Ovarian tumors constitute a complex and heterogenous group of neoplasms arising from surface epithelium, germ cells, or sex cord-stromal elements [1]. Globally, ovarian cancer is the seventh most common malignancy among women and the fifth leading cause of cancer-related deaths [2]. In India, it ranks third among gynecological cancers after breast and cervical cancers [3].

The silent nature of ovarian malignancies often results in delayed diagnosis, with nearly 70% of cases identified at advanced stages (FIGO stage III/IV) [4]. Risk factors include nulliparity, advancing age, hormonal therapy, BRCA1/BRCA2 mutations, and a positive family history [5, 6]. Tumors are classified based on WHO histological subtypes into epithelial (serous, mucinous, endometrioid), germ cell (teratoma, dysgerminoma), and stromal tumors (granulosa, thecoma) [7].

Ultrasound, especially with O-RADS scoring, is pivotal in early evaluation. While CA-125 is a widely used tumor marker, its diagnostic accuracy is limited by low specificity [8]. Studies show that integrating radiologic and biochemical markers with histopathology improves early detection and classification [9, 10].

This study aims to correlate histopathological diagnoses of ovarian tumors with clinical and sonological findings, including CA-125 levels and O-RADS scoring.

This observational study included 50 female patients diagnosed with ovarian tumors at Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, between June 2022 and December 2024. Ethical approval was obtained from the institutional ethics committee.

Inclusion Criteria:

• Patients with sonologically identified ovarian masses.
• Availability of clinical, biochemical, and histopathological records.
• Surgical specimens confirmed by histopathology.

Exclusion Criteria:

• Non-neoplastic ovarian lesions.
• Incomplete records or loss to follow-up.

Data Collection:

Clinical symptoms (pain, mass per abdomen, menstrual irregularities), parity, age, CA-125 levels, and ultrasound reports were noted. O-RADS scoring (0–5) was used for risk stratification. All resected specimens underwent histopathological examination with H&E staining.

Ultrasound Parameters:

Features analyzed included size, laterality, contour, septa, echogenicity, papillary projections, and Doppler flow.

Statistical Analysis:

SPSS v26 was used. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Chi-square and Fisher’s exact tests were used for categorical variables. A p-value < 0.05 was considered statistically significant.

Among the 50 patients studied, a majority of ovarian tumors were benign (n = 32, 64%), followed by malignant (n = 13, 26%) and borderline tumors (n = 5, 10%). The mean age of presentation was 34.5 ± 9.8 years in patients with benign tumors, whereas those with malignant tumors had a higher mean age of 43.7 ± 5.4 years, indicating a tendency for malignancies to occur in older age groups. Notably, nulliparity was observed in 38.5% (5 out of 13) of the malignant tumor cases, suggesting a potential association between nulliparity and ovarian malignancy.

The most frequently diagnosed histological subtype was serous cystadenoma, accounting for 30% (15 cases) of the total. This was followed by mucinous cystadenoma (18%, 9 cases) and mature cystic teratoma (12%, 6 cases). Among malignant neoplasms, high-grade serous carcinoma was the most prevalent subtype (10%, 5 cases). Granulosa cell tumors represented 4% (2 cases), while mucinous borderline tumors constituted 6% (3 cases). The detailed distribution is presented in Table 1.

Table 1: Histopathological Distribution of Ovarian Tumors (n = 50)

Ultrasound findings were classified using the O-RADS (Ovarian-Adnexal Reporting and Data System) scoring system. A total of 24 patients (48%) were categorized as O-RADS 1–2, indicative of low risk for malignancy. Eight patients (16%) were categorized as O-RADS 3, and 18 patients (36%) were categorized as O-RADS 4–5, suggesting higher malignancy risk.

A statistically significant correlation was observed between higher O-RADS scores and histopathologically confirmed malignancy (p = 0.003). Among the 13 malignant cases, 12 (92.3%) had O-RADS scores of 4–5. In contrast, the majority of benign tumors (65.6%) were classified as O-RADS 1–2.

