Histopathological patterns of ovarian lesions: A study of 161 cases

Ovarian lesions are commonly encountered pathologies that cannot be categorized clinicoradiologically. Definite diagnosis is of great importance for therapeutic and prognostic purposes. Histopathology gives accurate diagnosis in most cases. Few cases need supportive tests like immunohistochemistry. Objective: to study the histomorphological diversity of ovarian lesions, their age and location in North of Iraq (Mosul and Duhok). Patients and methods: In the period extended from January 2008 to December 2011, 161 cases of ovarian lesions were collected from pathology departments in Azadi General Hospital “Duhok” and Al-Jamhori Teaching Hospital “Mosul”. Automated tissue processor was used for histologic study and Streptavidin-biotin method on paraffin sections was applied for immunohistochemistry. Result: There was a wide age range, most being in the third decade. The right ovaries were more common involved than the left. Histologically, 58 (36%) cases were non-neoplastic and 103 were neoplastic including 90 (55.9%) benign and 9 (5.6%) malignant tumors. The remaining 4 (2.4%) cases comprised borderline serous cystadenoma. Conclusion: Most ovarian lesions were functional non-neoplastic followed by benign neoplastic. Apart from few cases, diagnosis was merely histological without any ancillary test. BIOCELL 2019 43(3): 175-181 Doi: 10.32604/biocell.2019.06884 www.techscience.com/biocell Introduction Ovarian lesions form a frequent cause of hospitalization among females with different ages. Although most cases are physiological with no need for therapy, considerable number come as complicated cases and require surgical intervention. On the other hand, many ovarian lesions comprise neoplastic conditions, benign, borderline or malignant that may be life threatening if not urgently diagnosed and dealt with. Their great diversity possesses a great challenge for both surgeons and pathologists (Valentin et al., 2006; Koonings et al., 1989). Definite diagnosis is pathological rather than clinical or radiological. Histologic categorization is of great importance as the treatment differ depending on the nature of the lesion. The WHO classification (2002) of ovarian tumors, on the basis of tissue origin, acquired a universal acceptance (Fatima et al., 2017; Kant et al., 2017). Material and Methods Patients In the period extended from January 2008 to December 2011, 161 cases of ovarian lesions were collected from pathology departments of Azadi General Hospital-Duhok *Address correspondence to: Abdulkareem Younis SULEIMAN, zaad28653@gmail.com and Al-Jamhori Teaching Hospital-Mosul. Automated tissue processor was used, and slides were stained by hematoxylin and eosin (HE). Tumors were classified according to the WHO classification, 2002 (Fatima et al., 2017; Kant et al., 2017). The few morphologically undiagnosed cases, immunohistochemistry (IHC) was applied using Streptavidinbiotin method on paraffin sections on poly-l-lysine-coated slides. Monoclonal or polyclonal mouse or rabbit primary antibodies (depending on the target antigen), manufactured by DAKO Corporation (Dako Denmark A/S), were added to confirm the diagnosis of granulosa cell tumor (CD99, Inhibin alpha, vimentin, calretinin) and to differentiate primary from metastatic adenocarcinoma (CK7, CK20, CDX2, WT, CA125, Estrogen receptors). Cases were analyzed using statistical analysis (IBM SPSS v. 22.00 for Windows) and p < 0.05 was considered statistically significant.


Introduction
Ovarian lesions form a frequent cause of hospitalization among females with different ages. Although most cases are physiological with no need for therapy, considerable number come as complicated cases and require surgical intervention. On the other hand, many ovarian lesions comprise neoplastic conditions, benign, borderline or malignant that may be life threatening if not urgently diagnosed and dealt with. Their great diversity possesses a great challenge for both surgeons and pathologists (Valentin et al., 2006;Koonings et al., 1989). Definite diagnosis is pathological rather than clinical or radiological. Histologic categorization is of great importance as the treatment differ depending on the nature of the lesion. The WHO classification (2002) of ovarian tumors, on the basis of tissue origin, acquired a universal acceptance (Fatima et al., 2017;Kant et al., 2017).

