Abstract
This study aims to analyze the clinical characteristics and discuss appropriate surgical strategy of ovarian fibroma/fibrothecoma in premenopausal women. A review of the patients’ medical records was undertaken at Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, from January 2015 to December 2023. Altogether, 286 cases were identified. The mean age was 47.73 years (14–89 years) and premenopausal women accounted for 51.40% (147/286). The proportion of patients appeared similar across all age decades from 21 to 70. Of these patients, 204 (71.33%) underwent surgeries due to the presence of a pelvic mass with a mean diameter of 6.25 cm (1.2–37 cm). The tumor size in premenopausal women (n = 81) was significantly smaller than that in postmenopausal women (n = 123; 4.78 cm vs 7.21 cm). Of these 81 premenopausal patients, 66 (81.48%) women underwent laparoscopy and 15 (18.52%) underwent laparotomy. The tumor size in the laparotomy group was significantly larger than that in the laparoscopy group (7.89 cm vs 4.08 cm). Tumorectomy and unilateral salpingo-oophorectomy served as the main surgical approaches in the laparoscopy and laparotomy group, respectively. Besides, 82 patients were diagnosed incidentally with a mean age of 36.82 years and an average diameter of 0.76 cm (0.2–2.3 cm), among which 66 (80.49%) were premenopausal and 85.37% lesions were on the ovarian surface. All premenopausal patients were alive with no recurrence after surgery. Ovarian fibroma/fibrothecoma may occur at an earlier age than conventionally estimated. Laparoscopic tumorectomy remains the preferred surgery for patients at reproductive age. A thorough and meticulous intraoperative examination is essential to identify and remove the early-stage lesion on the ovarian surface.
Keywords: clinical characteristic, laparoscopy, ovarian fibroma/fibrothecoma, premenopausal women, tumorectomy
1. Introduction
As the most common benign solid tumor of the ovary, ovarian fibroma/fibrothecoma is classified as sex cord-stromal tumors, accounting for approximately 1% to 4% of all ovarian tumors, and including 3 pathological subtypes (fibroma, thecoma, and fibrothecoma).[1–3] Fibroma is composed of spindle-shaped fibroblastic cells with abundant cytoplasm. Occasionally, lipid-laden theca cells may be seen in the neoplasm, which is then called fibrothecoma. When the predominant cells are round to oval, resembling theca cells, it is classified as thecoma.[4]
Most of ovarian fibroma/fibrothecoma are asymptomatic and often detected incidentally by routine pelvic examination, ultrasound, computed tomography, and magnetic resonance imaging.[2,3] In general, ovarian fibroma/fibrothecoma often occurs in older perimenopausal and postmenopausal women.[3,5,6] The average age at diagnosis is 48 years.[2,7]
With respect to the solid nature, surgery remains the preferred treatment option. Several studies have reported the surgical treatment for premenopausal patients. However, the sample sizes were limited, ranging from 22 to 73 cases.[5,8–10] Owing to the infrequency of this tumor in premenopausal women, studies with restricted sample sizes might not reflect the reality. Therefore, the aim of this study was to analyze the clinical characteristics of ovarian fibroma/fibrothecoma in premenopausal women with the largest number to provide some new information about this tumor, and to discuss the appropriate management options.
2. Materials and methods
In the retrospective study, a review was undertaken of the medical records of patients who underwent primary surgery and pathologically diagnosed as ovarian fibroma/fibrothecoma at the Department of Obstetrics and Gynecology of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China, from January 2015 to December 2023. The hospital ethics committee approved this retrospective study (approval number: 2024-2698-01). The study was performed in accordance with the Declaration of Helsinki. Informed consent was obtained from all patients during a follow-up phone call.
Demographic, clinical, ultrasonic, laboratory and surgical data were extracted from electronic medical records. Demographic data, including age, gravidity, parity, body mass index, and menopausal status were analyzed. Color Doppler ultrasound was performed preoperatively in all patients to image pelvic lesions and surrounding structures. The tumor size, location, sonographic characteristics, and the presence of associated ascites and hydrothorax were recorded by ultrasonography. Serum cancer antigen 125 (CA125) level was examined preoperatively and the level of 35 U/mL or above was defined as elevated.
The definitive diagnosis depends on the histopathology and immunohistochemistry analysis. The distinction of these tumors relies mainly on the histological appearance. Positive results of several immunohistochemical markers, such as vimentin, WT1 and α-inhibin, calretinin, contribute to confirm the histological impression of fibroma and thecoma, respectively (Figs. 1–3).[11] All histopathologic evaluations were performed by experienced pathologists from the Pathology Department.
Figure 1.
