遇到甲状腺和乳腺冰冻时，心里还好；到卵巢冰冻时心里老是有不踏实的感觉！还得回到平时的基本功 和解读冰冻的注意事项和语言描述技巧！

 这样报卵巢冰冻时，让自己更好地把握度、心里更有底！

对照下面的大纲逐个整理以理清诊断标准和思路！

Questions to be answered by intraoperative consults in adnexal masses.

Establishing the diagnosis of neoplasia

Establishing the diagnosis of malignancy

Degree of malignancy if present, borderline versus frankly malignant

Type of neoplasm: primary versus metastatic

Type and subtype of primary neoplasm: epithelial, sex cord/stromal,

or germ cell

Nature of peritoneal nodules

Nature of adhesions

Factors in assessing risk at time of intraoperative consultation

Age

Menstrual history

Bilaterality

Size of tumor

Ultrasound characteristics of the mass

Any family history of breast or ovarian cancer (BRCA1 or BRCA2 status)

History of previous malignancy

Most common ovarian neoplasms

Cystic neoplasms                         Solid neoplasms

Benign                                 Benign

Serous cystadenoma                         Fibroma

Mucinous cystadenoma                      Thecoma

Cystic teratoma

Malignant                               Malignant

Serous cystadenocarcinoma                  Adenocarcinomas, primary

Mucinous cystadenocarcinoma               Adenocarcinomas, metastatic

NON-NEOPLASTIC LESIONS非肿瘤性病变

Non-neoplastic lesions presenting as adnexal masses

Functional cysts: follicular, theca lutein, luteal 功能性囊肿：（滤泡性，膜黄体细胞，黄体）

Luteoma of pregnancy 妊娠黄体瘤

Salpingooophoritis and tuboovarian abscess: acute and chronic

                                     急性和慢性输卵管卵巢炎、输卵管卵巢脓肿

Endometriosis 子宫 内膜异位

Torsion  扭转

Ectopic pregnancy 异位妊娠

Stromal hyperplasia 间质细胞增生

Hyperthecosis  卵泡膜细胞增殖

Leydig cell hyperplasia   Leydig cell 增生

Massive ovarian edema  重度 卵巢水肿

名称：图1 Thecomatosis 卵泡膜细胞增殖
描述：The hyperplastic luteinized theca cells, often seen in both ovaries, are diffusely arranged and encompass follicles or corpora albicantia, in contrast to forming a well circumscribed mass intheca cell tumors (H&E, medium power).

SURFACE EPITHELIAL TUMORS表面上皮肿瘤

Relative incidence of surface epithelial stromal tumors of ovary.

Serous neoplasms 46%

Mucinous neoplasms 36%

Endometrioid neoplasms 8%

Clear cell neoplasms 3%

Transitional neoplasms 2%

Undifferentiated neoplasms 2%

Mixed neoplasms 3%

Relative incidence of surface epithelial carcinoma of ovary.

Serous cystadenocarcinoma 42%

Mucinous cystadenocarcinoma 12%

Endometrioid carcinoma 15%

Clear cell carcinoma 6%

Undifferentiated carcinoma 17%

Mixed 3%

Serous Neoplasms浆液性肿瘤

Key Features of Benign Serous Tumors

• Unilocular or multilocular cysts containing clear watery fluid
       • Range in size from 1 to 10 cm (less than 1 cm is classified as
          inclusion cyst)
      • Bilateral in 10–20% of cases
      • Cyst wall is thin and often transparent
      • Epithelial lining mostly ciliated with a few secretory cells
      • Epithelium lacks significant cytologic nuclear atypia
      • Papillae lack significant architectural atypia or complexity
       • Variable amount of stromal component

Key Features of Serous Borderline Tumors

• Large cystic lesions, often bilateral (25–30%)
• Fluid content is usually serous but occasionally mucinous
• Surface papillary excrescences (50%)
• Numerous broad fronds and lush papillae filling some cysts
• Complex branching pattern of fine velvet like papillae, tufting,
and “detached” budding
• Can have micropapillary foci with long thin papillae
• Cellular stratification up to three layers
• Nuclear atypia is mild to focally moderate at most
• Rare mitotic figure with altered distribution

