Ovary and Peritoneal Washings

  • Kyle C. Strickland
Part of the Practical Anatomic Pathology book series (PAP)


This chapter addresses common questions about the cytology of ovarian lesions and technical aspects of ovarian aspiration and peritoneal washings. Aspiration of small ovarian masses and cysts is an uncommon technique used to evaluate adnexal lesions in nonsurgical candidates or grossly benign cysts in women of reproductive age. Primary ovarian lesions are more often sampled by fine-needle aspiration (FNA) and core biopsy in cases of detectable abdominal metastases or pelvic masses of unknown origin. Thus, attention is given to both the clinicopathologic and cytologic features of ovarian lesions. The second part of this chapter will address technical aspects of peritoneal washings, specimens that are routinely obtained in the setting of gynecologic and other abdominal malignancies to exclude occult intraperitoneal disease.


Ovary Peritoneal washings Ovarian cancer Uterine cancer Serous carcinoma Serous neoplasia Endometrial adenocarcinoma Endometrioid adenocarcinoma Mucinous adenocarcinoma Sex cord-stromal tumor Germ cell tumor Abdominal washings Fine-needle aspiration Cytology 





Adult granulosa cell tumor


American Joint Committee on Cancer


Bilateral salpingo-oophorectomy


Carcinoembryonic antigen




Estrogen receptor


International Federation of Gynecology and Oncologists


Fine-needle aspiration


Human chorionic gonadotropin


Hemosiderin-laden macrophage




Juvenile granulosa cell tumor


Progesterone receptor


World Health Organization


  1. 1.
    Kjellgren O, Angström T, Bergman F, Wiklund DE. Fine-needle aspiration biopsy in diagnosis, and classification of ovarian carcinoma. Cancer. 1971;28(4):967–76. Accessed 11 Feb 2018.CrossRefGoogle Scholar
  2. 2.
    Angstrom T, Kjellgren O, Bergman F. The cytologic diagnosis of ovarian tumors by means of aspiration biopsy. Acta Cytol. 1972;16(4):336–41. Accessed 11 Feb 2018.PubMedGoogle Scholar
  3. 3.
    Khaw KT, Walker WJ. Ultrasound guided fine needle aspiration of ovarian cysts: diagnosis and treatment in pregnant and non-pregnant women. Clin Radiol. 1990;41(2):105–8. Scholar
  4. 4.
    Ateş O, Karakaya E, Hakgüder G, Olguner M, Seçil M, Akgür FM. Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage. J Pediatr Surg. 2006;41(10):e9–e11. Scholar
  5. 5.
    Oleszczuk J, Leszczyńska-Gorzelak B, Kamiński K, Baranowski W. Evaluation of ovarian cysts by means of transabdominal fine needle aspiration or laparotomy in pregnant women. Ginekol Pol. 2002;73(4):367–370. Accessed 11 Feb 2018.
  6. 6.
    CRESPIGNY LC, ROBINSON HP, DAVOREN RAM, FORTUNE D. The “simple” ovarian cyst: aspirate or operate? BJOG An Int J Obstet Gynaecol. 1989;96(9):1035–9. Scholar
  7. 7.
    Trimbos JB, Hacker NF. The case against aspirating ovarian cysts. Cancer. 1993;72(3):828–31.<828::AID-CNCR2820720331>3.0.CO;2-T.CrossRefPubMedGoogle Scholar
  8. 8.
    Duke D, Colville J, Keeling A, Broe D, Fotheringham T, Lee MJ. Transvaginal aspiration of ovarian cysts: long-term follow-up. Cardiovasc Intervent Radiol. 2006;29(3):401–5. Scholar
  9. 9.
    Koutlaki N, Nikas I, Dimitraki M, et al. Transvaginal aspiration of ovarian cysts: our experience over 121 cases. Minim Invasive Ther Allied Technol. 2011;20(3):155–9. Scholar
  10. 10.
    Nikolaou M, Adonakis G, Zyli P, et al. Transvaginal ultrasound-guided aspiration of benign ovarian cysts. J Obstet Gynaecol (Lahore). 2014;34(4):332–5. Scholar