Fibroma. (A) H&E. (B) Diffuse expression of vimentin. (C) Negative expression of α-inhibin. (A–C) From the same case. H&E indicates hematoxylin and eosin.
Figure 3.
Thecoma. (A) H&E. (B) Expression of α-inhibin. (C) Expression of calretinin. (A–C) From the same case. H&E indicates hematoxylin and eosin.
Figure 2.
Fibrothecoma. (A) H&E. (B) Diffuse expression of WT1. (C) Patchy expression of α-inhibin. (A–C) From the same case. H&E indicates hematoxylin and eosin.
SPSS version 23.0 (SPSS Inc, Chicago) was used for all analyses. The Student t test was used for comparison of continuous data. The chi-square or Fisher exact test was used for comparison of categorical data. A two-sided P value of <.05 was considered to be statistically significant.
3. Results
During the study period, a total of 286 cases of ovarian fibroma/fibrothecoma were diagnosed, including 224 (78.32%) fibromas, 56 (19.58%) fibrothecomas and 6 (2.10%) thecomas. Of these patients, 204 (71.33%) underwent surgeries due to the presence of a pelvic mass. Besides, 82 (28.67%) patients were diagnosed incidentally, including 70 (85.37%) cases of intraoperative finding and 12 (14.63%) cases of postoperative finding, among whom the surgical indications included ovarian mass (71, 86.58%), infertility (9, 10.98%), and uterine myoma (2, 2.44%).
The mean age was 47.73 years (14–89 years) and premenopausal patients accounted for 51.40% (147/286). The age distribution is summarized in Table 1. Symptoms were observed in 32 women, including 24 cases of abdominal pain or discomfort, 3 cases of palpable abdominal mass, 2 cases of abnormal vaginal bleeding, and 3 cases of irregular menstruation cycle. Moreover, 91.67% (22/24) patients with abdominal pain or discomfort had a tumor larger than 5 cm (11.77 cm, 5.2–37 cm).
Table 1.
The age distribution of patients with ovarian fibroma/fibrothecoma.
| Age, yrs | Patients with preoperative diagnosis of pelvic mass (n = 204) |
Cumulative percentage | Patients with unexpected fibroma/fibrothecoma (n = 82) |
Cumulative percentage | All patients with ovarian fibroma/fibrothecoma (n = 286) | Cumulative percentage |
|---|---|---|---|---|---|---|
| 11–20 | 2 (0.98%) | 0.98% | 3 (3.66%) | 3.66% | 5 (1.75%) | 1.75% |
| 21–30 | 20 (9.80%) | 10.78% | 30 (36.59%) | 40.24% | 50 (17.48%) | 19.23% |
| 31–40 | 30 (14.71%) | 25.49% | 24 (29.27%) | 69.51% | 54 (18.88%) | 38.11% |
| 41–50 | 31 (15.20%) | 40.69% | 10 (12.20%) | 81.71% | 41 (14.34%) | 52.45% |
| 51–60 | 58 (28.43%) | 69.12% | 6 (7.32%) | 89.02% | 64 (22.38%) | 74.83% |
| 61–70 | 45 (22.06%) | 91.18% | 4 (4.87%) | 93.90% | 49 (17.13%) | 91.96% |
| 71–80 | 13 (6.37%) | 97.55% | 5 (6.10%) | 100% | 18 (6.29%) | 98.25% |
| 81–90 | 5 (2.45%) | 100% | 0 (%) | 100% | 5 (1.75%) | 100% |
In patients with preoperative diagnosis of pelvic mass, the mean diameter was 6.25 cm (1.2–37 cm). The tumor size in premenopausal women (n = 81) was significantly smaller than that in postmenopausal women (n = 123; 4.78 cm vs 7.21 cm, P < .01). Ovarian torsion was observed in 12 (5.88%) patients, including 2 premenopausal and 10 postmenopausal women. The incidence in pre and postmenopausal women was 2.47% (2/81) and 8.13% (10/123), respectively (P = .13). The average diameter of tumor in patients with and without ovarian torsion was 9.53 cm and 6.04 cm (P = .64). The clinical characteristics of premenopausal and postmenopausal patients with preoperative diagnosis of pelvic mass is summarized in Table 2.
Table 2.
