High concordance of malignant tissues across ultrasound-guided transvaginal tru-cut biopsy cores of ovarian lesions: a prospective feasibility study

High concordance of malignant tissues across ultrasound-guided transvaginal tru-cut biopsy cores of ovarian lesions: a prospective feasibility study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report High concordance of malignant tissues across ultrasound-guided transvaginal tru-cut biopsy cores of ovarian lesions: a prospective feasibility study Munachiso Iheme Ndukwe, Tatana Reslova, Jan Laco, Dominik Habes, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8694671/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Objective Ultrasound-guided transvaginal tru-cut biopsy is widely used for histological confirmation of ovarian malignancy. Although multiple cores are routinely obtained to improve diagnostic yield, the distribution of malignant tissue across cores obtained during a single biopsy session has not been systematically evaluated. This question is particularly relevant for translational workflows, such as tissue cryopreservation, where histological verification of each individual core is impractical. We present a prospective feasibility study evaluating intra-procedural concordance of malignant tissue across ultrasound-guided transvaginal tru-cut biopsy cores of ovarian lesions. Results Twenty-one patients undergoing ultrasound-guided transvaginal tru-cut biopsy of ovarian lesions were included in the final analysis. Trucut biopsy yielded a diagnostic result in 20 of 21 procedures (95.2%; Wilson 95% confidence interval 78.1%–99.4%). In all biopsy procedures in which malignant tissues was identified in at least one core, malignant tissue was consistently present in all other evaluable cores obtained during the same session, with no discordant cases observed. When tissue fragments were present, malignant tissue was also consistently identified in fragments whenever malignant tissue was present in cores. One procedure, involving a mucinous adenocarcinoma arising in the background of a borderline tumor, yielded no malignant in any submitted material. Overall, these findings demonstrate a high degree of intra-procedural concordance of malignant tissue across biopsy cores and support the feasibility of biopsy workflows relying on confirmation of malignant tissue in a single core. transvaginal ultrasound-guided biopsy tru-cut biopsy ovarian lesions malignant tissue concordance feasibility study tissue cryopreservation Introduction Ultrasound-guided tru-cut biopsy is an established minimally invasive technique for the histological evaluation of suspected malignant ovarian lesions[1–3]. It is commonly used in advanced disease, recurrent settings, or when primary surgery is deferred, allowing confirmation of diagnosis and tumor type prior to treatment initiation. When performed by experienced operators, the procedure is considered safe and offers the advantage of real-time visualization of the target lesion[4]. In a recent systematic review and meta-analysis with 1867 patients included, ultrasound-guided tru-cut biopsy showed high overall tissue adequacy for histology and immunohistochemistry (mean 95.1%) and high diagnostic accuracy (mean 95.5%), with excellent pooled sensitivity (98.6%) for confirming malignancy[5]. Routine clinical practice during ultrasound-guided tru-cut biopsy involves obtaining multiple cores from the same ovarian lesion to reduce sampling error and ensure sufficient tissue for histological, immunohistochemical, and molecular analyses. Recent expert consensus recommendations advise obtaining at least two biopsy cores of adequate length and caliber[6]. However, published studies have almost exclusively evaluated outcomes based on whether a biopsy session yields at least one malignant tissue-positive core, leaving the distribution of malignant tissue across individual cores obtained during the same, successfully targeted procedure largely unexamined[7–11]. This question is increasingly relevant as core biopsy material has the potential to be used for biobanking and cryopreservation to support translational research, in which multiple tissue cores may be allocated to downstream analyses following confirmation of malignant tissue, rather than undergoing exhaustive histological verification of each individual core[12]. This prospective feasibility study therefore aimed to assess intra-procedural concordance of malignant tissue across ultrasound-guided transvaginal tru-cut biopsy cores obtained from ovarian lesions during a single biopsy session. Methods Study design and setting This study was designed as a prospective, single-center observational cohort study conducted at a tertiary referral center. Consecutive patients undergoing ultrasound-guided tru-cut biopsy of radiologically suspicious ovarian lesions between April and December 2025 were prospectively recorded and included in the analysis. Ultrasound-guided tru-cut biopsy procedure All biopsies were performed using a transvaginal ultrasound-guided approach under real-time imaging by a single level III expert sonographer with advanced competency in gynecologic ultrasound, who had performed more than 50 ultrasound-guided tru-cut biopsies annually over the preceding three years. Procedures were carried out using a high-resolution ultrasound system (Voluson E10, GE Healthcare) equipped with a transvaginal probe and biopsy guidance system in an out-patient setting. Prior to biopsy, all patients underwent comprehensive transvaginal and transabdominal ultrasound evaluation to assess lesion size, morphology, vascularization, and relationship to adjacent structures[13]. Color or power Doppler imaging was used to identify viable tumor areas and to avoid vascular structures. Following confirmation of indication and signed informed consent, biopsy was performed during the same clinical session. Patients were positioned in the lithotomy position, and all procedures were conducted under strict aseptic conditions without local or general anesthesia. Tissue sampling was performed using an automated core biopsy system (BIP-Evocore EC2215, 18G × 250 mm needle). The biopsy needle was advanced under continuous real-time ultrasound guidance, with visualization of the needle tip at all times. According to technical feasibility and lesion accessibility, two to four tru-cut cores were obtained from each target lesion, consistent with institutional practice. All intact cores, as well as any tissue fragments generated during the procedure, were