Histomorphological Spectrum of Ovarian Tumors in A Tertiary Care Hospital

Background: To study or analyse the histomorphological spectrum and distribution of benign and malignant ovarian neoplasms in women of different age groups Methods: 633 cases of ovarian tumors were studied over a period of 6 years(from July 2011 to July 2017) at the Department of Pathology, SDMH. All the cases were subjected to histopathological examination and IHC as & when required. Results: In total,633 ovarian tumor specimens were examined. Out of which ,468 cases (73.9%)were benign, 23 (3.6%)were boderline and 142(22.4%)were malignant. Most of the benign tumors occurred between 31 & 40 years of age while malignant lesions presented commonly between 41 & 50 years of age. Most common histological types were serous cystadenoma (24.18%) followed by mature cystic teratoma (22.90%).The commonest benign tumor was serous cystadenoma & the commonest malignant tumor was serous cystadenocarcinoma. Serous tumors showed bilateral involvement more commonly than bilateral mucinous tumors. Conclusion: We noted that serous cystadenoma tumors are the commonest variety of ovarian tumors. Also the age of presentation of these malignant tumors was an earlier age as compared to others.


Introduction
Ovarian cancer accounts for about 3% of all cancers in women. 1 Ovarian malignancy is the second most common cancer of the female reproductive system and the leading cause of death from gynecologic malignancy. 2,3 The age adjusted incidence rates of ovarian cancer vary between 5.4 and 8 per 100,000 populations in different parts of the country. 4,5 Diversity in histological patterns of ovarian tumours is important in diagnosis, treatment as well as prognosis. 5 Indian Cancer Registry data project ovary as an important site of cancer in women, comprising up to 8.7% of cancers in different parts of the country. 3,6 Thus , in this study we highlight the histomorphological spectrum and clinical presentation of patients with ovarian tumors in a tertiary care hospital.

Materials and methods
This retrospective study included 633 cases of ovarian tumors studied over a period of 6 years. Detailed clinical information were recorded which included age and sex of the patients, signs & symptoms, FNAC finding of available cases, CBC, USG/CT findings and biochemical investigations like tumor markers CA125, AFP and Beta hCG.
Oophorectomy specimen, ovarian cystectomies, wedge sections as well as hysterectomy with unilateral or bilateral salphing oophorectomy specimens were included in this study. Formalin-fixed, paraffin-embedded tissue sections were stained with Hematoxylin and Eosin and other special stains as and when required. A protocol for SEE-FIM (Sectioning and Extensively examining the Fimbriated end of fallopian tube was followed to detect "early carcinoma". It entails amputation and longitudinal sectioning of the infundibulum and fimbrial segment (distal 2 cms). The isthmus and ampulla are cut transversely at 2and 3 mm intervals. IHC stains were performed for further sub-typing whenever required (p53, AFP, PLAP, CK7, CK 20, Inhibin, EMA) The patients were divided into groups based on WHO classification of ovarian tumors and we studied correlation of histopathological patterns with age, bilaterality, morphology and grading of the tumour

Results
Total 633 cases of ovarian tumours were studied during a 6-year period of 2011 to 2017.Out of which,468 cases (73.9%)were benign, 23 (3.6%) were borderline and 142(22.4%) were malignant as in Table1. The mean age was 32 years with the youngest patient as a case of mature cystic teratoma and oldest as a case of Mucinous cystadenoma.
http://www.pacificejournals.com/awch Maximum number of cases were seen in the age group of 31-40 years, 185 cases (29.2%). The malignant neoplasms were seen more commonly in the age group of 41-60 years, 33 cases (23.2% of malignant neoplasms) ( Table 3 ). The youngest patient was a 9 month year old girl and the oldest was 72 years old. In the present study, the tumours had an average size of 12.15 cm. (table 2) The largest tumor encountered in the study was mucinous cystadenoma measuring 29 × 22 × 14 cm Of 633 tumours, 338 (53.3%) were cystic, 255 (40.2%) were mixed and 40 (6.3%) were solid. 312 Cystic tumours (49.2%) were benign. 144 of the 255 cases with mixed consistency were benign and 106 were malignant, whereas out of 40 solid tumours, 12 were benign and 26 malignant as in Table4. Unilateral occurrence was more common than bilateral.Most of the unilateral cases were of mature cystic teratoma. Among the bilateral tumors, serous tumors were the most common tumors.(Table2) Histologically serous cystadenoma was the most common tumor accounting for 24.18% followed by mature cystic teratoma (22.9%), serous cystadenofibroma (17.71%) and mucinous cystadenoma(7.59%) Table1

Discussion
Ovarian tumors are regarded as one of the most complex tumour of women in terms of histiogenesis, clinical behaviour and malignant potentiality . It represents the sixth most common female cancer and the fourth leading cause of death due to cancers in women. 7,8 Histomorphological classification of ovarian tumours forms an integral part of the evaluation of the neoplasms. 8,9 In the present study , a total 633 ovarian tumor specimens were examined. Out of which ,468 cases (73.9%)were benign, 23 (3.6%)were boderline and 142 ( The most common benign tumour were serous cystadenoma (24.18%) followed by mature cystic teratoma (22.90%) , similar results reported by Yasmin et al 16  When the tumor is confined to the ovaries, such as in borderline tumor, intraepithelial carcinoma and microinvasive carcinoma (with stromal invasive foci <10mm 2 ),the prognosis is good as compared to carcinoma with invasive implant or carcinoma with peritoneal lesions like pseudomyxoma peritonei. 18 Common problems encountered while diagnosing tumors of Epithelial origin especially serous and mucinous ovarian tumors is that tumor may include benign and borderline components in one area and malignant counterpart in other area. Therefore, extensive sampling including including upto 1 histological section per 1-2 cms of tumor diameter as well as sampling of suspicious lesions (solid area or mural nodule) is essential. Also, at times, it is difficult to differentiate primary tumor from metastatic carcinoma from appendix, large intestine, stomach, pancreas or cervix. The tumor morphology of these tumors resemble primary mucinous ovarian carcinoma.IHC staining such as CK7 and CK20 ,along with clinical information evaluation , is necessary to determine the origin of the cancer. 18,19 One case (0.15%) of endometrioid carcinoma in this study, which was lower than the percentage of Ahmad Z et al 13

Conclusion
To conclude, histomorphologically, majority of the ovarian tumors are benign. Among the malignant tumors, tumors originating from surface epithelium are the commonest. Awareness among public and doctors is essential for early detection and treatment of ovarian lesions.