  11. 11.
    Higgins RV, Matkins JF, Marroum M-C. Comparison of fine-needle aspiration cytologic findings of ovarian cysts with ovarian histologic findings. Am J Obstet Gynecol. 1999;180(3):550–3. Scholar
  12. 12.
    Bonilla-Musoles F, Ballester MJ, Simon C, Serra V, Raga F. Is avoidance of surgery possible in patients with perimenopausal ovarian tumors using transvaginal ultrasound and duplex color Doppler sonography? J Ultrasound Med. 1993;12(1):33–9. Scholar
  13. 13.
    Geier GR, Strecker JR. Aspiration cytology and E2 content in ovarian tumors. Acta Cytol. 1981;25(4):400–6. Accessed 11 Feb 2018.PubMedGoogle Scholar
  14. 14.
    Moran O, Menczer J, Ben-Baruch G, Lipitz S, Goor E. Cytologic examination of ovarian cyst fluid for the distinction between benign and malignant tumors. Obstet Gynecol. 1993;82(3):444–6. Accessed 11 Feb 2018.PubMedGoogle Scholar
  15. 15.
    Zhou AG, Levinson KL, Rosenthal DL, VandenBussche CJ. Performance of ovarian cyst fluid fine-needle aspiration cytology. Cancer Cytopathol. 2018;126(2):112–21. Scholar
  16. 16.
    Sevelda P, Dittrich C, Salzer H. Prognostic value of the rupture of the capsule in stage I epithelial ovarian carcinoma. Gynecol Oncol. 1989;35(3):321–2. Scholar
  17. 17.
    Dembo AJ, Davy M, Stenwig AE, Berle EJ, Bush RS, Kjorstad K. Prognostic factors in patients with stage I epithelial ovarian cancer. Obstet Gynecol. 1990;75(2):263–73. Accessed 11 Feb 2018.PubMedGoogle Scholar
  18. 18.
    Trimbos JB, Schueler JA, van Lent M, Hermans J, Fleuren GJ. Reasons for incomplete surgical staging in early ovarian carcinoma. Gynecol Oncol. 1990;37(3):374–7. Scholar
  19. 19.
    Sjovall K, Nilsson B, Einhorn N. Different types of rupture of the tumor capsule and the impact on survival in early ovarian carcinoma. Int J Gynecol Cancer. 1994;4(5):333–6. Scholar
  20. 20.
    Zanetta G, Trio D, Lissoni A, et al. Early and short-term complications after US-guided puncture of gynecologic lesions: evaluation after 1,000 consecutive cases. Radiology. 1993;189(1):161–4. Scholar
  21. 21.
    Livraghi T, Damascelli B, Lombardi C, Spagnoli I. Risk in fine-needle abdominal biopsy. J Clin Ultrasound. 1983;11(2):77–81. Scholar
  22. 22.
    Spanos WJ. Preoperative hormonal therapy of cystic adnexal masses. Am J Obstet Gynecol. 1973;116(4):551–6. Scholar
  23. 23.
    Brown DL, Doubilet PM, Miller FH, et al. Benign and malignant ovarian masses: selection of the most discriminating gray-scale and Doppler sonographic features. Radiology. 1998;208(1):103–10. Scholar
  24. 24.
    Mulvany N, Ostör A, Teng G. Evaluation of estradiol in aspirated ovarian cystic lesions. Acta Cytol. 1995;39(4):663–8. Accessed 11 Feb 2018.PubMedGoogle Scholar
  25. 25.
    Allias F, Chanoz J, Blache G, Thivolet-Bejui F, Vancina S. Value of ultrasound-guided fine-needle aspiration in the management of ovarian and paraovarian cysts. Diagn Cytopathol. 2000;22(2):70–80.<70::AID-DC3>3.0.CO;2-J.CrossRefPubMedGoogle Scholar
  26. 26.
    Stanley MW, Horwitz CA, Frable WJ. Cellular follicular cyst of the ovary: fluid cytology mimicking malignancy. Diagn Cytopathol. 1991;7(1):48–52. Scholar
  27. 27.
    Nuñez C, Diaz JI, Selvaggi S. Ovarian follicular cysts: a potential source of false positive diagnoses in ovarian cytology. Diagn Cytopathol. 1992;8(5):532–7. Scholar
  28. 28.
