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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 21-26

Evaluation of adnexal masses – Correlation of clinical and radiologic features with histopathologic findings: an observational study in a tertiary care center of Eastern India


1 Department of Pathology, Medical College, Kolkata, West Bengal, India
2 Department of Pathology, Serampore Walsh Sub Divisional Hospital, Serampore, West Bengal, India

Date of Submission17-Jan-2021
Date of Acceptance20-Feb-2021
Date of Web Publication13-Mar-2021

Correspondence Address:
Dr. Senjuti Dasgupta
Department of Pathology, Medical College, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_7_21

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  Abstract 


Background: Ovarian carcinoma is the seventh most common cause of carcinoma-induced deaths among women of the world. Adnexal masses often pose a diagnostic challenge to a treating physician. The aim of the present study was to find out the incidence of various categories of ovarian tumors and their correlation with clinicopathologic parameters among patients attending a tertiary care center of Eastern India. Another aim was the evaluation of diagnostic accuracy of clinical, laboratory, and radiological findings. Methods: A prospective, observational study was carried out for a period of 1 year. Female patients with adnexal masses were included in the study. Clinical, laboratory, and sonographic findings of each patient were recorded along with their histopathological reports. Results: The median age of 59 patients included in the study was 36 years. Most patients (32, 54.2%) were between 30 and 50 years of age. Thirty-six (61%) ovarian tumors were found to be benign and the rest (23, 39%) malignant. Surface epithelial tumors were the most common type (35, 59.3%), followed by germ cell tumors (11, 18.6%) and sex cord stromal tumors (9, 15.3%). A statistically significant association was noted between parity, menstrual status, laterality, size, gross appearance of tumor, and nature (benign/malignant) of the mass. Sensitivity (57%) and specificity (86%) of the clinical diagnosis were good, but diagnostic accuracy (88%) of sonographic findings was better. While serum CA125 level measurement had a diagnostic accuracy of 78%, the risk of malignancy index (RMI) 2 score, with an accuracy of 86%, has the potential to guide further management in a patient with adnexal mass. Conclusion: Increased incidence of malignancy was noted with postmenopause, nulliparity, bilaterality of tumors, and complex tumor morphology. All these risk factors were found to be statistically significant. RMI 2 score may be used routinely for diagnosis and guidance of further management of adnexal masses.

Keywords: Adnexal masses, clinicopathologic parameters, diagnostic accuracy, incidence


How to cite this article:
Dasgupta S, Mangal S, Naskar K. Evaluation of adnexal masses – Correlation of clinical and radiologic features with histopathologic findings: an observational study in a tertiary care center of Eastern India. Biomed Biotechnol Res J 2021;5:21-6

How to cite this URL:
Dasgupta S, Mangal S, Naskar K. Evaluation of adnexal masses – Correlation of clinical and radiologic features with histopathologic findings: an observational study in a tertiary care center of Eastern India. Biomed Biotechnol Res J [serial online] 2021 [cited 2021 Jun 22];5:21-6. Available from: https://www.bmbtrj.org/text.asp?2021/5/1/21/311100




  Introduction Top


Adnexal masses, both painful and asymptomatic, are commonly encountered entities in clinical practice. These lesions (both neoplastic and nonneoplastic) pose a great challenge to a gynecological oncologist. Their proper recognition and classification are important to allow appropriate therapy. Ovarian carcinoma is the seventh leading cause of cancer death (age-standardized mortality rate: 4/100,000) among women worldwide. In India, it comprises up to 8.7% of cancers in different parts of the country.[1]

It is important to triage adnexal masses so that the malignant cases and those suspicious of malignancy may be referred to a gynecological oncologist. This is required for appropriate surgical staging and ensuring improved overall survival of patients.[2]

Pelvic ultrasonography (US) is the imaging modality most commonly used to detect and further characterize all adnexal masses. The main aim of the evaluation is to distinguish between benign and malignant masses. About 90% of adnexal masses can be adequately characterized with US alone. In some cases, follow-up US, computed tomography (CT), or magnetic resonance imaging (MRI) may be necessary.[3] For diagnosis and follow-up of epithelial malignancies, serum CA125 level provides a valuable tool. At present, there are no screening tests available for ovarian carcinomas. The evidence for recommendation of combined use of pelvic ultrasound and serum CA125 level for screening of ovarian carcinoma is still lacking. Till date, the gold standard for distinguishing between benign from malignant tumors is histopathological examination.[2] However, risk of malignancy index (RMI), based on menopausal status of patient, sonographic findings, and serum CA125 level, holds promise for easy application in preliminary evaluation of all adnexal masses, which may assist in reducing mortality and morbidity of patients of ovarian carcinoma.[4]

The aim of the study was to find out the frequency of occurrence of neoplastic (benign and malignant) adnexal masses in patients attending a tertiary care center of Eastern India during the study period. One of the objectives was to evaluate the correlations between various clinicopathologic parameters of neoplastic adnexal masses and their histopathological diagnoses. A further aim of the present study was to find out the diagnostic accuracy of clinical, laboratory, and radiological findings and also to evaluate the correlations of these findings with histopathological diagnoses.


