jhc-2019-jul-v-3-n-2-study-ansari-m

Study of Ovarian Tumours: Histomorphological Types

 *Ansari M,1  Khan AH,2 Hossain S,3 Khanom F4

  1. *Dr. MAS Ansari, Associate Professor of Pathology, Sylhet Women’s Medical College, Sylhet. drmasansari@gmail.com
  2. Professor Dr. Amjad Hossain Khan, Professor of Pathology, Sylhet Women’s Medical College, Sylhet.
  3. Sabbir Hossain, Associate Professor of Pathology, North East Medical College, North East Medical College, Sylhet.
  4. Farida Khanom, Medical Officer of Gynae & Obs, Jalalabad Ragib-Rabeya Medical Colleg, Sylhet.

 *For correspondence

 Abstract

Background: Ovarian tumour accounts for 3% of total cancer in females and is the 5th most common form of cancer related death in females with a varied clinical, morphological and histological features.

Objectives: The present  study was carreid out with an aim to find out  the frequency, age distribution and the histopathological  patterns of ovarian tumours.
Methods: Retrospective  study was done during the period  of 3 years comprised of 125 ovarian tumours diagnosed in the Department of Pathology, Sylhet Women’s Medical College, Sylhet. After thorough gross examination, representative bits were routinely processed and stained with H & E. Tumours were classified as per WHO classification.
Results: Out of 125 cases studied, majority were benign tumours (88%), followed by malignant (10.4%) and borderline tumour (1.6%). Age ranged from 11-70 years. Epithelial tumours were most common (76%), followed by germ cell tumours (16%), sex cord stromal tumours (7.2%) and metastatic ovarian tumours (0.8%). Serous cystadenoma was the commonest benign tumour and serous cyst adenocarcinoma was the commonest malignant ovarian tumour.
Conclusion: The prognosis and varying therapeutic strategies of ovarian tumours necessitate an accurate pathological evaluation. Although newer techniques like IHC and molecular analysis have made the diagnosis easier and more precise, in the institutes with provision of limited resources, histopathological study is still the gold standard in diagnosing most of these tumours.

 [Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):125-133]

Key words: Ovarian tumour, Histopathology

 Introduction

Ovarian tumours include complex, wide spectrum of neoplasms involving a variety of histological patterns ranging from epithelial tissues, connective tissues, specialized hormone secreting germinal and embryonal cells.1

The poor survival is due to the fact that they do not clinically manifest early and approximately 60-70% of the neoplasms present as either stage III or stage IV.1,3,4 Benign ovarian cysts are the commonest constituting about 80% of ovarian tumours and mostly occur in young women between the ages of 20-40 years. Borderline tumours occur at slightly older ages whereas the malignant tumours are common in older women between the ages of 40-65 years.1,4 Metastatic tumours subsequently involve the ovaries and mimic primary ovarian neoplasia. Approximately, 7% of lesions presenting clinically as primary ovarian tumours are of metastatic origin.5, 6 It is important to determine the histological pattern of ovarian tumour to achieve the optimum treatment response as prognosis depends on the degree of differentiation.2,3,7

Thus present study was undertaken to analyse the frequency of various histological subtypes, age distribution pattern and the  histopathological pattern of ovarian tumours.

 Methods

This retrospective  study was conducted for a period of 3 years (January2015 – December 2018) at Sylhet women’s Medical College, Sylhet.

Specimens sent in 10% formalin were routinely processed with paraffin embedding after adequate fixation. Paraffin sections and slides from fresh blocks and the retrieved blocks were stained with H & E. The slides were then reviewed microscopically in detail and tumours were classified according to the WHO classification of ovarian tumours.

Inclusion criteria

All histologically proven both primary and secondary ovarian tumours.

Exclusion criteria

Non- neoplastic ovarian lesions of study period.

Results

A total number of 125 cases were studied. Among these, majority were primary ovarian tumours (124; 99.2%), while one was metastatic ovarian tumours (1; 0.8 %). Of them 69 cases were benign (88%), 15 cases were malignant (10.4%) and rest 2 cases (1.6%) were borderline. Epithelial tumours (ET) were the most common histological type (95;76%), followed by Germ cell tumours (GCT) (20;16%) and sex cord stromal tumour (SST 9;7.2%; Table I).

