European Journal of Cardiovascular Medicine

Two ovaries are situated on either side of the uterus in the pelvis. This is the most common yet complex site for incidents of neoplasm in women [1]. In 2018, ovarian carcinoma ranked as the eighth most common cancer diagnosed and cause of cancer death in women, with an estimated 295,000 cases and 184,000 deaths worldwide. According to the Global Cancer Observatory (GLOBOCAN) 2018, the age-standardized incidence rate for India is 3.8-5.5 cases per 100,000 females per year [2], whereas this was 10.2/100,000 females in India in 2013 [3]. The observed decline was mainly attributed to the use of oral contraceptives, which have long lasting protective effects against ovarian cancer after several years of use. Other factors, like high parity and breastfeeding, have also been reported as protective factors [1]. The Indian Cancer Registry data project states that the ovary is an important location for carcinoma and comprises up to 8.7% of cancers in various parts of India [4]. However, other factors like obesity, nulliparity, cigarette smoking, and genetic changes pose risk factors for the development of ovarian carcinoma.

About 80% of ovarian tumors are benign and occur in young women between the ages of 20 and 45, whereas 20% are malignant tumors common in older women between the ages of 40 and 65 with poor prognosis [2].

Ovarian cancer has the worst prognosis among gynecological malignancies due to a lack of proper signs, symptoms, and presentation and is usually detected in the later stages of the disease [5]. The precise diagnosis of ovarian carcinoma depends on histopathology before starting definitive treatment.

This study was performed to identify the various histopathological variations in ovarian neoplasm (ON) and assess them according to the World Health Organization's (WHO) 2020 classification. Further analysis of the prevalence, age, clinical features in patients, and distribution of various ovarian tumors is assessed

An observational (retrospective) study was conducted in the Department of Pathology at Karmaveer M. S. Kannamwar, GMCH Chandrapur, Maharashtra,  India. The data of the patients from the from January 2022 to December 2022, were retrieved and assessed. A total of 23 cases were analyzed after taking informed consent telephonically from the patient, wherever available. The ethical clearance was granted by Aryabhatta Knowledge University, India (approval number: 280/22). Inclusion criteria included all the ovarian biopsies and ovarian lesions that were radiologically assayed as either neoplastic or non-neoplastic and received either as a single lesion or as a total hysterectomy. Normal ovaries were excluded from the study.

Gross and microscopic findings, including clinical details of patients with ovarian masses, were analyzed. The ovarian specimens were fixed in 10% neutral buffered formalin. The weight of the tumor was measured.

A gross examination was done, visualizing the outer surface and on-cut surface diligently looking for a cyst, its locularity, and type of cystic fluid, further looking for solid areas, papillary projections, hemorrhage, and necrosis. Standard procedures were followed during tissue processing, and paraffin-embedded blocks were made. Tissue sections of 5 μ thickness were cut using a rotary microtome and stained with hematoxylin and eosin, followed by microscopic examination.

The data obtained after microscopy included information about the type of tumor and other relevant details. The data were entered into an Excel sheet, and further analysis was done using IBM Statistical Package for Social Sciences (SPSS) for Windows, Version 25.0, Armonk, NY, to assay the frequencies and percentages of all variables that were documented. The data thus analyzed were correlated for relevant findings and classified according to the 2020 WHO classification of ovarian tumors.

An observational study was conducted, and a total of 23 cases of ovarian neoplasms were assessed for the patients who underwent ovarian biopsy or hysterectomy. The types of specimens received were those of total abdominal hysterectomy, salphingoopherectomy, and unilateral or bilateral ovarian cystectomy. The maximum number of patients were in their third decade of life, and the distribution of the cases was within the age range of 15-74 years, as shown in Figure 1. The majority of cases of benign tumors were mostly seen in 21-30-year-olds, borderline tumors in 61-70-year-old age group.

Figure 1. Distribution of age and number of cases of ovarian neoplasms.

The most common presentation of ovarian neoplasms was mass and heaviness in the abdomen, seen in 36% of patients, followed by abdominal pain (32%). Few tumors presented with torsion and came with acute findings of distress and pain; this was seen in 7% of cases, as shown in Figure 2. An emergency laparotomy was done in such patients, and a sample was sent for histopathological examination.

Figure 2. Clinical manifestations of patients with ovarian neoplasms.

Out of 23  cases of ovarian neoplasms, 91.4% were benign; malignancy was seen in 4.3% of cases, while borderline tumors were seen in 4.3% of cases. These tumors were classified according to WHO classification 2020 and categorized as shown in Table 1. Surface epithelial tumors constituted the majority of the ovarian neoplasm with 77 cases, followed by germ cell tumors, which constituted 23 cases; sex cord stromal tumors were seen in three cases; and metastatic tumors were found in seven cases.

Among benign tumors, serous cystadenomas were seen in the maximum number of cases, constituting 38% of the total cases, which were surface epithelial tumors. These were followed by benign teratomas, constituting 16.3% of the total cases; germ cell tumors; and mucinous cystadenomas, accounting for 7.2% of total ovarian neoplasms. Among malignant lesions, high-grade serous cyst adenocarcinomas were seen in 9% of cases, followed by low-grade serous cystadenocarcinomas (4.5%).

Table 1. Ovarian neoplasm distribution according to WHO Classification (2020).

Seven occurrences of metastatic carcinoma were seen, including two cases of signet ring cell adenocarcinoma (Krukenberg tumor), two cases of undifferentiated adenocarcinoma, and two cases of squamous cell carcinoma (SCC) in individuals who had previously experienced cervical SCC.

