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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 4  |  Page : 264-268

A 10-year retrospective, clinicopathological study of 2100 ovarian lesions in a rural medical college hospital of West Bengal, India


Department of Pathology, Bankura Sammilani Medical College, Bankura, West Bengal, India

Date of Submission19-Aug-2019
Date of Acceptance28-Sep-2019
Date of Web Publication03-Dec-2019

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


DOI: 10.4103/bbrj.bbrj_123_19

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  Abstract 


Background: Distribution of the different ovarian cancers has been widely studied in Western countries. However, such studies are limited in West Bengal of India, especially in rural areas. The aim was to study the distribution of morphological pattern of benign, malignant, and nonneoplastic ovarian lesions and bilateral involvement in different morphologic subtypes. The study was also aimed to observe different clinical presentations in ovarian lesions. Methods: A retrospective study from August 2009 to July 2019 was undertaken. A total of 2100 surgical specimens of ovaries were analyzed. Detailed clinical information and radiological findings were recorded from patients' case history sheets. Results: Of 2100 cases, benign ovarian lesions were found in 1491 cases (71%), malignant in 252 cases (12%), and nonneoplastic in 357 cases (17%). Serous cystadenoma was 41.45% of all benign tumors (618/1491 cases), followed by mucinous cystadenoma (22%, 328/1491 cases) and mature cystic teratoma (18.44%, 275/1491 cases). Among the malignant cases, highest bilaterality was seen in serous cystadenocarcinomas (41.30%) and among benign tumors in endometrioid tumors (27.58%). Bilateral follicular cysts were found in 35.21% cases among nonneoplastic diseases. Conclusion: Earlier presentation of malignant tumors was observed. Lower percentage of endometrioid carcinoma was also noted compared to other studies. The most common primary ovarian tumor with bilateral involvement was serous cystadenocarcinoma (41.30%) followed by endometrioid adenocarcinoma (33.33%).

Keywords: Bilaterality, histopathology, ovarian lesions, rural tertiary care hospital


How to cite this article:
Mondal SK. A 10-year retrospective, clinicopathological study of 2100 ovarian lesions in a rural medical college hospital of West Bengal, India. Biomed Biotechnol Res J 2019;3:264-8

How to cite this URL:
Mondal SK. A 10-year retrospective, clinicopathological study of 2100 ovarian lesions in a rural medical college hospital of West Bengal, India. Biomed Biotechnol Res J [serial online] 2019 [cited 2019 Dec 8];3:264-8. Available from: http://www.bmbtrj.org/text.asp?2019/3/4/264/272184




  Introduction Top


According to a recent study by Bray et al. in 2018, ovary constituted 295,414 new cases (1.6%) of all cancers worldwide.[1] The number of deaths from ovarian cancers globally was 184,799 (1.9%). They estimated cancer incidence and mortality with a focus on geographic variability across 20 regions worldwide. They found 18.1 million new cancer cases and 9.6 million cancer deaths in 2018. In their study, it was observed that lung cancer was the most common malignancy (11.6% of total cases) when both male and female sexes combined. Lung cancer was also the most common cause of cancer deaths (18.4% of total cancer deaths). It was followed by female breast cancer (11.6%), prostate cancer (7.1%), and colorectal cancer (6.1%) for incidence while colorectal cancer (9.2%), stomach cancer (8.2%), and liver cancer (8.2%) for mortality.[1]

In females, breast cancer was the most common malignancy, followed by colorectal cancer, lung cancer, and cervical cancer. Ovarian cancer constituted 3.4% of total cancers (8th most common cancer), and mortality was 4.4% of all cancer deaths in females (8th most common).[1]

Age-standardized incidence rate (ASR) of ovarian cancers in India varies from region to region, and it ranges from 0.9 to 8.4/100,000 person-years. The ASR is highest in Delhi and Pune.[2] In India, the age-specific incidence rate for ovarian cancer revealed that the disease increases from 35 years of age, which reaches a peak between 55 and 64 years of age.[2] As per Indian cancer registries, ovarian cancers are the third most common cancer trailing behind cervical and breast cancer.

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.[3] Tumors of the ovary are not uncommon neoplasms in women. Histology of ovarian tumors exhibits wide spectrum of variation. Distribution of the different ovarian neoplasms has been widely studied in Western countries. However, such studies are limited from West Bengal (a state of Eastern India), especially in rural areas. An accurate and early diagnosis of malignant lesions will go a long way in 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.[4],[5] 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).[6],[7]

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 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 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 (WHO) classification of ovarian tumors. The identification of various histological patterns is important for predicting tumor behavior to decide further management of patients.


