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Clinical and pathologic evaluation of 342 benign ovarian tumors
Int. J. Gynaecol. Obstet.,1984,22: 263-267 International Federation of Gynaecology & Obstetrics
263
CLINICAL AND PATHOLOGIC EVALUATION OF 342 BENIGN OVARIAN TUMORS
JOSi A. PORTUONDO, BORJA GIMENEZ, JO& M. RIVERA, J. GARRIGA and ALFONSO ALEGRE Department of Obstetrics and Gynecology, Department of Pathology, Ciudad Sanitaria “Enrique Sotomayor”, Bilbao, Schooiof Medicine, Cruces-Bilbao jspainj
University of
(Received April 21st 1984) (Accepted April 24th, 1984)
Abstract Portuondo JA, Gimenez B, Rivera JM, Garriga J. Alegre A (Department of Obstetrics and Gynecology, Department of Pathology, Ciudad University Sanitaria ‘Enrique Sotomayor”, of Bilbao, School of Medicine, Cruces-Bilbao, Spain). Clinical and pathological evaluation . of 342 benign ovarian tumors. Int J Gynaecol Obstet 22: 263-26 7.1984 A series of 289 patients who were diagnosed with 342 benign ovarian tumors (BOT) at laparotomy have been reviewed. Mean age was 36.7 years (S.D. f 13.9), mean parity was 1.5 (S. D. f I. 6); 236 (81.7%) patients had a single unilateral ovarian tumor; 29 (10%) patients had bilateral ovarian tumors. Benign cyst teratoma was diagnosed in 89 (26%) tumors, and it was the most frequent histological type. In eight patients (2.8%) the post-operative pathologic report was compatible with malignancy, despite the lack of suspicion at laparotomy. Mean maximal diameter of BOT was 9.1 cm, and almost 60% of the mutinous cystoadenomas were larger than 16 cm. Benign cyst teratoma and serous cytoadenoma had a medium size, about 6-10 cm. Lower abdominal-pelvic pain was the symptom most frequently reported by patients with BOT. Calcifications were most frequently seen in benign cyst teratoma. Tumors of I I-1.5 cm in size were the tumors most frequently torsioned. Twenty four (8.3%) patients had their surgical operation done during pregnancy; benign cyst teratoma was the tumor most frequently associated with pregnancy. OQ20-7292184/SO3.00 0 1984 International Federation of Gynaecology & Obstetrics Published and Printed in Ireland
Keywords: Clinical and pathological evaluation; Benign ovarian tumors; Laparotomy; Mean age; Mean parity; Unilateral and bilateral tumors; Benign cyst teratoma was diagnosed. Introduction Fifteen percent of the female tumors originated in the ovary, and 75% of them were considered to be benign [ 141. Preoperative diagnosis of BOT is always desirable, despite the difficulties involved [ 211. Here, we present the clinical and pathologic features of BOT in an attempt to evaluate the usefulness of the clinical preoperative diagnosis. Materials and methods A series of 289 patients who were diagnosed with BOT at laparotomy was retrospectively reviewed. In 8 patients (2.8%), the postoperative pathologic report was consistent with malignancy, but these patients were included in this study since their surgical diagnosis at laparotomy was considered to be compatible with BOT. Pathologic reports were made using the international histological ‘classification on tumors proposed by W.H.O. [ 231. Statistical analysis of data was performed using the x2 and Student t-test. Results Mean age of the patients with BOT was 36.7 years (S.D. k 13.9) with a range from 11 Int J Gynaecol Obstet 22
264
Portuondo et al.
Table I.
Histologic diagnosis of the 342 BOTs according to W.H.O. classification [23].
