Original article / research
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2022 |
Month :
July
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Volume :
11 |
Issue :
3 |
Page :
PO75 - PO80 |
Full Version
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Histomorphological Study of Ovarian Lesions with Emphasis on Rare Entities- A Descriptive Study
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Shri Lakshmi Surapaneni, Vandana Gangadharan, Harika Pentakota, Krishna Kumari Sala
1. Associate Professor, Department of Pathology, NRI Institute of Medical Sciences, Sangivalasa, Vishakapatnam, Andhra Pradesh, India.
2. Associate Professor, Department of Pathology, NRI Institute of Medical Sciences, Sangivalasa, Vishakapatnam, Andhra Pradesh, India.
3. Senior Resident, Department of Pathology, NRI Institute of Medical Sciences, Sangivalasa, Vishakapatnam, Andhra Pradesh, India.
4. Professor and Head, Department of Pathology, NRI Institute of Medical Sciences, Sangivalasa, Vishakapatnam, Andhra Pradesh, India.
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Correspondence
Address :
Shri Lakshmi Surapaneni,
Flat No 401, Varanasi Residency, Waltair Uplands Near Lata Hospital
VIshakapatnam-530003, Andhra Pradesh, India.
E-mail: rkgummadi95@gmail.com
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| | | ABSTRACT |  | : Introduction: The ovaries are bilateral organs on either side of the uterus. Non neoplastic and neoplastic lesions occur in all age groups and can present with similar clinical and radiological features. Histopathology remains the gold standard for diagnosing and categorising these lesions.
Aim: To study the prevalence of ovarian lesions in relation to age and clinical findings. Classifying the neoplastic lesions histologicaly as per World Health Organisation (WHO) guidelines and to compare the findings with previous studies.
Materials and Methods: The present observational descriptive study of all ovarian lesions was undertaken in the Department of Pathology in NRI Institute of Medical Sciences, Sangivalasa, Vishakhapatnam, Andhra Pradesh, India, from June 2018 to November 2021. Specimens were received as ovarian masses alone, or in combination with hysterectomy with either unilateral or bilateral salpingo-oophorectomy. Relevant clinical information was obtained from the records. The tissues were processed by using an automatic tissue processor, paraffin blocks were made and sections cut were stained with Haematoxylin and Eosin (H&E) and examined under the microscope. The lesions were categorised as non neoplastic and neoplastic. The neoplastic lesions were classified according to the latest 2020 WHO guidelines. Incidence of various lesions was expressed in percentage.
Results: A total of 119 specimens were studied. Some of the specimens had bilateral ovaries and the second ovary had a different non neoplastic lesion in 18 cases. Total 80 (60.60%) were non neoplastic lesions and 52 (39.39%) were neoplastic lesions. 5 cases of torsion could not be classified into neoplastic or non-neoplastic due to lack of viable histological features. Non neoplastic lesions were more common in the 31-50 years age group. Benign neoplasms were common in 41-50 years age group. Malignant tumours were more common in the perimenopausal and postmenopausal age group. The most common non neoplastic lesion were 39 cases (48.75%) of follicular cyst followed by 26 cases (32.5%) of corpus luteal cyst, 13 cases (16.25%) of cystic follicles and 2 cases (2.5%) of endometriotic lesions. Of the neoplastic lesions, 47 cases (90.38%) were benign, 2 cases (3.84%) were borderline and 3 cases (5.76%) were malignant tumours. Surface epithelial tumours were 42 cases (80.76%), followed by 6 cases (11.53%) of germ cell tumours and 4 cases (7.69%) of sex cord stromal tumours.