Age Distribution

Majority of the tumours occurred in the reproductive age group (57; 45.6%) followed by 41-50 years of age group (26; 20.8%).Youngest patient was 13 years of age and older patient was about 68 years. Epithelial tumours and Sex cord stromal tumours had its peak between 31 to 40 years, whereas Germ cell tumours showed a peak in 21 to 30 years. Metastatic tumoursshowed  distribution between 61-70 years of age group.

 Gross Features

Most of the cases in this study were unilateral (117; 93.6%) and few were bilateral (8; 6.4%). Out of the total 95 Epithelial tumours, 76 were cystic in nature (80%), followed by those with cystic to solid in consistency (18; 18.9%) and solid (1; 1.05%), whereas most of Germ cell tumours were cystic in nature (16; 72.7%), followed by solid in consistency (5; 22.7%). Majority of sex cord stromal tumours (5; 71.4%) and all of the metastatic tumours were partly solid to cystic in consistency.

 Microscopy

The most common benign tumour was Serous cystadenoma (54; 43.2%), followed by Mucinous cystadenoma (14; 11.2%) and Mature cystic teratoma (16; 12.8%). Serous cyst adenocarcinoma was the most common malignant tumour (6; 4.8%), followed by Adult granulosa cell tumour (3; 2.4%). Borderline serous tumour were two in numbers. There was one case of metastatic ovarian tumours, was Krukenbergtumour. (Table II).

Discussion

Ovarian tumours are one of the major health problems and their diagnosis can be difficult due to variety of pathologic conditions affecting the ovaries. Thus knowledge of morphology and age-specific characteristics can help refine the diagnosis.8, 9

In the present study of 125 ovarian tumours, Primary ovarian neoplasms (99.2%) were the most common tumours of all ovarian tumours. Similar observations were made by Bhagyalakshmi A et al.10 (98.5%) and Vaddatti T et al.3 (98.9%). Most of the tumours belonged to Epithelial tumour category (76%) which was comparable to the results seen by Singh S et al.11 (69.17%), Krishna M & Maurya G12 (77.7%) and Badge S et al.13 (77%). GCT and SST accounted for 16% and 7.2%, respectively in our study compared to 42.2% and 3.1% reported in the others.14

In the present study, majority of the tumours were benign (88%) followed by malignant tumours (10.4%) and rest was borderline (1.6%). Findings of the present study correlated well with the studies of various authors.However, in this study the frequency of malignant tumours (10.4%) was little less than the study of Couto F et al.15 (40%).

In the present study, the patient’s age ranged from 11 years to 70 years and this was supported by the study done by Swamy GGEt al.16 where the youngest patient was 13 years old and the oldest was 68 years old. The majority of ovarian tumours (60.7%) were seen in the age group of 21-40 years, which was consistent with the study done by Kuladeepa A VK et al.17 (58.9%) and Pilli GS et al.18 (58.3%) .

In our study, majority of the tumours were unilateral (97.1%) and least were bilateral (2.9%) which were consistent with the findings of  VaddattiT et al.3, Jindal U8 and Prabhakar BR and Maingi K.19

In the present study, majority of the tumours were cystic (72%), followed by partly cystic & solid (18.4%) and few were solid (9.6%). These findings were comparable with the findings of Misra RK et al.20 where most of the tumours were cystic (78.2%) and few were solid (4.1%), whereas Couto F et al.15 have found 10.2% solid tumours which was close to our findings. Benign epithelial tumors were the commonest type (88.4%), followed by malignant epithelial tumors (9.47%) and the rest was borderline (2.10%). These findings were almost similar as observed in the study conducted by Kuladeepa A VK et al.17) Sharma I et al.21

In this study, maximum number of epithelial tumors (78%) were noted in 31-50 years age group. All malignant tumours were seen in the cases above 50 years of age. The results corroborated with the various studies done by Tushar K et al. (2005),22 Jha R & Karki S14 and Jindal U.8 Among the histomorphological types of epithelial tumors, Seroustumours (73.6%) were the most common, followed by Mucinous tumours (16.8%), Seromucinoustumours (8.42%) and least common were endometrioid tumours (1.05%). Similar results were seen by Krishna M & Maurya G12 andSarkar R.23 Serous cystadenoma was the commonest ET (53.3%) followed by Mucinous cystadenoma (21.7%) and serous cyst adenocarcinoma (8.4%). Similar results were reported by various authors in their studies.