Histological diagnosis
No. of patients
No. of tumors
%
Bilateral
%
Benign cystic teratoma Functional cysts Serous cystoadenoma Paraovarian cyst Endometrioid cyst Mutinous cystoadenoma Tecomo-fibroma
81 54 53 36 25 28 12
89 58 57 38 32 31 12
26 17 16.7 11.1 9.3 9.1 3.5
8 4 4 2 7 3 _
9.9 7.4 7.5 5.5 28 10.7 -
Serous cystoadenofibroma Malignant tumors Malignant bordeline Mutinous cystoadenoma Malignant bordeline Others
7 8 3
8 8 3
2.3 2.3 0.9
1 _ -
14.3 _
2 4
2 4
0.6 1.2
_ _
_
289
342
100%
29
100%
Total
to 8 1 years. Mean parity of patients with BOT was 1.5 (S.D. + 1.6). One third of patients (36%) were nulliparous. The 289 patients had a total of 342 ovarian tumors which were grouped as follows: 236 (8 1.7%) patients had a single unilateral ovarian tumor; 29 (10%) patients had bilateral ovarian tumors; 24 (8.3%) patients had two histologically different tumors in the same ovary. Table II.
Table I shows the histological diagnosis of the 342 ovarian tumors. Benign cystic teratoma (BCT) occurred in 89 (26%) tumors and it was the tumor most frequently reported. Table II shows the mean maximal diameter of the 342 tumors; mutinous cyst have usually (58% of cases) a maximal diameter greater than 16 cm. BCT, paraovarian cyst and serous cystoadenoma frequently
Mean maximal diameter of the 342 BOTs according to their histologic diagnosis.
Histological Diagnosis
No. of tumors
Mean maximal diameter (cm)* 6-10
<6
Benign cyst teratoma Functional cysts Serous cystoadenoma Paraovarian cyst Endometrioid cyst Mutinous cyst Tecoma-fibroma Serous cystoadenofibroma Malignant tumors Malignant bordeline Mutinous cystoadenoma Malignant bordeline Others ax’ = 187.72, P < 0.05. Int J Gynaecol Obstet 22
89 58 57 38 32 31 12 8 8 3 2 4
No.
%
No.
%
No.
13 20 8 14 12 1 2 2 -
14.6 34.5 14 36.8 37.5 3.2 16.6 25 -
50 27 25 21 16 4 4 3 3
56.2 46.5 43.8 55.3 50 12.9 33.3 37.5 37.5 -
17 9 17 2 4 8 1 2 3
-
-
1
25
2
16-20
11-15 %
19.1 15.6 29.8 5.3 12.5 25.8 8.3 25 100
-
-
_
50
-
-
>20
No.
%
No.
%
5 2 6 9 5 _ 4 -
56.6 3.4 10.5
4 1 1 9 _ 1 1 -
4.5 _
2 _
_ _ 29 41.7 50 100 _
1.8 2.6 _ 29.0 _ 12.5 12.5 _
_ 1
25
Review of benign ovarian tumors
265
Table 111. Frequency of tumoral calcifications in 89 patients who had X-ray examination. Histological diagnosis
X-ray calcificationsa
No. of patients
Absent
Present No.
%
No.
%
BCT Other tumors
27 62
21 2
71.8 3.2
6 60
22.2 96.8
Total
89
23
25.8
66
74.2
ax2 = 54.69, P < 0.001.
have a maximal diameter measuring about 6-l 0 cm; differences in the size were statistically significant. Clinical symptoms of the 289 patients with BOT were as follows: no symptoms, 18 (6.2%) patients; lower abdominal or chronic pelvic pain, 161 (55.7%) patients; menstrual disturbances such as oligoamenorrhea 55 ( 19%) patients; chronic abdominal discomfort, 32 (11.1%) patients; abdominal distention, 3 1 30 ( 10.7%) patients; urinary symptoms, ( 10.4%) patients; affected general condition, 25 (8.6%) patients: acute pelvic pain, 8 (2.8%) patients; others, 15 (5.2%) patients. Ascites was present at laparotomy in 6 (2%) patients associated with BOT, and 8 patients with malignant tumors (unsuspected at laparotomy) did not have ascites at all. Table III shows the frequency of tumoral calcifications found in 89 patients who Frequency of tumoral torsion according to maxiTable N. mal diameter Tumoral size
No. of tumors
Torsiona No. of cases
%
<6 6-10 11-15 16620 >20
73 155 63 33 18
-
-
16 20 5 1
10.3 31.7 15.1 5.5
Total
342
42
12.3
ax1 = 34.22 P < 0.001.