submitted for routine histopathological examination. The ultrasound operator was blinded to the study endpoint of individual core adequacy. Immediately after the procedure, a control ultrasound examination was performed to exclude procedure-related complications. Pathological evaluation All biopsy specimens were handled according to standard institutional pathology protocols. Tru-cut cores and any accompanying tissue fragments were immediately fixed in 10% neutral buffered formalin. During handling, the length of each core was measured in millimeters, each core was placed in a separate cassette, routinely processed, and embedded in paraffin. Three serial sections were prepared from each block and stained with hematoxylin and eosin (H&E). Immunohistochemical analysis was performed in all cases as part of routine diagnostic workup, according to established institutional protocols. Pathology reports were reviewed prospectively. For each biopsy procedure, the number of cores obtained, the number of evaluable cores, the presence or absence of malignant tissue in each individual core, the presence of malignant tissue in associated tissue fragments when reported, and the final histopathological diagnosis were recorded. Malignant tissue presence was defined as unequivocal histological evidence of malignancy identified within a core or tissue fragment on routine histological and immunohistochemical evaluation. Feasibility endpoint The primary feasibility endpoint was concordance of malignant tissue presence across cores obtained during the same biopsy session. Discordance was defined as the presence of malignant tissue in at least one core and absence of malignant tissue in at least one other evaluable core from the same lesion. Results Patient and biopsy characteristics Number of patients in the study was originally 22. One patient was excluded from the analysis because only one core was obtained from the biopsy. This left 21 patients for the final evaluation. The median age of the cohort was 60 years (IQR: 47–72 years), and the median body mass index was 26.4 kg/m² (IQR: 21.2–31.1 kg/m²). The study population represented a heterogeneous spectrum of malignant diagnoses, including primary gynecologic malignancies, metastatic disease originating from extragenital primaries, and hematologic malignancies. Most biopsy procedures yielded three cores, with a range of two to seven cores per session, most commonly three. In some cases, tissue fragments were also reported in addition to intact cores. No peri-procedural or early post-procedural complications were observed in the study cohort. For further patient characteristics, see Table 1 . Table 1 Patient and biopsy characteristics Characteristic Value Number of patients 21 Age, median (IQR Q1-Q3), years 60 (47–72) BMI, median (IQR Q1-Q3), kg/m² 26,4 (21,2–31,1) Lesion laterality – Left ovary 6 (28,57%) – Right ovary 9 (42,86%) – Bilateral 6 (28,57%) Size of the lession Median length (IQR Q1-Q3), mm 57,3 (42,7–77,4) Median width (IQR Q1-Q3), mm 39,3 (25,1–62,6) Median depth (IQR Q1-Q3), mm 53,3 (41,1–90,5) Minimal and maximal length, mm 23,3–200 Minimal and maximal width, mm 17–150 Minimal and maximal depth, mm 19,7–220 Lesion morphology on ultrasound – Solid tumor 12 (57,14%) – Unilocular/multilocular-solid cyst 9 (42,86%) Histology High-grade serous ovarian carcinoma 8 Metastatic carcinoma (breast, pancreas, sigmoideum) 7 Adult granulosa cell tumor 3 Mucinous ovarian carcinoma 2 Small-cell B-cell lymphoma 1 Adenocarcinoma (non specific) 1 Malignant tissue concordance across cores In all biopsy procedures where malignant tissue was identified in at least one core, malignant tissue was also present in all other evaluable cores obtained during the same biopsy session. No discordant cases were observed in which one core contained malignant tissue while another core from the same lesion was free of malignant tissue. When tissue fragments were present, malignant tissue was consistently identified in fragments whenever malignant tissue was present in cores. In 20 of 21 biopsy procedures (95.2%), trucut sampling yielded a diagnostic result at the patient level. The Wilson 95% confidence interval for diagnostic yield was 78.1%–99.4% (exact Clopper–Pearson 76.7%–99.9%). One case, later characterized as a mucinous adenocarcinoma arising in the background of a borderline tumor, yielded no malignant tissue in any submitted material. The corresponding miss rate was 4.8% (Wilson 0.6%–21.9%), implying a ≥ 95.2% probability that a randomly chosen single biopsy site would be diagnostic in this cohort. For full results, see Table 2 . Table 2 Procedural characteristics of ultrasound-guided tru-cut biopsy of ovarian lesions ID Final diagnosis category Number of cores Core configuration Core length range (mm) Cores with tumor Tumor in fragments Concordance P01 High-grade serous carcinoma 2 intact cores 9–12 2 yes concordant P02 High-grade serous carcinoma 3 intact cores 6–11 3 N/A concordant P03 Mucinous carcinoma 2 core + fragments 4 2 yes concordant P04 Metastatic carcinoma (ductal breast carcinoma) 3 intact cores 12–16 3 N/A concordant P05 Metastatic adenocarcinoma (sigmoid) 2 intact cores 18–22 2 N/A concordant P06 Metastatic adenocarcinoma (unknown origin) 3 intact cores 5–18 3 N/A concordant P07 High-grade serous carcinoma 3 intact cores 6–20 3 N/A concordant P08 Adult granulosa cell tumor 3 intact cores 10–14 3 N/A concordant P09 Small-cell B-cell lymphoma 3 intact cores 8–14 3 N/A concordant P10 Metastatic adenocarcinoma (sigmoid) 3 intact cores 5–10 3 N/A concordant P11 High-grade serous carcinoma 3 intact cores 3–16 3 N/A concordant P12 Metastatic adenocarcinoma (sigmoid) 3 intact cores 3–5 3 N/A concordant P13 High-grade serous carcinoma 3 core + fragments 5–9 3 yes concordant P14 High-grade serous carcinoma 3 intact cores 6–15 3 N/A concordant P15 Metastatic carcinoma (ductal breast carcinoma) 3 Core 2–6 3 yes concordant P16 Adult granulosa cell tumor 3 core + fragments 16–19 3 yes concordant P17 Metastatic adenocarcinoma (ductal pancreatic) 3 core + fragments 16–19 3 yes concordant P18 Mucinous adenocarcinoma arising in a background of a borderline tumor 3 core + fragments 7–11 0 N/A non-diagnostic P19 High-grade serous carcinoma 3 intact cores 5–8 3 yes concordant P20 Adult granulosa cell tumor 0 fragments only 1–2 7 yes concordant P21 High-grade serous carcinoma 4 intact cores 8–12 4 no concordant Discussion This prospective feasibility study demonstrates a high degree of intra-procedural concordance of malignant tissue across