Original Article

Clinicopathological study of ovarian tumour: An institutional study of six years.

A K M Maruf Raza1, Mehdi Ashik Choudhury2, Mariya Tabassum3, Shegufta sharmin,4Akash
sheikh,5Nur e tamanna,6

Names of the authors:

1. Dr. A K M Maruf Raza, Associate Professor of Pathology, Jahurul Islam Medical

College, Bajitpur, Kishoregonj.
2. Dr. Mehdi Ashik Choudhury, Associate Professor, Department of Pathology, Tairunnessa
Memorial Medical College, Tongi, Gazipur.
3. Dr. Mariya Tabassum,Associate Professor (CC), Dept. of Biochemistry, Abdul Malek
Ukil Medical college,Noakhali
4. Dr.Shegufta sharmin,Associate Professor, pathology, Shaeed Monsur Ali Medical
College
5. Akash sheikh,5th year MBBS student,Tairunnessa Memorial Medical College,
6. Nur e tamanna,5 th yesr MBBS student,Sylhet womens medical college

Address of correspondence:
Dr. A K M Maruf Raza, Associate Professor, Department of Pathology, Jahurul Islam
Medical College, Kishoregonj, Mobile: 01711306123, Email: [email protected]

Abstract
Background: Ovarian tumours are common neoplasm in women and accounts for around 30%
of the female genital tract cancers. Though benign tumours are more common than to malignant
tumours, ovarian cancer is the sixth most common cancer in women and the leading cause of
death in women with gynaecological malignancy.
Objective: The objective of this study was to see the distribution of ovarian tumour
histopathologically in different age groups with their various clinical presentations.
Methods: Retrospective study of six years duration in Jahurul Islam Medical college Hospital,
Kishoregonj with sample of 432 cases of ovarian lesions underwent excision surgery were
included in this study.
Results: There were 420 lesions comprising of 40% of neoplastic lesions and 60% of non-
neoplastic lesions. Among the ovarian neoplasms, 91.1% were benign lesions, 7.1% malignant
and 1.8% were borderline malignant. Serous tumors were the commonest tumors (46.4%)
followed by mucinous tumors and germ cell tumors (23.2% each). Endometriotic cysts (34.5%)
were the commonest non-neoplastic lesions. The distribution of benign tumors in the
reproductive age groups was only slightly more than that in the perimenopausal age group. All
malignant tumors were in the perimenopausal age group. Menstrual complaints like irregular
bleeding and menorrhagia, lump and pain in the abdomen formed the majority of clinical
presentation.
Conclusion: Benign ovarian tumors are common in reproductive age group as well as
perimenopausal age group. The most common neoplasm present was surface epithelial tumors -
serous tumors followed by germ cell and mucinous tumors. The most common non-neoplastic
lesions were endometriotic cysts and inclusion cysts. Common clinical presentations were
menstrual problems and abdominal pain.
Keywords: Ovarian tumour, Histopathology, Gynaecological malignancy
Introduction

Ovarian masses are common forms of neoplasms in women. Ovarian tumors that present in the
reproductive age group are mostly benign while about 30% in the postmenopausal age group are
malignant 1. They present themselves in various clinical forms and surprisingly many a time as
vague, non-gynaecological complaints. Ovarian tumors show histological heterogenecity. The
classification of ovarian tumors by World Health Organization is based on the histogenesis of
ovary. They are largely divided in to epithelial cell tumors, germ cell tumors, and sex cord
stromal cell tumors 2. Many ovarian tumors are asymptomatic in the early stages and are
unfortunately diagnosed in the advanced state. The high mortality rate of ovarian cancer is due to
its late detection, thus earning itself the term “Silent Killer” 3. The definitive diagnosis of the
ovarian tumor is by histopathological study 4. However, around ninety percent of adnexal masses
are detected by pelvic ultrasound which provides clinical information about the origin of the
adnexal mass 5.
Objective of this present work were to study various clinical and histo-morphological features of
ovarian neoplasms which are more prevalent in our population and to study the frequency of
benign and malignant neoplasms of ovary in this region.

Methods
This study was done retrospectively in the department of Pathology, Jahurul Islam Medical
college, Bajitpur, Kishoregonj. 420 histologically proven cases of ovarian tumor operated in the
Gynecology and Obstetrics department during the period of 6 years (year 2016 to year 2021)
were included in the study. The patients who underwent surgery for ovariotomy alone or along
with hysterectomy with salphingo-oophorectomy were included in the study. Ovarian tumors
managed conservatively were excluded from the study. Data regarding age, clinical symptoms,
details of the mass like size, laterality, per-operative findings were collected. Histopathological
examination of the resected specimen was done in the department of Pathology following
appropriate staining (haematoxylin and eosin; H&E). The histopathological reports were based
on WHO classification of ovarian tumors. All the necessary and relevant data were processed
and analyzed by using the Microsoft Excel and SPSS (version-18) software package.
Results

Among the 420 lesions, there were 168 neoplastic tumors and 252 non-neoplastic lesions.
Among the neoplastic lesions, 91.1% (153/168) were benign, 7.1% (12/168) were malignant and
there was only 1.8% (3/168) with borderline malignant.