Conclusion: Non neoplastic lesions and neoplastic lesions present with similar clinical and radiologic picture and must be differentiated histopathologically. Non neoplastic lesions were more common in the present study. Among the neoplasms, benign tumours were more common and surface epithelial tumours were more common than any other category. Torsion ovary, Seromucinous cystadenoma, atypical endometrioid tumour and granulosa cell tumour were some rare entities that were encountered in the study. Classifying tumours helps in better patient management. |
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| Keywords
: World health organisation 2020, classification of Ovarian tumours, Neoplastic, Non neoplastic,
Ovary, Seromucinous cystadenoma |
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| DOI and Others
: DOI: 10.7860/NJLM/2022/53606.2657
Date of Submission: Dec 17, 2021
Date of Peer Review: Feb 01, 2022
Date of Acceptance: Feb 27, 2022
Date of Publishing: Jul 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METH |
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INTRODUCTION |
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The ovaries are bilateral organs on either side of the uterus. It is an organ that is constantly changing cortical contours. Changes in the ovaries can be both physiological and pathological. The common lesions in the ovary include functional or benign cysts and tumours (1). Non neoplastic lesions of the ovary can present as a pelvic mass and may be associated with abnormal hormonal manifestations mimicking an ovarian neoplasm (2). Lesions must be differentiated for proper clinical management of patients. Inspite of radiological advances, histopathological examination is necessary to differentiate the two. All lesions, both non neoplastic and neoplastic occur in all age groups from childhood to postmenopausal age group. Neoplastic lesions especially malignant ones have to be identified and treated. The present study was under taken to study the spectrum of ovarian lesions in a rural location.
This study aims to study the prevalence of ovarian lesions in relation to age and clinical features and categorise lesions into non neoplastic and neoplastic. The neoplastic lesions will be histologically classified as per WHO classification of ovarian tumours (1). The prevalence of various lesions in this study will be compared with that in other studies.
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Material and Methods |
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The present observational descriptive study was conducted in the Department of Pathology, NRIIMS, Sangivalasa, Vishakhapatnam, Andhra Pradesh, India, during the period between June 2018 to November 2021. After getting ethical clearance from Institutional Ethical Committee.
Inclusion criteria: All gynaecological specimens with ovaries were included in the study.
Exclusion criteria: Gynaecological specimens which did not include ovaries were excluded from the study.
Study Procedure
The specimens were received as ovarian masses alone or in combination with hysterectomy with either unilateral or bilateral salpingo-oophorectomy. Relevant clinical information was obtained from the records. The specimens were grossed after proper fixation in 10% formalin. The gross findings were noted in detail. Appropriate sections of 3 mm thickness were given. The tissues were processed by using an automatic tissue processor, paraffin blocks were made and the sections cut were stained with Haematoxylin and Eosin (H&E) and examined under the microscope. The lesions were categorised as non neoplastic and neoplastic. The neoplastic lesions were classified according to the latest 2020 WHO guidelines.
STATISTICAL ANALYSIS
Incidence of various lesions was expressed in percentage.
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Results |
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A total of 119 specimens with ovarian lesions were studied. Some of the specimens had bilateral ovaries and in 18 of them, the second ovary had a different non neoplastic lesion. 80 (60.60%) were non neoplastic lesions and 52 (39.39%) were neoplastic lesions. We had 9 cases of torsion and the lesions could not be classified into non neoplastic or neoplastic category in 5 cases due to lack of viable histological features. Clinically symptoms ranged from no symptoms in 54 cases (45.37%) , Menorrhagia in 31 cases (26%), mass per abdomen in 18 cases (15.13%), Abdominal pain in 13 cases (10.92%), low backache in 3 cases (2.52%). Most of the non neoplastic lesions were incidental. In the present study, non neoplastic lesions were more common in the 31-50 years age group. The most common non neoplastic lesion was 39 cases (48.75%) of follicular cyst followed by 26 cases (32.5%) of corpus luteal cyst. Thirteen cases (16.25%) were cystic follicles and 2 cases (2.5%) were endometriotic lesions (Table/Fig 1). Benign neoplasms were more common in the 41-50 years age group. Malignant tumours were more common in the perimenopausal and postmenopausal age groups (Table/Fig 2).
There were 9 cases of torsion of the ovary comprising 7.56% of all ovarian lesions. A total of four were identified as benign serous tumours due to preservation of lining epithelium in the lesion and the other cases could not be typed due to obscuration of cellular details in them due to ischaemic and haemorrhagic necrosis.