underwent pelvic X-rays; calcifications were present in 77.8% of patients with BCT, and were absent in 96.8% of the remainder of the tumors; these differences were also statistically significant. Table IV shows the frequency of torsion in the 342 BOTs, according to the tumor’s size; ovarian tumors sized 1 l-l 5 cm are the most frequently torsioned. Out of 289 patients, 24 (8.3%) underwent operation for ovarian tumors during pregnancy ; 9 patients (10.1%) had a BCT; 3 (9.7%) patients had mutinous cyst; 5 (8.6%) patients had functional cysts; 4 (7%) patients had serous cystoadenoma; 2 (5.3%) patients had paraovarian cysts. Discussion BOTs occurred in women with a mean age of 36.7 + 13.9 years, consistent with the mean age of 34.2 + 13.5 years reported in other publications [ 181. Mean parity was 1.5 + 1.6 just half of the parity reported by others [ 181. Since the two series have the same mean age, differences in the parity might be related to the populations studied. Single unilateral ovarian tumor is the more frequent finding (8 1.7%) and bilateral tumors occur in 10% of the present series. It is interesting to point out that these figures do not differ from other series which include patients with a totally different racial distribution [ 181. We should also point out that 8.3% of the population showed two histologiInt J Gynaecol Obstet 22
266
pbrtuondo et al.
tally different benign tumors in the same ovary, and this coincidence has also been reported in the literature [ 10,221. BCT was the single benign ovarian tumor most frequently seen in our series (Table I). Serous cystoadenoma was more frequently seen than mutinous cystoadenoma: in other series [ 181 mutinous cystoadenoma has always been reported to be more frequent than serous cystoadenoma. In other series, endometrioid cyst [ 211 and serous cystoadenoma [ 21 were the BOTs more frequently reported. We would like to point out that 8 (2.8%) patients showed malignant pathologic reports although their surgical diagnosis at laparotomy was of BOT without ascites; in such patients intra-operative frozen biopsy would have been of great advantage, but no external suspicions were available at surgery to indicate that procedure. Mean maximal diameter of BOTs was 9.18 cm (S.D. + 6.4), and mutinous cystoadenoma was the largest BOT; almost 60% of the mutinous cystoadenomas measured more than 16 cm maximal diameter. These findings are consistent with other publications [4,12, 161. BOTs with a medium size (6-10 cm) are frequently benign cyst teratomas, paraovarian cysts or serous cystoadenomas. As reported by other investigators [ 4,12,16] abdominal pain was the symptom most frequently found in patients with BOTs. Menstrual disturbances have been considered a frequent symptom in other series [ 211. Approximately, 6% of patients were free of symptoms, and the diagnosis was made in a routine gynecological examination. Ascites was present in 6 (2%) of the patients, mainly associated with mutinous cystoadenoma or fibroma [ 3,8,9] . Conversely, 8 patients whose pathologic report was of malignancy, did not have ascites at all. The incidence of X-ray calcifications in patients with BCT (77.8%) was (P < 0.001) greater than the 3.2% of calcifications which were found in other tumors (Table III); therefore X-ray examination has been reported very useful in the preoperative diagnosis of BOT [ 111. Int J Gynaecol Obstet 22
