Histopathological study of ovarian lesions at a tertiary rural hospital

Background:Ovaries are the third leading site of cancer among women trailing behind cervical and breast cancer according to the Indian cancer registries. The spectrum of ovarian lesions is wide with harmless simple cystic lesions at one end and the fatal aggressive malignant lesions at the other end. Thus, ovarian neoplasm offers a good field for research. The present study is aimed to observe the frequency of neoplastic and non-neoplastic lesions in a tertiary care centre of rural India. 
Methods: This was a prospective two years observational study and was conducted at the Department of Pathology SRTR GMC, Ambajogai, including 185 ovarian lesions. 
Result: Total 185 ovarian lesions were studied, 101 cases were non-neoplastic while 84 cases were neoplastic. The most common non-neoplastic lesion was corpus luteal cyst (27.7%) followed by simple ovarian cyst (24.7%) and follicular cyst (21.8%). Among 84 neoplastic cases, 74 cases (88.1%) were benign,02 cases (2.4%) were borderline tumours and 08 cases (9.5%) were diagnosed malignant. Surface epithelial tumours contributed 75% cases, while germ cell tumours and sex-cord stromal tumourcontributed 20.8% and 4.8% respectively. 
Conclusions: Both non-neoplastic as well as neoplastic lesions of ovary often present with similar clinical and radiological features. So histopathological study is essential to diagnose ovarian tumours and predict their prognosis.


Introduction
The ovary has three main histologic compartments i.e. the surface Mullerian epithelium, the germ cells and the sexcord stromal cells. Each compartment gives rise to distinct non-neoplastic and neoplastic lesions [1,2]. Such lesions can be found from neonatal to postmenopausal ages and it accounts for around 30% of all female genital cancers [3].
The incidence and prevalence of ovarian cancer vary in different geographical areas of the country. Indian trend analysis reveals a steady increase in the age-standardized incidence rate of ovarian cancer ranging from 0.26% to 2.44% per year in different area registries [4].
However, a few of the benign lesions can be confused with neoplasm clinically, intra-operatively or on histopathological examination. Ovarian tumours include a complex, wide spectrum of neoplasms involving a variety of histological patterns ranging from epithelial tissues, connective tissues, specialized hormone-secreting germinal and embryonal cells [5].
The pathology of ovarian tumours and tumour-like conditions is one of the most complex areas in gynaecology. This is because the ovary produces a wide range and variety of tumours in the body relative to any other organ [6]. In addition, the aetiology of ovarian cancers is poorly understood. Past epidemiological research focused on epithelial tumour aetiology and classified it as variables with increased risk of ovarian cancer, including a family history of ovarian cancer, advanced age, and nulliparity.
Many factors known to be associated with decreased risk of ovarian cancer include a history of tubal ligation or hysterectomy, number of births, and the use of oral contraceptive (OC).
There are several causes that have an inconclusive link to the incidence of ovarian cancers such as smoking, alcohol or coffee intake, fertility and infertility drug use, hormone replacement therapy (HRT), talc use, diet, obesity, firstborn period, menarche/menopause period, breastfeeding [7][8][9].
March, 2020/ Vol 6/ Issue 3 The treatment and prognosis of ovarian neoplasms are based upon the accurate surgical staging and thorough pathological evaluation. Few organs exhibit as diverse a variety of tumour types as the ovary itself. For this cause, the surgical pathologist's differential diagnosis of ovarian tumours remains a daunting task.
Nonetheless, significant progress has been made in the awareness of ovarian tumours and their molecular genetics and histopathological characteristics over the past few years and new therapeutic modalities have been developed accordingly [10]. The present study has been conducted with the aim to observe the frequency of neoplastic and non-neoplastic lesions in a tertiary care centre of rural India.

