Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : January | Volume : 16 | Issue : 1 | Page : QC09 - QC13 Full Version

Evaluation and Management of Suspicious Adnexal Masses in Pregnancy- A Retrospective Study


Published: January 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/47226.15873
Kavitha Sukumar, Delphin Supriya, P Usha

1. Associate Professor, Department of Gynaec Oncology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India. 2. Fellow Postgraduate, Department of Gynaec Oncology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India. 3. Fellow Postgraduate, Department of Gynaec Oncology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Delphin Supriya,
BS-2, Navin’s Aradhana Apartments, No. 1, Church Road, Perungudi,
Chennai, Tamil Nadu, India.
E-mail: delphinsupriya.j@gmail.com

Abstract

Introduction: The incidence of suspicious ovarian masses in pregnancy is on the rise due to the increased use of ultrasonography in recent times. However little is known about their management during pregnancy due to the lack of large randomised trials.

Aim: To evaluate the incidence, nature and management of suspicious adnexal masses diagnosed during pregnancy at our institution.

Materials and Methods: This was a retrospective study of 33 pregnant women who presented with suspicious ovarian masses at the Department of Gynaec Oncology at the Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India, from August 2018 to September 2020. Patients were evaluated with imaging studies as per the International Ovarian Tumour Analysis (IOTA) ultrasound rules along with Magnetic Resonance Imaging (MRI) and tumour markers and surgical intervention were performed for cases with definite indications. The Statistical Package for Social Science (SPSS) version 28.0 was used for statistical analysis.

Results: Mean age of the patients was 26.1±2.1 years (20-33 years). Most common gestational age of presentation was the 2nd trimester of pregnancy (mean-18.9 weeks). Out of 33 patients, 27 were benign (81.82%) and 6 (18.18%) malignant. Surgical intervention was done for 18 cases (54.55%) and 15 (45.45%) patients were kept under observation. Five were primary ovarian and one was metastatic from carcinoma stomach.

Conclusion: Thorough clinical evaluation with personalised imaging and appropriate timely intervention aid in the diagnosis and management of suspicious adnexal masses in pregnancy.

Keywords

Carcinoma ovary in pregnancy, Chemotherapy in pregnancy, Ovarian mass in pregnancy, International ovarian tumour analysis group

The incidence of ovarian masses in pregnancy is around 0.2-2%, malignancy rate is 1-6%, vast majority of these masses are benign. Most adnexal masses are identified during routine pregnancy ultrasonography (1). With the widespread use of ultrasonography in pregnancy, the detection rates of suspicious ovarian masses have increased. In general, most adnexal masses are discovered in the first two trimesters of pregnancy, usually in the first trimester early pregnancy scan. 65-80% of these masses are asymptomatic (2). Most functional cysts regress spontaneously when observed in subsequent scans. However, surgical intervention would be needed in all ovarian masses with imaging features suspicious of malignancy, those that significantly increase in size and those that present with acute pain during pregnancy (3).

Ovarian malignancy in pregnancy is very rare. Irrespective of the gestational age at diagnosis, an ovarian malignancy warrants immediate intervention keeping in mind the well-being of the mother (3). However, possibility of continuation of pregnancy alongside treatment of the ovarian carcinoma has also been discussed in several case reports (4),(5). In the absence of large prospective randomised trials and cohort studies, there are no standard guidelines for management of these patients. It is necessary to identify surgical strategies with or without antenatal chemotherapy that results in safe oncologic and foetal outcomes. This study was thus undertaken, to help establish institutional guidelines for the management of suspicious ovarian masses complicating pregnancy.

Material and Methods

The present study was a single centre retrospective study conducted in the Department of Gynaec Oncology at the Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamil Nadu, India, by reviewing the departmental records of patients diagnosed and treated with suspicious ovarian masses between August 2018 to September 2020. The analysis of the data was done in October 2020.

Inclusion criteria: All patients diagnosed with suspicious adnexal masses in pregnancy that satisfy the IOTA M (Malignant) rules and those that were considered inconclusive according to IOTA classification were included in the study (6). The criteria also included ovarian masses which showed rapid increase in size in successive scans and/or presence of ascites or evidence of extra ovarian disease.