ultrasound-guided tru-cut biopsy cores obtained from the same lesion. Once malignant tissue was identified in one core, all additional evaluable cores obtained during the same biopsy session also contained malignant tissue. Importantly, no discordant cases were observed in this cohort. These findings address a distinct and underexplored aspect of Tru-Cut biopsy performance. Previous studies have reported that increasing the number of biopsy cores improves diagnostic adequacy; however, this improvement has been defined at the procedure level, namely as the likelihood of obtaining at least one diagnostic core[4][14]. In contrast, the present analysis evaluates diagnostic adequacy at the level of individual cores obtained within a single biopsy. Our results demonstrate comparable diagnostic information across individual cores, suggesting that beyond the first representative sample, additional cores may offer limited incremental diagnostic value. In this respect, our findings challenge the assumption that increasing the number of cores necessarily enhances overall biopsy performance, and instead point toward potential redundancy in multi-core sampling. The single non-diagnostic case occurred in a mucinous adenocarcinoma arising in the background of a borderline tumor. Such lesions are characterized by marked heterogeneity and well-recognized challenges in histopathological evaluation [15,16]. This observation underscores that lesion biology remains a critical determinant of sampling success. From a practical standpoint, these preliminary findings support the feasibility of tissue handling strategies in which histological confirmation of tumor presence in a single core is used as a surrogate marker for representativeness of additional cores obtained during the same biopsy session. This approach is particularly relevant for cryopreservation protocols, where conventional histopathological processing of each individual core would preclude preservation of viable tissue for downstream translational applications. Limitations This study represents a small, single-center feasibility study, limiting statistical power and precluding formal hypothesis testing. Quantitative assessment of tumor burden within individual cores and correlation with core-level imaging features were not performed, preventing evaluation of partial or focal tumor sampling. These findings should therefore be considered exploratory, and validation in large, multicenter prospective studies with standardized biopsy and pathology protocols is required before broader clinical or translational implementation. Conclusion In this prospective feasibility study, tumor presence across ultrasound-guided tru-cut biopsy cores obtained from the same lesion was consistently concordant when tumor was present. These findings support the feasibility of workflows that rely on confirmation of tumor in a single core to represent additional cores obtained during the same biopsy session. A multi-centric prospective study is needed to further clarify the robustness and generalizability of this observation. Declarations Ethics approval and consent to participate This prospective single-center observational study was approved by the Ethics Committee of University Hospital Hradec Králové (Hradec Králové, Czech Republic; approval number 202411 P05). The study was registered at ClinicalTrials.gov (registration number NCT06689605). All participants received oral and written information about the procedure and the study and provided written informed consent prior to undergoing ultrasound-guided transvaginal tru-cut biopsy. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by Charles University (Grant No. 246125), the project BBMRI-CZ LM2023033 and by the Cooperatio program of Charles University in the research areas ONCO, DIAG, and MATC. This work was also supported by MH CZ–DRO (UHHK, 00179906). Authors’ contributions MIN: study concept and design, data collection, data analysis, manuscript drafting and revision. TR: performance of ultrasound-guided biopsies, contribution to methodology, manuscript revision. JL: pathological evaluation, data interpretation, manuscript revision. DH: statistical analysis, manuscript revision. HV: data collection and clinical oversight, manuscript revision. DP: data management and clinical data collection, manuscript revision. PB: manuscript drafting and revision. IS: study supervision, data interpretation, manuscript revision. All authors read, reviewed and approved the final manuscript. Acknowledgements The authors thank the patients who participated in this study and the clinical and pathology staff of University Hospital Hradec Králové for their support of study procedures and sample processing. References Thabet A, Somarouthu B, Oliva E, Gervais DA, Hahn PF, Lee SI. Image-Guided Ovarian Mass Biopsy: Efficacy and Safety. J Vasc Interv Radiol. 2014;25:1922-1927.e1. https://doi.org/10.1016/j.jvir.2014.08.009. Kong T-W, Chang S-J, Paek J, Cho H, Lee Y, Lee EJ, et al. Transvaginal Sonography-Guided Core Biopsy of Adnexal Masses as a Useful Diagnostic Alternative Replacing Cytologic Examination or Laparoscopy in Advanced Ovarian Cancer Patients. Int J Gynecol Cancer. 2016;26:1041–7. https://doi.org/10.1097/igc.0000000000000728. Holloway CMB, Al-Riyees L, Saskin R. Utilization of Percutaneous Needle Biopsy for Breast Diagnosis in a Comprehensive Breast Center: Implications for Development of Quality Indicators. World J Surg. 2016;40:1590–9. https://doi.org/10.1007/s00268-015-3293-0. Fischerova D, Planchamp F, Alcázar JL, Dundr P, Epstein E, Felix A, et al. ISUOG/ESGO Consensus Statement on ultrasound-guided biopsy in gynecological oncology. Int J Gynecol Cancer. 2025;35:101732. https://doi.org/10.1016/j.ijgc.2025.101732. Ndukwe MI, Pavone M, Habes D, Bizzarri N, Stepan M, Bretová P, et al. The role of ultrasound-guided tru-cut biopsy in ovarian cancer: a systematic review of its safety, adequacy, and accuracy with meta-analysis of diagnostic performance. J Ovarian Res. 2025;18:166. https://doi.org/10.1186/s13048-025-01739-7. Fischerova D, Planchamp F, Alcázar JL, Dundr P, Epstein E, Felix A, et al. ISUOG/ESGO Consensus Statement on ultrasound‐guided biopsy in gynecological oncology. Ultrasound Obstet Gynecol. 2025;65:517–35. https://doi.org/10.1002/uog.29183. Pelayo-Delgado I, Sancho J, Pelayo M, Corraliza V, Perez-Mies B, Valle CD, et al. Contribution of Outpatient Ultrasound Transvaginal Biopsy and Puncture in the Diagnosis and Treatment of Pelvic Lesions: A Bicenter Study. Diagnostics. 