to cited text no. 4
[PUBMED]    
5.
du Bois A, Reuss A, Pujade-Lauraine E, Harter P, Ray-Coquard I, Pfisterer J. Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: A combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: By the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe d'Investigateurs Nationaux Pour les Etudes des Cancers de l'Ovaire (GINECO). Cancer 2009;115:1234-44.  Back to cited text no. 5
[PUBMED]    
6.
Böhm S, Faruqi A, Said I, Lockley M, Brockbank E, Jeyarajah A, et al. Chemotherapy response score: Development and validation of a system to quantify histopathologic response to neoadjuvant chemotherapy in tubo-ovarian high-grade serous carcinoma. J Clin Oncol 2015;33:2457-63.  Back to cited text no. 6
    

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Correspondence Address:
Kedar K Deodhar
Department of Pathology, Tata Memorial Hospital, 8th Floor, Annexe Building, Dr. E Borges Road, Parel, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.191780

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