Exclusion criteria: Benign looking cysts that satisfy the IOTA B (Benign) rules, small (size ≤5 cm) cysts, simple/functional cysts and dermoid cysts or endometriotic cysts with typical imaging features were excluded.

Patient records were verified for demographic characteristics, Ultrasonography (USG) features, Ca125 (cancer antigen 125) and Carcinoembryonic Antigen (CEA) levels and Magnetic Resonance Imaging (MRI) abdomen and pelvis if available. Other specific tumour markers were noted if done. Masses diagnosed in first trimester were followed-up if not suggestive of malignancy.

Surgical intervention was done in selected cases. The criteria for surgical intervention included large masses ≥10 cm, masses suspicious of malignancy and those that increased in size when observed from the first trimester through the second trimester. Also, cases that presented with acute abdominal pain suggestive of torsion or rupture were taken up for emergency laparotomy irrespective of the gestational age. Elective laparotomies were done between 16 to 18 weeks as second trimester of pregnancy is considered to be the safest for surgical intervention. Those who did not meet the criteria for surgical intervention were kept under close follow-up with monthly ultrasonogram.

For those who underwent surgical intervention, a fertility sparing staging including peritoneal washings cytology, thorough inspection and palpation of entire abdominal cavity, Unilateral Salphingo-oopherectomy, pelvic peritoneal biopsies and infracolic omentectomy was done. Use of “hands off the Uterus” technique was ensured for safe handling of the uterus to reduce the risk of miscarriage and preterm labour (7). Postoperatively patients received progesterone supplements and uterine tocolytics according to their gestational age.

The final histopathology and clinical outcomes were analysed. Those patients who were reported to have malignancies on histopathology were counselled regarding the options of continuation of pregnancy, need for chemotherapy during pregnancy, risks to the foetus, prognosis and probable stage of the disease, the need for completion surgery at the time of delivery, the need for further adjuvant chemotherapy and the risk of recurrence post delivery. Follow-up records of the cases were analysed with regards to recurrence and survival. The mean follow-up was 18 months. The institutional protocol deciphered through present study is as follows (Table/Fig 1).

Statistical Analysis

The Statistical Package for Social Science (SPSS) version 28.0 was used for statistical analysis.

Results

There were 33 patients with ovarian masses complicating pregnancy, 30 were diagnosed during pregnancy and the other three were incidentally diagnosed at caesarean section. The incidence of suspicious ovarian masses in pregnancy was found to be 1/929 deliveries (from 2018-2020), from 30,657 deliveries at our hospital. Furthermore, the incidence of ovarian carcinomas in pregnancy was found to be 1 in 5109 deliveries.

The mean age of the study group was 26.1±2.1 years (20-33 years). Mean time of diagnosis of ovarian tumour was 18.9 weeks (range 8 to 40 weeks of gestational age). In the patients diagnosed during pregnancy, 72.7% (24/33) of cases were asymptomatic. Ca125 levels were available for 30 cases. It was normal in all but one case, which was a case of metastatic ovarian cancer with primary in the stomach. The mean value of Ca125 in present study was 18.4±2.7 U/l. Alpha Feto Protein was available for 22 cases and it was elevated in one case of germ cell tumour.

Intervention was done in 18 out of 33 cases (54.55%) of which 17 underwent uterus preserving staging laparotomy. One patient was a case of advanced carcinoma stomach diagnosed at eight weeks underwent Medical Termination of Pregnancy followed by chemotherapy. Among the 17 laparotomies, 15 were elective and two were emergencies in view of suspected torsion. The most common period of intervention was the second trimester (mean gestational age at intervention 21.4±1.5 weeks) (Range 13-32 weeks). The characteristics of patients with ovarian mass during pregnancy were indicated in (Table/Fig 2).

Elective laparotomy was done between 16-18 weeks. However, 2 cases went in for emergency laparotomy, 1 at 12 weeks and another at 1 month postdelivery respectively in view of torsion.

Among the cases, decided for observation and follow-up (n=15) with monthly ultrasonogram, complete resolution of mass was observed in eight cases while significant regression in size was observed in five cases. These cases were followed upto six months postdelivery with serial ultrasound (Table/Fig 3).

Among 18 patients who underwent surgical intervention, 12 (70.58%) cases turned out to be benign, four being serous tumours, five mucinous, one case of endometriotic cyst, one case of mucinous cystadenoma arising in a dermoid cyst and one case of hyper reactio leutealis.

