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PATIENTS AND METHOD: 55 cases of ovarian tumours admitted from 19th July 2003 to 20th July 2005 were analyzed retrospectively. All patients were given registration number and the medical record was saved in a preformed proforma, data analysis was done with demographic characteristic, sign and symptoms, investigations, type of surgical treatment, histopathology, chemotherapy, follow up and mortality associated with this disease. SPSS 16 software was used for analysis of descriptive statistical results.
RESULT: Out of 55 women admitted with ovarian tumours 15 (27.27%) were malignant across all age group and 40 (72.72%) were benign. Thus the incidence of ovarian malignancy during the study period was 1.29%. Mean age of women with malignant ovarian tumour was 45.83 ± 13.72 years, and for benign tumours was 30.82 ± 10.2 years, the commonest tumour was epithelial in origin, most of patients present in late stage when survival is limited.
Conclusion: Early detection, prompt treatment of tumour can reduce morbidity and mortality.
Keywords: Ovarian tumours, incidence and management of ovarian malignancy.
INTRODUCTION: Of all gynecological cancer ovarian malignancies represent the greatest challenge. It is the second most commonly diagnosed malignancy of the female reproductive system and fifth leading cause of the death. 1, 2
Among gynecological malignancies it is unfortunately being increasingly encountered in Pakistan. According to multicenter study on the frequency of malignant ovarian tumour supported by Pakistan Medical Research Council (PMRC) incidence rate of ovarian malignancy found to be 3.37% in 1973. 2 Contrary to the western studies and in India, ovarian tumour were more frequent than cervical cancers.3 Early ovarian cancer mass does not cause obvious symptoms, 4 most of the women present with advanced stage where the prognosis is poor in spite of intensive and complex therapies, earlier detection and treatment improve the survival rate. 5, 6
The importance of the studies has increased because ovarian cancer is a silent killer and most of the patients present in an advanced stage due to lack of screening.
Aims & Objectives: In this study we wanted to find out the incidence, early detection by proper screening when the prognosis is good and in advanced stage multidisciplinary approach to patient and management will ensure the best results to reduce morbidity and mortality.
MATERIAL AND METHODS: Retrospectively records of 55 patients admitted from 19th July 2003 to 20th July 2005 were analyzed with regards to incidence, type, clinical picture their diagnosis and management.
History, physical examination, routine investigation, tumour markers, ultrasonography and CT scan finding were noted on preformed proforma. Depending on provisional diagnosis, surgical staging was done. Two patients after biopsy were given direct chemotherapy while in the rest of the cases cystectomy, oophrectomy, total abdominal hysterectomy (TAH) and bilateral salpingo oophrectomy (BSO), omentectomy was done depending on age, family completion and suspicion of malignancy. Post operative chemotherapy for 4-6 cycles was given depending on histopathology report.
RESULTS: Total numbers of gynecological patients admitted in the period of 2 years were 1160 as shown in Table 1. Out of total 55 women admitted with ovarian tumours, 15 (27.27%) were malignant across all age groups while remaining 40 (72.72%) were benign. Hence incidences of ovarian malignancy were 1.29%. Ovarian cancer is unusual before age of 40 years. Table II showed the peak age range between 40-45 years, 09 (54.01%) patients were in this age group, while youngest patient recorded with us was 10 years of age.
Of all the benign tumours, maximum number of patients were 28 (70%) in the age group of 21-40 years. Table III showed that 10 (68.8%) were malignant in multiparous women while almost half 20 (50%) were in benign group. In low parity 50% were benign and 5 (31.32%) were malignant. Table IV showed the sign and symptom of patients in benign tumour, most common presenting complaint was pain in abdomen in 100% patients, and 10 (25%) had infertility and 20 (50%) irregular menstrual cycle while in malignant tumour abdominal distention was more common in 10 (66.67%) patients.
