Accuracy of Frozen Section in Borderline Ovarian Tumor

Accuracy of Frozen Section in Borderline Ovarian Tumor Abstract Borderline ovarian tumor or low malignant tumor present in 10-15% of all ovarian cancers, they usually affect younger women and they have favorable prognosis even with conservative surgery, in which fertility can be preserved. Lack of reliable diagnostic tool to indicate the type of malignancy before surgery or at the time of surgery make the borderline ovarian tumor one of the most controversial topics of gynecology malignancy. This leads to many overtreatment cases with radical surgery or undertreatment with conservative surgery with the higher rate of overtreatment compared to undertreatment. In this review article, we extensively searched for all reported data regarding the accuracy of frozen section in borderline ovarian tumor and compared the results. Our literature search and reviewing the result of 6 studies, which specifically considered the accuracy of frozen section in borderline ovarian tumors, gave us an accuracy of 60% with an agreement between final pathology and frozen section results. 24.5% of under-diagnosed cases where malignant interpreted to benign and 4.9% over-diagnosed cases where benign tumor considered as a malignant. Frozen section is a reliable tool to exclude benign tumor from borderline and malignant but under-diagnosed percentage is higher than to be accepted for a reliable diagnostic method. There are limitations in this review included the low number of enrolled cases, different time of diagnosis and different countries, which did not have similar criteria and classification. Introduction For the first time in 1929, Taylor described the borderline ovarian tumor (BOT) or low malignant tumor [1]. About 10-15% of all ovarian cancers are BOT. They have very interesting histological behavior. Epithelial cell stratification, increased mitotic activity and nuclear atypia are some features of malignancy that present in borderline tumor. They lack the invasion into the stroma and they usually affect younger women and have a favorable prognosis (2). However small percentage, which are invasive and classified in advanced stage are associated with poor prognosis and recurrence rate of about 1-50% (3). Histologically BOTs are classified based on their epithelial characteristics as serous, mucinous, endometrioid, clear cell or Brenner tumors. Their different histologic type plays an important role in their clinical presentation, thus it is very important to determine the cell type before assessment of BOTs [4-6]. Staging is based on International Federation of Gynecology and Obstetrics (FIGO) staging system for ovarian carcinoma. Review of literature indicated very interesting controversy in distribution of BOTs based on the geographic region. In western country USA and Europe, the leading histological type of BOTs reported as serous (7-9). Interestingly, studies from Korea and Japan have showed that mucinous type was the most common one (10-11). Nevertheless, limited number of patients in these studies did not help to come to the conclusion based on geographic area. Surgery is a standard of care to treat BOTs. Determinant factors that help to choose the surgical methods including patients’ age, fertility status and most importantly the histological characteristic of the tumor. Two standard methods worldwide are used in order to treat the BOTs, conservative or radical surgery. Borderline tumors have favorable prognosis even when they are treated with conservative method of surgery. Despite their benign behavior, the treatment of borderline tumor has been more aggressive just because they are regarded as a subset of carcinoma conservatively. Choosing and applying the correct surgery method is vitally important since patient fertility should be preserved when a conservative surgery is chosen as a method of surgery. Patients benefit from conservative surgery, if the tumor has not invaded into the stroma. In contrast, malignant epithelial neoplasm are needed to be treated more aggressively with radical surgery. Therefore, it is critically impo rtant to detect the right histology stage of the tumor at the time of surgery. An accurate test will have a golden value in these patients because it can avoid overtreatment by radical surgery and save the patient fertility when it is on early stage. On the other hand, it would not lead to catastrophic underestimation of tumor when it is on advanced stage (12). Preoperative imaging and tumor markers are usually used to estimate the characteristic of these tumors, but what is obtained from these methods are limited (13, 14). Most of the time, the decision should be made at the time of surgery in case of disseminated malignancy. Earlier stage of tumor FIGO stage 1, 2 are controversial ones. Preliminary diagnosis can be made based on cytology but tissue biopsy is generally the only definitive available diagnostic tool. Intraoperative frozen section can be an alternative to make the diagnosis intra-operatively. Frozen section as a diagnostic tool is widely used to detect the staging of the tumor. Therefore, the right decision on the surgical path with this method not only gives us information about the malignancy but also can report presence of