Key Features of Serous Adenocarcinoma

• Large, complex, solid, and cystic masses
• Bilateral in two thirds of cases
• Most patients present with extraovarian spread
• Cysts with irregular and thick septae
• Solid nodules with necrosis and/or hemorrhage
• Complex branching papillae, glands, or solid sheets of cells
• Marked stratification (>3 layers), marked nuclear atypia
• Destructive stromal invasion with desmoplasia and necrosis
• Capsular or vascular invasion

名称：Serous cystadenoma

名称：Serous borderline tum

名称：Serous cystadenocarcinoma
Serous Carcinoma of the Peritoneum腹膜浆液性腺癌

Key Features of Serous Carcinoma of the Peritoneum

• Rare, usually elderly women
• Diffuse involvement of peritoneum
• Superficial invasion of ovaries is absent or minimal
• Histology similar to ovarian serous carcinoma

Peritoneal Implants腹膜种植

Key Features of Noninvasive Implants

• Well defined deposits with a few glands, papillae, and small epithelial nests
• Nests extend into fibrous septa between fat lobules, but maintain well defined contours
• Small submesothelial spaces filled with papillae
• Desmoplastic type shows fibrous nests plastered on surface and minimal epithelial component
• Lacks irregular destructive invasion of the underlying stroma
• Hierarchical branching of papillae
• Minimal nuclear atypia and only rare mitotic figure, if any
• Psammoma bodies frequent

Key Features of Invasive Implants

• Destructive invasion of deep omental or visceral adipose tissues
by glands and small nests with irregular tentacular contours
• The nests incorporate adipose tissue and extend beyond the fibrous stroma
• Individual cells or clusters infiltrating stroma, often surrounded by artifactual stromal retraction or space with   no lining
• Epithelial cells are dominant and disorderly distributed
• More significant nuclear atypia, similar to low-grade carcinoma, with mitotic figures
• Stromal desmoplasia

名称：Invasive peritoneal implants
描述：Deep destructive invasion by irregular nests of epithelial cells with marked nuclear atypia. The nests have tentacular outline, in contrast to the smooth outline of noninvasive implants illustrated in the previous figure, and often induce a desmoplastic response in the stroma

名称：Noninvasive peritoneal implant
描述：A well circumscribed nest of papillae with a psammoma body. The epithelial cells do not show nuclear atypia (H&E, medium power).

Mucinous Neoplasms粘液性肿瘤

Key Features of Primary Benign Mucinous Tumors

• Large unilateral cystic mass
• Usually multilocular smooth lined bluish white cysts
• Cysts lined by intestinal type (goblet) or endocervical type (tall columnar mucinous) epithelium
• Lack of nuclear atypia
• May have a serous or Brenner component and, rarely, mature teratoma
• May coexist with borderline or malignant mucinous component

Key Features of Mucinous Borderline Tumors

• Large unilateral cystic mass
• Multilocular cysts with finer honey-comb pattern
• Large cysts are surrounded by small “daughter” cysts
• Papillary folds demonstrating variable complexity of architecture
• Stratification of epithelial lining into 2–3 layers
• Mild cytologic atypia
• Altered distribution of mitotic figures, some away from the basal layers
      Key Features of Primary Mucinous Adenocarcinoma

• Large (>10 cm) complex unilateral solid and cystic mass
• Irregular thick cyst wall with septations and solid nodules with necrosis
• Often demonstrate coexistence of benign, borderline, and invasive carcinoma components
• Complex architecture with cribriform or irregular glands
• Expansile invasion or less commonly destructive stromal invasion with necrosis and desmoplasia
• Marked cytologic atypia and frequent mitosis
• Intestinal type tends to have fewer papillae than endocervical type
• Endocervical type often associated with serous elements and pelvic endometriosis

名称：Mucinous cystadenoma
描述：( a ) A single layer of tall columnar endocervical type epithelium lines the cyst (H&E, medium power). ( b ) Intestinal type epithelium with goblet cells (H&E, medium power).