2023;13:380. https://doi.org/10.3390/diagnostics13030380. VLASAK P, BOUDA J, KOSTUN J, BEREZOVSKIY D, ZIKAN M, WEINBERGER V, et al. Diagnostic Reliability, Accuracy and Safety of Ultrasound-guided Biopsy and Ascites Puncture in Primarily Inoperable Ovarian Tumours. Anticancer Res. 2020;40:3527–34. https://doi.org/10.21873/anticanres.14341. Yousefi Z, Frazestanian M, Davachi B, Saeed S, Azad A, Khorasani ST. Is Transvaginal Core Needle Biopsy A Safe Method in Diagnosis of Ovarian Cancer? Int J Cancer Manag. 2018;11. https://doi.org/10.5812/ijcm.8121. Verschuere H, Froyman W, Bosch TV den, Hoefs MV, Kaijser J, Schoubroeck DV, et al. Safety and efficiency of performing transvaginal ultrasound-guided tru-cut biopsy for pelvic masses. Gynecol Oncol. 2021;161:845–51. https://doi.org/10.1016/j.ygyno.2021.03.026. Mascilini F, Quagliozzi L, Moro F, Moruzzi MC, Blasis ID, Paris V, et al. Role of transvaginal ultrasound-guided biopsy in gynecology. Int J Gynecol Cancer. 2020;30:128. https://doi.org/10.1136/ijgc-2019-000734. Bonizzi G, Zattoni L, Capra M, Cassi C, Taliento G, Ivanova M, et al. Standard operating procedures for biobank in oncology. Front Mol Biosci. 2022;9:967310. https://doi.org/10.3389/fmolb.2022.967310. Timmerman D, Planchamp F, Bourne T, Landolfo C, Bois A du, Chiva L, et al. ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors. Ultrasound Obstet Gynecol. 2021;58:148–68. Verschuere H, Froyman W, Bosch TV den, Hoefs MV, Kaijser J, Schoubroeck DV, et al. Safety and efficiency of performing transvaginal ultrasound-guided tru-cut biopsy for pelvic masses. Gynecol Oncol. 2021;161:845–51. Fischerova D, Zikan M, Dundr P, Cibula D. Diagnosis, Treatment, and Follow‐Up of Borderline Ovarian Tumors. Oncol. 2012;17:1515–33. Hart WR. Mucinous tumors of the ovary: a review. Int J Gynecol Pathol : Off J Int Soc Gynecol Pathol. 2005;24:4–25. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor invited by journal 27 Jan, 2026 Editor assigned by journal 27 Jan, 2026 Submission checks completed at journal 27 Jan, 2026 First submitted to journal 25 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8694671","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":588335851,"identity":"8b2cf2ff-60f8-4b79-8e1c-02c46bc7e972","order_by":0,"name":"Munachiso Iheme Ndukwe","email":"","orcid":"","institution":"University Hospital Hradec Králové","correspondingAuthor":false,"prefix":"","firstName":"Munachiso","middleName":"Iheme","lastName":"Ndukwe","suffix":""},{"id":588335852,"identity":"1329a216-df54-4320-a882-d1786d9d9b9a","order_by":1,"name":"Tatana Reslova","email":"","orcid":"","institution":"University Hospital Hradec Králové","correspondingAuthor":false,"prefix":"","firstName":"Tatana","middleName":"","lastName":"Reslova","suffix":""},{"id":588335853,"identity":"1161913c-966b-4831-b9c7-8506ec136862","order_by":2,"name":"Jan Laco","email":"","orcid":"","institution":"University Hospital Hradec Králové","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"","lastName":"Laco","suffix":""},{"id":588335854,"identity":"97d3127b-432d-4123-8cc5-5b2095ea74a0","order_by":3,"name":"Dominik Habes","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDCCAyBkkMBgwMAD5FXY8DNIsJGk5UyaZAMxWoAAqoWx7TBhLXzHuxMPFxSkMZiznz348AfbeQlz6bYEhh9/cGuRPHN2w+EZBjkMlj15ycY8PLclLOccO8DYw4Nbi8GN3A2HeQwqGAwO5JhJM0jcrjO4kd7AzCBBjJbzb8x//jA4JwHRYkBQSw6QkWPGwJNwAKgl7QAzMDzw+4XHII3H4Ma7ZGmeA8kgLQkHew7g1sJ3vHfzZ54/yXIG53MPfvz5zw6kxfABvhCDAdQQwmPHKBgFo2AUjAJiAABRUlfHyZh19wAAAABJRU5ErkJggg==","orcid":"","institution":"University Hospital Hradec Králové","correspondingAuthor":true,"prefix":"","firstName":"Dominik","middleName":"","lastName":"Habes","suffix":""},{"id":588335856,"identity":"efe870cf-0ebe-494b-9072-9b9a322a2517","order_by":4,"name":"Hana Vosmikova","email":"","orcid":"","institution":"University Hospital Hradec Králové","correspondingAuthor":false,"prefix":"","firstName":"Hana","middleName":"","lastName":"Vosmikova","suffix":""},{"id":588335859,"identity":"f8af4c27-afb7-4507-9549-dbb637e1ae7d","order_by":5,"name":"Denisa Pohankova","email":"","orcid":"","institution":"University Hospital Hradec Králové","correspondingAuthor":false,"prefix":"","firstName":"Denisa","middleName":"","lastName":"Pohankova","suffix":""},{"id":588335862,"identity":"d3e898fc-8e5c-42a3-9392-d99c21d6c69e","order_by":6,"name":"Petra Bretova","email":"","orcid":"","institution":"University Hospital Hradec Králové","correspondingAuthor":false,"prefix":"","firstName":"Petra","middleName":"","lastName":"Bretova","suffix":""},{"id":588335864,"identity":"1219fcc1-b176-4cca-ad29-3a7bdaea7003","order_by":7,"name":"Igor Sirak","email":"","orcid":"","institution":"University Hospital Hradec Králové","correspondingAuthor":false,"prefix":"","firstName":"Igor","middleName":"","lastName":"Sirak","suffix":""}],"badges":[],"createdAt":"2026-01-25 20:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8694671/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8694671/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102397640,"identity":"31468283-376c-4235-a929-14aaffc4254c","added_by":"auto","created_at":"2026-02-11 10:18:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":761929,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8694671/v1/6c309464-ef49-417b-9ea3-d04081d33dcb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"High concordance of malignant tissues across ultrasound-guided transvaginal tru-cut biopsy cores of ovarian lesions: a prospective feasibility study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUltrasound-guided tru-cut biopsy is an established minimally invasive technique for the histological evaluation of suspected malignant ovarian lesions[1\u0026ndash;3]. It is commonly used in advanced disease, recurrent settings, or when primary surgery is deferred, allowing confirmation of diagnosis and tumor type prior to treatment initiation. When performed by experienced operators, the procedure is considered safe and offers the advantage of real-time visualization of the target lesion[4].