  Methods Top


A prospective, observational study was carried out for a period of 1 year. Female patients with adnexal masses that were surgically removed in the gynecology department and specimens subsequently sent to the department of pathology for histopathological examination were included in the study. Those who did not give consent for the study were excluded. The patients with ectopic pregnancy, adnexal masses due to nongynecological causes, and midline uterine lesions were also excluded. The nonneoplastic ovarian lesions were not included in the final analysis of results. The study was approved by the institutional ethical committee.

For each patient, detailed history about demographic factors, presenting complaints, and menstruation were obtained. The clinical findings (complete general physical examination and bimanual examination) and the provisional diagnosis made solely on the basis of history and clinical examination were recorded. Each case was assigned a menopausal score (M) which was rendered a value of 1 if the patient was premenopausal and 4 if menopausal. Menopause was defined as a state of amenorrhea which persisted for a year or more and also included those patients who had previously undergone hysterectomy.[5]

The sonographic findings of each patient were also noted. The morphological criteria of ultasonographic assessment which were recorded include bilaterality, multilocularity, and presence of solid areas, ascites, and metastases. An ultrasound score (U) was assigned to each case based on the number of criteria present. If none of these criteria was present or only one was found, a score of 1 was assigned. If two or more criteria were present, a score of 4 was rendered.[5]

If additional radiological investigations by CT scan or MRI were done, those findings were also recorded. The reports of routine laboratory tests were noted, which included complete hemogram, fasting and postprandial blood sugar levels, liver and renal function tests, beta-human chorionic gonadotropin (in suspicion of pregnancy), and CA125 levels with a cutoff value of 35 U/ml.

After the specimen was received in the department of pathology, gross examination was done in details and the findings were recorded. Relevant sections were submitted for processing. Sections were cut from the prepared paraffin blocks and stained with hematoxylin and eosin stain for histopathological examination. All the slides were meticulously examined and the final report was rendered.

For each case, RMI 2 was calculated according to the formula used by Tingulstad et al.: U × M × CA125, where U is the ultrasound score, M is the menopausal score, and CA125 is the serum CA125 level. A cutoff of 200 was defined to distinguish between benign and malignant tumors.[5]

All data were collected and meticulously tabulated. The sensitivity, specificity, and negative and positive predictive values of clinical diagnosis, sonographic findings, CA125 level, and RMI were calculated. The correlations of these diagnostic investigations with histopathological diagnoses were evaluated using Chi-square test. Similarly, the correlations between various clinicopathologic parameters and histopathological diagnoses were also assessed using Chi-square test. All statistical analyses were done using GraphPad Prism 6™ (San Diego, CA). P < 0.05 was considered to be statistically significant.


  Results Top


Initially, the number of cases with adnexal masses included in the study was 80. However, two patients refused to give consent, another four were diagnosed later to have ectopic pregnancy, and in three more patients, the cause of adnexal mass was found to be nongynecologic. These nine patients were excluded from the study. Further, after histopathological examination, the adnexal mass was diagnosed to be nonneoplastic in 12 patients. These cases were not included in the analysis of results. Hence, the study population ultimately consisted of 59 patients.

The median age of the study subjects was 36 years. Majority of the patients belonged to the age group between 30 and 50 years (32, 54.2%). The age distribution among the different histopathological types of ovarian tumors is shown in [Figure 1]. Even though malignant tumors were more commonly found in patients of older age, the correlation between age group and histopathological diagnosis was not found to be statistically significant [Table 1].
Figure 1: Age distribution among the different histopathological types of ovarian tumors

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Table 1: Distribution of subjects by age, parity, menstrual status, laterality, size and gross appearance of ovarian tumors, and correlation of these clinicopathologic parameters with the nature of ovarian tumors

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The correlation of parity and menstrual status of patients with the nature (benign/malignant) of adnexal masses was found to be statistically significant. Among the nulliparous women, 80% of tumors were diagnosed to be malignant. Furthermore, 64.3% of postmenopausal patients in the study had malignancy [Table 1]. Most patients complained of more than one symptom. While the most common complaint was abdominal pain (55%), others suffered from a combination of abdominal swelling (32%), menstrual irregularities (31%), and bleeding per vagina (8%). The clinical diagnosis was benign in 41 cases (69.5%) and malignant in 18 (30.5%) cases.

