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Histomorphological Spectrum of Ovarian Masses in a Tertiary Centre of Eastern Nepal

Aims: To analyze the trends of ovarian masses in a tertiary centre in eastern Nepal. Methods: This was a retrospective cross sectional study conducted in Department of Pathology at Nobel Medical College and teaching hospital, Biratnagar, Nepal. Database of two years from April 2019 to April 2021 was searched. Gross and microscopic findings of cases including demographic details of patients with ovarian mass were analyzed and presented by descriptive parameters. Results: Out of 127 cases of ovarian masses studied, 95 (74.8%) were neoplastic. The common types were Germ cell tumors (47; 37%), epithelial tumors (43; 33.9%) and endometriotic cyst (23; 18.1%). Mean age was 38.1 (range: 17-77) years in benign, 47.1 (30 – 70) years in malignant and 36.9 (21-53) years in non-neoplastic tumors; 11 cases were malignant and 63.6% were solid; and 23.8% of serous tumors were bilateral. Conclusions: Benign neoplastic lesions were the most common lesions and presented earlier than borderline and malignant lesions. Endometriotic cysts comprised the most common non-neoplastic lesions. The non-neoplastic lesions were predominantly cystic and the malignant lesions were predominantly solid. Most of the benign lesions were solid-cystic. Most mucinous tumors and all the sex-cord stromal tumors were unilateral while the seromucinous tumor and a significant number of serous tumors were bilateral.


INTRODUCTION
Ovaries are a common site for both neoplastic and non-neoplastic lesions. They have extensive heterogeneity within and between histologic subtypes and the spectrum ranges from harmless simple cysts to aggressive malignant ones. 1 Globally, ovaries are the third most common site of primary malignancy in female genital tract after cervix and endometrium. They are also the second most frequent cause of death from gynaecological cancers after cervical cancer. 2 Ovarian tumors generally escape detection until they attain a large size. 3 Even the physical examination, ultrasound and tumor markers aren't sufficient to differentiate neoplastic and non-neoplastic lesions. Grossly, most benign tumors of epithelial category are cystic, while the findings of necrosis, heterogeneous solid elements and papillary projections make malignancy more likely. [4][5][6][7] A thorough knowledge of the spectrum of ovarian disorders and its presentation is thus essential. The present study is undertaken to study the varying gross presentation, the histomorphological patterns and degree of differentiation for the specific diagnosis. This has tremendous significance to both pathologist and gynecologist for better understanding of the disease, its prognosis and planning proper patient management. 8,9 METHODS This is a retrospective cross sectional study performed in the Department of Pathology at Nobel Medical College, Biratnagar, Nepal. It was conducted over a period of 2 years from April 2019 to April 2021. Surgically managed cases with ovarian masses su-bmitted to the Pathology lab were included in the study irrespective of the surgical modality. Thus, cystectomy, oophorectomy, salpingo-oophorectomy and total abdominal hysterectomy with unilateral or bilateral salpingo-oophorectomy were included in the study.
The specimens were fixed in 10% neutral buffered formalin. Gross appearance, laterality and size were noted and representative sections taken. The tissues were processed and stained with Hematoxylin and Eosin stain as per standard protocol. The slides were then examined microscopically by Pathologists.
Histologic categorisation was done according to World Health Organization (WHO 5 th edition) guidelines. The variables were entered in a database and data were analysed in SPSS version 20.0
[ Figure Germ cell tumors were the most common neoplasms were Germ cell tumor (49.5%) followed by epithelial (45.2%) and sex-cord stromal tumor (5.3%). Only two of the 47 (4.3%) germ cell tumors were malignant. Serous cystadenoma was the most common surface epithelial tumor followed by mucinous cystadenoma. There were 11 malignant tumors with high grade serous carcinoma being the commonest malignancy followed by mucinous carcinoma. In the non-neoplastic category, endometriotic cyst was the most common (23; 71.9%) followed by corpus luteal cyst. [   Our finding is however consistent with the observation in a similar study in central Nepal 12 with 24% non-neoplastic cases. Vast majority of the ovarian tumors in our study belonged to benign category with mature cystic teratoma being the predominant one. This finding is also in corroboration with other studies. [13][14][15] Benign tumors were also common in younger age group with the mean age being 37.5 years as opposed to the aggressive tumors which were more common in older age group. This finding is also consistent with that of other studies that showed malignant ovarian tumors more frequent in older females. [16][17][18] Only one case of surface epithelial tumor and both the cases of malignant germ cell tumor were below 40 years of age. All the other malignant ovarian tumors comprised patients more than 40 years. Thus, our study agrees with other studies that malignant germ cell tumors frequently present in a younger population. 19,20 High grade serous carcinomas was the most common malignancy in our study that is in accordance with the results obtained by other studies. 15,21 Likewise, endometriotic cyst was the most common non-neoplastic mass (71.9%) followed by corpus luteal cyst (25%). This finding also matches with that of other literatures. 12,14 The predominantly cystic lesions were nonneoplastic and the solid-cystic lesions were mostly benign germ cell tumors. Most of the predominantly solid lesions were malignant and only 2 cases in the malignant category were cystic. This is also in agreement with other studies on ovarian tumors. 10,[22][23][24] As seen in the study by Kaur et al 25 , malignant lesions had a larger mean dimension than benign and non-neoplastic lesions. However, size of the only benign seromucinous tumor and some benign mucinous tumors in our study exceeded that of malignant tumors. Similar finding of larger mucinous cystadenomas were noted by Zaman et al. 26 Hence tumor dimension alone may not be of much help to distinguish benign and malignant lesions.
All the seromucinous tumors and most of the mucinous epithelial tumors, regardless of their nature were bilateral. One of the limitations is that our study had only 2 cases with seromucinous phenotype. Moreover, our study showed a significant number of serous neoplasms and all the sex-cord stromal tumors to be unilateral. Similar observations had been made before in clinical series. 4,5,27,28 CONCLUSIONS Benign neoplastic lesions were the most common lesions and presented earlier than borderline and malignant lesions. Endometriotic cysts comprised the most common non-neoplastic lesions. The nonneoplastic lesions were predominantly cystic and the malignant lesions were predominantly solid.
Most of the benign lesions were solid-cystic. Most mucinous tumors and all the sex-cord stromal tumors were unilateral while the seromucinous tumor and a significant number of serous tumors were bilateral.