  Methods Top


A retrospective study of total 2100 cases of nonneoplastic and neoplastic lesions of the ovary was conducted in the Department of Pathology, over 10 years from August 2009 to July 2019. The study was done after obtaining Institutional Ethical Clearance Committee clearance. 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 (FNAC) findings of the available cases, complete blood count, ultrasonography/computed tomography findings and biochemical investigations including serum tumor markers such as CA-125, alpha-fetoprotein, and beta-human chorionic gonadotropin. In our study, all ovarian specimens obtained from total abdominal hysterectomy specimens with unilateral or bilateral adnexa, oophorectomy, and cystectomy specimens were received in the department. The specimens were analyzed macroscopically for various parameters such as external surface and cut surface with contents of cyst. Tissues were processed by formalin-fixed paraffin-embedded techniques and sections stained with hematoxylin and eosin and examined microscopically. Periodic acid–Schiff stain was done to highlight the presence of mucin and glycogen and to confirm mucinous and clear cell tumor of the ovary.

In the present study, the latest WHO classification was followed which was revised by Robert Kurman et al. in 2014.[8] According to this study, the classification of benign and borderline ovarian tumors has been revised. Serous tumors of the ovary with foci of ≥10% borderline architecture are now classified as serous borderline tumors (SBTs).[8] If the borderline component is <10%, then it is classified as “serous cystadenoma with focal epithelial proliferation.” However, diagnostic criteria for SBT are same as in previous classification (more than three cell layers, mild nuclear atypia, etc.). Criteria for microinvasion in SBT have also been modified. Only small clusters of epithelial cells (<5 mm) which cytologically look similar to surface epithelial cells of SBT and are surrounded by retraction spaces are defined as microinvasion.[8] If the solid nests or cribriform glands (even < 5 mm) are cytologically similar to low-grade serous carcinoma (LGSC), then these lesions are termed as LGSC rather than microinvasion. SBT micropapillary is regarded as a subtype of SBT now.[8] As per the latest WHO classification, peritoneal implants from ovarian malignancies are of two types – invasive and noninvasive implants. Any serous tumor with peritoneal invasive implants is now characteristic of LGSC and not of SBT (only associated with noninvasive peritoneal implants).[8] In the present study, borderline tumors were placed in the malignant category of respective tumor when tables were prepared and were not shown separately in the table as borderline tumors have low malignant potential.

Limitation of the study

There were few limitations of the present study.

  1. The study was undertaken in a single rural medical college hospital. Sometimes, malignant ovarian neoplasms get referred to cancer hospitals. In addition, some patients preferred to get treatment in government as well as private hospitals of metropolitan cities
  2. Genetic analysis of ovarian tumor was not carried out as it was not available in this rural medical college hospital.


Statistical analysis

Data were entered in Microsoft Excel and analysis was done using SPSS Version 22 (IBM, Bangalore, Karnataka, India).


  Results Top


Among the 2100 cases of ovarian tumor, the median age of presentation was 38 years. The age-wise distribution of ovarian lesions was: <20 years (8.1%), 20–29 years (14.2%), 30–39 years (32.6%), 40–49 years (20.9%), 50–59 years (15.4%), 60–69 years (5.4%), 70–79 years (2.8%), and ≥ 80 years (0.6%). The common clinical presentations were abdominal pain (54.7%), abdominal mass (42.6%), ascites (9.2%), and abnormal vaginal bleeding (7.5%) [Table 1]. Most of the benign tumors occurred between 20 and 29 years of age, while the malignant lesions presented commonly between 40 and 49 years. Germ cell tumors were encountered in younger age group. The presentation of surface epithelial tumors varied widely involving all age groups. Histologically, the most common benign neoplasm was serous cystadenoma (29.42%), followed by mucinous cystadenoma (15.61%) and mature cystic teratoma (13.09%) [Table 2]. Major portion of malignant ovarian tumors was contributed by surface epithelial tumors (167/252 cases or 66.27%) of which serous cystadenocarcinoma predominated the malignant group (92/252 cases or 36.51% of malignant neoplasms and 92/2100 of total cases or 7.61% of total cases) followed by mucinous cystadenocarcinoma (51/252 cases or 20.24% of malignant neoplasms and 51/2100 of total cases or 2.43% of total cases) [Table 3]. Endometrioid carcinoma was found in 0.43% (9 cases), clear cell carcinoma in 0.38% (8 cases), malignant Brenner in 0.24% (5 cases), and immature teratoma in 0.43% (9 cases). Among nonneoplastic diseases of the ovary, corpus luteal cyst was found in 5.09% (107 cases), follicular cyst 3.38% (71 cases), hemorrhagic corpus luteal cyst 3.23% (68 cases), and endometriosis 5.28% (111 cases) [Table 4]. Among malignant ovarian neoplasms, the highest bilateral involvement was noted in serous cystadenocarcinoma (41.30%), followed by endometrioid carcinoma (33.33%), mucinous cystadenocarcinoma (27.45%), and immature teratoma (22.22%). Among benign ovarian tumors, endometrioid tumor showed the highest bilateral involvement (27.58%), followed by benign Sertoli–Leydig cell tumor (23.53%), serous cystadenoma (17.64%), and mucinous cystadenoma (14.33%).
Table 1: Age group-wise distribution, percentage, and clinical signs and symptoms of benign and malignant ovarian neoplasms (n=1743)

