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 Table of Contents  
Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 28-31

Histological spectrum, bilaterality, and clinical evaluation of ovarian lesions – A 10-year study in a rural tertiary hospital of India

1 Department of Pathology, Bankura Sammilani Medical College, Bankura, West Bengal, India
2 Department of Pathology, Malda Medical College, Malda, West Bengal, India

Date of Submission28-Jul-2019
Date of Acceptance30-Oct-2019
Date of Web Publication23-Jan-2020

Correspondence Address:
Dr. Santosh Kumar Mondal
“Subarnabhumi Complex”, Kamini III, Flat A302, 36 Gorakshabashi Road, Dumdum, Kolkata - 700 028, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kleuhsj.kleuhsj_165_19

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BACKGROUND: Ovarian malignancy is the second most common cancer of the female reproductive system and the leading cause of death from gynecologic malignancy. Study on the distribution of the different ovarian neoplasms is limited from Eastern India, especially in rural areas.
AIMS AND OBJECTIVES: The aim was to study the distribution of morphological pattern of benign, malignant, and nonneoplastic lesions of the ovary in different age groups and to determine the likelihood of bilateral involvement in different morphologic subtypes.
MATERIALS AND METHODS: A retrospective study from January 2009 to December 2018 was undertaken. A total of 2100 surgical specimens were obtained. Detailed clinical information and radiological findings were recorded from the case sheets. Grossing of the surgical specimens was done in the pathology department, followed by histological examination.
RESULTS: Of 2100 cases, benign cases were 1491 (71%), malignant cases were 252 (12%), and nonneoplastic were 357 (17%). The distribution of malignant cases was 10–19 years (18 cases, 7.14%), 20–29 years (50 cases, 19.84%), 30–39 years (23 cases, 9.13%), 40–49 years (61 cases, 24.20%), 50–59 years (70 cases, 27.78%), and 60–69 years (30 cases, 11.91%). Among the benign cases, serous cystadenoma was 684 cases (32.57%), followed by mucinous cystadenoma cases (330, 15.71%) and mature cystic teratoma cases (270, 12.86%). Among the malignant cases, bilateral serous cystadenocarcinomas were found in 42.85% of the cases, and among benign cases, bilateral endometrioid tumors were found in 27.58% of the cases, and among nonneoplastic diseases, bilateral follicular cysts were found in 35.21% of the cases.
CONCLUSION: In this study, an earlier presentation of malignant tumors was observed. Furthermore, a lower percentage of serous cystadenocarcinoma was noted compared to other studies.

Keywords: Bilaterality, histopathology, ovarian lesion, tertiary hospital

How to cite this article:
Mondal SK, Bhattacharya S, Mandal S, Panda UK. Histological spectrum, bilaterality, and clinical evaluation of ovarian lesions – A 10-year study in a rural tertiary hospital of India. Indian J Health Sci Biomed Res 2020;13:28-31

How to cite this URL:
Mondal SK, Bhattacharya S, Mandal S, Panda UK. Histological spectrum, bilaterality, and clinical evaluation of ovarian lesions – A 10-year study in a rural tertiary hospital of India. Indian J Health Sci Biomed Res [serial online] 2020 [cited 2022 Aug 15];13:28-31. Available from: https://www.ijournalhs.org/text.asp?2020/13/1/28/276417

  Introduction Top

Ovarian lesions are unusual because of their diverse morphology and association with relatively mild symptoms. Ovarian cancer has extensive heterogeneity within and between histologic subtypes.[1] Tumors of the ovary are not uncommon neoplasms in women. Histology of ovarian tumors exhibits a wide spectrum of variation. Distribution of the different ovarian neoplasms has been widely studied in Western countries. However, such studies are limited from Eastern India, especially in rural areas. An accurate and early diagnosis of malignant lesions will go a long way in the optimal management of these cases. Ten-year survival for all ovarian cancer is approximately 30%–40% according to the Surveillance, Epidemiology, and End Results Program Registry and other studies.[2],[3] Ovarian tumors are often difficult to detect until they are advanced in stage or size, as symptoms are vague and insidious. Long-term survival of women with high-grade serous carcinoma is low and often associated with completely resected disease (without residual disease/tumor).[4],[5]

In India, during 2004–2005, the proportion of ovarian cancer varied from 1.7% to 8.7% of all female cancers in various urban and rural population-based registries. Age-standardized incidence rate of ovarian cancers in India varies from region to region and it ranges from 0.9 to 8.4/100,000 person-year. Age-standardized incidence is highest in Delhi and Pune.

