February 2019, Volume 69, Issue 2

Student's Corner

Evaluation of histo-pathogical patterns of ovarian masses in relation to age in Rawalpindi-Islamabad region - Lab Research

Maryam Khalid Cheema  ( Army Medical College, National University of Medical Sciences, Rawalpindi. )
Amina Nadeem  ( Army Medical College, National University of Medical Sciences, Rawalpindi. )
Saleem Ahmed Khan  ( Army Medical College, National University of Medical Sciences, Rawalpindi. )
Tariq Sarfraz  ( Army Medical College, National University of Medical Sciences, Rawalpindi. )
Kainat Intikhab  ( Army Medical College, National University of Medical Sciences, Rawalpindi. )
Tayyaba Shahzad  ( Army Medical College, National University of Medical Sciences, Rawalpindi. )


Objective: To evaluate the histopathological patterns of ovarian tumours in relation to age in Rawalpindi-Islamabad region of Pakistan.
Methods: The retrospective study was conducted at the Army Medical College, Rawalpindi, Pakistan, and comprised data related to ovarian tumour cases from 2013 to 2017). Tumour type, tumour subtype, tumour size, cancer staging and age of patients were noted from the medical records. Ovarian tumours were broadly classified in accordance with the World Health Organisation system for ovarian neoplasms.
Results: Out of 420 ovarian tumour cases, 250 (59.5%) were benign, 24 (5.7%) were borderline, and 146 (34.8%) were malignant. In terms of classification, 268 (63.8%) were surface epithelial tumours, 100 (23.8%) germ cell tumours, 29 (6.9%) sex cord stromal tumours, 12 (2.9%) metastatic tumours, n= and 11(1.2%) were miscellaneous.. Of the malignant tumours, 146(61.6%) were found in patients
aged over 40 years. Serous cystadenoma was the most common 82(32.8%) benign tumour, while serous cyst-adenocarcinoma constituted the main bulk 48(32.9%) of malignant tumours.
Conclusion: The frequency of ovarian tumours was found to be quite high among women of Rawalpindi-Islamabad region.
Key Words: Ovarian tumour, Ovarian mass, Surface epithelial tumours, Germ cell tumours, Sex cord stromal tumours. (JPMA 69: 285; 2019)


Ovarian cancer is the seventh most common cancer among women. Every year 238,719 new cases of ovarian cancer are diagnosed globally, while 151,917 women lose their lives to this deadly disease.1 Epidemiological data
from around the globe reveals that 1 in 71 women will eventually develop ovarian cancer over the course of her lifetime, while 1 in 95 will be unfortunate enough to die
of the disease.2 The global burden of cancer, once considered largely to
be a problem of the financially privileged nations, is now shifting dramatically to the developing world. Studies 1 predict that most new cases (56.8%) of cancer and associated mortality (64.9%) will occur in developing countries. In Pakistan, the incidence of malignant tumours is on rise. Ovarian cancer is found to be the fifth most common cancer (4.8%) among women of the region.3 Furthermore, Pakistan has one of the highest mortality rates for ovarian cancer.4 Although the exact aetiology of ovarian cancer is unknown, various risk factors have been implicated in the development of the disease. Extensive studies have shown that genetic predisposition, number of ovulations, early menarche, genital talc usage, infertility, endometriosis, pelvic inflammatory disease, oestrogen replacement therapy, obesity and smoking are all directly related to ovarian cancer incidence. On the other hand, parity, lactation, oral contraceptive usage, intrauterine device placement, vegetable-rich diet, physical activity, nonsteroidal anti-inflammatory drugs (NSAID)/aspirin/ metformin usage and procedures likeoophorectomy, hysterectomy and tubal ligation are associated with a reduced risk.5 Unfortunately, early symptoms of ovarian cancer are minimal and non-specific. Few cases (15%) are diagnosed with localised tumour (stage 1) when the 5-year survival rate is 92%.6 Parameters that govern the survival prognosis of patients with ovarian cancer include tumour stage, age, general health and post-operative residual tumour. Mucinous tumours have a significantly worse prognosis than serous papillary and endometrial cancers.7 The current study was planned to evaluate the frequency and histopathological features of ovarian tumours in the Rawalpindi-Islamabad region of Pakistan.