名称：Mucinous cystadenofibroma

名称：Mucinous tumor of borderline
描述：Small daughter cysts are budding from the large cyst (H&E, low power).

名称：Mucinous tumor of borderline
描述：Papillae with complex architecture and stratification to two or three cell layers (H&E, low power).

名称：Mucinous tumor of borderline
描述：Mild nuclear atypia and mitotic figures away from the basal layer are seen (H&E, medium power).

名称：Mucinous adenocarcinoma

Peritoneal Adenomucinosis (Pseudomyxoma Peritoneii)腹膜假粘液瘤

These are benign or borderline neoplastic mucinous glands and free mucin that dissect between fibrous and omental tissues. They are only seen in association with benign and malignant mucinous tumors of intestinal type, particularly borderline lesions (15%) and are not an indicator of ovarian cancer. The majority of recurrent cases are associated with mucinous tumors of appendix.

名称：Peritoneal adenomucinosis
描述：( a ) Abundant mucoid gelatinous material removed from the abdominal cavity of the patient depicted in the previous figure (H&E, low power). ( b ) Pools of mucin are sparsely cellular, with a few glands. Examination of the appendix is critical, since many cases are associated with mucinous lesions of the appendix (H&E, low power).

Endometrioid Tumors内膜样肿瘤

Key Features of Benign Endometrioid Tumors

• Unilateral, solid mass with small cysts
• Well spaced glands resembling endometrial type glands
• Background of fibrous stroma

Key Features of Borderline Endometrioid Tumors

• Unilateral or bilateral lesions
• Solid or partially cystic
• Atypical or histologically malignant endometrioid glands within
   a fibrous stroma or with a papillary architecture
• Lack stromal invasion

Key Features of Endometrioid Adenocarcinomas

• Cystic or solid with hemorrhage and necrosis
• Often demonstrate transition from benign, borderline to carcinoma
• Complex glandular, villoglandular, cribriform, or solid architecture
• Squamous, mucinous, ciliated, or secretory metaplasia can be present
• Destructive stromal invasion

名称：Endometrioid adenofibroma
描述：A fibrous stroma separates glands of endometrial type (H&E, medium power).

名称：Borderline Endometrioid Tumor
描述：阿克曼九版

名称：Endometrioid adenocarcinoma
描述：( a ) Irregular glands and solid nests, with focal squamous metaplasia infiltrate a desmoplastic stroma (H&E, medium power). ( b ) The cells are of endometrioid type, with nuclear atypia and stratification. Villoglandular pattern and presence of focal squamous metaplasia supports endometrioid differentiation (H&E, medium power).

Clear Cell Neoplasms透明细胞肿瘤

Key Features of Benign and Borderline Clear Cell Tumors

• Unilateral, solid with small cysts
• Glands and tubules lined by flat, cuboidal cells, or hobnail cells with clear or eosinophilic cytoplasm
• Minimal or moderate atypia and rare mitosis
• Background fibrous stroma (adenofibroma)良性和交界性卵巢透明细胞肿瘤非常少见，鉴别交界性肿瘤的要点是上皮有中到重度的增生和非典型性，而未见得间质浸润。

Key Features of Clear Cell Carcinoma

• Unilateral cystic mass with thick walls
• Solid nodules with necrosis and hemorrhage
• Admixture of growth patterns: tubulocystic, papillary or solid architecture
• Polyhedral, cuboidal, or hobnail cells with clear to eosinophilic cytoplasm,
• Marked nuclear atypia, hyperchromasia, and mitotic activity

名称：透明细胞腺纤维瘤-低到中度核异型（交界性）

名称：Clear cell carcinoma
描述：( a ) Cystic tumor, with thick walls and irregular papillary growth within the cyst. Necrosis and hemorrhage are often seen (H&E, medium power). ( b ) Cells with well defined borders and clear cytoplasm lining clefts and glandular spaces. The nuclei are pleomorphic with some hobnail pattern (H&E, medium power).

