original article clinico-pathological correlation of tubo-ovarian … · cysts and 1 (5%) case...

DOI: 10.21276/aimdr.2018.4.3.PT11

Original Article ISSN (O):2395-2822; ISSN (P):2395-2814

Annals of International Medical and Dental Research, Vol (4), Issue (3) Page 51

Section: P

athology

Clinico-Pathological Correlation of Tubo-Ovarian Lesions. Anika Mittal1, Ramesh Kumar Kundal2, Khushpreet Kaur3, Manoj Mathur4, Amitoj Sandhu1,

Neetika Kaushal1 1Junior Resident, Department of Pathology, Government Medical College, Patiala, Punjab, India.

2Professor and Head, Department of Pathology, Government Medical College, Patiala, Punjab, India.

3Professor, Department of Obstetrics and Gynaecology, Government Medical College and Rajindra Hospital, Patiala, Punjab, India.

4Associate Professor, Department of Radiology, Government Medical College and Rajindra Hospital, Patiala, Punjab, India.

Received: April 2018 Accepted: April 2018

Copyright: © the author(s), publisher. Annals of International Medical and Dental Research (AIMDR) is an Official Publication of “Society for Health Care & Research Development”. It is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT Background: The tubo-ovarian lesions manifest a wide spectrum of clinical, morphological, and histological features. Aims and objectives- To classify the lesions of tubes and ovaries and to correlate the various clinical and histopathological findings with age, chief complaints, and microscopic appearances of lesions. To correlate them radiologically and histopathologically. Methods: The present prospective study was based on the clinico-pathological correlation of various tubo-ovarian lesions in 75 cases over a period of 2 years. The histopathological reports were used to classify the tubo-ovarian lesions and correlate /substantiate the clinical and radiological findings. Results: Out of 75 cases, 51 (68%) ovarian, 18 (24%) tubal, and 6 (8%) cases showed simultaneous involvement of both tube and ovary. Amongst 18 tubal lesions,16 were of ectopic gestation (6 were ruptured) and the rest 2 of salpingitis. Amongst the ovarian lesions,41 cases were of ovarian neoplasms which were categorized as benign and malignant. Serous cystadenoma was the most common benign tumor and serous cystadenocarcinoma was the most malignant tumor. Conclusion: Clinical, radiological and histopathological diagnosis were compared and analysed statistically and the correlation was highly significant. An accurate clinical and radiological examination along with the histopathological examination aids in improving the diagnostic accuracy. Keywords: Histopathological, cystadenoma, cystadenocarcinoma.

INTRODUCTION Fallopian Tube and Its Lesions The fallopian tubes are paired hollow structures that run throughout the apex of the broad ligament, spanning the distance between the uterine cornua and the ovaries.[1] The most common afflictions in fallopian tubes are inflammation and less often they are affected by ectopic tubal pregnancy followed in order of frequency by endometriosis and the rare primary tumors.[2] Ectopic pregnancy is an implantation of a fertilized egg outside the uterine corpus.[3] The incidence of ectopic pregnancy in developed countries is about 19.7/1000 pregnancies and that in India is 3.12/1000 pregnancies.[4,5] The most common site for ectopic pregnancy is fallopian tubes (90–95%).[6,7] Signs and symptoms of ectopic pregnancy include, vaginal bleeding (in varying amounts), sudden lower abdominal pain,[8] pelvic pain, a tender cervix, an adnexal mass, or adnexal tenderness.[9] Name & Address of Corresponding Author Dr. Ramesh Kumar Kundal, Professor and Head Department of Pathology, Government Medical College, Sangrur Road, Patiala, Punjab, India.

Non Neoplastic Lesions of the Ovary Classification [10]

• Inflammatory disorders: Infectious and Noninfectious.

• Non inflammatory disorders: Cystic and Non cystic. • Pregnancy related disorders.

Neoplastic Lesions Of The Ovary Ovarian cancer is the sixth most common cancer and the seventh leading cause of cancer deaths among women worldwide. In most of the population-based cancer registries in India, ovarian cancer is the third leading site of cancer among women, trailing behind cervix and breast cancer.[11] World Health Organization classification of tumors of the ovary.[12] Surface epithelial

1. Serous tumors 2. Mucinous tumors 3. Endometriod tumors 4. Clear cell tumors 5. Transitional cell tumors 6. Squamous cell tumors 7. Mixed epithelial tumors 8. Undifferentiated and unclassified tumors