metastases. Accuracy of frozen section has been reported to be good in terms of malignant and benign tumors but its reliability in BOT has not been investigated sufficiently to be statically significant to be used as a diagnostic tool (15). Material and methods In this review article, we extensively search for all reported data regarding the accuracy of frozen section in BOT and compared the results. In order to write this review, we did an extensive search on Medline, preliminary search words were borderline ovarian tumor and frozen section, borderline and borderline ovarian tumor. Finally, we found 30 articles, which investigated the accuracy of frozen section in ovarian tumor, but only 6 of them reviewed in this study (18-23) because other studies was not evaluated the accuracy of frozen section in borderline ovarian tumor or it was evaluated in subgroups. We looked at accuracy of test in all the studies individually. All data were pooled and overall accuracy, over-diagnosed and under-diagnosed then calculated. Discussion Gultekin and colleagues retrospectively evaluated the 82 cases diagnosed with BOT at their clinic in Izmir, Turkey between 1995 and 2007. They compared the result of frozen sections with permanent paraffin section. Their data showed the 69.5% rate of correct diagnosis, 1.2% over-diagnostic rate and 29.3% under-diagnostic rate (18) Tempfer et al. were looked at 96 cases of BOT between 1995 and 2007. The result of frozen section and paraffin were compared in 71.9% of cases, which accounted for 69 of 96 the result of FS and definitive histology were the same. Results showed an overall sensitivity of 75% and PPV of 94.5%. Twenty-eight percentage (27 out of 96) were under-diagnosed and none over-diagnosed has reported (19). Kayikcioglu and colleagues conducted their study on thirty-three patients evaluated based on frozen sections between February 1992 and December 1997. The correlation between frozen section diagnosis and final pathological examination was 72.7% (24/33). Nine percentage (2/22) had inaccurate results in the serous type and 36.6% (4/11) in the mucinous type. They found that the sensitivity and specificity of frozen section diagnosis were 86.95 and 57.14%, respectively. They concluded that frozen section evaluation in identifying a borderline ovarian malignancy was accurate enough to exclude the(20) K. Houck, et al review between 1980 and 1998 at Massachusetts General Hospital found by reviewing 140 cases in their study, which had 60% consistency with frozen section and final pathology results. 10.7% over-diagnosed and 29.3% under-diagnosed cases were reported in their study whereas the positive predictive value of borderline by frozen section was 89.3%. Another study conducted at University of Pennsylvania by Menzin and colleagues evaluating frozen section and final pathology results of 48 patients between 1986 and 1993. In all of these 48 cases, frozen section was suggested the BOT. Their analysis showed 27.1% under-diagnosed and none of the final pathology results was benign while frozen section suggested borderline. They concluded that frozen section was accurate in excluding the benign tumor but when it came to distinguish between borderline and invasive tumor it was not reliable (22). Kim and colleagues reviewed all pathology reports with BTO in both frozen and permanent section analyses between 1994 and 2008 at Seoul St. Marys Hospital. Similar to other studies, they have compared the results of frozen section and permanent histology. They showed 62.4% agreement between frozen section and permanent histology results, which accounted for 63 of 76 cases. They had 76 cases of BOT diagnosed by frozen section. Eight has been under-diagnosed and 5 over-diagnosed, which was 10.5% and 6.6% respectively. 50% sensitivity and 80% specificity was reported in mentioned study (23). Summary of all above mentioned studies and pooled data are shown on table .1 In addition to the accuracy of frozen section compared to the permanent histology results, some other variables have been evaluated in some of these studies. Some of them examined serous type and mucinous type of the tumor despite the controversial result. One concluded that serous type had more missing diagnosed cases (20) while other results showed that tumors other than serous were more likely to be missed (21). Expert pathologist was another controversial variable expressed in Gultekin et al in their research and some other retrospective reviews showed that expert pathologist and accuracy of frozen section diagnosis were parallel (18). Menzin and Tempfer studies have shown no difference in expertise of pathologist regarding accuracy of frozen section.(19,22) Conclusion It is important to choose the right surgical policy at pelvic mass operation, especially when it comes to BOT, which have the favorable prognosis even with conservative surgery due to preservation of fertility in younger women. There is no accurate diagnostic method to evaluate the ovarian tumor, before or at the time of surgery. Frozen section analysis can provide valuable hiftological information in term of malignant ovarian mass. However, the overall diagnostic performance for BOTs has not been reported satisfactory in any study. As it is shown in table 1, according to previous published data FS has under-diagnostic rate of 24.5%. It showed an excellent result in term of excluding the benign tumor. These result have its own limitations. All the published data were based on retrospective studies, performed on different time frame with different diagnostic criteria and various recommendations. Moreover, they were from different area, which might cause some bias. Number of enrolled cases were limited in addition to different inclusion and exclusion criteria in each study. Although most of the result were statistically acceptable with p-value of