It is found that women between 65 and 84 years of age have ovarian cancer incidence rates two to three times higher compared to younger women. A major problem with ovarian tumors is that they initially give vague signs and symptoms only. These tumors are notorious for their large size but a frequent association with relatively mild symptoms. Risk factors for ovarian cancer are not clearly defined. However, there is general agreement on two risk factors: nulliparity and family history. A higher frequency of ovarian carcinoma is seen in unmarried women and in married women with low parity.

The prognosis of ovarian tumors depends on specific histological type, grading, and tumor stage. Staging of ovarian tumors is done by the TNM system, which was established by the American Joint Committee on Cancer and also by the International Federation of Gynecology and Obstetrics staging system. Histological typing and grading are done mainly by the World Health Organization classification of ovarian tumors. The identification of various histological patterns is important for predicting tumor behavior to decide further management of patients.

  Materials and Methods Top

A retrospective study of a total of 2100 cases of nonneoplastic and neoplastic lesions of the ovary was conducted in the Department of Pathology, Bankura Sammilani Medical College and Hospital, over a period of 10 years from January 2009 to December 2018 with the permission of ethical committee. Detailed clinical information and radiologic findings were recorded from the case sheets. These included age and sex of the patients, signs and symptoms, fine-needle aspiration cytology findings of the available cases, complete blood count, ultrasonography/computed tomography findings, and biochemical investigations including serum tumor markers such as CA125, alpha-fetoprotein, and beta-human chorionic gonadotropin. In our study, all ovarian specimens were obtained from total abdominal hysterectomy specimens with unilateral or bilateral adnexa, oophorectomy, and cystectomy specimens received in the department. The specimens were analyzed macroscopically for various parameters such as external surface and cut surface with contents of the cyst. Tissues were processed by formalin-fixed paraffin-embedded techniques and sections stained with H and E and examined microscopically. The study was approved by Institutional Ethical Clearance Committee.

  Results Top

Among the 2100 cases of ovarian tumor, the median age of presentation was 38 years. Most of the benign tumors occurred between 20 and 29 years of age, while the malignant lesions presented commonly between 50 and 59 years. Germ cell tumors were encountered in the younger age group. The presentation of surface epithelial tumors varied widely involving all age groups. The most common histological types were serous cystadenoma (32.57%), followed by mucinous cystadenoma (15.71%) and mature cystic teratoma (12.86%) [Table 1]. Major portion of malignant ovarian tumors was contributed by surface epithelial tumors (66.61%) [Table 2]. Mucinous cystadenocarcinoma predominated the malignant group (7.61%) followed by serous cystadenocarcinoma (3.33%). Clear-cell carcinoma is 0.38% (08 cases), malignant Brenner is 0.24% (05 cases), and immature teratoma is 0.43% (09 cases). Among nonneoplastic diseases of the ovary, corpus luteal cyst is 5.09% (107 cases), follicular cyst is 3.38% (71 cases), hemorrhagic corpus luteal cyst is 3.23% (68 cases), and endometriosis is 5.28% (111 cases) [Table 3]. Studying the bilaterality of different ovarian tumors, serous cystadenocarcinoma shows bilaterality of 42.85% and mucinous cystadenocarcinoma shows 28.12% following immature teratoma (22.22%) and clear-cell carcinoma (12.5%). Among benign ovarian tumors, endometrioid tumor shows 27.58% bilaterality followed by clear-cell tumors (13.33), fibrothecoma (10.81%), granulosa cell tumor (10.71%), benign Brenner tumor (7.89%), mature cystic teratoma (6.29%), serous cystadenoma (3.94%), and mucinous cystadenoma (3.03%).
Table 1: Distribution of benign ovarian tumors (n=2100)

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Table 2: Distribution of malignant ovarian tumors (n=2100)

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Table 3: Distribution of nonneoplastic lesions of the ovary (n=2100)