    Wojcik EM, Selvaggi SM. Fine-needle aspiration cytology of cystic ovarian lesions. Diagn Cytopathol. 1994;11(1):9–14. Scholar
  29. 29.
    Zaloudek CJ, Garg K. Tumors of the female genital tract: ovary, fallopian tube, and broad and round ligaments. In: Fletcher CDM, editor. Diagnostic histopathology of tumors 2. 4th ed. Philadelphia, PA: Elsevier; 2013. p. 658–761.Google Scholar
  30. 30.
    Nucci M, Oliva E. Diagnostic pathology: gynecological. 1st ed. Philadelphia, PA: Amirsys; 2014.Google Scholar
  31. 31.
    Kurman R, Carcangiu M, Herrington C, Young R, editors. WHO classification of tumours of female reproductive organs. 4th ed. Lyon: IARC Press; 2014.Google Scholar
  32. 32.
    Malpica A, Deavers MT, Lu K, et al. Grading ovarian serous carcinoma using a two-tier system. Am J Surg Pathol. 2004;28(4):496–504. Accessed 21 Feb 2018.CrossRefGoogle Scholar
  33. 33.
    Neely Larry Copeland EJ, Gershenson DM, Taylor Wharton J, Sneige N, Edwards CL, Rutledge FN. Microscopic disease at second-look laparotomy in advanced ovarian cancer. Accessed 18 Feb 2018.
  34. 34.
    Cancer Genome Atlas Research Network. Integrated genomic analyses of ovarian carcinoma. Nature. 2011;474(7353):609–15. Scholar
  35. 35.
    Cole AJ, Dwight T, Gill AJ, et al. Assessing mutant p53 in primary high-grade serous ovarian cancer using immunohistochemistry and massively parallel sequencing. Sci Rep. 2016;6(1):26191. Scholar
  36. 36.
    Singer G, Stöhr R, Cope L, et al. Patterns of p53 mutations separate ovarian serous borderline tumors and low- and high-grade carcinomas and provide support for a new model of ovarian carcinogenesis. Am J Surg Pathol. 2005;29(2):218–24. Scholar
  37. 37.
    Okuda T, Otsuka J, Sekizawa A, et al. p53 mutations and overexpression affect prognosis of ovarian endometrioid cancer but not clear cell cancer. Gynecol Oncol. 2003;88(3):318–25. Scholar
  38. 38.
    Ho ES, Lai CR, Hsieh YT, et al. p53 mutation is infrequent in clear cell carcinoma of the ovary. Gynecol Oncol. 2001;80(2):189–93. Scholar
  39. 39.
    Tashiro H, Isacson C, Levine R, Kurman RJ, Cho KR, Hedrick L. p53 gene mutations are common in uterine serous carcinoma and occur early in their pathogenesis. Am J Pathol. 1997;150(1):177–85. Accessed 18 Feb 2018.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Lax SF. Molecular genetic pathways in various types of endometrial carcinoma: from a phenotypical to a molecular-based classification. Virchows Arch. 2004;444(3):213–23. Scholar
  41. 41.
    Fadare O, Gwin K, Desouki MM, et al. The clinicopathologic significance of p53 and BAF-250a (ARID1A) expression in clear cell carcinoma of the endometrium. Mod Pathol. 2013;26(8):1101–10. Scholar
  42. 42.
    DeLair D, Oliva E, Köbel M, Macias A, Gilks CB, Soslow RA. Morphologic spectrum of immunohistochemically characterized clear cell carcinoma of the ovary. Am J Surg Pathol. 2011;35(1):36–44. Scholar
  43. 43.
    Lee KR, Scully RE. Mucinous tumors of the ovary: a clinicopathologic study of 196 borderline tumors (of intestinal type) and carcinomas, including an evaluation of 11 cases with “pseudomyxoma peritonei”. Am J Surg Pathol. 2000;24(11):1447–64. Accessed 21 Feb 2018.CrossRefGoogle Scholar
  44. 44.
    Lee KR, Young RH. The distinction between primary and metastatic mucinous carcinomas of the ovary: gross and histologic findings in 50 cases. Am J Surg Pathol. 2003;27(3):281–92. Accessed 21 Feb 2018.CrossRefGoogle Scholar
  45. 45.