Table 2: Correlation of O-RADS Score with Histopathological Diagnosis

*p-value = 0.003

Serum CA-125 was elevated (>35 IU/ml) in 10 of the 13 malignant tumor cases (76.9%), compared to only 3 of 32 benign cases (9.3%). Among borderline tumors, CA-125 was elevated in 2 of 5 cases (40%). Based on these findings, the sensitivity of CA-125 for detecting malignant tumors was 76.9%, while specificity was 90.7%, confirming its limited role as a standalone diagnostic marker.

Table 3: Distribution of Elevated CA-125 Levels Across Tumor Categories

On ultrasonography, features such as thick septa, papillary projections, and solid components were significantly more common in malignant tumors. Specifically, 84.6% of the malignant tumors exhibited solid areas or thick septations. However, the morphological scoring system demonstrated high specificity (82.86%) but relatively low sensitivity (20%) for detecting malignancy, underscoring its role as a supportive diagnostic tool rather than a definitive one.

Table 4: Diagnostic Accuracy of Morphological Ultrasound Scoring

A comparative analysis of O-RADS score, CA-125 levels, and morphological ultrasound features indicates that combining these parameters improves preoperative suspicion for malignancy. However, histopathological examination remains essential for definitive diagnosis.

In the present study, benign ovarian tumors constituted the majority of cases, accounting for 64% of the total sample. This finding is consistent with existing literature, where benign tumors have been shown to predominate among ovarian neoplasms in clinical practice, particularly among women in reproductive age groups [5]. Among the benign subtypes, serous cystadenoma emerged as the most frequently encountered tumor, representing 30% of all cases. This is in line with reports identifying it as the most common surface epithelial tumor due to its simple cystic structure and early detection through imaging techniques [6].

Among malignant tumors, high-grade serous carcinoma was the most common subtype, representing 10% of all tumors in this study. This trend reflects the global predominance of this entity among epithelial ovarian cancers, where it accounts for the majority of ovarian malignancies due to its aggressive behavior and advanced-stage presentation at diagnosis [7]. Additionally, the mean age of patients with malignant tumors (43.7 years) was notably higher than those with benign lesions (34.5 years), reinforcing the established association between advancing age and increased risk of ovarian malignancy [8].

Sonological features proved instrumental in the preoperative evaluation of ovarian tumors. Parameters such as the presence of solid components, thick septa, and papillary projections were found to be significantly associated with malignancy. These ultrasonographic markers have been validated in prior studies for their strong predictive value in distinguishing between benign and malignant ovarian masses [9]. In the current study, 84.6% of the malignant tumors exhibited these features, highlighting their clinical relevance.

The implementation of the O-RADS (Ovarian-Adnexal Reporting and Data System) scoring system further enhanced diagnostic accuracy. A substantial proportion of histopathologically confirmed malignancies (92.3%) were categorized under O-RADS 4–5, demonstrating a statistically significant correlation between higher O-RADS scores and malignant histology (p = 0.003). This underscores the value of structured reporting systems in improving the standardization and reliability of ultrasonographic assessments [10].

Serum CA-125 levels were also evaluated as part of the diagnostic workup. Elevated CA-125 was observed in 76.9% of malignant cases, indicating a high sensitivity for malignancy. However, the specificity was limited by false-positive elevations seen in benign and borderline lesions, including cases of endometriosis and inflammatory conditions. This limitation reduces its utility as a standalone diagnostic tool, necessitating its use in conjunction with imaging modalities [11].

Despite these adjunctive diagnostic strategies, histopathological examination remains the gold standard for definitive diagnosis. It not only confirms the nature of the tumor but also provides critical information for further therapeutic planning, including tumor grade and subtype. The integration of imaging features, serum biomarkers, and histopathological correlation presents a comprehensive approach that enhances diagnostic precision and facilitates early intervention [12–15].

Ovarian tumors exhibit diverse clinical and pathological profiles. While sonological and biochemical tools aid in early identification, histopathology remains indispensable for definitive diagnosis. Combining O-RADS scoring and CA-125 enhances diagnostic precision. Early detection through multimodal evaluation can significantly improve patient outcomes.

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