Materials and Methods

The retrospec tive study was conduc ted at the Histopathology Department of Army Medical College, Rawalpindi, Pakistan, from October to December 2017, and comprised data of ovarian tumour cases from 2013 to 2017 that was retrieved non-probability purposive sampling technique from the lab archives of the department after due permission from the department head of Histopathology was taken. The data related to benign ovarian neoplasms as well as malignant ovarian  tumours diagnosed on the basis of their histopathological features. Functional ovarian cysts were excluded. Tumour type, tumour subtype, tumour size, cancer staging and age of patients were noted from the medical records. Ovarian tumours were broadly classified into five major types in accordance with the World Health Organisation (WHO) system for Ovarian Neoplasms;8 surface epithelialstromal tumours, germ cell tumours, sex cord-stromal tumours, metastatic tumours, and miscellaneous tumours. Percentage frequency  distribution, mean tumour size and mean age for each of the tumour subtype were calculated. Data analysis was done using Excel 2013.


There were 420 tumours and the median age of the patients was 36 years (interquartile range [IQR]: 9 months to 80 years). Of the cases studied, 250 (59.5%) tumours were benign, 24(5.7%) were borderline and 146 (34.8%) were malignant. Benign tumours were found to be most common in the third decade of life 92(36.8). Malignant neoplasms were most common in the fifth decade of life 49(33.6%), and 90(61.6%) were seen in patients aged above 40 years. In terms of classification, there were 268(63.8%) surface epithelial-stromal tumours, 100 (23.8%)
germ cell tumours, 29(6.9%) sex cord-stromal tumours, 12(2.9%) metastatic tumours, and11(2.6%) miscellaneous tumours. Tumour subtypes and their relation with age were noted (Tables 1-3).

Serous cyst-adenocarcinoma was the most common type of malignant tumours 48(32.9%). It was followed by  endometrioid adenocarcinoma 20(13.7%), mucinous cystadenocarcinoma 15(10.3%), granulosa cell tumour 15(10.3%), metastatic tumour 12(8.2%), mixed germ cell tumour 8(5.5%), yolk sac tumour 5(3.4%), mixed surfaceepithelial tumour 4(2.7%), dysgerminoma 4(2.7%), fibrothecoma 3(2.1%), transitional cell tumour 1(0.7%) and sertoli-stromal cell tumour 1(0.7%). Serous cystadenoma topped the list of most common benign ovarian tumours 82(32.8%), benign teratomas 73(29.2%), mucinous cystadenoma 59(23.6%), serous cystadenofibroma 14(5.6%), monodermal tumour 10 (4%), fibrothecoma 5(2%), fibroma 5(2%), and cystadenoma 1(2.5%). Dysgerminoma tumours comprised the largest malignant tumours with a mean size of 19.8± 10.6cm, while benign fibrothecomas constituted the largest benign neoplasms with a mean size of 11± 7.4 cm. Of the 146 malignant tumours, only 50(34.2%) had been staged (Table 4).


