Clinicopathological analysis of ovarian tumors in perimenopausal women: A study in a rural teaching hospital of eastern India

Introduction: Ovarian tumors are important in perimenopausal women as they are more likely to be malignant. Aim: The aim was to study the various histological pattern of ovarian tumors and their clinical presentation in perimenopausal age group. Materials and Methods: The study was carried out in the departments of Gynaecology and Obstetrics and Pathology in a teaching hospital for two years from June 2007 to May 2009. All patients presented with ovarian tumors of perimenopausal age group (40-50 years) were included. Detailed clinical information, radiological findings and histopathological reports were recorded. Results: A total 52 ovarian tumors were included in this study. Most common histological types were surface epithelial tumors (92.3%), out of which 54.2% were benign, 41.7% were malignant and 4.2% were borderline. Serous cystadenoma was the most common benign tumor and serous cystadenocarcinoma was the commonest malignant tumor. Abdominal discomfort was the commonest presenting symptom both in benign and malignant tumors (85.7% and 45.4% respectively). Most of the malignant tumors were presented in stage III (50%), followed by stage II (27.3%). Conclusion: In this study, we found a relatively higher proportion of ovarian malignancies. So, any ovarian tumor in perimenopausal age group is more likely to be malignant and that require a thorough evaluation and management. Further research should be advocated in this field. Bangladesh Journal of Medical Science Vol. 12 No. 03 July ’13 Page 263-268 DOI: http://dx.doi.org/10.3329/bjms.v12i3.12232


Introduction
Ovarian cancer is the second most common gynaecological malignancy after cervical cancer in India 1 . Asian countries have rate of 2-6 new cases per 1,00,000 women per year 2 . Approximately 25% of all gynaecologic malignant tumors are of ovarian origin, but ovarian cancer is the most common fatal gynaecologic malignancy 3 . Ovarian carcinoma accounts for the greatest number of deaths from malignancies of the female genital tract and is the fifth leading cause of cancer fatalities in women 4 . Although ovarian cancers affect all age groups, primarily it is seen in postmenopausal women 3,5 . Perimenopausal women are also at high-er risk of developing ovarian malignancies as postmenopausal women. The term perimenopause should include the period immediately before the menopause (when the endocrinological, biological and clinical features of approaching menopause commence) and the first year after menopause 6 .
Variability is the hallmark of the menopausal transition and no operational definition was given of those features by the WHO 6 . However a better practical definition is the phase preceding the onset of menopause, generally occurring around 40-50 years of age during which the regular cycle of a woman transitions to a pattern of irregular cycles 7 .
In India, the mean age of menopause is 45 years 8 .
During this time, in addition to the various perimenopausal symptoms including menstrual disorders as a result of anovulation, women also become at increased risk of developing various ovarian pathologies. Various studies revealed that malignant ovarian tumor is common after 40 years [9][10][11][12] . Surface epithelial tumors account for majority of malignancies 3,13 .
Ovarian cancers are usually fatal when diagnosed because of delay in diagnosis. Symptoms are usually absent in early stages and nonspecific in advanced cases. Common presenting symptoms are abdominal lump or distension of abdomen, pain in abdomen, pressure effects and menstrual disturbances 8,10,14 . In this background, this study was undertaken to determine clinical presentation and histological pattern of ovarian tumor in perimenopausal age group in a rural teaching hospital of eastern India.

Materials and methods
The study is a prospective study of two years duration undertaken in a teaching hospital of eastern India, in the departments of Gynaecology and Obstetrics and department of Pathology from June 2007 to May 2009. Before starting the study, clearance from ethical committee was obtained. A total 52 ovarian tumors of perimenopausal age group, diagnosed histopathologically were included. All oophorectomy specimens as well as hysterectomy with bilateral or unilateral salpingoophorectomy specimens in perimenopausal age group were included in this study. Ovarian tumors in which histological typing could not be done due to torsion were excluded from this study.
Detailed clinical history was reviewed with regard to age, clinical features, mode of presentation and radiological findings. Information regarding signs and symptoms, fine needle aspiration (FNAC) findings of available cases, complete blood count, ultrasonography (USG)/ Computed tomography (CT) findings and biochemical investigation findings including serum tumor markers like CA125, fetoprotein and human chorionic gonadrotrophin (HCG) levels were recorded in available cases.
Histopathological typing of ovarian tumors were done according to World Health Organization classification 15 . We took 40-50 years age group as per-imenopausal age group. Womens, who were diagnosed with ovarian tumors after their menopause even if she falls in this age group, were excluded from the study.
Among surface epithelial tumors serous tumors were the commonest (57.7%), followed by mucinous tumors (23.1%). The most common benign tumor was serous cystadenoma (53.6% of all benign tumors), which was also the commonest of all ovarian tumors (28.8%). Majority of malignant tumors were of surface epithelial origin, serous cystadenocarcinoma being the commonest (63.6% of all malignant tumors) followed by mucinous cystadenocarcinoma [ Table 1]. Endometrioid tumors comprises 7.7% and Brenner tumor ( Figure  1) comprises only 3.8% of all ovarian tumors. Only 2 cases of sex-cord stromal tumors were found,  Other varieties includes only 1 case of germ cell tumor (mature cystic teratoma) and 1 Krukenberg tumor.
Abdominal discomfort was the commonest presenting symptom both in benign and malignant tumors (85.7% and 45.4% respectively) [ Histologically, surface ovarian tumors are the commonest. In our study also surface epithelial tumors were the commonest ovarian tumors (92.3%) which is higher than previous studies 5,9,10,11,21,22 . This is because these tumors are more common in older age group. Among the surface epithelial tumors, serous cystadenoma is the commonest of all tumors (28.8%) and also the commonest in benign category (53.6%). In the study by Saeed et al and Ahmad et al found 38.09% and 31.42% of serous cystadenoma which is close to our study 23,24 . In other studies, benign germ cell tumors constitutes a major proportion of benign group, which is common in younger age group. This younger age group was excluded from our study. Majority of malignant tumors were of surface epithelial origin. serous cystadenocarcinoma being the commonest (63.6% ) of all malignant tumors. This finding is similar to previous studies 9,14 . Endometrioid carcinoma ranges from 10-25% of all primary ovarian cancers 25 . However in India, its proportion is found to be low ranging from 4.2% to 5% 9,26 . But we have not found any malignant endometrioid tumors. It may be due to small sample size of our study.
Sex-cord stromal tumors were the second largest group of tumors in this study comprising 3.8% of tumors which is similar with previous study from eastern India 9,26 . Germ cell tumors in our study comprises only 1.9% of all tumors. This finding is contrary to the previous studies 9-11,25 . This is because germ cell tumors are mostly seen in children and young adults 27 . This age group is excluded from our study. The majority of women with epithelial ovarian cancer have vague and non-specific symptoms 28-30 . In early stage, irregular menses (especially in premenopausal women), urinary frequency, constipation, lower abdominal distension, pressure or pain such as dyspareunia are usually seen [28][29][30]

Conclusion
In this study, we found that surface epithelial tumors were the commonest ovarian tumor in perimenopausal age group with a higher incidence of malignancy. This is an alarming finding. However our sample size is very small to make any definite opinion. Amongst malignant ovarian tumors delayed diagnosis is common and patients usually present in late stage of the disease. So awareness among public and doctors for early detection of ovarian cancer in this vulnerable perimenopausal age group and further research in this field with larger samples are advocated.