    Vang R, Gown AM, Wu L-S-F, et al. Immunohistochemical expression of CDX2 in primary ovarian mucinous tumors and metastatic mucinous carcinomas involving the ovary: comparison with CK20 and correlation with coordinate expression of CK7. Mod Pathol. 2006;19(11):1421–8. Scholar
  46. 46.
    Moh M, Krings G, Ates D, Aysal A, Kim GE, Rabban JT. SATB2 expression distinguishes ovarian metastases of colorectal and appendiceal origin from primary ovarian tumors of mucinous or endometrioid type. Am J Surg Pathol. 2016;40(3):419–32. Scholar
  47. 47.
    Shah SP, Köbel M, Senz J, et al. Mutation of FOXL2 in granulosa-cell tumors of the ovary. N Engl J Med. 2009;360(26):2719–29. Scholar
  48. 48.
    Zhao C, Vinh TN, Mcmanus K, Dabbs D, Barner R, Vang R. Identification of the most sensitive and robust immunohistochemical markers in different categories of ovarian sex cord-stromal tumors. Accessed 1 Feb 2018.
  49. 49.
    Ramos P, Karnezis AN, Craig DW, et al. Small cell carcinoma of the ovary, hypercalcemic type, displays frequent inactivating germline and somatic mutations in SMARCA4. Nat Genet. 2014;46(5):427–9. Scholar
  50. 50.
    FIGO Committee on Gynecologic Oncology. Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia. Int J Gynaecol Obstet. 2009;105(1):3–4. Accessed 16 Feb 2018.CrossRefGoogle Scholar
  51. 51.
    Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet. 2009;105(2):103–4. Accessed 16 Feb 2018.CrossRefGoogle Scholar
  52. 52.
    Havrilesky LJ, Cragun JM, Calingaert B, et al. The prognostic significance of positive peritoneal cytology and adnexal/serosal metastasis in stage IIIA endometrial cancer. Gynecol Oncol. 2007;104(2):401–5. Scholar
  53. 53.
    Sonoda Y, Zerbe M, Smith A, Lin O, Barakat RR, Hoskins WJ. High incidence of positive peritoneal cytology in low-risk endometrial cancer treated by laparoscopically assisted vaginal hysterectomy. Gynecol Oncol. 2001;80(3):378–82. Scholar
  54. 54.
    Zullo F, Palomba S, Falbo A, et al. Laparoscopic surgery vs laparotomy for early stage endometrial cancer: long-term data of a randomized controlled trial. Am J Obstet Gynecol. 2009;200(3):296.e1–9. Scholar
  55. 55.
    Prat J. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynecol Obstet. 2014;124(1):1–5. Scholar
  56. 56.
    Heintz APM, Odicino F, Maisonneuve P, et al. Carcinoma of the ovary. Int J Gynecol Obstet. 2003;83(S1):135–66. Scholar
  57. 57.
    Fadare O, Mariappan MR, Hileeto D, Wang S, McAlpine JN, Rimm DL. Upstaging based solely on positive peritoneal washing does not affect outcome in endometrial cancer. Mod Pathol. 2005;18(5):673–80. Scholar
  58. 58.
    Anastasiadis PG, Romanidis KN, Polichronidis A, Koutlaki NG, Tamiolakis D, Simopoulos K. The contribution of rapid intraoperative cytology to the improvement of ovarian cancer staging. Gynecol Oncol. 2002;86(3):244–9. Accessed 17 Feb 2018.CrossRefGoogle Scholar
  59. 59.
    Fadare O, Mariappan MR, Wang S, Hileeto D, Mcalpine J, Rimm DL. The histologic subtype of ovarian tumors affects the detection rate by pelvic washings. Cancer. 2004;102(3):150–6. Scholar
  60. 60.
    Bentrem D, Wilton A, Mazumdar M, Brennan M, Coit D. The value of peritoneal cytology as a preoperative predictor in patients with gastric carcinoma undergoing a curative resection. Ann Surg Oncol. 2005;12(5):347–53. Scholar
  61. 61.
