How do you determine the presence of lesions or abnormalities during grossing of ovarian specimens in patients with a history of ovarian surgery or endometriosis?

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Determining Lesions and Abnormalities During Grossing of Ovarian Specimens

During grossing of ovarian specimens in patients with prior ovarian surgery or endometriosis, you must perform meticulous macroscopic examination with systematic serial sectioning (one section per centimeter along the greatest diameter), carefully documenting specimen integrity, surface characteristics, and any masses while being particularly vigilant for subtle white or mixed-color lesions that may represent endometriosis or atypical changes. 1

Essential Pre-Grossing Requirements

Clinical Information Review

  • Review the complete clinical history before beginning the gross examination, including details of prior ovarian surgeries, documented endometriosis, and any neoadjuvant chemotherapy, as these significantly alter gross and microscopic tumor appearance. 1
  • Verify whether the patient has a history of endometriosis, as this increases risk for ovarian remnant syndrome and endometriosis-associated ovarian cancer (EAOC). 2, 3

Specimen Handling

  • Transport the excised tissue intact and unopened to the laboratory as rapidly as possible to preserve tissue quality for all necessary analytical tests. 1
  • Ensure appropriate fixative is used for all potential analytical tests that might be required. 1

Systematic Macroscopic Examination Protocol

Initial Documentation

  • Record the weight and three-dimensional measurements of all specimens received, including ovaries, fallopian tubes, and any associated omentum. 1
  • Document specimen integrity immediately: assess whether the ovarian capsule or tubal serosa is intact or ruptured, as capsular rupture affects FIGO staging (IC1 for intraoperative rupture vs IC2 for preoperative rupture). 1

Surface Examination

  • Carefully inspect the ovarian surface for tumor involvement before opening the specimen, noting any surface excrescences, adhesions, or color changes. 1
  • Look for characteristic endometriosis features: white lesions, mixed-color lesions, red lesions, black lesions, or chocolate-colored cysts (endometriomas). 4, 5
  • Document the presence of adhesions, which are common in patients with prior surgery or endometriosis and may indicate ovarian remnant syndrome. 2

Serial Sectioning Technique

  • Perform serial sectioning at 1 cm intervals along the greatest diameter of all ovarian lesions to ensure adequate sampling. 1
  • Pay particular attention to white and mixed-color lesions, as these have the highest frequency of histologically confirmed endometriosis (76% for mixed-color lesions). 5
  • Measure and document lesion dimensions: lesions >5 mm wide or deep are more likely to be endometriosis than smaller lesions. 4

Specific Lesion Characteristics to Document

Endometriosis-Related Features

  • Document lesion color systematically: black, red, white, mixed-color, or endometriomas, as white and mixed-color lesions are more frequently confirmed as endometriosis histologically. 4, 5
  • Measure lesion depth and width: lesions deeper than 5 mm or wider than 5 mm have higher likelihood of being endometriosis. 4
  • Note lesion location: cul-de-sac (64%), utero-sacral ligaments (68%), and ovarian fossa (70%) are the most common sites. 5
  • Identify endometriomas: these appear as cysts with chocolate-colored fluid and homogeneous content, and those deeper than 1 cm are almost always histologically confirmed endometriosis. 4

Atypical Features Requiring Extra Attention

  • Look for architectural atypia (hyperplasia-type changes) in endometriotic tissue, as this is associated with higher risk of EAOC and is more commonly found in patients with ovarian cancer (88.9% vs 71.4% for cellular atypia alone). 3
  • Document any solid components, papillary projections, or mural nodules within cystic lesions, as these suggest possible malignant transformation. 6
  • Note the presence of multiple endometriotic lesions, as associated ovarian endometrioma is a marker for more severe disease with mean 2.51 lesions vs 1.64 without endometrioma. 7

Sampling Strategy

Standard Sampling

  • Submit multiple well-directed samples from all ovarian lesions (one block per centimeter along the greatest diameter). 1
  • Sample any extra-ovarian spread and all routine biopsies taken during surgical staging. 1
  • For grossly negative omentum, take 4-6 blocks in patients with ovarian carcinoma or borderline tumors. 1

Enhanced Sampling for High-Risk Cases

  • In patients with prior endometriosis, sample all suspicious areas including subtle red or white lesions, as 60% of patients with only subtle lesions have at least one lesion positive for endometriosis. 5
  • Carefully examine areas of adhesions or fibrosis for ovarian remnant tissue in patients with prior bilateral salpingo-oophorectomy. 2
  • Submit additional blocks from areas showing architectural complexity or hyperplastic changes in endometriotic tissue. 3

Critical Pitfalls to Avoid

Common Errors

  • Do not dismiss subtle red or white lesions as insignificant—58% of these contain endometriosis histologically. 5
  • Do not assume black lesions are always endometriosis—they are actually less frequently confirmed histologically than white or mixed-color lesions. 4, 5
  • Do not overlook small lesions in patients with prior endometriosis, as even lesions <5 mm may represent significant pathology. 4

Special Considerations

  • In patients with neoadjuvant chemotherapy, recognize that tumor appearance may be significantly altered, making typing and grading difficult; increased sampling may be necessary. 1
  • When ovarian tissue cannot be identified in a patient with prior surgery, consider ovarian remnant syndrome and carefully examine all fibrotic or adhesive tissue. 2
  • If architectural atypia is identified in endometriosis, flag this for the pathologist as it carries higher risk for EAOC than cellular atypia alone. 3

Fallopian Tube Examination

Complete Tubal Assessment

  • Make a careful effort to identify the fallopian tube in all cases, as the presence or absence of serous tubal intraepithelial carcinoma (STIC) determines whether a high-grade serous carcinoma is classified as tubal vs ovarian primary. 1
  • Examine both fimbrial and non-fimbrial portions completely to exclude STIC before classifying as primary peritoneal carcinoma. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Ovarian remnant syndrome.

Clinical obstetrics and gynecology, 2006

6
Guideline

Ultrasonographic Characteristics of Endometriomas

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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