The neoplastic lesions were classified as per the 2020 WHO classification of ovarian tumours. A total of 47 cases (90.38%) were benign, 2 cases (3.84%) were borderline and 3 cases (5.76%) were malignant tumours. Surface epithelial tumours were 42 cases (80.76%) and the most common tumours followed by 6 cases (11.53%) of germ cell tumours and 4 cases (7.69%) of sex cord stromal tumours. The most common benign epithelial tumour was serous cystadenoma with 25 cases (50%) followed by 13 cases (25%) of mucinous cystadenoma. We had 1 case (1.92%) of seromucinous tumour. There were two borderline tumours, 1 case (1.92%) of atypical mucinous tumour and 1 case (1.92%) of proliferative endometrioid tumour. The only malignant epithelial tumour was a case of Mucinous cystadenocarcinoma (1.92%). There were 6 cases (11.5%) of mature cystic teratoma under the germ cell category. There were 2 cases (3.84%) of granulosa cell tumour and 2 cases (3.84%) of ovarian fibroma in the sex cord-stromal cell category (Table/Fig 3).
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Discussion |
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Ovarian lesions are seen across all age groups from childhood to postmenopausal age. They may be incidental findings or may present with symptoms related to their function or as a result of mass effect in the pelvic region. Non neoplastic lesions are quite common in the reproductive age group (2). Malignant ovarian tumours are often detected late and therefore have bad prognosis. Histopathological diagnosis is the gold standard for differentiating various lesions. This study enables us to map out ovarian lesions in this geographic location and find out their incidence and behaviour and help in guiding later management.
The youngest patient in the study was 18 years and the oldest was 84 years. In the present study, non neoplastic lesions were more common in the 31-50 years age groups. These findings were similar to findings in various studies (3),(4),(5),(6),(7),(8),(9),(10),(11),(12),(13),(14). Benign neoplasms were more common in the 41-50 years age group and malignant lesions were more common in the postmenopausal age group similar to various studies (3),(4),(5),(6),(7),(8),(9),(10),(11),(12),(13),(14). Non neoplastic lesions were more common in the present study as well as most of the studies [3,5-8] but neoplastic lesions were more common in the studies done by Mondal SK et al., and Chanu SM et al., (Table/Fig 4) (4),(10).
Non neoplastic lesions were mostly seen as incidental findings in patients treated surgically for various symptoms. The most common lesion was 39 cases of Follicular cyst followed by 26 cases of corpus luteal cysts. Follicular cysts were the most common lesion in all studies except in the study done by Chanu SM et al., where corpus luteal cysts were more common (Table/Fig 5) (3),(5),(7),(8),(9),(10),(11),(13),(14).
There were 2 cases (2.56%) of endometriosis in the present study, similar to a study done by Kanthikar SN et al., (14). Endometriotic cysts were higher in studies done by Chanu SM et al., and Neelgund S and Hiremath P (10),(13). The most common site for endometriosis is the ovary (Table/Fig 6). The various theories for endometriosis of the ovary are when surface ovarian endometriotic deposits adhere to other structures and block the egress of menstrual fluid causing the collection of fluid which causes the ovarian cortex to invaginate (15). Other theories are those in which endometriotic tissue colonises pre-existing inclusion cysts or when endometriosis gains access to a follicle at the time of ovulation (Table/Fig 7) (15).
Torsion of the ovary was seen in 9 (7.56%) cases in the present study. Torsion was seen in studies done by Warpe BM et al., Prakash A et al., Ranabhat S et al., and Neelgund S and Hiremath P (7),(9),(11),(13). Torsion is one of the causes of a gynaecological emergency (16). The main risk factor for torsion of the ovary is an ovarian mass measuring 5 cm or more. Increase in ovarian mass increases the chance of the ovary twisting on the axis of the two ligaments suspending it and compromising blood supply. In this study, all the lesions which underwent torsion were more than 5 cm and the size ranged from 6×5×4 cm to 22×17×10 cm. Torsion was seen in the age group 19-46 years in the present study. Viable lining was seen in only four cases and all of them were serous cystadenoma. Ovarian torsion is more likely in a benign tumour rather than in a malignancy [2,16]. The incidence of ovarian torsion in a malignant tumour is less than 2% in most studies (16). Determining the type of ovarian lesion with ancillary studies is necessary to exclude a malignant lesion for further management in such cases. Total of 5 of present cases could not be classified as benign or malignant.
