A clinicopathological analysis of 270 ovarian tumours.
Ovarian neoplasms have become increasingly important not only because of the large variety of neoplastic entities but more because they have gradually increased the mortality rate in female genital cancers.
A systematic study of all ovarian neoplasms encountered in a large institute over a period of years is more likely to produce a significant amount of useful data as regards the clinical manifestations, the incidence of various types of ovarian tumours and the type of treatment offered. This data can then be utilized for the purpose of suggesting ways and means of early detection of ovarian neoplasms and also for a better therapeutic approach to the problem.
A total of 270 cases of ovarian tumours managed at the Department of Obstetrics Gynaecology, K.E.M. Hospital, Bombay from the year 1969 to July 1978 are analyzed regarding the incidence of various types, the clinical picture, their diagnosis and the management.
Among these 270 ovarian tumours, 20(7.41%) were non-neoplastic (functional) while of the remaining 250 tumours, 173 (64.07%) were benign and 77 (28.52%) malignant.
Among the neoplastic tumours a large majority consisted of epithelial tumours (61.60%). The different types of epithelial tumours are presented in [Table 1].
There were 17 sex cord stromal tumours forming about 6.80% of all ovarian neoplasms. Granulosa cell tumours numbered 8 out of which two were benign and 6 were malignant. Thecomas constituted two; fibromas, 4; fibrothecomas, two and androblastomas only one.
Germ cell tumours (62) (24.8%) constitute the 2nd most common group of ovarian tumours, largely due to the high incidence of benign cystic teratomas (47 tumours). There was one case each of malignant teratoma and immature teratoma. In this group of germ cell tumours, there were 6 dysgerminomas, two endodermal sinus tumours, two primary choriocarcinomas, one secondary choriocarcinoma, and two cases of struma ovarii which is a highly specialized group of monodermal tumours.
The other varieties of tumours encountered in the present study were as follows. There were two cases of unclassified tumours and one case of soft tissue tumour which was not specific to ovary. Six cases had secondary metastatic tumours and eight cases had combined tumours.
We did not encounter any lipid cell tumours nor any gonadoblastoma in our study.
About 2 /3rds of all benign neopleasms were seen between the age group of 20 to 40 years. While 2/3rd of all malignant ovarian neoplasms were seen after the age of 40 years. The youngest patient in our series was a 10 year old girl, while the oldest was a 73 year old lady. Fifteen per cent of all ovarian neoplasms were bilateral. Twenty nine (37.6%) of 77 malignant tumours were bilateral while only 10 out of 173 benign were bilateral. The commonest bilateral tumour was found to be serous cyst adnocarcinoma. The signs and symptoms observed in all these patients are presented in [Table 2]. The commonest symptom amongst all These cases of ovarian neoplasms was lump in abdomen or distension of abdomen, pain in abdomen being the second most common symptom.
Post menopausal bleeding was not a common presenting complaint, but ascites was present in about 50 per cent of all malignant ovarian neoplasms and one sixth of all benign tumours.
Pregnancy was associated in 15 cases, while complications like torsion in 12 cases. Associated infection complicated the picture in 5 (2.89%) and adhesions to surrounding structure in 19 (10.98%) cases. Two patients were explored with a probable diagnosis of ectopic pregnancy; one was found to have ruptured granulosa cell tumour and the other endodermal sinus tumour with intraperitoneal haemorrhage.
Of the 77 malignant tumours 12 were found to be inoperable.
[Table 3] shows the various operative procedures carried out.
There were 12 patients with inoperable malignant ovarian tumours; of these, in seven cases a biopsy was taken and in the other five, attempts were made to remove as much of the tumour mass as was possible.
Ten patients died within 2 weeks of surgery. Eight of these had inoperable ovarian malignancy.
The incidence, clinical appearance and the behavior of the different types of ovarian tumours is extremely variable. It is generally impossible to diagnose the nature of the ovarian tumour preoperatively just by clinical examination and even on exploration, though certain investigations like peritoneal fluid cytology, estimation of serum lactic dehydrogenase, fibrin degradation products and immunological tests have been reported to be of some help in predicting the nature of the pathology. Hence one has to depend on the microscopic appearance of the tumour for further management of the ovarian neoplasms.
The commonest category of the ovarian tumours encountered in our series is epithelial tumours, second commonest being germ cell tumours. The incidence of malignancy in our series is 28.2% while various other authors have reported the incidence ranging between 14 and 40%. Allen and Hertig2 found an incidence of 15.2%, Ramchandran et al gave an incidence of 31.12% while Patil et al reported that 40.0% of their ovarian tumours were malignant.
Majority of the benign neoplasms occurred during the productive age as against the malignant tumours which were common in the postmenopausal age. Similar age incidence has been reported by Ramchandran et al.
Among the signs and symptoms it was unusual to find that the incidence of postmenopausal bleeding was nearly same in both benign and malignant groups, but the overall incidence was much less as compared to the incidence given by Agrafojo et al1 of 8.0% and 13.7% in benign and malignant (mucinous tumours alone) ovarian tumours respectively. Malloy et al reported an incidence of 17.0% in their series of ovarian carcinoma. Another interesting feature in our series was ascites, which was present in half of the malignant ovarian tumours as against only in 6 out of 903 cases reported by Ramchandran et al. Even the incidence of ascites was not insignificant in the benign group in our series; it was 16.18% whereas Agrafojo et al1 did not report any case of benign ovarian neoplasms with ascites. According to Selye, ascitic accumulations are found in about 30-60% of serous tumours and in about 10% of the mucinous cyst adenomata. He says that although ascites is more common in malignant than benign ovarian tumours it is not pathognomonic of malignancy.
The main principle in treating these cases of ovarian neoplasms, especially the malignant one's, was the surgical excision of the tumour mass as much as possible. We know that in an ovarian malignancy surgery alone never suffices as various authors have expressed their helplessness in improving the five years survival rate beyond 25% in spite of the combination of surgery with radiation or chemotherapy. We know our limitations in the treatment of malignancies due to lack of facilities for either chemotherapy or radiation. Majority of our patients also fail to report back for follow up and further treatment.
We are grateful to Dr. C. K. Deshpande, Dean, Seth G.S. Medical College & K.E.M. Hospital, Bombay for the permission to publish the paper. We also extend our sincere thanks to Dr. A. R. Chitale for giving us the pathological diagnosis of these cases.