A sclerosing stromal tumor, one of the rare tumors of the ovary, was also found in a 24-year-old patient, where the tumor weighed around 2kg and was 20cm in length.

Ovarian neoplasms are one of the most notorious tumors in the female body. Because of their anatomical position, they remain undiagnosed for an extensive period of time. An ovarian neoplasm causes mass in the abdomen, pain, and abdominal distension in many cases and hence presents as a silent killer. Due to monthly endocrine and traumatic insults during ovulatory cycles, the ovaries have become susceptible to tumor genesis [3].

Ovarian neoplasms were categorized according to the 2020 WHO classification of ovarian tumors into serous, mucinous, endometroid, clear cell, seromucinous, and Brenners; these are surface epithelial tumors (SET) categorized into benign, borderline, and malignant categories [2]. A few of the SETs gross pictures and in the age range of 21-30. Pain in the abdomen and mass per abdomen are the most common clinical  presentations for ovarian neoplasms. This was in accordance with Kaur A et al.'s [4] findings; Amita S Patel et al. [1] stated in their study that the majority of the patients presented with vague abdominal pain.

When the comparison was made among different types of percentage incidence of ovarian neoplasm, it was found that our study showed the maximum number of benign cases followed by malignant and borderline tumors, which was in concordance with the studies by Poonam et al. [6], Singh et al., and many others as described in Table 2, but was not correlating with Gupta N et al. as they showed the predominance of borderline tumors compared with malignant ones.

When a comparison was made between different histopathological types, it was found that the most common neoplasm was a surface epithelial tumor, followed by a germ cell tumor, which was maximally correlating with other studies as shown in Table 3.

The limitation in this study was the sample size, as a larger sample size would have helped in categorizing a large number of cases. This was just the study of a single institute; hence, it does not consider the frequency of ovarian neoplasms in a whole country or state.

The overall diagnosis of ovarian neoplasms primarily depends on the histomorphological examination, which is still the gold standard method of evaluation of the tumor; however, the support of ancillary studies such as special stains and immunohistochemistry is always helpful in the exact categorization of the neoplasm. Clinical parameters such as age, size, site, and stage are additional factors that guide the overall management and prognosis of this neoplasm. It is concluded that benign ovarian neoplasms are found more frequently, followed by malignant ones. Surface epithelial tumors are the most common histological subtype of ovarian tumors. Thus, categorizing ovarian tumors according to histopathological features as described in the 2020 WHO classification of ovarian tumors into various categories helps to know the clinical presentation, treatment, clinical outcome, and prognosis of the tumors.

Additional Information

Disclosures

Human subjects: Consent was obtained or waived by all participants in this study. Aryabhatta Knowledge University, issued approval 280/22. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

1. Patel AS, Patel JM, Shah KJ: Ovarian tumors-incidence and histopathological spectrum in tertiary care center, Valsad . IAIM. 2018, 2:84-93. 2. McCluggage WG, Singh N, Gilks CB: Key changes to the World Health Organization (WHO) classification of female genital tumours introduced in the 5th edition (2020). Histopathology. 2022, 80:762-78. 3. Dutta A, Imran R, Saikia P, Borgohain M. : Histopathological spectrum of ovarian neoplasms in a tertiary care hospital . Int J Contemp Med Res. 2018.
2. Kaur A, Faujdar M, Kariya T, Gupta S: Histomorphological spectrum of ovarian tumors in a tertiary care hospital. Ann Woman Child Health. 2017, 3:A52-61.
3. Batool A, Rathore Z, Jahangir F, Javeed S, Nasir S, Chughtai AS: Histopathological spectrum of ovarian neoplasms: a single-center study. Cureus. 2022, 14:e27486.
4. Sharma P, Bharadwaj S: Histomorphological spectrum of ovarian tumours in a tertiary care centre in North India. J Med Sci Clin Res. 2019, 7:841-5. 1
5. Sampurna K, Jyothi B: Histomorphological spectrum of ovarian tumors- a tertiary care center experience .Asian J Med Sci. 2022, 13:111-7. 10.3126/ajms.v13i1.39783
6. Thakkar NN, Shah SN: Histopathological study of ovarian lesions . Int J Sci Res. 2015, 4:1745-9.
7. Sawant A, Mahajan S: Histopathological study of ovarian lesions at a tertiary health care institute . MVP J Med Sci. 2017, 4:26-9.
8. Singh S, Saxena V, Khatri S, Gupta S, Garewal J, Dubey K: Histopathological evaluation of ovarian tumors .Imp J Interdiscip Res. 2016, 4:435-9 .
9. Hathila R, Nishal A, Shah P, Patel M, Bajaj JH: Histomorphological spectrum of ovarian lesions in a tertiary care institute in Gujarat with special emphasis on ovarian tumors. Int J. Sci Study. 2020, 8:93-100.
10. Maheshwari V, Tyagi SP, Saxena K, Tyagi N, Sharma R, Aziz M, Hameed F: Surface epithelial tumours of the ovary. Indian J Pathol Microbiol. 1994, 37:75-85.
11. Gupta N, Bisht D, Agarwal AK, Sharma VK: Retrospective and prospective study of ovarian tumours and tumour-like lesions. Indian J Pathol Microbiol. 2007, 50:525-7.
12. Pilli GS, Suneeta KP, Dhaded AV, Yenni VV: Ovarian tumours: a study of 282 cases . J Indian Med Assoc.2002, 100:420, 423-4, 447.
13. Badge SA, Gosavi AV, Sulhyan KR: Histopathological study of ovarian tumors . Indian Med Gaz. 2013, 147:345-51.