Table 1: Histopathological distribution of ovarian tumour (n=168)

Histopathological type No. of cases Percentages

Surface epithelial tumours 120 71.4

i. Serous tumour 78 46.4

Serous Cystadenoma 75 44.6

Serous Cystadenocarcinoma 3 1.8

ii. Mucinous tumour 39 23.2

Mucinous cystadenoma 30 17.8

Mucinous cystadenocarcinoma 6 3.6

Borderline mucinous cystadenocarcinoma 3 1.8

iii. Endometrioid adenocarcinoma 3 1.8

Germ cell tumour 39 23.2

i. Benign cystic teratoma (dermoid cyst) 36 21.4

 ii. Struma ovary 3 1.8

Sex cord stromal tumour 9 5.3

i. Fibroma/ Fibrothecoma 6 3.6

ii. Granulosa cell tumour 3 1.8

Serous cyst adenomas (44.6%), followed by Germ Cell tumors (23.2%) and mucinous cyst
adenoma (17.8%) were the most common benign tumors. Of the 12 malignant tumors, 6 were
mucinous cyst adenocarcinoma, 3 each were serous cystadenocarcinoma and endometrioid
adenocarcinoma. The borderline tumor belonged to the mucinous group. Among the non-
neoplastic masses, commonest was endometriotic cyst 34.5% (87/256), followed by inclusion
cysts 28.5% (72/256). The pie chart showing distribution of non neoplastic ovarian lesion
(Figure 1).

Non Neoplastic lesions

Inclusion cyst
Chronic oophoritis, 3, 1%

Follicular cyst
Endometri- Inclusion
otic cyst, 77, cyst, 72, 30%
32% Hemorrhagic
copus leuteal
cyst

Endometriotic
cyst
Follicular cyst, 42,
Hemorrhagic 17%Chronic oophori-
copus leuteal tis
cyst, 48, 20%

Figure 1: Distribution of non-neoplastic lesions (n=252)

Maximum number of benign ovarian tumors was in the 21-40 year age group. Majority of the
non neoplastic lesion were in the 41-60 year age group followed by 21 to 40 years group. All the
malignant tumors [100% (12/12)] were in the 41-60 year age group. Table 2 showing ovarian
lesion in different age group.

Table 2: Distribution of ovarian lesion in different age group.

Ag Neoplastic Tumour Non Neoplastic lesion
e
(in Serous Mucinous G Endo S Incl F End C Chro
ye tumours tumours er metr e usio ol ome o nic
ar m ioid x n li trio p ooph
s) ce aden c cyst c tic u oritis
ll ocar o ul cyst s
tu cino r a l
m ma d r e
ou t c u
r u ys t
m t e
o a
u l
r c
y
s
t
B M B BL M
<20 3 - - - - 3 - - 6 - - 6 -
21-40 21 - 18 3 - 21 - 6 12 9 33 9 -
41-60 33 3 9 - 6 12 3 3 42 30 33 27 3
>60 9 - - - - 3 - - 3 - 3 - -

Common clinical presentations in this study for both neoplastic and non-neoplastic lesions were
menstrual complaints (Table 3). Menstrual problems were common in the reproductive age
group comprising of 19.3% of patients followed by pain in the abdomen and feeling of lump in
the abdomen. However, incidental finding of ovarian mass was the second most common
(18.6%).
Table 3: Clinical presentation of patients (n=420)
Clinical presentation No. of patients with percentage

Menstrual abnormality 81 (19.3%)

Pain abdomen 63(15%)

GI symptoms 27(6.4%)

Post menopausal bleeding 18(4.3%)

Abdominal lump 12(2.9%)

 Infertility 15(3.6%)

Incidental finding 78(18.6%)

Out of 420 ovarian tumor patients, 72 (22.22%) were nulliparous and 256 (77.78%) were
multiparous.
Most of the ovarian tumors (53.7%) are within 1cm to 22 cm. in maximum diameter. Maximum
number of surface epithelial tumors (51.11%) were within 10-19 cm. The malignant tumors are
larger in comparison to benign tumors. Majority of the benign tumors (63.63%) are cystic and
majority of the malignant tumors (37.7%) are solid. 20.45% of benign tumors were variegated
whereas 26.22% of malignant tumors are variegated. 25% of the benign tumors are unilocular
whereas 18.3% of malignant tumors are unilocular.
Different tumour markers were estimated during admission , prior surgery for the evaluation of
tumour burden. Table 4 shows CA125 was the most commonly done tumor marker which was
elevated mostly in the serous cystadenocarcinoma. CEA and CA19.9 were also commonly done
in cases of ovarian tumors. AFP and LDH were significantly raised in germ cell tumors.