\u003c/p\u003e \u003cp\u003eIn a recent systematic review and meta-analysis with 1867 patients included, ultrasound-guided tru-cut biopsy showed high overall tissue adequacy for histology and immunohistochemistry (mean 95.1%) and high diagnostic accuracy (mean 95.5%), with excellent pooled sensitivity (98.6%) for confirming malignancy[5]. Routine clinical practice during ultrasound-guided tru-cut biopsy involves obtaining multiple cores from the same ovarian lesion to reduce sampling error and ensure sufficient tissue for histological, immunohistochemical, and molecular analyses. Recent expert consensus recommendations advise obtaining at least two biopsy cores of adequate length and caliber[6]. However, published studies have almost exclusively evaluated outcomes based on whether a biopsy session yields at least one malignant tissue-positive core, leaving the distribution of malignant tissue across individual cores obtained during the same, successfully targeted procedure largely unexamined[7\u0026ndash;11]. This question is increasingly relevant as core biopsy material has the potential to be used for biobanking and cryopreservation to support translational research, in which multiple tissue cores may be allocated to downstream analyses following confirmation of malignant tissue, rather than undergoing exhaustive histological verification of each individual core[12].\u003c/p\u003e \u003cp\u003eThis prospective feasibility study therefore aimed to assess intra-procedural concordance of malignant tissue across ultrasound-guided transvaginal tru-cut biopsy cores obtained from ovarian lesions during a single biopsy session.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis study was designed as a prospective, single-center observational cohort study conducted at a tertiary referral center. Consecutive patients undergoing ultrasound-guided tru-cut biopsy of radiologically suspicious ovarian lesions between April and December 2025 were prospectively recorded and included in the analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eUltrasound-guided tru-cut biopsy procedure\u003c/h3\u003e\n\u003cp\u003eAll biopsies were performed using a transvaginal ultrasound-guided approach under real-time imaging by a single level III expert sonographer with advanced competency in gynecologic ultrasound, who had performed more than 50 ultrasound-guided tru-cut biopsies annually over the preceding three years. Procedures were carried out using a high-resolution ultrasound system (Voluson E10, GE Healthcare) equipped with a transvaginal probe and biopsy guidance system in an out-patient setting.\u003c/p\u003e \u003cp\u003ePrior to biopsy, all patients underwent comprehensive transvaginal and transabdominal ultrasound evaluation to assess lesion size, morphology, vascularization, and relationship to adjacent structures[13]. Color or power Doppler imaging was used to identify viable tumor areas and to avoid vascular structures. Following confirmation of indication and signed informed consent, biopsy was performed during the same clinical session.\u003c/p\u003e \u003cp\u003ePatients were positioned in the lithotomy position, and all procedures were conducted under strict aseptic conditions without local or general anesthesia. Tissue sampling was performed using an automated core biopsy system (BIP-Evocore EC2215, 18G \u0026times; 250 mm needle). The biopsy needle was advanced under continuous real-time ultrasound guidance, with visualization of the needle tip at all times.\u003c/p\u003e \u003cp\u003eAccording to technical feasibility and lesion accessibility, two to four tru-cut cores were obtained from each target lesion, consistent with institutional practice. All intact cores, as well as any tissue fragments generated during the procedure, were submitted for routine histopathological examination. The ultrasound operator was blinded to the study endpoint of individual core adequacy.\u003c/p\u003e \u003cp\u003eImmediately after the procedure, a control ultrasound examination was performed to exclude procedure-related complications.\u003c/p\u003e\n\u003ch3\u003ePathological evaluation\u003c/h3\u003e\n\u003cp\u003eAll biopsy specimens were handled according to standard institutional pathology protocols. Tru-cut cores and any accompanying tissue fragments were immediately fixed in 10% neutral buffered formalin. During handling, the length of each core was measured in millimeters, each core was placed in a separate cassette, routinely processed, and embedded in paraffin. Three serial sections were prepared from each block and stained with hematoxylin and eosin (H\u0026amp;E). Immunohistochemical analysis was performed in all cases as part of routine diagnostic workup, according to established institutional protocols. Pathology reports were reviewed prospectively. For each biopsy procedure, the number of cores obtained, the number of evaluable cores, the presence or absence of malignant tissue in each individual core, the presence of malignant tissue in associated tissue fragments when reported, and the final histopathological diagnosis were recorded. Malignant tissue presence was defined as unequivocal histological evidence of malignancy identified within a core or tissue fragment on routine histological and immunohistochemical evaluation.\u003c/p\u003e\n\u003ch3\u003eFeasibility endpoint\u003c/h3\u003e\n\u003cp\u003eThe primary feasibility endpoint was concordance of malignant tissue presence across cores obtained during the same biopsy session. Discordance was defined as the presence of malignant tissue in at least one core and absence of malignant tissue in at least one other evaluable core from the same lesion.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient and biopsy characteristics\u003c/h2\u003e \u003cp\u003eNumber of patients in the study was originally 22. One patient was excluded from the analysis because only one core was obtained from the biopsy. This left 21 patients for the final evaluation. The median age of the cohort was 60 years (IQR: 47\u0026ndash;72 years), and the median body mass index was 26.4 kg/m\u0026sup2; (IQR: 21.2\u0026ndash;31.1 kg/m\u0026sup2;). The study population represented a heterogeneous spectrum of malignant diagnoses, including primary gynecologic malignancies, metastatic disease originating from extragenital primaries, and hematologic malignancies.