King Epsilon

As a student, I think that It Is more enjoyable if a teacher explains the lessons In a certain subject with some twists or making stories that would hook the interests of a student. It is not only for students to be interested but also the information is easy to understand and remember. Humor helps things suck In our minds. The story teaching real analysis in the land of making is a great idea of Julie Barnes. Teachers who tell good stories can make subject interesting or easier to relate to. It helps the student to do better In the exams Like what the students of Julie Barnes experienced.She said that roughly 90% of her students told her that the story had made the material much easier for them to understand, remember, and use. So every year, she used the story and she always got the same positive results. It helps us to understand some definitions found in a standard introductory real analysis. The story had made learning calculus simple because it is stated in a child friendly way . The author used the deferent symbols In calculus as Its character In the story The equations there are easy to remember.For Students it is more interesting eating tales and stories more than memorizing all the equations and definitions in calculus without twists. When you read tales or stories, you can easily remember the equations by recalling the story of King Epsilon. Julie Barnes is Just so great. It's not easy to make a tale or a story especially when you are relating It to math definitions or a certain equations. It Is an Informative story that teaches us a lot of things about calculus. The story was about a certain tale of convergence in the real line. There was a king named King Epsilon who lived In the Castle Analysis.HIS wife named Queen Delta already died. There are many citizens living on a subset of a real line. In the country, there was a caste system, and everyone is ranked. The king himself would not allow them to call him by a natural number. He was never part of the natural order of things. King Epsilon had a collection of laws of the kingdom. It is a brilliant idea to a lot of problems that the citizens of the real line have dealt with for centuries. He had a Rule 1 which is the convergence day. During convergence day, King Epsilon would decree the most citizens must travel o a certain place.King Epsilon realized that it is very important for all of his decrees to be obeyed. So he declared that If the subjects didn't comply with a convergence day there would be an extra tax imposed on all the citizens. He asked some of his advisors about this and came up with the following observation. There was never a need to Impose the tax for noncompliance of Rule 1 . HIS Rule 2 Is Cauchy days. He realized that having too many convergence days would actually be harder on the citizens on the real line than not having enough convergence days. He met a young authenticate named Cauchy came to King Epsilon with an Idea.He suggested that instead of specifyin g a town and having a convergence day, these could be simply be days when the citizens have to get together. For any given distance epsilon the lower class citizens would have to be within epsilon of everyone else. There comes this year of hurricanes. It was not uncommon for king epsilon to order mass evacuations from the real line into a parallel universe. King Epsilon proposed was the Hurricane Evacuation Policy where the government must find a parallel universe to evacuate as soon as possible. All citizens must travel to the new world on magic carpets via a function.Once a functions is chosen, there are two things are of great importance to every citizen: The size of the warp zone that needs to be traveled through the entire world and how magic carpets are measured. There are 4 cases. Case 1 is under perfect conditions, average citizens should be sent to safety in a continuous fashion. Case 2 is the Police officers, rescue workers, and medical personnel are sent wherever they are needed, even if this forces them to travel together. Case 3 is if the function moves in a uniformly continuous fashion, the overspent will mass-produce the magic carpets.Lastly, the Case 4 Convergence days are not affected by evacuations. King Epsilon was a great king who is very kind and an intelligent, brave man. His love for Queen Delta is definitely wonderful for he has named a certain area to his queen so he could remember her all the time or whenever he went at that area of the country. Every character was really been a part of the calculus subject. The story doesn't have an ending. Maybe King himself will integrate new ideas into his current kingdom to help students with differentiation and integration.