Transitional Cell (Brenner) Tumors移行细胞（Brenner）肿瘤

This group encompasses benign, borderline, and malignant Brenner tumors,

as well as non-Brenner transitional carcinoma.The tumor is characterized by islands of uniform epithelial cells with nuclear “coffee-bean” folds, embedded in fibrous tissue. Small cysts lined by mucinous cells may be seen, and there is tendency to be associated with teratomas or mucinous neoplasms. Borderline (proliferating) Brenner tumors are large solid or partially cystic neoplasms, with stratification and nuclear pleomorphism of the epithelium lining the cysts and the papillae. Frankly malignant Brenner tumors are rare. They show necrosis, hemorrhage, prominent nuclear atypia, and an invasive growth pattern

名称：Transitional cell tumor
描述：( a ) Nests of transitional cells surrounded by fibrous stroma (H&E, low power). ( b ) The nuclei are uniform and show longitudinal “coffee-bean like” grooves (H&E, medium power).

名称：borderline(proliferating)tumor
描述：Prominent epithelial proliferation, papillae and focal mucinous differentiation are not uncommon in borderline (proliferating) tumors (H&E, medium power).

名称：
描述：Malignant transitional cell tumor with nuclear pleomorphism, an infiltrative pattern and areas of necrosis (H&E, medium power).

 

Other Surface Epithelial Neoplasms其他表面上皮肿瘤

 The surface epithelium of the ovary may develop malignancy in the form of mixed müllerian tumors. These consist of several mesenchymal and epithelial elements similar to those previously described under uterine corpus. Such tumors behave aggressively and are usually encountered in postmenopausal women.

描述：Malignant mixed müllerian tumor: ( a ) Large tumor with variegated colors and consistency, showing necrosis and hemorrhage. ( b ) A mixture of malignant epithelial and stromal tissues, including cartilage is evident. Some striated muscle is illustrated in inset (H&E, high power, oil).

SEX CORD AND STROMAL TUMORS性索间质肿瘤

Granulosa Cell Tumors粒层细胞瘤（颗粒细胞瘤）

Key Features of Adult Granulosa Cell Tumors 成年型

• Unilateral, solid or solid/cystic lesions
• Yellow white cut surface with areas of hemorrhage
• Solid, trabecular, microfollicular, insular, watered silk and gyriform patterns
• Fibrothecomatous background which may be luteinized
• Cells with scant cytoplasm, round to oval nuclei with grooves
• Minimal cytologic atypia and low mitotic rate

Key Features of Juvenile Granulosa Cell Tumors 幼年型

• Unilateral, solid, and cystic mass
• Lobulated gray white to tan yellow surface with occasional hemorrhage and necrosis
• Diffuse or nodular architecture
• Moderate to abundant eosinophilic to clear cytoplasm and hyperchromatic nuclei lacking nuclear grooves
• Can demonstrate marked nuclear atypia and brisk mitotic activity

名称：Granulosa cell tumor:
描述：( a ) Neoplastic cells form rosettes and small cysts. Identification of areas with Call Exner like rosettes is quite helpful in supporting the diagnosis (H&E, low power). ( b ) Granulosa cells have scant cytoplasm, uniform round to oval nuclei, some with nuclear grooves. The rosettes are not true acini; their center contains degenerated cells with nuclear and cytoplasmic debris (H&E, medium power).
名称：Granulosa cell tumor
描述：The trabecular pattern

名称：Granulosa cell tumor
描述：上图高倍

名称：Granulosa cell tumor
描述：( a ) Neoplastic cells arranged diffusely in a sarcomatoid or solid pattern. Note the difficulty in identifying classic rosettes in this frozen section (H&E, medium power). ( b ) The cells have scant cytoplasm and some nuclear grooves, although grooves may be difficult to appreciate in thick sections (H&E, high power).