Tumoral torsion was found in 12.3% of patients in our series. Ovarian tumors sized 1 l-l 5 cm were more frequently torsioned and these differences were statistically significant (P < 0.001). In other series medium size tumors are those that more frequently are torsioned since they have enough weight and room in the pelvis for such a complication [ 19,201. Twenty four (8.3%) patients were diagnosed and operated upon during pregnancy. The coincidence of ovarian tumor and pregnancy occurred in 4.34% of the patients at the Emil Novak Tumor Registry [ 171, and this coincidence is considered to be important since ovarian tumors are more difficult to diagnose during pregnancy and have a greater incidence of complications [ 71. Malignancy of ovarian tumors associated with pregnancy has been reported to be extremely rare [ 1,6,13,15 I . As it has been reported by others [5,24], BCT was the ovarian tumor most frequently associated (10.1%) with pregnancy. BOTs occurred usually in patients with a mean of 36.7 years of age, 1.5 children as the mean parity, who complained of pelvic-abdominal pain; BOTs have a 12.3% torsion rate and 8.3% of patients were operated upon during pregnancy; Eight patients (2.8%) had malignant tumors despite a benign diagnosis at laparotomy. References Be&her NA: Growth and malignancy of ovarian tumors in pregnancy. Aust J Obstet Gynaecolll: 208,197l. Bennington J, Ferguson BR, Haber SL: Incidence and relative frequency of benign and malignant ovarian neoplasms. Obstet Gynecol32: 627,1968. Bigart JH, Macafee CHG: Tumours of the ovarian mesenthyme. A clinicopathological survey. J Obstet Gynaecol Br Emp 62: 892: 1955. Calatroni CJ, Ruiz V: Terapbtica Ginecokjgica. Ed Interamericana Buenos Aires, 1977. Chowdhury NNR: Ovarian tumors complicating pregnancy. A critical analysis of 24 cases. Am J Obstet Gynecol38: 615,1962. Chung A, Birnbaum SJ: Ovarian cancer associated with pregnancy. Obstet Gynecol Jl: 211,1978. Dewhurst CJ : Integrated Obstetrics and Gynaecology for Postgraduates. Blackwell Scientific Publications, London, 1980.
Review of benign ovarian tumors 8 Dockerty MB, Masson JC: Ovarian Bbromas: a clinical and pathological study of two hundred and eighty-three cases. Am J Obstet Gynecol47: 741, 1944. 9 Driscoll JA: Ovarian fibroma. J Irish Med Assoc 58: 184, 1964. lf! Fox H, Langley FA: Tumours of the Ovary. William Heinemann Medical Books Ltd., London, 1976. 11 Gauter PJ: Reflexions sur les kystes dermoides de l’ovaire. Gynecologie 30: 105, 1979. 12 Govan ADT: Ovarian tumours: clinical and pathological features. Clin Obstet Gynecol3: 89, 1976. 13 Mili LM, Johnson CE, Ler RA: Ovarian surgery in pregnancy. Am J Obstet Gynecol122: 365,197s. 14 Janovski NA, Paramanandhan PL: Ovarian Tumours. Saunders, Philadelphia, 1973. 15 Munnell EW: Primary ovarian cancer associated with pregnancy. Clin Obstet Gynecol6: 983,1963. 16 Novak ER, Steegar G, Jones HW: Novak’s Textbook of Gynecology, 8th ed, The Williams & Wilkins Company. Baltimore, 1970. 17 Novak ER, Dambrou CD, Woodruff JD: Ovarian tumour registry review. Obstet Gynecol46: 40,197s. 18 Ong HC, Chan WF: Mutinous cystadenoma, serous cistadenoma, and benign cystis teratoma of the ovary. Clinico-pathological differences observed in a Malaysian Hospital. Cancer 41: 1538, 1978.