Material and Methods
Type of study and duration of study: After obtaining Institutional Ethical Committee approval, thisprospective observational study was carried out in a Department of Pathology at S.R.T.R. GMC Ambajogai, India during a period of two years from November 2017 to October 2019.
Study population: Total 434 ovarian specimens were received in the Department of Pathology during the study period but in 249 cases no specific pathology other than normal findings was observed. Hence, only 185 cases were included in the study.
Inclusion criteria were all the ovarian specimens received in the Pathology department in the form of resected ovarian masses/ cystectomy specimens, ovarian biopsy specimen, tubo-ovarian masses and hysterectomy with salpingo-oophorectomy specimen.
Normal ovaries and specimens other than ovaries and ovarian specimens received after the study period were excluded from the study.
Surgical specimens were obtained in fixative (10% formalin). Detailed clinical history, investigation, the radiologic finding was noted in each patient. Specimen were identified, specimen number was given to each specimen.
Type of specimen was identified. Gross examination was done which included size, colour, and consistency and cut surface. The most representative areas of each specimen were found, and sections were taken of size 1.5x 1 cm.
Tissue processing was done.
The section was dehydrated in alcohol, cleared in xylol and embedded in paraffin wax. The corresponding blocks were prepared and 3 to 5-micron thick section were cut from each paraffin block and stained with hematoxylin and eosin stain [11]. Histopathological slides were examined by a senior pathologist;the correlation was done with clinical presentation. Data were entered into Microsoft Excel to calculate number and percentages.

Results
In the present study of 2 years from November 2017 to October 2019, in total 434 ovarian specimens were received. Out of 434 specimens, 249 showed no specific pathology, other than normal findings.
The most common germ cell tumour observed in the present study is mature cystic teratoma (14; 16.6%). One case of each immature teratoma, dysgerminoma and yolk sac tumour was noted. All the 4 cases of sex-cord stromal tumours in the present study were fibro-thecoma.

Discussion
The ovary is the only organ of the body in which the tumour shows a wide histological variation, different behaviour and various histomorphological features. Clinico-morphological features are helpful for the diagnosis and management of patients as they give an idea of disease progression. In the present study, a total of 4950 specimens were received, out of which 434 were specimens of the ovary, constituting 8.76% which is similar tostudy done by Parvatala et al [12]. Out of 434 specimens, 249 showed no specific pathology, other than normal findings. Hence, only185 ovarian lesions were included in the study of which 101 (54.6%) were non-neoplastic lesions and 84 (45.4%)were neoplastic ovarian lesions.This finding is in accordance with the previous studies [12][13][14][15]. In all these studies non-neoplastic lesions were more as compared to neoplastic lesions. Most of the non-neoplastic lesions were incidentally detected (42.6%) with either hysterectomy or in pregnant patients during caesarean section or salpingo-oophorectomy in case of Ectopic pregnancy. Corpus luteal cysts were the most common nonneoplastic lesion in the current study (27.7%) followed by simple ovarian cysts (24.7%), this incidence iscomparable with the other studies [14][15][16] (Table-3). All the cases of corpus luteal cyst were less than 10 cms in diameter as similar tothe study done by Zaman et al [17].
March, 2020/ Vol 6/ Issue 3     In the existing study, benign ovarian tumours were most commonly seen in the age group of 21-30 years and were more common unilaterally (70; 94.6%) than bilaterally (4; 5.4%). Whereas malignant ovarian tumours were most commonly observed in the group of 51-60 years and 75% cases of malignant tumours were unilateral and 25% were bilateral.
Serous cystadenoma was observed to be the most common benign ovarian tumour in the present study (40.5%) as well as in the studies done by Makwana et al [14] and Prakashet al [21].The incidence of serious cystadenocarcinoma and mucinous cystadenocarcinoma were the same (25 %) which was the most common malignant ovarian tumour as reported by Jhaand Karki [22]. The histological distribution of surface epithelial-stromal tumours showed that serous cystadenoma (47.6%) and mucinous cystadenoma (38.1%) was the most common tumour whichis comparable with the other studies [14,19]. On histopathology, most common germ cell tumour was mature cystic teratoma (82.3%) which is similar to the findings of Sudha et al [20] study (87.5%).
Limitation of the study-There wasvariationobservedinthe resultsof other studies and present study due to the small sample size of the present study. So, there is a need to study our experience with a larger population of patients.

Conclusion
Non-neoplastic ovarian lesions were more commonly seen in the present study. Among neoplastic lesions, benign tumours were more common than malignant and surface epithelial tumours were the most common histologic type. Ovarian malignancies act as "Silent Killer," as they occur in the advanced stage. Both non-neoplastic and neoplastic ovarian lesions often present with similar clinical and radiological characteristics. Histopathological research is therefore important for the diagnosis and prediction of ovarian tumours. The present study suggested that patients receive medical advice late in rural health facilities because of the geographic location, deprivation and analphabetism. So, awareness among public and doctors, educating people, passive surveillance and community screening facility will be helpful in early detection of the ovarian lesions and tumours.