Table 4: Estimation of various tumour markers in evaluation of ovarian tumours.

Types No. of CA125 CA19.9 CEA AFP LDH
tumour

Serous cystadenocarcinoma 3 3 - 1 - -

Mucinous 6 3 - 4 - 2
cystadenocarcinoma

Borderline mucinous 3 2 1 - - -
cystadenocarcinoma

Endometrioid 3 1 - - - 2
adenocarcinoma

Germ cell tumour 39 16 - 8 10 20

Discussion
There are various types of ovarian tumour. About 80% are benign and occurs mostly in between
ages of 20 and 45 years. Borderline tumours occur at slightly older ages. Malignant tumours are
more common between the ages of 45 and 65 years6.
Ovarian tumors show histological heterogeneity. The WHO classification of ovarian tumors is
based on the tissue of origin like surface epithelial tumours, germ cell tumours, sex cord stromal
tumours7. It is globally seen that, surface epithelial tumors are the most common ones1. Surface
epithelial tumors formed 71.4% (120/168) the main bulk of neoplasm observed in this study. The
majority of epithelial tumors were serous tumors (46.4%) and mucinous and germ cell tumors
(23.2% each). Among serous tumors, serous cyst adenoma constituted 44.6% and serous cyst
adenocarcinoma was 1.8%. Among mucinous tumors, 17.8% were mucinous cystadenoma, 3.6%
were cyst adenocarcinoma and 1.8% was with borderline pathology. Among the germ cell
tumors, 36 cases were benign cystic teratoma with three having a predominance of thyroid tissue
(struma ovary).
The frequency of distribution of ovarian tumors in the present study was similar to that as
reported by Swami GG et al. They reported an incidence of 61.6% of epithelial tumors and
21.7% of germ cell tumors8. This was in concordance with the study by Mondal et al who
reported surface epithelial tumors to be the most common (67.9%)9 . Among the non-neoplastic
lesions, 34.5% were endometriotic ovarian cysts, which explain the predominant complaint of
menstrual abnormality. A similar high incidence of ovarian endometriosis (45.9%) was observed
by Al-Fozan H et al10. In this study (Table 2), benign tumors were more in the reproductive age
group (21-40 years). All 12 malignant ovarian tumors were in the age group (41-60 years). The
single borderline tumor was present in the younger age group (21-40 years). Manivasakan J
observed an equal distribution of benign ovarian tumors in reproductive and perimenopausal age
groups11. Sharadha SO noted maximum number of neoplasm (89.9%) is in the reproductive age
groups12. On the contrary, study done by Ashraf A et al reported a high percent (71.4%) of
malignant tumors in the reproductive age group13. However, most of available literature from the
western world report ovarian cancer to be more in the elderly perimenopausal women 14.
Common clinical presentations in this study for both neoplastic and non-neoplastic lesions were
menstrual abnormality (Table 3). Menstrual problems common in the reproductive age groups
were irregular bleeding, menorrhagia and dysmenorrhoea. A good number of ovarian masses
were diagnosed incidentally during histopathological examination of hysterectomy and salpingo-
ophorectomy specimens. Abdominal pain and back pain were reported by 15% of our patients.
Cause of this abdominal pain probably was due to torsion, associated saphingo-ophoritis and
chronic pelvic inflammatory disease. Findings similar to our study regarding menstrual
complaints and abdominal pain were seen by Kanthikar SN et al15. Size of the ovarian masses in
our study ranged from 1 cm to the largest being 22.5 cm. Most of the masses less than 5 cm were
nonneoplastic lesions and the large ones (>15 cm) belonged to the mucinous and endometriotic
lesions. Benign tumours were smaller in comparison to malignant tumour. Benign tumours are
less variegated on cut section than to malignant. Malignant tumours were more solid in nature.
These finding are in co-ordinance with other study6.
Estimation of various tumor markers was done. CA125 is the commonest tumors markers seen
(28.75%) followed by CEA (5.83%) and LDH (4.58%). Different authors also described CA 125
is mainly raised in serous tumour and CEA is raised in mucinous tumour of ovary16.

Conclusion

Ovarian neoplasm is one of the most common and lethal malignancy in female reproductive tract
in older age group. It is difficult to always differentiate between malignant and benign tumors
clinically. Since most of the ovarian cancers remain asymptomatic for prolonged period so
measures should be taken for early diagnosis for better outcome.
Limitations

This present study is a single institution based retrospective study, a large multicentric approach
is needed to compare present study results. Causative factors are not well analyzed. Due to
limitation of the accurate data regarding survival in malignant ovarian tumors authors could not
comment on prognosis.
Conflict of interest: None

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