In spite of including only suspicious ovarian masses for evaluation, the final histopathology was still benign in 70.58% of cases (Table/Fig 4).

Six cases of ovarian malignancies were reported in present study, five of which were primary ovarian and one metastatic from stomach primary.

Of the five primary ovarian malignancies, 3 (60%) were epithelial carcinomas and 2 (40%) were germ cell tumours (Table/Fig 5). Of the epithelial ovarian carcinomas seen, one case of clear cell carcinoma, one case of primary mucinous ovarian carcinoma and one case of low grade serous carcinoma respectively. There was one case of yolk sac tumour and one case of immature teratoma as well. There was one case of krukenberg tumour with primary in the stomach. Of these six patients with ovarian malignancies, four received chemotherapy during pregnancy; one underwent termination of pregnancy at 12 weeks (metastatic ca stomach); and one was a case of recurrent immature teratoma diagnosed at the time of caesarean section. The intraoperative picture of clear cell carcinoma is shown in (Table/Fig 6). All four patients who had antenatal chemotherapy had full term delivery of healthy babies without any congenital malformations. Two patients (clear cell carcinoma and low grade serous carcinoma) underwent completion surgery in the form of hysterectomy and contralateral salphingoophorectomy at the time of delivery and the other two were kept under observation. Of the two patients who had fertility sparing treatment, the one with yolk sac tumour developed recurrence at 14 months after the first conservative surgery. She was treated with secondary cytoreduction and adjuvant second line chemotherapy. The patient with primary mucinous cystadenocarcinoma refused completion surgery at delivery and presented with recurrence at the para-aortic nodes four months postpartum. Since, she was platinum resistant, she was started on second line chemotherapy, but she unfortunately progressed and succumbed to the disease six months postpartum.

The krukenberg case and immature teratoma were lost to follow-up. However, the other three ovarian malignancies are currently under follow-up and are disease free.

Discussion

Detection of suspicious ovarian masses in pregnancy is usually incidental, often diagnosed by routine early pregnancy ultrasonogram. These patients however have the important advantage of being diagnosed at early stages of the disease, mostly stage 1 (8).

Functional cysts are the most common ovarian masses encountered in pregnancy (9). Follicular cysts and haemorrhagic cysts are also common in pregnancy. All these were excluded from present study as these are clear cut benign conditions. The other most commonly encountered cystic adnexal lesion was mature cystic teratoma (dermoid cyst). These lesions are benign with <2% malignant transformation rate into invasive carcinoma (10). Dermoid cysts have typical sonographic features which makes their diagnosis less doubtful. In present study, dermoid cysts with typical imaging findings were excluded. Therefore, only one case of mature cystic teratoma with mucinous differentiation was reported.

Endometrioma (chocolate cyst) can also occur in pregnancy with suspicious imaging findings and one such case has been reported in present study. Endometriomas can have altered appearance in imaging during pregnancy because of decidualised walls due to high levels of progesterone (11). A previous history of symptoms of endometriosis can be indicative. However, when the diagnosis remains uncertain further investigation is advised to rule out a malignant neoplasm.

Surgical management of an adnexal mass in pregnancy creates a dilemma to gynaecologists. Sometimes, it is difficult to discriminate ovarian malignancies from functional cysts or benign ovarian tumours. If an adnexal mass, larger than 10 cm or has complex features on imaging, or ascites or shows significant increase in size, surgical management is critical for obtaining a final histological diagnosis and ruling out malignancy. Elective surgery for suspicious ovarian masses should be delayed until the second trimester (16-18 weeks of gestation), as the risk for spontaneous abortion is comparatively low in this period of pregnancy. Also, in the first trimester, the rate of spontaneous abortion after surgery is around 10%, while 76.3% patients progress to full-term delivery. When a mass is first noticed in the third trimester, it is ideal to wait for foetal maturity as long as the clinical suspicion of malignancy is low (12). In present study also, all elective laparotomies (n=12) were performed between 16-18 weeks. Patients had no complications postoperatively and all pregnancies continued till term. One case of emergency laparotomy, performed at 30 weeks of gestation in view of torsion, subsequently went in for preterm delivery and the baby could not be salvaged in view of extreme prematurity.