Mittal et al; Clinico-Pathological Correlation of Tubo-Ovarian Lesions


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Sex cord–stromal tumors 1. Granulosa–stromal cell tumors 2. Granulosa cell tumor group 3. Tumors in thecoma-fibroma group 4. Sertoli-stromal cell tumors 5. Sex cord–stromal tumors of mixed or unclassified

cell types Sex cord tumor with annular tubules 6. Gynandroblastoma 7. Steroid cell tumors

Germ cell tumors Primitive germ cell tumors

1. Dysgerminoma 2. Yolk sac tumor 3. Embryonal carcinoma 4. Polyembryoma 5. Nongestational choriocarcinoma 6. Mixed germ cell tumors

Biphasic or triphasic teratomas 1. Immature 2. Mature 3. Monodermal teratomas

Germ cell sex cord-stromal tumors 1. Gonadoblastoma 2. Mixed germ cell–sex cord–stromal tumor of

nongonadoblastoma type Tumors of rete ovarii Miscellaneous tumors

1. Small-cell carcinomas, hypercalemic type 2. Gestational choriocarcinoma 3. Soft-tissue tumors not specific to ovary

Tumor like conditions Lymphoid and haematopoietic tumors Secondary tumors

MATERIALS AND METHODS In the present study, 75 cases of tubo-ovarian lesions were studied in the Department of Pathology, Government Medical College and Rajindra Hospital, Patiala, India. Patients presenting with complaint of pain abdomen or abdominal distension with or without bleeding per vaginum were examined and looked for any tubo-ovarian lesion. After radiological opinion, surgical intervention was carried out on the diagnosed cases and the specimens were sent to the Pathology Department in formalin containers. Gross examination was done and the tissues were processed after fixation. The paraffin sections were stained with H&E stain and viewed microscopically.The data was collected and the histo-pathological reports were used to classify the lesions and correlate the clinical and radiological findings.

RESULTS A total of 75 cases of tubo ovarian lesions were studied.

Table 1: Distribution Of Organ Involved. Organ Frequency Percentage Ovary 51 68.0 Tube 18 24.0

Tubo Ovarian 6 8.0 Total 75 100.00

Table 2: Frequency Of Tubal And Tubo Ovarian Lesions In Various Age Groups (N=24).

Age Groups

(in years)

Histopathological Examination Total Ectop

ic Inflammat

ory Rupture Ectopic

11-25 4 2 2 8 26-40 6 5 4 15 41-55 0 1 0 1 >55 0 0 0 0

Total 10 8 6 24

Table 3: Frequency Of Ovarian Lesions In Various Age Groups (N=51)

Age Groups (in years)

Histopathological Examination

Total

Benign Malignant 11-25 14 2 16 26-40 19 0 19 41-55 6 4 10 >55 2 4 6

Total 41 10 51

Table 4: Presenting complaints in Tubo-ovarian lesions Presenting complaint

Present Absent

Mass abdomen 46(61.30%) 29(38.70%) Pain abdomen 72(96.0%) 3(4.0%) Bleeding per

vaginum 34(45.30%) 41(54.70%)

Table 5: Histopathological diagnosis Diagnosis Frequency Percent Dermoid 10 13.3

Dysgerminoma 2 2.7 Ectopic 10 13.3 Fibroma 2 2.7

Follicular Cyst 3 4.0 Granulosa Cell Tumor 2 2.7

Haemorrhagic Cyst 7 9.3 Inflammatory 7 9.3

Granulomatous 1 1.3 Mucinous Cystadenoma 3 4.0

Mucinous Cystadenocarcinoma 1 1.3 Metastatic Deposits 1 1.3 Ruptured Ectopic 6 8.0

Serous Cystadenoma 16 21.3 Serous Cystadenocarcinoma 4 5.3

Total 75 100.0

Figure 1: Tubal ectopic showing chorionic villi (H&E 100X)



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Figure 2: Granulomatous lesion showing well formed granulomas (H&E 100X)

Figure 3: Serous Cystadenoma – Section showing serous lining (H&E x 100)

Figure 4: Fibroma - Section showing bundles of spindle cells with abundant collagen (H&E x 100)

Figure 5: Bilateral Dermoid Cysts: Well encapsulated with cut surface showing cheesy material and hair (Gross)

Figure 6: Mature teratoma: Section showing epithelial lining along with hair follicles and sebaceous glands (H&E x 100)

Figure 7: Serous cystadenocarcinoma ((H&E X400)

Figure 8: Metastatic deposits (H&E x 100) Table 6: Classification of ovarian Neoplasms (n=41)

Type Frequency Percentage Surface Epithelial 24 58.50 Sex Cord Stromal 4 9.70

Germ Cell 12 29.20 Metastatic 1 2.40

Total 41 100

Correlation of Clinical and Radiological Diagnosis with Histopathological Diagnosis In Tubal And Ovarian Lesions There was 100% correlation in diagnosis of tubal and ovarian lesions. Stastistical analysis was performed and p value came to be <1 (p=.000) suggesting that the correlation is highly significant.