\u003c/p\u003e \u003cp\u003eMost biopsy procedures yielded three cores, with a range of two to seven cores per session, most commonly three. In some cases, tissue fragments were also reported in addition to intact cores. No peri-procedural or early post-procedural complications were observed in the study cohort. For further patient characteristics, see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient and biopsy characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (IQR Q1-Q3), years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (47\u0026ndash;72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, median (IQR Q1-Q3), kg/m\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26,4 (21,2\u0026ndash;31,1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion laterality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Left ovary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (28,57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Right ovary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (42,86%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Bilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (28,57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize of the lession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian length (IQR Q1-Q3), mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57,3 (42,7\u0026ndash;77,4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian width (IQR Q1-Q3), mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39,3 (25,1\u0026ndash;62,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian depth (IQR Q1-Q3), mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53,3 (41,1\u0026ndash;90,5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimal and maximal length, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23,3\u0026ndash;200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimal and maximal width, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u0026ndash;150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimal and maximal depth, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19,7\u0026ndash;220\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion morphology on ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Solid tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (57,14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ndash; Unilocular/multilocular-solid cyst\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (42,86%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh-grade serous ovarian carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetastatic carcinoma (breast, pancreas, sigmoideum)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdult granulosa cell tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMucinous ovarian carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmall-cell B-cell lymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenocarcinoma (non specific)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMalignant tissue concordance across cores\u003c/h3\u003e\n\u003cp\u003eIn all biopsy procedures where malignant tissue was identified in at least one core, malignant tissue was also present in all other evaluable cores obtained during the same biopsy session. No discordant cases were observed in which one core contained malignant tissue while another core from the same lesion was free of malignant tissue. When tissue fragments were present, malignant tissue was consistently identified in fragments whenever malignant tissue was present in cores.\u003c/p\u003e \u003cp\u003eIn 20 of 21 biopsy procedures (95.2%), trucut sampling yielded a diagnostic result at the patient level. The Wilson 95% confidence interval for diagnostic yield was 78.1%\u0026ndash;99.4% (exact Clopper\u0026ndash;Pearson 76.7%\u0026ndash;99.9%). One case, later characterized as a mucinous adenocarcinoma arising in the background of a borderline tumor, yielded no malignant tissue in any submitted material. The corresponding miss rate was 4.8% (Wilson 0.6%\u0026ndash;21.9%), implying a\u0026thinsp;\u0026ge;\u0026thinsp;95.2% probability that a randomly chosen single biopsy site would be diagnostic in this cohort. For full results, see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProcedural characteristics of ultrasound-guided tru-cut biopsy of ovarian lesions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinal diagnosis category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of cores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCore configuration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCore length range (mm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCores with tumor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTumor in fragments\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eConcordance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-grade serous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-grade serous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMucinous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ecore\u0026thinsp;+\u0026thinsp;fragments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic carcinoma\u003c/p\u003e \u003cp\u003e(ductal breast carcinoma)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic adenocarcinoma (sigmoid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u0026ndash;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic adenocarcinoma (unknown origin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-grade serous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdult granulosa cell tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmall-cell B-cell lymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic adenocarcinoma (sigmoid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-grade serous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic adenocarcinoma (sigmoid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-grade serous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ecore\u0026thinsp;+\u0026thinsp;fragments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-grade serous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic carcinoma (ductal breast carcinoma)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdult granulosa cell tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ecore\u0026thinsp;+\u0026thinsp;fragments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMetastatic adenocarcinoma (ductal pancreatic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ecore\u0026thinsp;+\u0026thinsp;fragments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMucinous adenocarcinoma arising in a background of a borderline tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ecore\u0026thinsp;+\u0026thinsp;fragments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003enon-diagnostic\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-grade serous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u0026ndash;8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdult granulosa cell tumor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003efragments only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-grade serous carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eintact cores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003econcordant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective feasibility study demonstrates a high degree of intra-procedural concordance of malignant tissue across ultrasound-guided tru-cut biopsy cores obtained from the same lesion. Once malignant tissue was identified in one core, all additional evaluable cores obtained during the same biopsy session also contained malignant tissue. Importantly, no discordant cases were observed in this cohort.