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Table 2: Histological spectrum and bilaterality in benign ovarian tumors (n=1491)

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Table 3: Histological spectrum and bilaterality in malignant ovarian tumors (n=252)

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Table 4: Histological spectrum and bilaterality in nonneoplastic lesions of ovary (n=357)

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  Discussion Top


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. Knowledge of morphology and age-specific characteristics can help refine the diagnosis.[9] Due to the deep-seated location, paucity of symptoms occurs. In the present study, the median age of presentation of all ovarian tumors was 28 years while the median age of presentation of all malignant lesions was 41 years. Benign tumors were diagnosed mostly in patients between 20 and 40 years of age. In another study from Iran, the median age for malignant lesion was reported to be 49 years. A higher median age of 60–65 years for malignant lesion has been reported from the Western countries.[2],[10],[11] 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 years.[12] In the present study, malignant epithelial tumors were found predominantly in 40–49 years and benign tumors found in 20–29 years. In the present study, benign tumors constituted 71% of all ovarian lesions 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.[13] In our study, histologically, surface epithelial tumors are the most common malignant neoplasm (167/252 cases or 66.27%), which is similar to most studies. Like many other studies, high-grade serous carcinoma was the most aggressive subtype and accounted for the majority of advanced-stage cases in our study.[4] It was observed that the use of intraperitoneal therapy in patients with microscopic and small volume residual disease after cytoreductive surgery had been associated with long-term survival.[14]

Among benign tumors in this study, serous cystadenoma comprises 41.45% (618/1491 cases), mucinous cystadenoma comprises 21.99% (328/1491 cases), mature cystic teratoma comprises 18.44% (275/1491 cases), and benign endometrioid tumor comprises 1.94% (29/1491 cases). Mature teratoma has been found to be the most common benign tumor in one study.[15] In one study, pregnancy has been observed in association with mature teratoma in 3% of patients and malignant changes were observed in 5% cases.[16]

In the present study, we encountered 38 cases (1.81%) of benign granulosa cell tumor. Granulosa cell tumors are an uncommon type of ovarian neoplasm that represent approximately 2%–5% of all ovarian malignancies.[17] Surgery is the mainstream of initial treatment aiming at achieving the histological diagnosis and appropriate staging.[18]

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 malignant ovarian tumor with bilateral involvement was serous cystadenocarcinoma (41.30%). This was followed by endometrioid carcinoma (33.33%). However, many reported that bilateral involvement is most common in mucinous adenocarcinoma.

Prognosis is strongly associated with the stage at diagnosis, but the histologic grade also plays a prognostic role, particularly in predicting recurrence.[19] Of women diagnosed with Stage I disease, 74% are under 65 years of age, and up to 70% of patients with epithelial ovarian cancer present at Stage III or IV. Our study also corroborated these findings. Epithelial ovarian cancer is histologically determined to be of low malignant potential (borderline tumors) in 15% of patients, and these tumors often diagnosed at Stage I, with 95%–99% 10-year survival rate. We also found most borderline tumors in Stage I and they had excellent prognosis. As in other studies, we also observed that older women were more likely to be initially diagnosed with advanced disease. Therefore, they experienced worse prognoses.


  Conclusion Top


Earlier presentation of malignant ovarian tumors was observed. Lower percentage of endometrioid carcinoma (only 0.43% of all ovarian cancers) was also noted compared to other studies. The most common primary ovarian tumor with bilateral involvement was serous cystadenocarcinoma (41.30%) followed by endometrioid adenocarcinoma (33.33%).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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