267
19 Pantoja E, Rodriguez-IbarIez I, Axtmayer RW, Noy MA, Pelegrina I: Complications of dermoid tumours of the ovary. Obstet Gynecol45: 89,197s. 20 Philippe E, De Mot E, Muller G, Foussereau S, Boog G, Candar R: Teratomes benigns quistiques de l’ovaire: etude anatomoclinique de 481 cases. Gynecol Obstet (Paris) 70: 513,197l. 21 Robert H, Dutranoy G: Aspect actuel des kystes de l’ovaire. A propos de 264 lesions benignes operees. J Chir (Paris) 114: 257, 1977. 22 Selye H: Encyclopaedia of Endocrinology. The Ovary. Section VII. Richardson Bond and Wright, Montreal, 1964. 23 Serov SF, Scully RE: Histological typing of ovarian turnours. W.H.O. Geneva, 1973. 24 Tawa K: Ovarian tumours in pregnancy. .4m J Obstet Gynecol90: 5 11, 1964. Address for reprints: Josh A. Portuondo, M.D. Associate Professor of Obstetrics and Gynecology Univeraidad de1 Pais Vaaco Fact&ad de Medicine de BIlbao “EnrIque Sotomayor” Ciudad SanItarIa Cruces-BiIbao, Spain
Int J Gynaecol Obstet 22
263
CLINICAL AND PATHOLOGIC EVALUATION OF 342 BENIGN OVARIAN TUMORS
JOSi A. PORTUONDO, BORJA GIMENEZ, JO& M. RIVERA, J. GARRIGA and ALFONSO ALEGRE Department of Obstetrics and Gynecology, Department of Pathology, Ciudad Sanitaria “Enrique Sotomayor”, Bilbao, Schooiof Medicine, Cruces-Bilbao jspainj
University of
(Received April 21st 1984) (Accepted April 24th, 1984)
Abstract Portuondo JA, Gimenez B, Rivera JM, Garriga J. Alegre A (Department of Obstetrics and Gynecology, Department of Pathology, Ciudad University Sanitaria ‘Enrique Sotomayor”, of Bilbao, School of Medicine, Cruces-Bilbao, Spain). Clinical and pathological evaluation . of 342 benign ovarian tumors. Int J Gynaecol Obstet 22: 263-26 7.1984 A series of 289 patients who were diagnosed with 342 benign ovarian tumors (BOT) at laparotomy have been reviewed. Mean age was 36.7 years (S.D. f 13.9), mean parity was 1.5 (S. D. f I. 6); 236 (81.7%) patients had a single unilateral ovarian tumor; 29 (10%) patients had bilateral ovarian tumors. Benign cyst teratoma was diagnosed in 89 (26%) tumors, and it was the most frequent histological type. In eight patients (2.8%) the post-operative pathologic report was compatible with malignancy, despite the lack of suspicion at laparotomy. Mean maximal diameter of BOT was 9.1 cm, and almost 60% of the mutinous cystoadenomas were larger than 16 cm. Benign cyst teratoma and serous cytoadenoma had a medium size, about 6-10 cm. Lower abdominal-pelvic pain was the symptom most frequently reported by patients with BOT. Calcifications were most frequently seen in benign cyst teratoma. Tumors of I I-1.5 cm in size were the tumors most frequently torsioned. Twenty four (8.3%) patients had their surgical operation done during pregnancy; benign cyst teratoma was the tumor most frequently associated with pregnancy. OQ20-7292184/SO3.00 0 1984 International Federation of Gynaecology & Obstetrics Published and Printed in Ireland
Keywords: Clinical and pathological evaluation; Benign ovarian tumors; Laparotomy; Mean age; Mean parity; Unilateral and bilateral tumors; Benign cyst teratoma was diagnosed. Introduction Fifteen percent of the female tumors originated in the ovary, and 75% of them were considered to be benign [ 141. Preoperative diagnosis of BOT is always desirable, despite the difficulties involved [ 211. Here, we present the clinical and pathologic features of BOT in an attempt to evaluate the usefulness of the clinical preoperative diagnosis. Materials and methods A series of 289 patients who were diagnosed with BOT at laparotomy was retrospectively reviewed. In 8 patients (2.8%), the postoperative pathologic report was consistent with malignancy, but these patients were included in this study since their surgical diagnosis at laparotomy was considered to be compatible with BOT. Pathologic reports were made using the international histological ‘classification on tumors proposed by W.H.O. [ 231. Statistical analysis of data was performed using the x2 and Student t-test. Results Mean age of the patients with BOT was 36.7 years (S.D. k 13.9) with a range from 11 Int J Gynaecol Obstet 22
264
Portuondo et al.