It is of utmost importance to make correct and efficient diagnosis of ovarian tumours in order to ascertain the nature of neoplasms as each tumour type has its own treatment regimen and prognosis. Age becomes a significant prognostic factor in patients of ovarian cancer.  It has now been established that younger women have a significant survival advantage over older patients.9 Extensive local and international studies have been carried out to evaluate the histopathological patterns of ovarian neoplasms in relation to age. A study 10 carried out in R awalpindi (n =2,146) demonstrated that 67% of all ovarian tumours were benign, 2.6% were borderline and 30.4% were malignant. However, the frequency of benign neoplasms (59.5%) in our study was lower, 5.7% were borderline while 34.8%
of all lesions fell into the malignant category. Surface epithelial tumours (59.6%) followed by germ cell tumours (25.5%) were found to be the most common tumour types in that study10 as was the case in our study. The study10 also revealed serous cystadenoma to be the commonest of benign ovarian tumours (29.5%) and serous cystadenocarcinoma to be the commonest of malignant ones (34.4%). Our study exhibited similar findings. It10 also showed that benign ovarian neoplasms were most common during the third decade of life (38.4% of benign lesions) while malignant were most common during the fifth decade (26.5%) which was consistent with our findings. A similar study11 conducted at Army Medical College reported 65.35% of ovarian tumours to be benign, 4.33% borderline and 30.31% malignant. Another study12 in Rawalpindi (n=107) from 1980-1985 showed 27.06% of ovarian tumours to be malignant. Mucinous variety constituted the main bulk of all tumours, benign (24.29%) as well as malignant (13.08%). These findings were in contrast to our study which exhibited a higher frequency (34.8%) of malignant lesions. Also, serous variety of cystadenoma and cyst-adenocarcinoma were the commonest types of tumours in our study. These findings suggest a rise in malignant cases over the years Another study13 was conducted in Lahore comprising 498 cases of ovarian tumours. Among them, 78.70% were benign and 21.29% were malignant. Thus, the incidence of malignant tumours was lower compared to our study. Benign serous cyst was the commonest benign tumour followed by mature cystic teratoma and mucinous cyst. Serous cyst-adenocarcinoma was the commonest malignant tumour followed closely by endometrioid carcinoma and granulosa cell tumour. These findings were in accordance with ours. According to a similar study14 conducted in Lahore, 64.57% ovarian neoplasms were benign and 35.43% (45/127) were malignant. The commonest benign tumour was dermoid cyst in contrast to our study which reported serous cystadenoma to be constituting the bulk. The frequency of malignant ovarian tumours was reported to be 31% in Jamshoro,15 20.26% in Mirpurkhas16 and 22% in Islamabad17, and these rates were lower compared to our rate of 34.8%. However, the predominant serous nature of most common benign and malignant neoplasmsremained the common finding of these studies which was consistent with ours. A U S stud y 18(n=55 ,775) showed serous c y stadenocarcinoma (37.7%) to be the most common of malignant ovarian tumours, followed by mucinous cystadenocarcinoma (12.5%) and endometrioid carcinoma (9.6%). The mean age at the time of diagnosis among women with serous carcinoma was 59.4 years, while it was 54.7 years for mucinous carcinoma, 58.4 years for endometrioid carcinoma, 26.6 years for germ cell (malignant) tumour and 52.6 years for sex-cord stromal (malignant) tumour. This age pattern was in contrast to that observed in our study which reported malignancy at a much younger age. In our study, mean age of serous carcinoma patients at the time of diagnosis was found to be 47.2 years while it was 43.1 years for mucinous carcinoma, 47.5 years for endometrioid carcinoma, 26.8 years for germ cell (malignant) tumour and 45.4 years for sex-cord stromal (malignant) tumour. Another US study19 reported that 75.0-80.0% of ovarian tumours were benign. An Indian study20 (n=100) reported that 73% of women with ovarian tumours had benign lesions while only 27% of the lesions were malignant. The occurrence of malignant neoplasms up to 40 years of age was quite low, accounting for only 25.9% of all malignant cases. It was in contrast to our study in which the frequency of ovarian malignancy among women in the same age group was high at 38.4% of all malignant cases. Also, our study reported an overall
higher frequency of malignancy (34.8%). A study21 on 161 ovarian tumour cases, conducted in Nepal, demonstrated an even lower frequency of malignant ovarian tumours (16.1%) compared to that found by our study. Mature cystic teratoma was the commonest benign tumour (48.2%) in contrast to our study which found serous cystadenoma to be the dominant type. However, serous adenocarcinoma constituted the bulk of malignant tumours (46.2%) as was the case in our sample. In a Nigerian study,22 163/203 (80.3%) of the true ovarian neoplasms were benign while malignant tumours were 40(19.7%). Tumours of germ cell origin were the commonest, accounting for 107 (52.7%) of the ovarian neoplasms seen. Mature teratoma was the commonest benign tumour, while serous cyst-adenocarcinoma (42.5%) was the commonest ovarian malignancy. A Chinese study23 found that median age of women at the time of diagnosis was 53, 44 and 23 years for epithelial ovarian cancer, sex-cord tumours and germ cell tumours respectively. This was similar to our findings. Our study suggests a higher frequency of malignant ovarian tumours among women of Rawalpindi-Islamabad compared to regions of other countries. Moreover, incidence of the disease is found to be at a relatively younger age. A number of factors can be attributed to the observed trends. Increasing elderly population, adoption of sedentary lifestyle and changes in dietary habits seem to have significantly contributed to an increase in all the non-communicable diseases, including ovarian cancer. Lack of screening facilities and quality treatment further exacerbates the problem. Preventive programmes should be the top priority in a country like Pakistan. Our study had its limitations. Being a retrospective study, it relied on administrative data that was not designed fo evaluative purposes and could have been subjected to registry bias. Therefore, it is imperative to design prospective studies with larger sample sizes in order to confirm the findings.


The frequency of ovarian tumours was found to be quite high among the women of Rawalpindi-Islamabad region. The histopathological typing and patterns of ovarian
masses were in concordance with those documented in other studies. However, the average age at diagnosis of ovarian cancer was relatively lower compared to that in other countries.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.