\u003c/p\u003e \u003cp\u003eThese findings address a distinct and underexplored aspect of Tru-Cut biopsy performance. Previous studies have reported that increasing the number of biopsy cores improves diagnostic adequacy; however, this improvement has been defined at the procedure level, namely as the likelihood of obtaining at least one diagnostic core[4][14]. In contrast, the present analysis evaluates diagnostic adequacy at the level of individual cores obtained within a single biopsy. Our results demonstrate comparable diagnostic information across individual cores, suggesting that beyond the first representative sample, additional cores may offer limited incremental diagnostic value. In this respect, our findings challenge the assumption that increasing the number of cores necessarily enhances overall biopsy performance, and instead point toward potential redundancy in multi-core sampling.\u003c/p\u003e \u003cp\u003eThe single non-diagnostic case occurred in a mucinous adenocarcinoma arising in the background of a borderline tumor. Such lesions are characterized by marked heterogeneity and well-recognized challenges in histopathological evaluation [15,16]. This observation underscores that lesion biology remains a critical determinant of sampling success.\u003c/p\u003e \u003cp\u003eFrom a practical standpoint, these preliminary findings support the feasibility of tissue handling strategies in which histological confirmation of tumor presence in a single core is used as a surrogate marker for representativeness of additional cores obtained during the same biopsy session. This approach is particularly relevant for cryopreservation protocols, where conventional histopathological processing of each individual core would preclude preservation of viable tissue for downstream translational applications.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study represents a small, single-center feasibility study, limiting statistical power and precluding formal hypothesis testing. Quantitative assessment of tumor burden within individual cores and correlation with core-level imaging features were not performed, preventing evaluation of partial or focal tumor sampling. These findings should therefore be considered exploratory, and validation in large, multicenter prospective studies with standardized biopsy and pathology protocols is required before broader clinical or translational implementation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this prospective feasibility study, tumor presence across ultrasound-guided tru-cut biopsy cores obtained from the same lesion was consistently concordant when tumor was present. These findings support the feasibility of workflows that rely on confirmation of tumor in a single core to represent additional cores obtained during the same biopsy session. A multi-centric prospective study is needed to further clarify the robustness and generalizability of this observation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis prospective single-center observational study was approved by the Ethics Committee of University Hospital Hradec Králové (Hradec Králové, Czech Republic; approval number 202411 P05). The study was registered at ClinicalTrials.gov (registration number NCT06689605). All participants received oral and written information about the procedure and the study and provided written informed consent prior to undergoing ultrasound-guided transvaginal tru-cut biopsy.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study was supported by Charles University (Grant No. 246125),\u0026nbsp;the project BBMRI-CZ LM2023033\u0026nbsp;and by the Cooperatio program of Charles University in the research areas ONCO, DIAG, and MATC. This work was also supported by MH CZ–DRO (UHHK, 00179906).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMIN: study concept and design, data collection, data analysis, manuscript drafting and revision.\u003cbr\u003e\u0026nbsp;TR: performance of ultrasound-guided biopsies, contribution to methodology, manuscript revision.\u003cbr\u003e\u0026nbsp;JL: pathological evaluation, data interpretation, manuscript revision.\u003cbr\u003e\u0026nbsp;DH: statistical analysis, manuscript revision.\u003cbr\u003e\u0026nbsp;HV: data collection and clinical oversight, manuscript revision.\u003cbr\u003e\u0026nbsp;DP: data management and clinical data collection, manuscript revision.\u003cbr\u003e\u0026nbsp;PB: manuscript drafting and revision.\u003cbr\u003e\u0026nbsp;IS: study supervision, data interpretation, manuscript revision.\u003cbr\u003e\u0026nbsp;All authors read, reviewed and approved the final manuscript.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors thank the patients who participated in this study and the clinical and pathology staff of University Hospital Hradec Králové for their support of study procedures and sample processing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eThabet A, Somarouthu B, Oliva E, Gervais DA, Hahn PF, Lee SI. Image-Guided Ovarian Mass Biopsy: Efficacy and Safety. J Vasc Interv Radiol. 2014;25:1922-1927.e1. https://doi.org/10.1016/j.jvir.2014.08.009.\u003c/li\u003e\n \u003cli\u003eKong T-W, Chang S-J, Paek J, Cho H, Lee Y, Lee EJ, et al. Transvaginal Sonography-Guided Core Biopsy of Adnexal Masses as a Useful Diagnostic Alternative Replacing Cytologic Examination or Laparoscopy in Advanced Ovarian Cancer Patients. Int J Gynecol Cancer. 2016;26:1041\u0026ndash;7. https://doi.org/10.1097/igc.0000000000000728.\u003c/li\u003e\n \u003cli\u003eHolloway CMB, Al-Riyees L, Saskin R. Utilization of Percutaneous Needle Biopsy for Breast Diagnosis in a Comprehensive Breast Center: Implications for Development of Quality Indicators. World J Surg. 2016;40:1590\u0026ndash;9. https://doi.org/10.1007/s00268-015-3293-0.\u003c/li\u003e\n \u003cli\u003eFischerova D, Planchamp F, Alc\u0026aacute;zar JL, Dundr P, Epstein E, Felix A, et al. ISUOG/ESGO Consensus Statement on ultrasound-guided biopsy in gynecological oncology. Int J Gynecol Cancer. 