名称：Juvenile granulosa cell tumor
描述：The cells are diffusely arranged, and have moderate to abundant amounts of cytoplasm. Cystic areas are often seen and focal luteinization of the neoplastic cells can be seen. The nuclei show atypia and lack nuclear grooves. Despite brisk mitotic activity, juvenile granulosa cell tumors behave less aggressively than the adult type (H&E, medium power).

 

Theca Cell Tumor and Fibroma卵泡膜细胞瘤和纤维瘤

Key Features of Theca Cell Tumors

• Postmenopausal women, may be virilizing
• Unilateral solid, orange, or yellow mass
• Plump spindled cells arranged in wavy bundles or nests
• Cytoplasm with vacuoles containing lipid
• Immunoreactive to inhibin
• Association with endometrial hyperplasia or carcinoma

名称：Fibrothecoma
描述：Most neoplasms of the fibrothecoma group are solid firm masses, with a smooth outer surface and a yellowish white cut surface, depending on the fibrous and lipid content of the tumor.

名称：Theca cell tumor
描述：( a ) Plump spindled cells arranged in a wavy fascicular pattern or as nests. They have a lipid rich pale or vacuolated clear cytoplasm. ( b ) Oil red O staining of a frozen section is helpful in confirming the presence of intracellular lipid in sex cord/stromal neoplasms (Oil-red O, medium power).

名称：Granulosa Theca cell tumor
描述：There is a mixture of granulosa and theca cell components in this tumor (H&E, medium power).

 

 

Key Features of Sertoli–Leydig Tumors

• Unilateral, usually solid tan to orange bosselated mass
• Tubules or cysts lined by columnar cells with uniform elongated basal nuclei
• Nests of Leydig cells with clear or amphophilic lipid rich cytoplasm
• Diffuse spindle stroma cells, trabeculae, and solid cords in poorly differentiated tumors

名称：Sertoli and Leydig cell tumors
描述：( a ) Cystic neoplasm in a postmenopausal patient with evidence of virilization. Most of these tumors, however, are predominantly solid. ( b ) A tumor resected from a 5 year old girl presenting with 3 months history of precocious puberty and vaginal bleeding. Note the brown-yellow color and the presence of cystic areas in the predominantly solid neoplasm

名称：Sertoli–Leydig cell tumor
描述：The stroma contains nests of polygonal to round Leydig cells with abundant clear or pale cytoplasm. Sertoli cells have scant cytoplasm and dark nuclei with dense chromatin and do not show tubule formation in this section. The 70 year old patient showed signs of virilization. The presence of Sertoli cell component helps differentiate these tumors from steroid cell and pure Leydig cell tumors,

 

名称：Sertoli cell tumor
描述：( a ) Well differentiated neoplasm, with cords and tubules lined by tall columnar cells. The elongated uniform nuclei are basally located and have small nucleoli. The fibrous stroma lacks Leydig cells (H&E, medium power).( b ) Trabeculae of sex cord cells arranged in a step-ladder fashion (H&E, low power).

 

 

名称：Leydig cell tumor
描述：(a) and (b) The neoplastic cells have moderately to abundant eosinophilic cytoplasm, and central nuclei. Search for the characteristic Reinke crystalloid requires time and is not practical at the time of frozen section consultation (H&E, medium power; inset at higher magnification ).

 

Other Sex Cord Stromal Neoplasms其他性索间质肿瘤

Pure Sertoli cell, Leydig cell and steroid cell neoplasms are rare.

Sampling of several areas is necessary to assure the absence of

other components in such neoplasms. A detailed discussion of these

tumors is beyond the scope of this text, since definitive classification

should await thorough sampling through routine fixation and

processing, but a review of some of the features is appropriate.