In the present study, majority of the  germ cell tumours were benign (81.8%) and include mature cystic teratoma and Struma ovarii. These results were closer to the findings of Agrawal P et al.24 and Verma K & Bhatia A25 with 77.7% and 83.5% respectively. Malignant tumours include Dysgerminoma and Embryonal carcinoma. Germ cell tumours showed maximum cases below 35 years of age, with a gradual decline in 31-40 years age group and they were found to be uncommon after the age of 60 years. These findings were consistent with the studies of Jha R & Karki S14 and Agrawal P et al.24

In this study, majority of the sex cord stromal tumours were benign (57.1%) and the results were not similar to the findings of Rao KN et al.26 (55.6%) and were lower when compared to the findings of Jindal U8 (75%). On the contrary study of Badge SAEt al.13 (66.7%) showed mostly benign sex cord stromal tumours against malignant. The age range of sex cord stromal  tumours in our study was 41-70 years whereas Bhagyalakshmi A Et al.10 recorded age range of 21-70 years in their study. Adult granulosa cell tumour which is potentially malignant tumour occurred in 2.4% of all ovarian tumours. The frequency was consistent with the findings of Gupta SC et al.27 and Pilli GS et al.18 who recorded it as 4.4% and 3.54% respectively.

Our study showed one case of secondary tumours and constituted 0.8% of all ovarian tumours. This was lower when compared to the findings of Badge SA Et al.13  (10.9%) but was almost similar to the studies of Gupta N et al.28 (2%), Jha R & Karki S14 (2.4%) and Bhagyalakshmi A Et al.10 (1.5%). The former when compared with the studies of Misra RK et al.20 (1.07%), Prabhakar BR and Maingi K19 (1.57%) and Couto F et al.15 (1.46%) showed a good correlation.

 Conclusion

Ovarian tumour is a silent menace that presents as a tremendous clinical challenge to gynaecologist, medical oncologist and radiotherapists. Emergence of borderline tumours with prognostic difference from the benign and malignant counterparts, has added a wing to research in the field of ovarian tumours. Accurate diagnosis of ovarian tumours can be rendered in almost all of cases by correlating the clinical presentation, radiographic appearance and histomorphological features, which remains the gold standard. Even then, in the modern era by the application of specialised methods like special stains, IHC markers, ultrastructural studies and cytogenetics, there is a vast scope for reaching specific & reliable diagnosis of difficult dilemmatic cases of ovarian tumours, by which the therapeutic and prognostic implications could be modified.