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  Discussion Top

The diagnosis of ovarian tumors can be difficult due to a variety of pathologic conditions that can affect the ovaries and present with similar clinical and radiologic manifestations. The knowledge of morphology- and age-specific characteristics can help refine the diagnosis.[6] Due to the deep-seated location, paucity of symptoms occurs. In the present study, the median age of presentation of all ovarian tumor was 40 years, while the median age of presentation of all malignant lesions was 50 years. Benign tumors were diagnosed mostly in patients between 20–40 years of age. In another study from Iran, the median age for malignant lesions was reported to be 49 years. A higher median age of 60–65 years for malignant lesions has been reported from the Western countries.[7],[8],[9] Malignant epithelial and sex cord-stromal tumors have been found to be more common after 50 years, while germ-cell tumors are more prevalent before the age of 20.[10] In the present study, malignant epithelial tumors were found predominantly in 50–59 years and benign tumors were found in 20–29 years. The major fraction of ovarian neoplasm in the present study comprises benign tumors (71%) followed by nonneoplastic lesions (17%) and malignant tumors (12%). In a similar study, Gupta et al. reported 72.9% benign, 4.1% borderline, and 22.9% malignant tumors.[11] Histologically, surface epithelial tumors are the most common tumors. In the present study, mucinous cystadenocarcinoma cases were 160 (63.49%). Serous cystadenocarcinoma cases were 70 (27.78%).

High-grade serous carcinoma is the most aggressive subtype and accounts for the majority of advanced-stage cases.[2] Nonetheless, the use of intraperitoneal therapy in a patient with microscopic and small-volume residual disease after cytoreductive surgery has been associated with long-term survival.[12]

Among benign tumors, serous cystadenoma comprises 45.88%, mucinous cystadenoma comprises 22.13%, and mature teratoma comprises 18.10%. Mature teratoma has been found to be the most common benign tumor in one study.[13] Pregnancy has been an association of mature teratoma in 3% of patients, and malignant changes are observed in 5% cases.[14]

In the present study, we encountered 28 (1.88%) cases of benign granulosa cell tumor. Granulosa cell tumors are an uncommon type of ovarian neoplasm that represent approximately 2%–5% of all ovarian malignancy.[15] Surgery is the mainstream of initial treatment aiming at achieving the histological diagnosis and appropriate staging.[16]

Ovarian tumors are well known for bilateral involvement. The likelihood of bilateral involvement by primary ovarian tumors varies with histologic subtype. In the present study, the most common ovarian tumor with bilateral involvement was serous cystadenocarcinoma (37.69%). This was followed by 23.80% of mucinous cystadenocarcinoma.

Prognosis is strongly associated with the stage at diagnosis, but the histologic grade also plays a prognostic role, particularly in predicting recurrence.[17] Of women diagnosed with Stage I disease, 74% are under 65 years of age.[8] Up to 70% of patients with epithelial ovarian cancer present at Stage III or IV.[18] Epithelial ovarian cancer is histologically determined to be of low malignant potential in 15% of patients, is often diagnosed at Stage I, and has a 95%–99% 10-year survival rate.[19] Older women are more likely to be initially diagnosed with advanced disease. Therefore, they experience the worse prognoses.

  Conclusion Top

In this study, an earlier presentation of malignant tumors was observed. Furthermore, a lower percentage of serous cystadenocarcinoma was noted compared to other studies. In our study, the most common ovarian tumor with bilateral involvement was serous cystadenocarcinoma (37.69%) which was followed by mucinous cystadenocarcinoma (23.08%).