People at Work Essay

There are many styles of management that produces different kinds of results. If not done right, it would either be too much or too little, bringing out effects such as being less creative, however efficient or being more creative but less efficient. Wanting to bring out the best of our employees, innovation in management tends to analyze workforce who are also more adept to technical innovations and easy practical solutions. In a generation with ever changing attitudes who are attuned to the trends of society, it is also a must that old management styles are being updated and innovated. Philips Cooke (2006) described innovation in its simplest form as the transformation of new creative ideas into new goods and services. It is not only focused on products and new technological gadgets, innovation are also most effective when applied to management. With innovative management applied in a company, results can be seen in effectiveness, production, excellence, spirited positioning, and market share. This is why, in management innovation, Emotional Intelligence or Emotional Quotient (EQ) has now become a very critical factor in the workplace and top management today because more than just smart heads and high IQ people, companies and businesses today takes more than just desks, ledgers, machines and materials to make a business work. More than anything else, businesses need people. People are needed to make a company grow, people who are working together, not necessarily on the same department or in the same building, but people pulling together so that the organization operates efficiently and can continue running the business. But sometimes, people are being funny or uncooperative. They do not pull or group together, and sometimes fail to manage their full share of load. Thus, the question now is, how will we know that our managers possessed the ability of being a leader? Does he know how to properly handle people? Does he know how to develop new ideas and implement it effectively? How will we know in the first place that we have the manager we are looking for, or how can we develop such? Literature Review Globalization had brought out a steep competition for the market of goods and services everyday and it is management innovation that brings forth key factors for company’s future survival. (Cooke. P, 2006) According to Kira Fabrizio (2006), the world is currently entirely driven by technology. Additionally business existence routines are transforming rapidly. All the same, proper innovation management skills will always guarantee future survival of any given organization for a company or a firm cannot operate smoothly if not managed properly. Due to tough competition, companies always aim to satisfy customers by producing quality products and services. Chesbrough (2006), Simcoe. T, (2006) and Allen, & L. D. Evans. (1997) argued that for an innovation to be a success, correct discharge of the creative ideas already born is critical in any organization. As a matter of fact the creativity emanating from an employee and/or from a team of employees forms the basis for innovation. A successful innovation can not be attained by the Production of creative ideas alone but by correct implementation of those creative ideas to bring about new or improved product and/or service within the organization. For creative ideas to be generated there must be a room to try out the ideas emanating from the creative employees. This is usually achieved in a loose and flexible environment. Innovative work does not well with rules used for routine handling of an organization however these rules are supported by theory and practice. The efficiency of day to day within an organization requires stable routine (Sunbo & F. Gallouj, 2000). This is usually achieved in a stable controlled environment. The trick is to have a management that balances the factors that allow creativity while at the same time promoting effective operations of the organization (Utterback, M. 1994). Innovation normally occurs through a management system that allows for combination of many diverse players within any particular organization. (West, J, 2006). The player may include among others managers, supervisors, technicians, employees, and consultants. Research on social networks involved in the development of innovation process points out that successful innovation normally occurs near or at the primary interface of an organization and manufacturer. With these, O’Connor (2006) said that innovation process requires the inputs of all personnel of a particular company that is from the top executives to subordinate staffs. It may also require the expertise of a consultant who is normally outsourced. Existing Management Innovations Innovative approaches are assessed based on its impact upon its profitability. Through implementing strategic management approaches in ones company, the need for customer satisfaction will be met, not only locally but world wide. Currently, there are many innovative approaches to management, which needs top management support to be implemented properly. The new ISO 9000:2000 standards promote the adoption of a process approach when devising, implementing and improving a quality management system (QMS). PCL – Petts Consulting Ltd) This model of a quality management system approach acknowledge the facts that quality results are achieved by producing a company manual, complete with work procedures and work