References

  1. Pradhan A, Sinha AK, Upreti D. Histopathological patterns of ovarian tumors at BPKIHS. Health Renaissance. 2012; 10(2):87-97.
  2. Malli M, Vyash B, Gupta S, Desai H. A Histological study of ovarian tumors in different age groups.Int J Med Sci Public Health. 2014; 3(3):338-341.
  3. Vaddatti T, Reddy ES, Vahini G. Study of morphological patterns of ovarian neoplasms. IOSR Journal of Dental and Medical Sciences. 2013; 10(6):11-16.
  4. Ellenson LH, Piorg EC. The Female Genital Tract.Kumar V, Abbas AK, Aster JC. In: Robbins and Cotran Pathological Basis of Diseases. 9th edn: Elseiver, 2014; 2:1022-1034.
  5. Prat J, Morice P. Secondary tumours of ovary. Tavassoli FA, Devilee P. In: WHO classifications of tumours: Pathology of the breast and female genital organs. 3th edn. IARC Press: Lycon, 2003, 193.
  6. Rosai J. Female reproductive system- Ovary. In: Rosai and Ackerman’s Surgical Pathology. 10th edn. Missouri: Elsevier, 2012; 2:1553-1609.
  7. Sohail I, Hayat Z, Saeed S. A comparative analysis of frequency and patterns of ovarian tumours at a tertiary care hospital between two different study periods 2002-2009. J Postgrad Med Inst. 2012; 26(2):196-200.
  8. Jindal U. Pattern of ovarian neoplasm in rural population: A five year study from tertiary care hospital. Journal of evolution of medical and dental sciences. 2014; 3(8):2033-2039.
  9. Mondal SK, Banyopadhya R, Nag DR, Roychowdhury S, Mondal PK, Sinha SK. Et al. Histologic pattern, bilaterality and clinical evaluation of 957 ovarian neoplasms: A 10-year study in a tertiary hospital of eastern India. J Can Res Ther. 2011; 7(4):433-437.
  10. Bhagyalakshmi A, Sreelekha A, Sridevi S, Chandralekha J, Parvathi G, Vekatalakshmi A. Et al. Prospective study of histopathological patterns of ovarian tumours in a tertiary care centre. Int J Res Med Sci. 2014; 2(2):448-456.
  11. Singh S, Saxena V, Khatri SL, Gupta S, Garewal J, Dubey K. Et al. Histopathological evaluation of ovarian tumors. Imperial Journal of Interdisciplinary Research. 2016; 2(4):435-439.
  12. Krsihna M, Maurya G. Pattern of ovarian tumors and their age distribution in Kangra Valley Himachal Pradesh. Journal of Evolution of Medical and Dental Sciences. 2015; 4(61):10602-10608.
  13. Badge SA, Gosavi AV, Sulhyan KR. Histopathological study of ovarian tumors. Indian Medical Gazette, 2013; 345-351.
  14. Jha R, Karki S. Histological pattern of ovarian tumors and their age distribution. Nepal Med Coll J. 2008; 10(2):81-85.
  15. Couto F, Naolkarni NS, Rebello MJ. Ovarian tumours in Goa: A clinic pathological study of ovarian tumours. J ObstetGynaecol of India. 1993; 43(3):408-12.
  16. Swamy GG, Saryanarayan N. Clinico pathological analysis of ovarian tumors – A study on five years samples. Nepal Med Coll J. 2010; 12(4):221-223.
  17. Kuladeepa AVK, Muddegowda PH, Lingegowda JB, Doddikoppad MM, Basavaraja PK, Hiremath SS Et al. Histomorphological study of 134 primary ovarian tumors.Adv Lab Med Int. 2011; 1(4):69- 82.
  18. Pilli GS, Suneeta KP, Dhaded AV, Yenni VV. Ovarian tumours: A study of 282 cases. J Indian Med Assoc, 2002; 100:423-424.
  19. Prabhakar BR, Maingi K. Ovarian tumors – prevalence in Punjab. Indian J PatholMicrobiol, 1989; 32:276-81.
  20. Misra RK, Sharma SP, Gupta V, Gaur R, Mishra SD. International Journal of Medical and Health Research ,Pattern of ovarian neoplasm in eastern UP. J ObstetGnecol. 1991; 41(2):242-6.
  21. Sharma I, Sarma U, Dutta UC. Pathology of ovarian tumour- A hospital based study. International Journal of Medical science and Clinical Invention. 2014; 1(6):284-286.
  22. Tushar K, Asaranti K, C MP. Intra-operative cytology of ovarian tumours.J ObstetGynecol India. 2005; 55(4):345-349.
  23. Sarkar R. Ovarian neoplasms – A 14 years study. J ObstetGynecol India, 1996; 46:156-160.
  24. Agrawal P, Kulkarni DG, Chakrabati PR, Chourasia S, Dixit M, Gupta K Et al. Clinico pathological spectrum of ovarian tumors: a 5 year experience in a tertiary health care center. Journal of Basic and Clinical Reproductive Sciences. 2015; 4(2):90-96.
  25. Verma K, Bhatia A. Ovarian neoplasms: A study of 403 tumors. J ObstGynecol India.1981; 31:406-411.
  26. Rao KN, Koteswari M, Devi CP, Sailabala G, Katta R. Morphological study of ovarian tumors with special reference to germ cell tumors. IOSR Journal of Dental and Medical Sciences. 2015; 14(1):55-60.
  27. Gupta SC, Singh PA, Mehrotra TN, Agarwal R, A clinic pathological study of ovarian tumours: Indian J PatholMicrobiol. 1986; 29(4):354-62.

28. Gupta N, Bisht D, Agarwal AK, Sharma VK. Retrospective and prospective study of ovarian tumours and tumour-like lesions.Indian J PatholMicrobiol. 2007; 50(3):525-7.