Table I.
Histologic diagnosis of the 342 BOTs according to W.H.O. classification [23].
Histological diagnosis
No. of patients
No. of tumors
%
Bilateral
%
Benign cystic teratoma Functional cysts Serous cystoadenoma Paraovarian cyst Endometrioid cyst Mutinous cystoadenoma Tecomo-fibroma
81 54 53 36 25 28 12
89 58 57 38 32 31 12
26 17 16.7 11.1 9.3 9.1 3.5
8 4 4 2 7 3 _
9.9 7.4 7.5 5.5 28 10.7 -
Serous cystoadenofibroma Malignant tumors Malignant bordeline Mutinous cystoadenoma Malignant bordeline Others
7 8 3
8 8 3
2.3 2.3 0.9
1 _ -
14.3 _
2 4
2 4
0.6 1.2
_ _
_
289
342
100%
29
100%
Total
to 8 1 years. Mean parity of patients with BOT was 1.5 (S.D. + 1.6). One third of patients (36%) were nulliparous. The 289 patients had a total of 342 ovarian tumors which were grouped as follows: 236 (8 1.7%) patients had a single unilateral ovarian tumor; 29 (10%) patients had bilateral ovarian tumors; 24 (8.3%) patients had two histologically different tumors in the same ovary. Table II.
Table I shows the histological diagnosis of the 342 ovarian tumors. Benign cystic teratoma (BCT) occurred in 89 (26%) tumors and it was the tumor most frequently reported. Table II shows the mean maximal diameter of the 342 tumors; mutinous cyst have usually (58% of cases) a maximal diameter greater than 16 cm. BCT, paraovarian cyst and serous cystoadenoma frequently
Mean maximal diameter of the 342 BOTs according to their histologic diagnosis.
Histological Diagnosis
No. of tumors
Mean maximal diameter (cm)* 6-10
<6
Benign cyst teratoma Functional cysts Serous cystoadenoma Paraovarian cyst Endometrioid cyst Mutinous cyst Tecoma-fibroma Serous cystoadenofibroma Malignant tumors Malignant bordeline Mutinous cystoadenoma Malignant bordeline Others ax’ = 187.72, P < 0.05. Int J Gynaecol Obstet 22
89 58 57 38 32 31 12 8 8 3 2 4
No.
%
No.
%
No.
13 20 8 14 12 1 2 2 -
14.6 34.5 14 36.8 37.5 3.2 16.6 25 -
50 27 25 21 16 4 4 3 3
56.2 46.5 43.8 55.3 50 12.9 33.3 37.5 37.5 -
17 9 17 2 4 8 1 2 3
-
-
1
25
2
16-20
11-15 %
19.1 15.6 29.8 5.3 12.5 25.8 8.3 25 100
-
-
_
50
-
-
>20
No.
%
No.
%
5 2 6 9 5 _ 4 -
56.6 3.4 10.5
4 1 1 9 _ 1 1 -
4.5 _
2 _
_ _ 29 41.7 50 100 _
1.8 2.6 _ 29.0 _ 12.5 12.5 _
_ 1
25
Review of benign ovarian tumors
265
Table 111. Frequency of tumoral calcifications in 89 patients who had X-ray examination. Histological diagnosis
X-ray calcificationsa
No. of patients
Absent
Present No.
%
No.