2025;35:101732. https://doi.org/10.1016/j.ijgc.2025.101732.\u003c/li\u003e\n \u003cli\u003eNdukwe MI, Pavone M, Habes D, Bizzarri N, Stepan M, Bretov\u0026aacute; P, et al. The role of ultrasound-guided tru-cut biopsy in ovarian cancer: a systematic review of its safety, adequacy, and accuracy with meta-analysis of diagnostic performance. J Ovarian Res. 2025;18:166. https://doi.org/10.1186/s13048-025-01739-7.\u003c/li\u003e\n \u003cli\u003eFischerova D, Planchamp F, Alc\u0026aacute;zar JL, Dundr P, Epstein E, Felix A, et al. ISUOG/ESGO Consensus Statement on ultrasound‐guided biopsy in gynecological oncology. Ultrasound Obstet Gynecol. 2025;65:517\u0026ndash;35. https://doi.org/10.1002/uog.29183.\u003c/li\u003e\n \u003cli\u003ePelayo-Delgado I, Sancho J, Pelayo M, Corraliza V, Perez-Mies B, Valle CD, et al. Contribution of Outpatient Ultrasound Transvaginal Biopsy and Puncture in the Diagnosis and Treatment of Pelvic Lesions: A Bicenter Study. Diagnostics. 2023;13:380. https://doi.org/10.3390/diagnostics13030380.\u003c/li\u003e\n \u003cli\u003eVLASAK P, BOUDA J, KOSTUN J, BEREZOVSKIY D, ZIKAN M, WEINBERGER V, et al. Diagnostic Reliability, Accuracy and Safety of Ultrasound-guided Biopsy and Ascites Puncture in Primarily Inoperable Ovarian Tumours. Anticancer Res. 2020;40:3527\u0026ndash;34. https://doi.org/10.21873/anticanres.14341.\u003c/li\u003e\n \u003cli\u003eYousefi Z, Frazestanian M, Davachi B, Saeed S, Azad A, Khorasani ST. Is Transvaginal Core Needle Biopsy A Safe Method in Diagnosis of Ovarian Cancer? Int J Cancer Manag. 2018;11. https://doi.org/10.5812/ijcm.8121.\u003c/li\u003e\n \u003cli\u003eVerschuere H, Froyman W, Bosch TV den, Hoefs MV, Kaijser J, Schoubroeck DV, et al. Safety and efficiency of performing transvaginal ultrasound-guided tru-cut biopsy for pelvic masses. Gynecol Oncol. 2021;161:845\u0026ndash;51. https://doi.org/10.1016/j.ygyno.2021.03.026.\u003c/li\u003e\n \u003cli\u003eMascilini F, Quagliozzi L, Moro F, Moruzzi MC, Blasis ID, Paris V, et al. Role of transvaginal ultrasound-guided biopsy in gynecology. Int J Gynecol Cancer. 2020;30:128. https://doi.org/10.1136/ijgc-2019-000734.\u003c/li\u003e\n \u003cli\u003eBonizzi G, Zattoni L, Capra M, Cassi C, Taliento G, Ivanova M, et al. Standard operating procedures for biobank in oncology. Front Mol Biosci. 2022;9:967310. https://doi.org/10.3389/fmolb.2022.967310.\u003c/li\u003e\n \u003cli\u003eTimmerman D, Planchamp F, Bourne T, Landolfo C, Bois A du, Chiva L, et al. ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors. Ultrasound Obstet Gynecol. 2021;58:148\u0026ndash;68.\u003c/li\u003e\n \u003cli\u003eVerschuere H, Froyman W, Bosch TV den, Hoefs MV, Kaijser J, Schoubroeck DV, et al. Safety and efficiency of performing transvaginal ultrasound-guided tru-cut biopsy for pelvic masses. Gynecol Oncol. 2021;161:845\u0026ndash;51.\u003c/li\u003e\n \u003cli\u003eFischerova D, Zikan M, Dundr P, Cibula D. Diagnosis, Treatment, and Follow‐Up of Borderline Ovarian Tumors. Oncol. 2012;17:1515\u0026ndash;33.\u003c/li\u003e\n \u003cli\u003eHart WR. Mucinous tumors of the ovary: a review. Int J Gynecol Pathol : Off J Int Soc Gynecol Pathol. 2005;24:4\u0026ndash;25.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"transvaginal ultrasound-guided biopsy, tru-cut biopsy, ovarian lesions, malignant tissue concordance, feasibility study, tissue cryopreservation","lastPublishedDoi":"10.21203/rs.3.rs-8694671/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8694671/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eUltrasound-guided transvaginal tru-cut biopsy is widely used for histological confirmation of ovarian malignancy. Although multiple cores are routinely obtained to improve diagnostic yield, the distribution of malignant tissue across cores obtained during a single biopsy session has not been systematically evaluated. This question is particularly relevant for translational workflows, such as tissue cryopreservation, where histological verification of each individual core is impractical. We present a prospective feasibility study evaluating intra-procedural concordance of malignant tissue across ultrasound-guided transvaginal tru-cut biopsy cores of ovarian lesions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty-one patients undergoing ultrasound-guided transvaginal tru-cut biopsy of ovarian lesions were included in the final analysis. Trucut biopsy yielded a diagnostic result in 20 of 21 procedures (95.2%; Wilson 95% confidence interval 78.1%\u0026ndash;99.4%). In all biopsy procedures in which malignant tissues was identified in at least one core, malignant tissue was consistently present in all other evaluable cores obtained during the same session, with no discordant cases observed. When tissue fragments were present, malignant tissue was also consistently identified in fragments whenever malignant tissue was present in cores. One procedure, involving a mucinous adenocarcinoma arising in the background of a borderline tumor, yielded no malignant in any submitted material. Overall, these findings demonstrate a high degree of intra-procedural concordance of malignant tissue across biopsy cores and support the feasibility of biopsy workflows relying on confirmation of malignant tissue in a single core.\u003c/p\u003e","manuscriptTitle":"High concordance of malignant tissues across ultrasound-guided transvaginal tru-cut biopsy cores of ovarian lesions: a prospective feasibility study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 13:14:58","doi":"10.21203/rs.3.rs-8694671/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-09T13:44:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T11:27:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107706146550165706926886537093051952347","date":"2026-02-08T07:16:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T16:32:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T10:02:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-27T08:41:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-27T08:39:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Research Notes","date":"2026-01-25T19:54:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e703848d-9d09-42bf-8563-aa9d35358461","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T11:24:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 13:14:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8694671","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8694671","identity":"rs-8694671","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}