Ovarian tumours fall into benign, borderline and malignant categories (1). In the present study, benign ovarian neoplasms were the most common tumours with 47cases (90.38%), borderline tumours were 2 cases (3.84%) and malignant tumours were 3 cases (5.76%), similar to various studies (Table/Fig 8) (5),(6),(7),(8),(9),(10),(12),(17),(18). Surface epithelial tumours were 42 cases (80.76%) and the most common tumours followed by 6 cases (11.53%) of germ cell tumours and 4 cases (7.69%) of sex cord stromal tumours similar to other studies (Table/Fig 9) (3),(5),(6),(7),(8),(9),(10),(11),(12),(13),(14). Ovarian tumours can be bilateral. In the present study, the authors had only 5 cases (9.61%) of bilateral tumours and all of there were surface epithelial tumours. Two were serous cystadenomas and three were mucinous tumours. One of the mucinous tumours was a malignant mucinous cystadenocarcinoma on one side and benign mucinous cystadenoma on the other.
The most common benign tumour in the present study was Serous cystadenoma with 25 cases (48.07%). In all studies, serous cystadenoma was the most common benign tumour except in a study done by Kanasagara A et al., where mature teratoma was the most common benign tumour (8). The size of these tumours ranged from 3×2×1.5 cm to 29×26×20 cm. Most of the tumours were smooth surfaced unilocular cystic masses and few were multilocular filled with serous fluid. A total of five of the tumours showed papillary processes on the inner surface. One of the largest tumour in the present study was a papillary serous cystadenoma measuring 29×26×20 cm.
There were 13 cases of mucinous cystadenoma in the study. The sizes ranged from 5×4×2 cm to 27×24×18 cm. All of them were multilocular and filled with mucinous material. Few had solid closely packed tiny cysts. They were more common in the age group of 31-50 years. The incidence of these tumours was similar to the studies done by Maurya G et al., Prakash A et al., and Sharma P et al., (5),(9),(17). Mucinous cystadenoma was the most common benign tumour in a study done by Mankar DV and Jain G, (18).
There was one case of bilateral seromucinous cystadenoma in a 50-year-old, a new entity introduced in the 2014 WHO classification. Seromucinous tumours were first described by Shappell et al., in 2002 as is described in the study of Idrees R et al., (19). They account for about 1% of ovarian benign epithelial neoplasms (20). Benign and borderline seromucinous tumours continue to remain in this category but seromucinous carcinoma is no longer an entity and is now considered as an endometrioid carcinoma with mucinous differentiation in the revised 2020 WHO classification. These tumours are mullerian in origin and therefore have a mixture of various cell types like endocervical-type mucinous, ciliated, endometrioid and squamous type of epithelium (20). In the present case, both the ovaries were smooth surfaced cystic masses and the left ovary was larger measuring 18×17×10 cm and the right one was 5.5×3×2cm (Table/Fig 10). Both of them were multiloculated and filled with serous to mucinous fluid in areas. They were lined by endocervical type mucinous and serous epithelium of tubal type without cellular atypia (Table/Fig 11), (Table/Fig 12).
There was one case of atypical proliferative mucinous tumour in a 63-year-old patient. The tumour was a smooth surfaced cystic mass measuring 15×14×8 cm which on cut section was multiloculated. The cysts were lined by columnar mucinous epithelium with papillary foldings and stratification (Table/Fig 13). Atleast 10% of the epithelial component must show increased proliferation with papillary formations or pseudostratification and mild to moderate nuclear atypia to be qualified as a mucinous borderline tumour (21). Among borderline tumours mucinous borderline tumours, are the second most common type and account for about 35-45% of them (21).
Only one case of mucinous cystadenocarcinoma in a 50-year-old was seen. Mucinous carcinomas comprise 2-3% of ovarian carcinomas (2). In this case, the ovarian lesions were bilateral and the left-sided tumour was 16×13×9 cm and the right was 10×5×2 cm. The left-sided tumour was a mucinous cystadenocarcinoma and right side was mucinous cystadenoma. Microscopy showed crowding of glandular epithelium, with little intervening stroma, and interconnected in a confluent or labyrinthine pattern with marked atypical features in the mucinous carcinoma (Table/Fig 14).