Sonographically, 38 cases (64.4%) were diagnosed to be benign and the rest (22, 35.6%) malignant. These radiologic findings were found to have a sensitivity of 82%, specificity of 92%, positive predictive value of 86%, negative predictive value of 89%, and diagnostic accuracy of 88%. The ultrasound score of 4 was statistically significant in diagnosing malignant ovarian tumors (P < 0.00001). A serum CA125 level more than 35 U/ml was also found to be statistically significant in the diagnosis of malignancy (P < 0.00001). The diagnostic accuracy of serum CA125 level was 78%. The association between RMI 2 values greater than 200 and ovarian malignancy was noted to be statistically significant (P < 0.00001) [Table 2].
Table 2: Predictive values and correlation of clinical diagnosis, ultrasound score, serum CA125 levels, and risk of malignancy index of benign and malignant ovarian tumors when compared with histopathological diagnosis as gold standard

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Following surgical removal of adnexal masses, gross examination revealed 24 (40.7%) tumors to be more than 10 cm in size, among which 13 (54.2%) turned out to be malignant on histopathological examination. Furthermore, out of 29 (49.1%) tumors that were found to contain both solid and cystic areas (complex nature) grossly, 19 (65.5%) were diagnosed to be malignant. There was statistically significant correlation between the histopathological diagnosis of ovarian tumor and its laterality, size, and gross appearance [Table 1].

Histopathological examination revealed that 61% of benign (36, 61%) and 56.5% of malignant tumors (23, 39%) were of surface epithelial type. Mucinous cystadenoma (12, 54.5%) was the most common benign while serous cystadenocarcinoma (6, 46.2%) was the most common type of malignant surface epithelial tumor. All the benign germ cell tumors (7, 19.4%) were mature cystic teratomas. The sex cord stromal tumors constituted 16.7% of benign and 13% of malignant tumors [Table 3].
Table 3: Histopathological categories of ovarian tumors

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  Discussion Top


The adnexal masses have a wide range of differential diagnoses which include nonneoplastic lesions such as the functional cysts, paraovarian cysts, fimbrial cysts, tubo-ovarian abscesses, hydrosalpinx, ectopic pregnancies, pregnancy in bicornuate uterus, pelvic kidney, sigmoid colon or colon distended with gasses or feces, broad ligament fibroid, benign and malignant ovarian tumors, and tubal malignancies. The initial investigation aimed at characterization of an adnexal mass is usually US. While the gold standard for diagnosis still remains histopathological examination, the need for evaluation of the diagnostic accuracies of various available investigations cannot be understated as they serve to make both diagnostic and management decisions.[6]

In the present study, the majority (18, 30.5%) of the adnexal masses were found in the age group between 30 and 40 years. Only one-tenth of the study population was above 60 years of age. Approximately 78% of the tumors were present in the reproductive age group. Surface epithelial tumors were uncommon to present in adolescent age group, whereas germ cell tumors had predilection for this age group. After the age of 40 years, surface epithelial tumors constituted the predominant category. Malignant tumors commonly affected older age group (>40 years), with only malignant sex cord stromal cell tumors involved younger patients. However, this increasing incidence of malignancy with increasing age was found to be statistically insignificant. The age distribution of tumors reported in the present study is comparable with the findings of other studies.[1],[2],[6],[7],[8]

Most of the patients in the study (37, 62.7%) were found to be multiparous. Premenopausal age group was more common than postmenopausal in the present study, contributing to 76% of the adnexal masses. Abdominal pain was the most common symptom (55% cases) followed by abdominal swelling (32%) and menstrual irregularities (31%). These findings were similar to those found in studies by Pillai and Anuranjani and Patil.[2],[8]

A benign clinical diagnosis was rendered in the present study in 41 cases (69.5%) and malignant in the rest (18, 30.5%). Kujur et al. clinically diagnosed 23.78% adnexal masses as malignant in their study.[9] The sensitivity of clinical diagnosis in the present study was found to be 57%. The authors agree with Radhamani and Akhila, who stated that clinical examination (bimanual examination) is not a sensitive method of distinguishing between benign and malignant adnexal tumors.[6]

A sonographic diagnosis of malignant neoplasm was reached in 22 (37.3%) cases. Comparably, Priya et al. diagnosed 34% of cases in their study to be malignant, based on ultrasonographic features.[10] Sonography (transvaginal and transabdominal) is a sensitive method for detecting ovarian carcinoma, and in the present study, 62.7% of cases were diagnosed radiologically which had been proved correct by histopathological examination. Sonographic findings have a sensitivity of 82%, specificity of 92%, and diagnostic accuracy of 88%. These findings are similar to that reported in the studies conducted by Wasim et al., Topuz et al., and Pourissa et al.[7],[11],[12]