%
BCT Other tumors
27 62
21 2
71.8 3.2
6 60
22.2 96.8
Total
89
23
25.8
66
74.2
ax2 = 54.69, P < 0.001.
have a maximal diameter measuring about 6-l 0 cm; differences in the size were statistically significant. Clinical symptoms of the 289 patients with BOT were as follows: no symptoms, 18 (6.2%) patients; lower abdominal or chronic pelvic pain, 161 (55.7%) patients; menstrual disturbances such as oligoamenorrhea 55 ( 19%) patients; chronic abdominal discomfort, 32 (11.1%) patients; abdominal distention, 3 1 30 ( 10.7%) patients; urinary symptoms, ( 10.4%) patients; affected general condition, 25 (8.6%) patients: acute pelvic pain, 8 (2.8%) patients; others, 15 (5.2%) patients. Ascites was present at laparotomy in 6 (2%) patients associated with BOT, and 8 patients with malignant tumors (unsuspected at laparotomy) did not have ascites at all. Table III shows the frequency of tumoral calcifications found in 89 patients who Frequency of tumoral torsion according to maxiTable N. mal diameter Tumoral size
No. of tumors
Torsiona No. of cases
%
<6 6-10 11-15 16620 >20
73 155 63 33 18
-
-
16 20 5 1
10.3 31.7 15.1 5.5
Total
342
42
12.3
ax1 = 34.22 P < 0.001.
underwent pelvic X-rays; calcifications were present in 77.8% of patients with BCT, and were absent in 96.8% of the remainder of the tumors; these differences were also statistically significant. Table IV shows the frequency of torsion in the 342 BOTs, according to the tumor’s size; ovarian tumors sized 1 l-l 5 cm are the most frequently torsioned. Out of 289 patients, 24 (8.3%) underwent operation for ovarian tumors during pregnancy ; 9 patients (10.1%) had a BCT; 3 (9.7%) patients had mutinous cyst; 5 (8.6%) patients had functional cysts; 4 (7%) patients had serous cystoadenoma; 2 (5.3%) patients had paraovarian cysts. Discussion BOTs occurred in women with a mean age of 36.7 + 13.9 years, consistent with the mean age of 34.2 + 13.5 years reported in other publications [ 181. Mean parity was 1.5 + 1.6 just half of the parity reported by others [ 181. Since the two series have the same mean age, differences in the parity might be related to the populations studied. Single unilateral ovarian tumor is the more frequent finding (8 1.7%) and bilateral tumors occur in 10% of the present series. It is interesting to point out that these figures do not differ from other series which include patients with a totally different racial distribution [ 181. We should also point out that 8.3% of the population showed two histologiInt J Gynaecol Obstet 22
266
pbrtuondo et al.
tally different benign tumors in the same ovary, and this coincidence has also been reported in the literature [ 10,221. BCT was the single benign ovarian tumor most frequently seen in our series (Table I). Serous cystoadenoma was more frequently seen than mutinous cystoadenoma: in other series [ 181 mutinous cystoadenoma has always been reported to be more frequent than serous cystoadenoma. In other series, endometrioid cyst [ 211 and serous cystoadenoma [ 21 were the BOTs more frequently reported. We would like to point out that 8 (2.8%) patients showed malignant pathologic reports although their surgical diagnosis at laparotomy was of BOT without ascites; in such patients intra-operative frozen biopsy would have been of great advantage, but no external suspicions were available at surgery to indicate that procedure. Mean maximal diameter of BOTs was 9.18 cm (S.D. + 6.4), and mutinous cystoadenoma was the largest BOT; almost 60% of the mutinous cystoadenomas measured more than 16 cm maximal diameter. These findings are consistent with other publications [4,12, 161. BOTs with a medium size (6-10 cm) are frequently benign cyst teratomas, paraovarian cysts or serous cystoadenomas. As reported by other investigators [ 4,12,16] abdominal pain was the symptom most frequently found in patients with BOTs. Menstrual disturbances have been considered a frequent symptom in other series [ 211. Approximately, 