There was one case of proliferative endometrioid tumour in a patient of 50 years who presented with postmenopausal bleeding. Atypical proliferative endometrioid ovarian tumours are very rare and constitute only 0.2% of all ovarian surface epithelial tumours (2),(22). They account for 2-3% of borderline ovarian tumours (21). Ultrasound scan showed a complex cyst. On gross examination, the uterus showed a fundal polyp measuring 3.5×1.5 cm. The ovarian lesion measured 8×8×3 cm and was partly solid and cystic (Table/Fig 15). The endometrial polyp showed simple hyperplasia. The tumour showed endometrioid glands embedded in a cellular and compact fibrous stroma (Table/Fig 16). The glands were of varying sizes and few were cystically dilated, lined by columnar cells with nuclear stratification. No stromal invasion was seen.
Atypical proliferative ovarian tumours or borderline ovarian tumours constitute a heterogenous group of epithelial tumours, which have intermediate clinical and histological features between benign cystadenomas, and high grade malignant surface epithelial ovarian tumours (21). They differ from benign cystadenomas by the presence of cellular atypia and from the high grade malignant tumours by the absence of stromal invasion. The absence of stromal invasion is a principal diagnostic criterion for borderline ovarian tumours. These tumours are mostly limited to the ovary in 80% of cases (21).
Germ cell tumours in the present study were 6 cases (11.53%) closest to studies done by Kulandaivelu AR et al., and Mankar DV et al., (12),(18). All cases were mature cystic teratoma. Mature cystic teratoma occurs relatively frequently and comprises approximately 20% of all ovarian neoplasms (2). The size of these lesions ranged from a maximum diameter of 4-10 cm. These cases were seen in an age ranging from 18-60 years consistent with literature. All of them showed mature elements derived from all three germ cell layers.
Granulosa cell tumour is a rare ovarian malignancy accounting for 1-2% of all tumours and 95% of tumours originating from sex cord-stromal cells (2),(23). There were 2 cases of granulosa cell tumours, one in a 43-year-old patient and the other a 50-year-old comprising 3.84% of all ovarian tumours in the present study, similar to a study done by Maurya G et al., (5). Both patients presented with menorrhagia. On gross examination, these tumours were 6×5×4 cm and 20×15×10 cm and had both cystic and solid components with yellowish areas (Table/Fig 17). Both cases were adult type granulosa tumours and showed cells arranged in sheets with call exner and coffee bean nuclei (Table/Fig 18).
In the present study, there were 2 cases (3.84%) of fibroma similar to a study done by Maurya G et al., (5). Ovarian fibroma/fibrothecoma is a sex cord stromal tumour and includes three pathologic subtypes (fibroma, thecoma, and fibrothecoma) based on the amount of fibre and theca cell component (24),(25). Fibromas are common benign stromal tumours and comprise 1-4% of all ovarian tumours and occur in older individuals (24). One case was a 19-year-old who came to the hospital for work-up for infertility and on ultrasound was diagnosed as a uterine fibroid but turned out to be an ovarian lesion on surgery. The other case was a 50-year-old woman who had undergone a hysterectomy 20 years earlier and presented clinically with mass per abdomen. The tumours were smooth surfaced solid tumours with the larger one measuring 15×12×10 cm (Table/Fig 19). Both the tumours showed spindle shaped fibroblastic cells and abundant collagen (Table/Fig 20).
Limitation(s)
Limitations of the study are the small sample size, lack of ancillary techniques and paucity of malignant lesions.
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Conclusion |
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Ovarian lesions range from non neoplastic to neoplastic and are found incidentally or present with various symptoms. Histopathologic examination is the only definitive way of diagnosing these lesions. This study helps in knowing the incidence of various ovarian lesions in this geographical location in comparison with other studies and categorising them helps in clinical management and treatment according to the histological diagnosis. Elaboration of new and rare entities like Seromucinous cystadenoms, Atypical endometrioid tumour and Granulosa tumour creates increased awareness. This study can be used as baseline study for more advanced research on ovarian lesions.
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