Table V showed on ultrasound bilateral tumour was common in malignant group. In ten (66.67%) cases with a size of >20 cm, solid and cystic in consistency present in 8 (53.33%) , while in benign tumour 30 (75%) had unilateral tumour with a size of 6-10 cm in 17 (42.5%) patients and 30 (75%) tumours had cystic consistency.
CA - 125 was raised in 11 (73.3%) in malignant ovarian tumours and only in 1 (25%) in benign. CT scan was done in 4 (26.67%) patients showed advanced malignancy. Table VI showed various type of operative procedure. In 30 (75%) benign cases oophrectomy / cystectomy was done. Total abdominal hysterectomy (TAH) and bilateral salpingo oophrectomy (BSO) done in 10 (25%) patients. In malignant group 11 (82.84%) patients had total abdominal hysterectomy (TAH), bilateral salpingo oophrectomy and omentectomy, while 2 (14.28%) had biopsy and debulking, Four (28.56%) patients received radiotherapy and chemotherapy, while the remaining had only chemotherapy. Three (21.42%) were present in stage I, they have regular follow-up and were free of disease, 3 patients (21.42%) were in stage III, 01 (7.14%) patient was lost on follow-up, and 2 (14.28%) patients had regular follow-up. 8 (57.14%) patients were admitted in stage IV with distant metastasis, among these one patient lost her follow-up, 6 (42.58%) patients were expired within six month after surgery during chemotherapy and one patient died before treatment.
DISCUSSION: Cancer has over taken heart disease as a leading cause of death all over the world, mortality from the cancer now accounting for one quarter of all death. Generally ovarian cancer is the disease of peri and post menopausal women. The risk of developing ovarian cancer peak is the 5th decade of life 7 which is comparable to our study. Nulliparity has been considered as significant risk factor, most of the women in our study were parous, this study was similar to the results reported by saeed et al 8 but contradict to western 9 world where only 8.2% 10 were nulliparous and Ahmed-J et al in Pakistan.11
In our study reported symptoms in malignant cases were abdominal distention and GIT upset and in benign cases abdominal pain was the commonest symptom.
Abdominal and pelvic ultrasound is the commonest investigation done for diagnosis of ovarian cases, this was recommended by National Institute of Health (NIH) as a preferred means of diagnosing ovarian mass.12 CA-125 was raised in 50% of the patient this test is useful in differential diagnosis and in follow-up of the disease, it is not accepted to detect early disease because of its low sensitivity13 staging and grading of the tumour has important prognostic value. Surgery remain the gold standard treatment.14 Western studies coated 36% women present- stage I, 19% in stage II, 32% in stage III and 13% in stage IV. 15 In our study higher percentage 73.33% were present in stage III + IV and 3 (20%) were in stage I. In early stage of the disease the reproductive potential of a young women is pursued with conservative surgery while in advance disease cytoreductive surgery reduces the tumour bulk, so that chemotherapy will exert a maximum effect. Follow-up is usually ignored by the patient, among these one patient was followed regularly and one last follow-up, six patients were expired with in 6 months after surgery during chemotherapy this similar pattern was seen. 16, 17
CONCLUSION: Ovarian cancer is the commonest gynaecological cancer second to breast cancer. Because of the lack of proper screening women always present in the late stage, when there is no established treatment, thus our aim should be early detection, thorough treatment and regular follow-up so to reduce the morbidity and mortality.
Table - 1 INCIDENCE OF OVARIAN MALIGNANCY
Total number of Gynecological patient admitted
Number of patients with ovarian tumors
Number of patients with benign ovarian neoplasm
Number of patients with malignant ovarian neoplasm
Incidence of ovarian malignancy
Table II Age
Table III Parity
Table IV Presentation of sign & symptoms
Pain In abdomen
Irregular vaginal bleeding
Table - V Investigations
U/S CT Scan
Cystic + solid
CA - 125
Table VI - Treatment Modalities
Number of patient.
Type of operation
Advance stage disease.
Biopsy / debulking
Table VII Out come of patient with malignant ovarian tumour.
Number of patient.
Lost follow up
IV and Advanced