instructions, proper recording and keeping of quality records and tracking of inputs and outputs. The HACCP (Hazard Analysis of Critical Control Points) System is a systematic approach to the identification, assessment of risk and severity, and control of biological, chemical and physical hazards associated with a particular food production process or practice. When speaking of HACCP, it is always associated with food safety. By using and by being certified with this system, the customers of the company are always assured of the safe processing of food. CSR (Corporate Social Responsibility) is about how companies manage the business processes to produce an overall positive impact on society. (Baker, 2006) It is the balance between the companies performance in terms of products and services to satisfy its market, on how the company manage ,treats and train its workers, on how the company shows its concern to its environment and on how it shows concern to the surrounding community. Low Morale due to Ineffective Management These are few of management innovations that are putting a company ahead of others. Today, companies encountered dilemmas such that too much management which ceased to innovate, thus, bringing out to little or no impact or improvements to a company at all. The problem here is that, businesses need more efficient people, have an environment to let innovative people flourish, however, it wont be effective if management does not have the skills and abilities to develop new ideas effectively. Thus, the question now is, how will we know that our managers possessed the ability of being a leader? Does he know how to properly handle people? Does he know how to develop new ideas and implement it effectively? How will we know in the first place that we have the manager we are looking for, or how can we develop such? The management should be flexible enough to absorb the views of all stakeholders. Management is not always willing to accept new ideas. Most managers always want to remain in a comfortable zone. Too much management, which is commonly found in large organization, should understand innovative people. Modern executives’ definition of efficiency is operating business which can supply their customers with better products or services at lowered cost. Modern executives are forever asking questions which is more concerned in productivity and efficiency rather than employees self regard and self esteem. â€Å"How are we doing? †, â€Å"Is production going up? †, â€Å"Sales up? †, â€Å"Costs going down? † are just few of executives questions about efficiency clearly showing the classic ways of hierarchal management systems. This results to low self-esteem which has a very strong relationship with morale. The loss of self-confidence or a feeling of discouragement may also be caused by frustration, which in turn causes mental efficiency and creativity to be lowered. This situation was experienced by Oracle. Ashby and Miles (2002) cited Oracle who was facing crisis in June 1992. Its culture â€Å"win at any cost, the end always justify the means† caused low morale and its effects on day-to-day operations was out of control since employees no longer pay attention to rules either internally or with customers. Applying EQ for Effective Management Innovations Change of management structure especially for large businesses to accommodate innovation is very critical for an organization to remain competitive (Tidd, J et al 1997). The management system in place should be flexible enough to create room for creative ideas. The management should easily adapt to changes brought about by trends in technologies and human issues. The organization needs to be loose and flexible enough to allow room for creative new ideas. A tight management system hinders creativity. Management should also motivate employees by rewarding not only success but also failure. This is because you cannot produce good ideas without bad ones (Maguire, 1994). Further for innovation to be successful there is a need for key personnel who are primarily concerned with the development of new product or services. The complexity of the procedures and levels involved in the production of a new product can impact negatively on the success of an innovation. (Fabrizio. K, 2006) For the success of an innovation the key is to delegate a few personnel on that activity, as too many people are less innovative compared to a few people. The virtuous circle can also impact negatively on the development of an innovation. It follows the following steps such as organization reputation for innovation, attraction of creative people, organizational need for creativity and innovation, development of innovation product, willingness within the organization to accept new ideas, motivation of people within organization to reduce frustration, high morale and protection of creative people (Henry et al: 1991). This means that if one the above listed steps is missed then innovation would not be established. So if we ask, why is there a need to apply Emotional Intelligence (EQ) in management innovations? This is because Emotional Intelligence (EQ) is now more important and useful especially in businesses. It tends to analyze and identify why people do what they do, think as they do and think as they do; with their abilities, motives, disappointments, ambitions, queer streaks. The successful business person is almost always efficiency minded through and through whether he is the boss