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DISCUSSION Combined study of lesions of both tubes and ovaries as tubo-ovarian mass is very rare. During a specified period of time, out of total 75 cases, pure ovarian lesions were found in 51 cases, 18 pure tubal lesions and 6 were combined tubal and ovarian lesions.

Rate of tubal pregnancy The rate of tubal pregnancy (15 out of 16 ectopic i.e.93.75%) in the present study is in close accordance with the study conducted by Seemer et al (2014) i.e. 88.89%[13]

Frequency of age distribution in tubal lesions In the present study, majority of the ectopic pregnancies including the ruptured ectopic were found in the age group of 26-40 years which resembles closely to the study conducted by Sharma and Biligi (2015) in which the maximum cases of ectopic were in the age group of 28 to 32 years (40.81%).[14]

Table 7: Clinical presentation of ectopic Author and year of

study Pain Mass

Abdomen Vaginal Bleeding

Seemer et al[13] (2014) 100% 73.3% 53.3%

Patel et al[15] (2016) 90% 82% 48% Present Study (2017) 100% 56.2% 100%

Table 8: Frequency of benign and malignant tumors of ovary Author and year of

study Benign Borderline Malignant Gupta et al[16] (2007) 72.9 4.1 22.9

Jha and Karki[17] (2008) 83.9 - 16.1

Kuladeepa et al[18] (2011) 82.35 3.68 13.97

Sohail et al[19] (2012) 74.8 1.6 23.4 Present study (2017) 80.4 - 19.6

Age distribution in ovarian lesions In a study conducted by Badge et al (2013),[20] the maximum number of benign tumors (20%) were seen during third decade whereas maximum number of malignant tumors (9%) were seen during 5th decade. In the present study also, maximum number of benign cases were seen in the age group 26-40 years (46.3%) and maximum malignant cases in patients >40 years of age. Table 9: The clinical presentation of the patients with ovarian tumor

Author and year of study

Mass abdomen

Pain abdomen

Bleeding per

vaginum Others Gupta et

al[16] (2007) 60.57% - 40.20% 14.3% Manoja[21]

(2017) 40.8% 37.5% 10% 9.2% Present study (2017) 68.6% 94% 27.4% -

Frequency of Non-neoplastic ovarian lesions In the present study, out of the total 15 cases of non-neoplastic lesions involving the ovary, majority were hemorrhagic luteal cysts, 7 (46.6%), infective pathology in tubo ovarian mass, 5 (33.3%) and follicular cysts, 3 (20%). In a study conducted by Maharjan et al (2013),[22] Out of 20 non-neoplastic ovarian lesions, majority of cases 14 (70%) were hemorrhagic luteal cysts, 3 (15%) cases endometriosis, 2 (10%) cases follicular cysts and 1 (5%) case tubo-ovarian abscess. Table 10: Comparison of histological types of ovarian neoplasms

Authors and year of study

Surface epithelia

l- stromal tumors

Sex cord- strom

al tumor

s

Germ cell

tumors

Metastatic tumors

Jha and Karki[17] (2008)

(n=161) 82.2 42.2 3.1 2.4 Swamy and

Satyanarayana[

23] (2010) (n=120) 61.6 21.7 11.7 5

Ashraf et al[24] (2012) (n=127) 52.76 43.31 3.15 0.78

Mondal et al[25] (2011) (n=957) 67.9 5.6 23.1 3.2

Badge et al[20] (2013) 77 6 16 -

Present study (2017) (n=41) 58.5 9.7 29.2 2.4

Frequency of subtype of ovarian neoplasm In the present study, among the total 31 neoplastic benign tumors, serous cystadenomas (51.6%) were the most common followed by mature cystic teratoma (32.2%) and amongst the 10 malignant tumors, the most common type was serous cystadenocarcinoma (40%) followed by dysgerminoma (20%) and granulosa cell tumor (20%). This is in close relation to the study conducted by Badge et al (2013).[20]

CONCLUSION

The tubal and ovarian lesions manifest a complex wide spectrum of clinical and pathological features. Though histopathological examination remains the gold standard for the diagnosis of these lesions, but an accurate clinical as well as radiological examination along with the histopathological examination aids in better grading and staging improving the diagnostic accuracy.

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Source of Support: Nil, Conflict of Interest: None declared

original article clinico-pathological correlation of tubo-ovarian … · cysts and 1 (5%) case...

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