The advantages of laparoscopy over laparotomy for benign masses are discussed increasingly, claiming that laparoscopy is superior with significantly lesser operative time, perioperative morbidity, length of hospital stay, and decreased postoperative pain resulting in faster postoperative ambulation (13),(14). However, in present study only laparotomy has been done in all cases requiring surgical intervention as all cases included were suspicious for malignancy.

The incidence of suspicious ovarian masses detected during pregnancy is 1/300 to 1/556 pregnancies. Of these, the incidence of ovarian malignancy is 1/15,000 to 1/32,000 in most reports (11). A higher incidence of ovarian malignancy in pregnancy of 1 in 1684 was reported by Ueda M and Ueki M but population selective bias could not be excluded in their study (15). In present study, detection of suspicious ovarian masses during pregnancy occurred in 1/929 deliveries that is around 33 cases out of 30,657 deliveries in two years (2018-2020) at our hospital. Furthermore, the incidence of ovarian cancers in pregnancy was found to be 1 in 5109 deliveries. This high incidence could be explained by the fact that our institute is a tertiary care and referral centre for gynaecological oncology cases again contributing to population selection bias.

The most common primary ovarian malignancies reported in pregnancy are germ cell tumours followed by borderline tumours and then epithelial ovarian cancers presumably due the younger age group involved (16).

Out of 33 patients in present study, 81.82% (n=27) were benign and 18.18% (n=6). In present study, the most common ovarian malignancies were epithelial followed by germ cell tumours. No case of borderline ovarian tumour was observed. This disparity may be due to the small sample size of present study. Most of the ovarian tumours in pregnancies are reportedly asymptomatic at presentation and diagnosed by routine ultrasound (17),(18). In present study too, 72.7% were asymptomatic at presentation.

Majority of reported ovarian cancers in pregnancy were identified in early stages (19),(20). However, in present study only one case (mucinous carcinoma) presented in an early stage (IC3). Others were all advanced. This may be attributed to the fact that epithelial ovarian cancers were the most common tumours seen in present study which inherently are known to present at advanced stages. Even the yolk sac tumour in present study series presented at an advanced disease of stage III C. Similar incidences of aggressive growth and recurrence of ovarian germ cell tumours in pregnancy have been previously reported (21),(22)

The management of advanced ovarian malignancy detected during pregnancy is controversial. Available evidence suggests that most women chose to terminate pregnancy in favour of treatment of the ovarian cancers. However, neoadjuvant chemotherapy for advanced epithelial ovarian cancer with paclitaxel and carboplatin in the second trimester of pregnancy has been described with completion surgery at the time of delivery (23),(24). In present study, there were four cases of advanced ovarian cancer where neoadjuvant chemotherapy was given during pregnancy. Three cases received carboplatin and paclitaxel doublet whereas one case received BEP chemotherapy since it was a germ cell tumour. All patients tolerated chemotherapy well and had no complications of chemotherapy and delivery was planned three weeks from the last dose.

Chemotherapy when administered in the first trimester can lead to congenital malformations at the rate of around 10-20%. Chemotherapy can be administered after 14 weeks of pregnancy with careful monitoring of the mother and foetus. However, there is an increased incidence of prematurity, low birth weight, intrauterine growth restriction and neonatal blood count reduction (25). Delivery should be planned atleast three weeks after the last cycle of chemotherapy in order to prevent myelosuppression and chemotherapy should not be given after 35 weeks as patient may enter spontaneous labour. In present study, no such complications were observed in all patients who received antenatal chemotherapy. All the four patients had term deliveries with normal birth weight. None of the babies had myelosuppression and are currently doing well. Breast feeding during chemotherapy is not encouraged (26). In present study too, breast feeding was withheld for all these patients since there were to be started on adjuvant chemotherapy. The long term health effects on children exposed to chemotherapeutic agents in utero remain unknown as there are no long term studies.