1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015; 136: E359-86.
2. Ahlgren JD. Epidemiology and risk factors in pancreatic cancer. Semin Oncol 1996; 23: 241-50.
3. Ahmad Z, Idrees R, Fatima S, Uddin N, Ahmed A, Minhas K, et al. Commonest Cancers in Pakistan - Findings and Histopathological Perspective from a Premier Surgical Pathology Center in Pakistan. Asian Pac J Cancer Prev 2016; 17: 1061-75.
4. Razi S, Ghoncheh M, Mohammadian-Hafshejani A, Aziznejhad H, Mohammadian M, Salehiniya H. The incidence and mortality of ovarian cancer and their relationship with the Human Development Index in Asia. Ecancermedical science 2016;10 : 628.
5. Reid BM, Permuth JB, Sellers TA. Epidemiology of ovarian cancer: a review. Cancer Biol Med 2017; 14: 9-32.
6. Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Waldron W, et al. SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesa, MD. [Online] [Cited 2018 Jan 07]. Available from: URL: http://seer.cancer.gov/csr/1975_2008
7. Burges A, Schmalfeldt B. Ovarian Cancer: Diagnosis and Treatment. Dtsch Arztebl Int 2011; 108: 635-41.
8. Kurman RJ, Carcangiu ML, Herrington CS, Young RH. WHO Classification of Tumours of Female Reproductive Organs. In WHO Classification of Tumours. 4. Lyon: International Agency for Research on Cancer (IARC); 2014.
9. Chan JK, Urban R, Cheung MK,Osann K, Husain A, Teng NN, et al. Ovarian cancer in younger vs older women: a population-based analysis. Br J Cancer 2006; 95: 1314-20.
10. Zubair M, Hashmi S, Afzal S, Muhammad I, Hamdani S, Ahmad R, et al. Ovarian Tumours: A Study of 2146 Cases at AFIP, Rawalpindi, Pakistan. Austral Asian J Cancer 2015; 14: 21-6.
11. Ahmed M, Malik TM, Afzal S, Mubarik A. Clinicopathological study of 762 ovarian neoplasms at Army Medical College Rawalpindi. Pak J Pathol 2004; 15: 147-52.
12. Muzaffar M, Malik I, Ashraf S. A clinicopathological study of 107 ovarian tumours. J Pak Med Assoc 1987; 37: 194-7
13. Zaman S, Majid S, Hussain M, Chughtai O, Mahboob J, Chughtai S. A retrospective study of ovarian tumours and tumour-like lesions. J Ayub Med Coll 2010; 22: 104-8.
14. Ashraf A, Shaikh AS, Ishfaq A, Akram A, Kamal F, Ahmad N. The relative frequency and histopathological patternof ovarian masses. Biomedica 2012; 28: 98-102
15. Shaikh N, Hashmi F, Samoo R. Pattern of ovarian tumours: report of 15 years\' experience at Liquat University Jamshoro. J Liaquat Uni Med Health Sci 2007; 6: 13-5
16. Bukhari U, Memon Q, Memon H. Frequency and pattern of ovarian tumours. Pak J Med Sci 2011; 27: 884-6
17. Zahra F. The pattern of ovarian masses. Ann King Edward Med Uni 2006;12: 480-2.
18. Goodman MT, Howe HL. Descriptive epidemiology of ovarian cancer in the United states, 1992-1997. Cancer 2003; 97: 2615- 30
19. Scully RE, Young RH, Clement PB. Atlas of tumour Pathology; Third series, Fascicle 23. Washington, DC: Armed Forces Institute of Pathology; 1998.
20. Malli M, Vyas B, Gupta S, Desai H. A histological study of ovarian tumours in different age groups. Int J Med Sci Public Health 2014; 3: 338-41
21. Jha R, Karki S. Histological pattern of ovarian tumours and their age distribution. Nepal Med Coll J 2008; 10: 81-5.
22. Onyiaorah IV, Anunobi CC, Banjo AA, Fatima AA, Nwankwo KC. Histopathological patterns of ovarian tumours seen in Lagos University Teaching Hospital: a ten year retrospective study. Nig Q J Hosp Med 2011; 21: 114-8.
23. Shen F, Chen S, Gao Y, Dai X, Chen Q. The prevalence of malignant and borderline ovarian cancer in pre- and post-menopausal Chinese women. Oncotarget 2017; 8: 80589-94.


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