    Kanellos I, Demetriades H, Zintzaras E, Mandrali A, Mantzoros I, Betsis D. Incidence and prognostic value of positive peritoneal cytology in colorectal cancer. Dis Colon Rectum. 2003;46(4):535–9. Scholar
  62. 62.
    Yamamoto S, Akasu T, Fujita S, Moriya Y. Long-term prognostic value of conventional peritoneal cytology after curative resection for colorectal carcinoma. Jpn J Clin Oncol. 2003;33(1):33–7. Scholar
  63. 63.
    Castillo CF-D, Rattner DW, Warshaw AL. Further experience with laparoscopy and peritoneal cytology in the staging of pancreatic cancer. Br J Surg. 1995;82(8):1127–9. Scholar
  64. 64.
    Makary MA, Warshaw AL, Centeno BA, Willett CG, Rattner DW, Castillo CF. Implications of peritoneal cytology for pancreatic cancer management. Arch Surg. 1998;133(4):361. Scholar
  65. 65.
    Pretorius RG, Lee KR, Papillo J, Baker S, Belinson J. False-negative peritoneal cytology in metastatic ovarian carcinoma. Obstet Gynecol. 1986;68(5):619–23. Accessed 17 Feb 2018.PubMedGoogle Scholar
  66. 66.
    Cheng L, Wolf NG, Rose PG, Rodriguez M, Abdul-Karim FW. Peritoneal washing cytology of ovarian tumors of low malignant potential: correlation with surface ovarian involvement and peritoneal implants. Acta Cytol. 1998;42(5):1091–4. Accessed 17 Feb 2018.CrossRefGoogle Scholar
  67. 67.
    Cibas ES. Peritoneal washings. In: Cibas ES, Ducatman BS, editors. Cytology: diagnostic principles and clinical correlates. 4th ed. Philadelphia, PA: Elsevier; 2014. p. 155–69.Google Scholar
  68. 68.
    Sneige N, Fernandez T, Copeland LJ, Katz RL. Müllerian inclusions in peritoneal washings. Potential source of error in cytologic diagnosis. Acta Cytol. 1986;30(3):271–6. Accessed 17 Feb 2018.PubMedGoogle Scholar
  69. 69.
    Slade AJ, Dieterich M, Sturgis CD. Eosinophilic metaplastic atypia in exfoliated cells of ovarian endometriosis: a potential cytodiagnostic pitfall in peritoneal fluids. Diagn Cytopathol. 2004;31(2):123–5. Scholar
  70. 70.
    Sidawy MK, Silverberg SG. Endosalpingiosis in female peritoneal washings: a diagnostic pitfall. Int J Gynecol Pathol. 1987;6(4):340–6. Accessed 17 Feb 2018.CrossRefGoogle Scholar
  71. 71.
    Sams VR, Benjamin E, Ward RH. Ectopic pancreas. A cause of false-positive peritoneal cytology. Acta Cytol. 1990;34(5):641–4. Accessed 17 Feb 2018.PubMedGoogle Scholar
  72. 72.
    Jacques SM, Selvaggi SM. Multiple peritoneal cytologies collected during laparotomy for gynecologic malignancy. Diagn Cytopathol. 1991;7(5):482–6. Scholar
  73. 73.
    Soslow RA. Histologic subtypes of ovarian carcinoma. Int J Gynecol Pathol. 2008;27(2):161–74. Scholar
  74. 74.
    Zhang Y, Garcia-Buitrago MT, Koru-Sengul T, Schuman S, Ganjei-Azar P. An immunohistochemical panel to distinguish ovarian from uterine serous papillary carcinomas. Int J Gynecol Pathol. 2013;32(5):476–81. Scholar
  75. 75.
    Kounelis S, Kapranos N, Kouri E, Coppola D, Papadaki H, Jones MW. Immunohistochemical profile of endometrial adenocarcinoma: a study of 61 cases and review of the literature. Mod Pathol. 2000;13(4):379–88. Scholar
  76. 76.
    Yemelyanova A, Vang R, Kshirsagar M, et al. Immunohistochemical staining patterns of p53 can serve as a surrogate marker for TP53 mutations in ovarian carcinoma: an immunohistochemical and nucleotide sequencing analysis. Mod Pathol. 2011;24(9):1248–53. Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Kyle C. Strickland
    • 1
  1. 1.Department of PathologyDuke University Medical CenterDurhamUSA

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