Patients
In the period extended from January 2008 to December 2011, 161 cases of ovarian lesions were collected from pathology departments of Azadi General Hospital-Duhok *Address correspondence to: Abdulkareem Younis SULEIMAN, zaad28653@gmail.com and Al-Jamhori Teaching Hospital-Mosul. Automated tissue processor was used, and slides were stained by hematoxylin and eosin (HE). Tumors were classified according to the WHO classification, 2002(Fatima et al., 2017Kant et al., 2017). The few morphologically undiagnosed cases, immunohistochemistry (IHC) was applied using Streptavidinbiotin method on paraffin sections on poly-l-lysine-coated slides. Monoclonal or polyclonal mouse or rabbit primary antibodies (depending on the target antigen), manufactured by DAKO Corporation (Dako Denmark A/S), were added to confirm the diagnosis of granulosa cell tumor (CD99, Inhibin alpha, vimentin, calretinin) and to differentiate primary from metastatic adenocarcinoma (CK7, CK20, CDX2, WT, CA125, Estrogen receptors). Cases were analyzed using statistical analysis (IBM SPSS v. 22.00 for Windows) and p < 0.05 was considered statistically significant.

Results
The age range was 11-81 years with a mean age of 32 years, ovarian cysts were more commonly seen in the age group 20-29 years (Tab. 1). Most cases were demonstrated in the right ovaries 92 (57.1%). The left ovaries were involved in 60 (37.2%) cases. The remainders (N = 9; 5.5%) were Bilateral.
We reported 3 cases of sex-cord stromal tumors which included 2 cases of fibrothecoma and a single case of granulosa cell tumor.

Discussion
In this study, the third decade was the dominant affected age which is comparable with what has been reported by Fatima et al. (2017) The right ovary was the commonest side involved (57.1%). Such observation was in agreement with other studies from Saudi Arabia and Qatar (Zahra, 2016;Abduljabbar et al., 2015).
Histologically, benign ovarian lesions functional cysts (non-neoplastic) and benign cystic tumors formed the dominant morphology (87.3%) whereas malignancy was identified in (5.6%) of cases. A similar finding was reported (Jha and Karki, 2008). However, in a study done by Ahmad et al. (2000) (the prevalence of benign tumors was lower (59.2%) and malignancy was higher (40%).
The most common histopathological diagnosis of ovarian cysts in the present study was functional (follicular/ corpus luteal) cysts (32.88%), a finding which is in agreement with other studies done in Iraq, Saudi Arabia, Pakistan, Iran (Abduljabbar et al., 2015;Arab et al., 2010;rasha, 2007;Ahmad et al., 2000), but it was in contrast with another study in Qatar (Zahra, 2016) where benign epithelial cysts formed the most common, and in Nigeria where the germ-cell tumor was the commonest pathology (Onyiaorah , 2011).
Surface epithelial tumor formed the commonest reported neoplasm (61.16%). Germ cell tumors (35.9%) formed the second most common type, among which mature cystic teratoma (22%) was the commonest type. Such observation is in agreement with other studies from Iraq and Iran (Arab et al., 2010;rasha, 2007), but in contrary to other study where mature cystic teratoma was the third commonest tumor (Abduljabbar et al., 2015).
We reported 3 cases of sex-cord stromal tumors which included 2 cases of fibrothecoma and a single case of granulosa cell tumor. Such observation is similar to other studies (Zahra, 2016;Jha and Karki, 2008).
Endometriosis is difficult to be determined accurately and common ly s e en in t he ovar ies (Agar wa l and Subramanian, 2010; Woodward et al., 2001). This study showed five (3.1%) cases of endometriosis. These findings were similar to (Gupta et al., 2010), but appear to be very low compared to European studies (Guerriero et al., 2009;De Kroon et al., 2004) this discrepancy may be attributed to the clinical diagnosis or the absence of the histological specimens of endometriosis in our studies. The molecular pathology of ovarian cancer is heterogeneous and involves various putative precursor lesions and multiple pathways of development (Christie and Oehler, 2006). The main subject in our research is ovarian cyst with few ovarian cancers and in the near future we have articles mainly involves ovarian cancer where molecular pathology and immunohistochemical method used in their diagnosis, classification and treatment.

Conclusion
Most ovarian lesions were functional non-neoplastic followed by benign neoplastic. Apart from few cases, diagnosis was merely histological without any ancillary test.