Termination of pregnancy is the treatment of choice for women presenting with advanced stage disease in early pregnancy warranting chemotherapeutic treatment. Hence, the case of carcinoma stomach with ovarian krukenberg tumour was offered termination of pregnancy followed by chemotherapy

The prognosis of ovarian cancers in pregnancies depends on the histological type and stage at presentation. Good outcomes have been reported for germ cell tumours and borderline ovarian tumours. However, epithelial ovarian malignancies have a poor outcome more so if identified at advanced stages. In a report of 23 ovarian cancers in pregnancy, all three cases of advanced epithelial ovarian cancers succumbed to the disease (27). In present study, one patient with mucinous ovarian cancer had an aggressive disease course and succumbed to the disease. The other two cases of advanced epithelial cancer and one case of advanced germ cell tumour are currently disease free.

The strength of the study lies in the fact that a multidisciplinary approach comprising the Gynaec Oncologist, Gynaecologist and Medical Oncologist was involved in the management of each of the cases.

Limitation(s)

However, small sample size and need for longer period of follow-up for the patients who were diagnosed with malignancy as well as the children born to mothers who were treated with antenatal chemotherapy could be considered the limitations of the study. It is further recommended that this study could be continued for a longer period of follow-up in order to draw better conclusions.

Conclusion

Each case of suspicious adnexal mass in pregnancy should be thoroughly evaluated, keeping in mind the risk of malignancy and treatment be tailored accordingly. Malignant appearing masses must be offered surgery. Chemotherapy can be offered in pregnancy after the first trimester and pregnancy can be continued with careful monitoring. However, malignant ovarian tumours in pregnancy must be taken care of by a multidisciplinary team consisting of Gynaecologists, Gynaecological Oncologists, Medical Oncologists and Paediatricians. Hence, these patients must be referred to centers with such facilities.