6% of patients were free of symptoms, and the diagnosis was made in a routine gynecological examination. Ascites was present in 6 (2%) of the patients, mainly associated with mutinous cystoadenoma or fibroma [ 3,8,9] . Conversely, 8 patients whose pathologic report was of malignancy, did not have ascites at all. The incidence of X-ray calcifications in patients with BCT (77.8%) was (P < 0.001) greater than the 3.2% of calcifications which were found in other tumors (Table III); therefore X-ray examination has been reported very useful in the preoperative diagnosis of BOT [ 111. Int J Gynaecol Obstet 22
Tumoral torsion was found in 12.3% of patients in our series. Ovarian tumors sized 1 l-l 5 cm were more frequently torsioned and these differences were statistically significant (P < 0.001). In other series medium size tumors are those that more frequently are torsioned since they have enough weight and room in the pelvis for such a complication [ 19,201. Twenty four (8.3%) patients were diagnosed and operated upon during pregnancy. The coincidence of ovarian tumor and pregnancy occurred in 4.34% of the patients at the Emil Novak Tumor Registry [ 171, and this coincidence is considered to be important since ovarian tumors are more difficult to diagnose during pregnancy and have a greater incidence of complications [ 71. Malignancy of ovarian tumors associated with pregnancy has been reported to be extremely rare [ 1,6,13,15 I . As it has been reported by others [5,24], BCT was the ovarian tumor most frequently associated (10.1%) with pregnancy. BOTs occurred usually in patients with a mean of 36.7 years of age, 1.5 children as the mean parity, who complained of pelvic-abdominal pain; BOTs have a 12.3% torsion rate and 8.3% of patients were operated upon during pregnancy; Eight patients (2.8%) had malignant tumors despite a benign diagnosis at laparotomy. References Be&her NA: Growth and malignancy of ovarian tumors in pregnancy. Aust J Obstet Gynaecolll: 208,197l. Bennington J, Ferguson BR, Haber SL: Incidence and relative frequency of benign and malignant ovarian neoplasms. Obstet Gynecol32: 627,1968. Bigart JH, Macafee CHG: Tumours of the ovarian mesenthyme. A clinicopathological survey. J Obstet Gynaecol Br Emp 62: 892: 1955. Calatroni CJ, Ruiz V: Terapbtica Ginecokjgica. Ed Interamericana Buenos Aires, 1977. Chowdhury NNR: Ovarian tumors complicating pregnancy. A critical analysis of 24 cases. Am J Obstet Gynecol38: 615,1962. Chung A, Birnbaum SJ: Ovarian cancer associated with pregnancy. Obstet Gynecol Jl: 211,1978. Dewhurst CJ : Integrated Obstetrics and Gynaecology for Postgraduates. Blackwell Scientific Publications, London, 1980.
Review of benign ovarian tumors 8 Dockerty MB, Masson JC: Ovarian Bbromas: a clinical and pathological study of two hundred and eighty-three cases. Am J Obstet Gynecol47: 741, 1944. 9 Driscoll JA: Ovarian fibroma. J Irish Med Assoc 58: 184, 1964. lf! Fox H, Langley FA: Tumours of the Ovary. William Heinemann Medical Books Ltd., London, 1976. 11 Gauter PJ: Reflexions sur les kystes dermoides de l’ovaire. Gynecologie 30: 105, 1979. 12 Govan ADT: Ovarian tumours: clinical and pathological features. Clin Obstet Gynecol3: 89, 1976. 13 Mili LM, Johnson CE, Ler RA: Ovarian surgery in pregnancy. Am J Obstet Gynecol122: 365,197s. 14 Janovski NA, Paramanandhan PL: Ovarian Tumours. Saunders, Philadelphia, 1973. 15 Munnell EW: Primary ovarian cancer associated with pregnancy. Clin Obstet Gynecol6: 983,1963. 16 Novak ER, Steegar G, Jones HW: Novak’s Textbook of Gynecology, 8th ed, The Williams & Wilkins Company. Baltimore, 1970. 17 Novak ER, Dambrou CD, Woodruff JD: Ovarian tumour registry review. Obstet Gynecol46: 40,197s. 18 Ong HC, Chan WF: Mutinous cystadenoma, serous cistadenoma, and benign cystis teratoma of the ovary. Clinico-pathological differences observed in a Malaysian Hospital. Cancer 41: 1538, 1978.
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