Serum CA125 level is a valuable parameter for both diagnosis and monitoring of epithelial carcinomas. The overall sensitivity of CA125 screening in distinguishing benign from malignant adnexal masses reportedly ranges from 61% to 90%, specificity from 71% to 93%, positive predictive value from 35% to 91%, and negative predictive value from 67% to 90%.[13] These values are comparable with those found in the present study. Wide range of variations in these figures occur due to differences in prevalence of carcinomas in the study populations, the proportion of postmenopausal patients, and the threshold level of CA125, which is considered abnormal. It is interesting to note that most of the clinical conditions with elevated CA125 occur in the premenopausal women while most epithelial ovarian carcinomas occur in the postmenopausal women. Hence, the sensitivity and specificity of an elevated CA125 level which accompanies a pelvic mass are highest after menopause. In the current study, 58% of patients presented with elevated CA125 level (>35 U/ml). Medeiros et al. reported better specificity than that found in the present study, using the same cutoffs, and they concluded that CA125 is a useful preoperative test for predicting the benign or malignant nature of ovarian tumors.[14] Sensitivity of the current study was almost similar to that found by Radhamani and Akhila.[6]

Most of the tumors in the present study were unilateral with only 10 out of 59 tumors (17%) having bilateral presentation. Three out of 36 (8.3%) benign and 7 out of 23 (30.4%) malignant tumors presented bilaterally. Hence, malignant tumors were common to present bilaterally and benign tumors unilaterally. These results were comparable with those of Thakkar et al. and Kar et al.[15],[16] In the present study, majority of tumors, i.e., 35 (59.3%), were <10 cm in the largest dimension. Only two tumors were of the diameter ranging between 21 and 30 cm. The largest tumor which measured 25 cm × 15 cm × 7 cm was a unilateral benign Brenner's tumor in a 60-year-old woman. Thakkar et al. reported that the largest tumor in their study measured 35 cm × 26 cm × 14 cm in a 56-year-old woman, who presented with mass in abdomen and was later diagnosed as mucinous cystadenoma.[15] The most common gross morphology of adnexal masses found in the present study was of the complex nature, contributing to 49.1% of all tumors. Most of these tumors turned out to be malignant so that among the malignant tumors; it was found that 32.2% had both solid and cystic areas grossly. Comparable results have been reported by Thakkar et al. and Gupta et al.[15],[17]

On histopathological examination, 36 tumors were found to be benign (61%) and 23 were malignant (39%). Badge et al. reported 76% of ovarian tumors to be benign and the rest (24%) to be malignant.[18] In the present study, surface epithelial tumors were the most common type (35, 59.3%), followed by germ cell tumors (11, 18.6%) and sex cord stromal tumors (9, 15.3%). The incidence of different types of ovarian tumors reported in other studies has been compared with that of the present study in [Table 4].[15],[19],[20],[21]
Table 4: Comparison of incidence of various types of ovarian tumors with that of other studies

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The evaluation of risk of ovarian malignancy is of utmost importance for further management. The RMI is one of the valuable tools for this purpose. RMI was initially developed by Jacobs et al. (RMI 1) and later modified by Tingulstad et al. (RMI 2 and 3) and Yamamoto et al. (RMI 4).[5],[22],[23],[24] Investigators have reported RMI 2 to be a very reliable means to distinguish between benign and malignant ovarian lesions.[5],[25] In the present study, RMI 2 was found to have a sensitivity of 87%, specificity of 86%, and an accuracy of 86%. The correlation between RMI 2 and nature of ovarian lesion was noted to be statistically significant. These results were comparable with those obtained in previous studies.[26],[27] The authors of the present study strongly recommend calculation of RMI in preoperative triage of patients with adnexal tumors.


  Conclusion Top


The authors conclude that adnexal masses were more commonly found in the reproductive age group. Even though the total number of nulliparous patients was low, the incidence of malignant ovarian tumors was higher in them. Surface epithelial ovarian tumors were the most common category followed by germ cell tumors. Sensitivity and specificity in diagnosing the characteristics of ovarian tumor were good clinically, but diagnostic accuracy increased when sonographic findings were taken into account. While there is no consensus so far regarding routine use of any screening tests for ovarian malignancies, RMI 2 score in a patient with adnexal mass has the potential to guide further management. Increased incidence of malignancy was noted with postmenopausal age group, nulliparity, bilaterality of tumors, and complex tumor morphology. All these risk factors were found to be statistically significant.

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Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Wasim T, Majrroh A, Siddiq S. Comparison of clinical presentation of benign and malignant ovarian tumours. J Pak Med Assoc 2009;59:18-21.  Back to cited text no. 7
    
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