or not. He keeps a close eye on the efficiency, and the personal efficiency of those working with him. According to Herrera (2006) IQ is quickly losing ground to EQ when it comes to predicting success. Moreover, supervisors and executives are generally rated on still more EQ qualities such as winning cooperation, handling people, suitable use of language and accepting suggestions and criticisms. This proves that the higher the position you can attain the higher EQ qualities, tests and evaluation that you have passed. An employee with more promotional possibilities shows high EQ for higher executives take on more social responsibilities at each step on the way up. According to Bradberry, T. & Greaves, J. (2005a), 16 hours of work can make a person feel 465 emotions in a day with (2005b) 90% top performers tested to have high EQ and only 20% high EQ individuals being rated as low performers. Rather than IQ, companies and corporations now opt for high EQ individuals to work for them. This is because, high EQ employees are more productive, and have great job performance and good leaders. High EQ employees and leaders are worker-centered which had higher producing work groups. And as we all know, companies aims for high productions at low cost and less turnovers. Conclusion Management systems have a significant effect on the innovation process. A tight management system normally hinders creativity because it does not allow employees to express and generate innovative ideas. All the same for small organizations suppressed management approaches can increase abilities to innovate through less formal management structures facilitating rapid decision-making, which is facilitated by having to communicate the changes to members of the organization. For innovation process to be a success there should be a â€Å"slack† element in the management Structure. To balance between effective running of an organization and creativity the management should know what is best for routine work and what is best for innovative work. And with this, management innovation and creativity is best improved by applying EQ tools. Today, EQ ratings are almost always taken with high importance in a company. During a company’s periodic reviews of individual efficiency, the boss, supervisor or head of the company watch work ways and attitudes of employees. According to Laird and Laird (1979) employees are rated according to desirable qualities or social characteristics such as cooperation, communication and appearance. This shows that individual efficiency is not based on high IQ but rather based on the qualities of high EQ. Production is also influenced by the friendly interaction of members of a work group. An employee’s level of EQ is tied in with friendliness because it shapes its interaction of people towards each other. High EQ of employees encourage warm and friendly atmosphere in the work place. On the other hand, employees with low EQ will be cold and aloof towards its co-workers. This will hinder the productivity of a worker with low EQ and increase the rate of absenteeism, thus, absenteeism is an outcome of an employee with low EQ. With this, managers will think that unnecessary absence from work shows irresponsibility. The human emotions shape the interactions of people to each other. With the types of people in one company, considering warm or friendly and cold or aloof, those employees with high EQ will stand out and be more productive than the others.

End of Life Issues Essay - 800 Words

END OF LIFE ISSUE- YOU DECIDE With major advancement in medical treatments, it is now possible to keep a patient alive, which would not have been possible in former times. This has made end of life issue one of the most controversial issues in healthcare. Medical improvements have set the stage for ethical and legal controversies about not only the patient’s rights but also the family’s rights and the medical profession’s proper role. It is critical that any decision made in such situation is ethical and legal to preserve the rights of the patient and also protect the healthcare institution involved. It is very important when making decisions to discontinue treatments to make sure all other alternatives have been explored.†¦show more content†¦It is absolutely important that the institution or the courts determine whether Lydia is competent or not to make medical decisions so as not to violate her right to autonomy. If Lydia is found to be incompetent to make medical decisions; who should? The husband is her legal guardian so in this case, I think it is clear who has the legal right to act as Lydia’s proxy. According to research, in most states, unless the non incompetent patient previously designated a different decision maker, the spouse may act as the proxy. He/she together with the guidance of the physician may decide to withhold life-sustaining treatment (including in most states artificial nutrition and hydration) for a patient diagnosed to be in a terminal or irreversible condition. In all states, however, a patient’s legally recognized surrogate decision maker may direct that life-sustaining treatment not be provided if the surrogate can demonstrate by clear and convincing evidence that the patient would not want the treatment under present circumstances. Another very important issue that has to be determined is Lydia’s prognosis; that is the likely outcome of her current illness. 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