References

1.
de Haan J, Verheecke M, Amant F. Management of ovarian cysts and cancer in pregnancy. Facts Views Vis Obgyn. 2015;7(1):25-31.
2.
Grigoriadis C, Eleftheriades M, Panoskaltsis T, Bacanu AM, Vitoratos N, Kondi-Pafiti A, et al. Ovarian cancer diagnosed during pregnancy: Clinicopathological characteristics and management. G Chir. 2014;35(3-4):69-72.
3.
Cavaco-Gomes J, Jorge Moreira C, Rocha A, Mota R, Paiva V, Costa A. Investigation and management of adnexal masses in pregnancy. Scientifica (Cairo). 2016;2016:3012802. Doi: 10.1155/2016/3012802. [crossref] [PubMed]
4.
Makrydimas G, Sotiriadis A, Paraskevaidis E, Pavlidis N, Agnantis N, Lolis D. Clear cell ovarian carcinoma in a pregnant woman with a history of infertility, endometriosis and unsuccessful IVF treatment. Eur J Gynaecol Oncol. 2003;24(5):438-41.
5.
Hummeida ME, Hamad K, Gadir AF, Ali AA. Ovarian cancer during pregnancy: A case report and literature review. Clin Pract. 2015;5(2):727. [crossref] [PubMed]
6.
Garg S, Kaur A, Mohi JK, Sibia PK, Kaur N. Evaluation of IOTA simple ultrasound rules to distinguish benign and malignant ovarian tumours. J Clin Diagn Res. 2017;11(8):TC06-09. Doi: 10.7860 /JCDR /2017 /26790.10353.
7.
Giuntoli RL 2, Vang RS, Bristow RE. Evaluation and management of adnexal masses during pregnancy. Clin Obstet Gynaecol. 2006;49(3):492-505. [crossref] [PubMed]
8.
D'Ambrosio V, Brunelli R, Musacchio L, Del Negro V, Vena F, Boccuzzi G, et al. Adnexal masses in pregnancy: An updated review on diagnosis and treatment. Tumori. 2021;107(1):12-16. 2020.107.030089162090914. 10.1177/0300891620909144. [crossref] [PubMed]
9.
Drake J. Diagnosis and management of the adnexal mass. Am Fam Physician. 1998;57(10):2471-76, 2479-80.
10.
Galczyń ski K, Jóź wik M, Lewkowicz D, Semczuk-Sikora A, Semczuk A. Ovarian endometrioma- a possible finding in adolescent girls and young women: A mini-review. J Ovarian Res. 2019;12:104. 10.1186/s13048-019-0582-5. [crossref] [PubMed]
11.
Hakoun AM, Abou Al-Shaar I, Zaza KJ, Abou-Al-Shaar H, A Salloum MN. Adnexal masses in pregnancy: An updated review. Avicenna Med. 2017;7:153-57. [crossref] [PubMed]
12.
Webb KE, Sakhel K, Chauhan SP, Abuhamad AZ. Adnexal mass during pregnancy: A review. Am J Perinatol. 2015;32:1010. [crossref] [PubMed]
13.
Shigemi D, Aso S, Matsui H, Fushimi K, Yasunaga H. Safety of laparoscopic surgery for benign diseases during pregnancy: A nationwide retrospective cohort study. Journal of Minimally Invasive Gynaecology. 2019;26(3):501-06. [crossref] [PubMed]
14.
Kurihara K, Minagawa M, Masuda M, Fukuyama M, Tanigaki K, Yamamoto A, et al. The evaluation of laparoscopic surgery on pregnant patients with ovarian cysts and its effects on pregnancy over the past 5 years. Gynaecol Minim Invasive Ther. 2018;7(1):01-05. [crossref] [PubMed]
15.
Ueda M, Ueki M. Ovarian tumours associated with pregnancy. Int J Gynaecol Obstet. 1996;55:59-65. [crossref]
16.
Morice P, Uzan C, Gouy S, Verschraegen C, Haie-Meder C. Gynaecological cancers in pregnancy. Lancet. 2012;379:558-69. [crossref]
17.
Goff BA, Paley PJ, Koh WJ, et al. Cancer in the pregnant patient. In Principles and Practice of Gynaecologic Oncology 3rd edition. Edited by: Hoskins WJ, Perez CA, Young RC. Philadelphia: Lippincott Williams & Wilkins; 2000:501-28.
18.
Behtash N, Zarchi MK, Gilani MM, Ghaemmaghami F, Mousavi A, Ghotbizadeh F. Ovarian carcinoma associated with pregnancy: A clinicopathologic analysis of 23 cases and review of the literature. BMC Pregnancy Childbirth. 2008;8:3. [crossref] [PubMed]
19.
Zanotti KS, Belinson JL, Kennedy AW. Treatment of gynaecologic cancers in pregnancy. Semin Oncol. 2000;27:686-98.
20.
Partridge EE, Phillips JL, Menck HR. The National Cancer Data Base report on ovarian cancer treatment in United States hospitals. Cancer. 1996;78:2236-46. [crossref]
21.
Karlen JR, Akbari A, Cook WA. Dysgerminoma associated with pregnancy. Obstet Gynaecol. 1979;53:330-35.
22.
Gershenson DM. Management of early ovarian cancer: Germ cell and sex cord-stromal tumours. Gynaecol Oncol. 1994;55:S62-72. [crossref]
23.
Méndez LE, Mueller A, Salom E, González-Quintero VH. Paclitaxel and carboplatin chemotherapy administered during pregnancy for advanced epithelial ovarian cancer. Obstet Gynaecol. 2003;102(5 Pt 2):1200-02. [crossref]
24.
Doi D, Boh Y, Konishi H, Asakura H, Takeshita T. Combined chemotherapy with paclitaxel and carboplatin for mucinous cystadenocarcinoma of the ovary during pregnancy. Arch Gynaecol Obstet. 2009;280(4):633-36. Doi: 10.1007/s00404-009-0950-2. Epub 2009 Feb 11. [crossref] [PubMed]
25.
Dekrem J, Van Calsteren K, Amant F. Effects of fetal effects to maternal chemotherapy. Paediatr Drugs. 2013;15:329-34. [crossref] [PubMed]
26.
Weed JC, Roh RA, Mendenhall HW. Recurrent endodermal sinus tumour during pregnancy. Obstet Gynaecol. 1997;54:653-56.
27.
Motegi M, Takakura S, Takano H, Tanaka T, Ochiai K. Adjuvant chemotherapy in a pregnant woman with endodermal sinus tumour of the ovary. Obstet Gynaecol. 2007;109(2):537-40. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/47226.15873

Date of Submission: Oct 16, 2020
Date of Peer Review: Dec 18, 2021
Date of Acceptance: Nov 08, 2021
Date of Publishing: Jan 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 17, 2020
• Manual Googling: Oct 30, 2021
• iThenticate Software: Dec 15, 2021 (9%)

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