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  References Top

Dao F, Schlappe BA, Tseng J, Lester J, Nick AM, Lutgendorf SK, et al. Characteristics of 10-year survivors of high-grade serous ovarian carcinoma. Gynecol Oncol 2016;141:260-3.  Back to cited text no. 1
Bowtell DD, Böhm S, Ahmed AA, Aspuria PJ, Bast RC Jr., Beral V, et al. Rethinking ovarian cancer II: Reducing mortality from high-grade serous ovarian cancer. Nat Rev Cancer 2015;15:668-79.  Back to cited text no. 2
Akeson M, Jakobsen AM, Zetterqvist BM, Holmberg E, Brännström M, Horvath G, et al. Apopulation-based 5-year cohort study including all cases of epithelial ovarian cancer in Western Sweden: 10-year survival and prognostic factors. Int J Gynecol Cancer 2009;19:116-23.  Back to cited text no. 3
Barlin JN, Jelinic P, Olvera N, Bogomolniy F, Bisogna M, Dao F, et al. Validated gene targets associated with curatively treated advanced serous ovarian carcinoma. Gynecol Oncol 2013;128:512-7.  Back to cited text no. 4
Suidan RS, Ramirez PT, Sarasohn DM, Teitcher JB, Mironov S, Iyer RB, et al. Amulticenter prospective trial evaluating the ability of preoperative computed tomography scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for advanced ovarian, fallopian tube, and peritoneal cancer. Gynecol Oncol 2014;134:455-61.  Back to cited text no. 5
Sutton CL, McKinney CD, Jones JE, Gay SB. Ovarian masses revisited: Radiologic and pathologic correlation. Radiographics 1992;12:853-77.  Back to cited text no. 6
Murthy NS, Shalini S, Suman G, Pruthvish S, Mathew A. Changing trends in incidence of ovarian cancer – The Indian scenario. Asian Pac J Cancer Prev 2009;10:1025-30.  Back to cited text no. 7
Yancik R. Ovarian cancer. Age contrasts in incidence, histology, disease stage at diagnosis, and mortality. Cancer 1993;71:517-23.  Back to cited text no. 8
Quirk JT, Natarajan N. Ovarian cancer incidence in the United States, 1992-1999. Gynecol Oncol 2005;97:519-23.  Back to cited text no. 9
Gilani MM, Behnamfar F, Zamani F, Zamani N. Frequency of different types of ovarian cancer in Vali-E-Asr hospital (Tehran University of medical sciences) 2001-2003. Pak J Biol Sci 2007;10:3026-8.  Back to cited text no. 10
Gupta N, Bisht D, Agarwal AK, Sharma VK. Retrospective and prospective study of ovarian tumours and tumour-like lesions. Indian J Pathol Microbiol 2007;50:525-7.  Back to cited text no. 11
Tewari D, Java JJ, Salani R, Armstrong DK, Markman M, Herzog T, et al. Long-term survival advantage and prognostic factors associated with intraperitoneal chemotherapy treatment in advanced ovarian cancer: A gynecologic oncology group study. J Clin Oncol 2015;33:1460-6.  Back to cited text no. 12
Ahmad Z, Kayani N, Hasan SH, Muzaffar S, Gill MS. Histological pattern of ovarian neoplasma. J Pak Med Assoc 2000;50:416-9.  Back to cited text no. 13
Papadias K, Kairi-Vassilatou E, Kontogiani-Katsaros K, Argeitis J, Kondis-Pafitis A, Greatsas G, et al. Teratomas of the ovary: A clinico-pathological evaluation of 87 patients from one institution during a 10-year period. Eur J Gynaecol Oncol 2005;26:446-8.  Back to cited text no. 14
Babarović E, Franin I, Klarić M, Ferrari AM, Karnjuš-Begonja R, Eminović S, et al. Adult granulosa cell tumors of the ovary: A retrospective study of 36 FIGO stage I cases with emphasis on prognostic pathohistological features. Anal Cell Pathol (Amst) 2018:9148124.  Back to cited text no. 15
Shim SH, Lee SJ, Kim DY, Kim J, Kim SN, Kang SB, et al. Along-term follow-up study of 91 cases with ovarian granulosa cell tumors. Anticancer Res 2014;34:1001-10.  Back to cited text no. 16
Gadducci A, Sartori E, Maggino T, Zola P, Landoni F, Fanucchi A, et al. Analysis of failures after negative second-look in patients with advanced ovarian cancer: An Italian multicenter study. Gynecol Oncol 1998;68:150-5.  Back to cited text no. 17
Pecorelli S, Boyle P, Odicino F, Sideri M, Maisonneuve P, Severi G et al. et al. FIGO annual report on the results of treatment in gynecologic cancer. J Epidemiol Biostat 1998;3:75-102.  Back to cited text no. 18
Seidman JD, Kurman RJ. Ovarian serous borderline tumors: A critical review of the literature with emphasis on prognostic indicators. Hum Pathol 2000;31:539-57.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3]

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