Sertoli cell tumor (Pure)纯支持细胞瘤

Steroid cell tumor:支持细胞瘤

Leydig cell tumor间质细胞瘤

Hilus cell tumor:门细胞瘤

Benign signet ring stromal tumor良性印戒细胞间质瘤

Sex cord tumor with annular tubules (SCTAT):伴有环状小管的性索瘤

名称：Signet-ring cell stromal tumor
描述：The signet ring cells have uniform bland nuclei, and the vacuoles lack lipid or glycogen, unlike those of Krukenberg tumors

描述：Sex cord tumor with annular tubules The neoplastic cells form tubules around a central core of hyaline material (H&E, medium power).

GERM CELL NEOPLASMS

Mature Cystic Teratoma成熟性囊性畸胎瘤

Key Features of Mature Cystic Teratoma

Immature Teratoma未成熟性畸胎瘤

Mature Solid Teratoma成熟性实性畸胎瘤

These tumors have similar clinical features and gross appearance as immature teratomas, including the presence of neural tissue. However, they lack immature components and rarely show mitotic activity or necrosis. They follow a benign course.

Monomorphic Teratomas单形性畸胎瘤

Although these are rare neoplasms in the ovary, a brief discussion of some of them is warranted since they enter into the differential diagnosis of some common ovarian tumors.

Struma ovarii卵巢甲状腺肿

Carcinoid类癌

Mucinous carcinoid粘液型类癌

Strumal carcinoid甲状腺类癌

Dysgerminoma无性细胞瘤

Key Features of Dysgerminoma

Other Malignant Germ Cell Tumors其他恶性生殖细胞肿瘤

Mixed germ cell tumors混合性生殖细胞肿瘤

Embryonal carcinoma胚胎性癌

Yolk sac tumor卵黄囊瘤

Choriocarcinoma绒毛膜癌

Gonadoblastoma性腺母细胞瘤

名称：Immature teratoma
描述：Immature tissues of the three germ cell layers are encountered. Neural tissue is usually the major component and is the basis for grading such tumors (H&E, low power).

名称：Struma ovarii
描述：( a ) A multinodular tumor, consisting of thyroid tissue with gelatinous-appearing translucent colloid material (H&E, low power). ( b ) Monodermal differentiation into thyroid tissue with follicles of variable sizes containing colloid (H&E, low power).

名称：Strumal carcinoid
描述：( a ) Cords and trabeculae of neuroendocrine cells form separate nodules or are mixed with thyroid follicles. Within the tumor, the two components maintain their individual immunophenotype (H&E, low power). ( b ) Higher magnification illustrates the cords (H&E, medium power).

名称：Yolk sac tumor
描述：The neoplastic cells have scant cytoplasm and are arranged in nests, loose network of tubules within a loose stroma. A Schiller Duval body with a central vessel surrounded by a mantle of cuboidal cells within a glomerulus-like space is evident in the upper left corner (H&E, low power).

METASTATIC TUMORS

Key Features that Favor Metastases over Primary Ovarian Tumors

Metastatic mucinous carcinomas转移性粘液腺癌

Colorectal cancer结直肠癌

Appendiceal lesions阑尾病变

Endometrioid like morphology子宫内膜样形态的

Breast cancer乳腺癌

Metastases from lung carcinomas转移性肺癌

Renal cell carcinoma肾细胞癌

Cervical cancer宫颈癌

Peritoneal mesotheliomas腹膜间皮瘤

Krukenberg Tumor

名称：Metastatic carcinoma from colo
描述：Abundant mucin and malignant glands lined by tall columnar epithelium. Free mucin is seen dissecting the fibrous stroma (

名称：Metastatic carcinoma from brea
描述：The neoplastic cells are small and occasionally retain the single file or a signet ring pattern (H&E, medium power).

名称：Krukenberg tumor
描述：

名称：Krukenberg tumor:
描述：( a ) Frozen section demonstrating signet ring cells with pleomorphic nuclei (H&E, medium power). ( b ) The few neoplastic cells may be masked by a prominent desmoplastic stromal response. The neoplastic cells should be differentiated from those of benign signet ring tumor

名称：Metastatic endometrial stromal sarcoma