The clinical characteristics of patients with preoperative diagnosis of pelvic mass.
| Premenopausal patients (n = 81) | Postmenopausal patients (n = 123) | P value | |
|---|---|---|---|
| Age, yrs | 36.77 ± 8.63 (17–52) | 62.24 ± 8.60 (47–89) | <.001 |
| Gravidity | 1.99 ± 1.71 (0–8) | 2.84 ± 1.33 (0–9) | <.001 |
| Parity | 0.93 ± 0.72 (0–2) | 1.57 ± 0.79 (0–4) | <.001 |
| Body mass index, kg/m2 | 22.22 ± 3.30 | 23.21 ± 3.62 | .051 |
| Symptomatic patients | 8 (9.88%) | 24 (19.51%) | .077 |
| Diameter of tumor, cm | 4.78 ± 2.72 (1.2–13.9) | 7.21 ± 5.69 (1.4–37) | <.001 |
| Location | |||
| Left | 44 (54.32%) | 55 (44.72%) | .10 |
| Right | 37 (45.68%) | 63 (51.22%) | |
| Bilateral | 0 | 5 (4.06%) | |
| Echogenicity of tumor | |||
| Hypoechoic | 75 (92.59%) | 99 (80.49%) | .027 |
| Mixed echoic | 5 (6.17%) | 22 (17.89%) | |
| Anechoic | 1 (1.23%) | 2 (1.63%) | |
| Acoustic attenuation | 27 (33.33%) | 34 (27.64%) | .44 |
| Doppler flow signal | |||
| None | 37 (45.68%) | 61 (49.59%) | .64 |
| Minimal | 29 (35.80%) | 38 (30.89%) | |
| Moderate | 11 (13.58%) | 21 (17.07%) | |
| Abundant | 4 (4.94%) | 3 (2.44%) | |
| Ascites | 5 (6.17%) | 21 (17.07%) | .03 |
| Meigs syndrome | 1 (1.23%) | 4 (3.25%) | .65 |
| Surgical approach | |||
| Laparoscopic surgery | 66 (81.48%) | 81 (65.85%) | .017 |
| Transabdominal surgery | 15 (18.52%) | 42 (34.15%) | |
| Surgical procedures | |||
| Tumorectomy | 53 (65.43%) | 1 (0.81%) | <.001 |
| USO | 26 (32.10%) | 7 (5.69%) | |
| BSO | 2 (2.47%)* | 115 (93.50%) | |
| Hysterectomy | 2 (2.47%) | 50 (40.65%) | <.001 |
| TAH | 1 | 23 | |
| TLH | 1 | 27 |
BSO = bilateral salpingo-oophorectomy, TAH = total abdominal hysterectomy, TLH = total laparoscopic hysterectomy, USO = unilateral salpingo-oophorectomy.
One patient was 47 years old and had a surgical history of breast cancer. She requested TLH + BSO, which would be helpful for breast cancer treatment. Another patient was 47 years old with a large (10 cm) solid ovarian tumor, and underwent TAH + BSO due to the patient’s concern about future malignancy and secondary surgery.
Of these 81 patients, 66 (81.48%) premenopausal women underwent laparoscopy and 15 (18.52%) underwent laparotomy. The tumor size in the laparotomy group was significantly larger than that in the laparoscopy group (7.89 cm vs 4.08 cm). A moderate or abundant Doppler blood flow signal within or around the tumor was more frequently observed in the laparotomy group. Meanwhile, the laparotomy group demonstrated a significantly higher prevalence of both ascites and elevated CA125 level compared to the laparoscopy group. Tumorectomy and unilateral salpingo-oophorectomy (USO) served as the main surgical approaches in the laparoscopy and laparotomy group, respectively. The laparoscopy group showed significantly less intraoperative bleeding and shorter hospital stay than the laparotomy group (22.50 mL vs 50.00 mL, 3.31 day vs 5.33 day). In addition, conversions to laparotomy or perioperative complications were not observed. After a mean follow-up of 51.10 months (12–117 months), patients were all alive with no disease recurrence after tumorectomy. The clinical characteristics of premenopausal patients with laparoscopic and laparotomic surgery after preoperative diagnosis of pelvic mass is summarized and illustrated in Table 3.
Table 3.
The clinical characteristics of premenopausal patients with laparoscopic and laparotomic surgery after preoperative diagnosis of pelvic mass.
| Laparoscopy group (n = 66) | Laparotomy group (n = 15) |
P value | |
|---|---|---|---|
| Age, yrs | 36.58 ± 8.27 | 37.60 ± 10.34 | .11 |
| Gravidity | 1.97 ± 1.75 | 2.07 ± 1.53 | .49 |
| Parity | 0.88 ± 0.67 | 1.13 ± 0.92 | .014 |
| Body mass index, kg/m2 | 22.31 ± 3.48 | 21.86 ± 2.41 | .73 |
| Symptomatic patients | 3 (4.55%) | 5 (33.33%) | .005 |
| Diameter of tumor, cm | 4.08 ± 1.89 (1.2–11.2) | 7.89 ± 3.62 (4–13.9) | <.001 |
| Location | |||
| Left | 36 (54.55%) | 8 (53.33%) | .58 |
| Right | 30 (45.45%) | 7 (46.67%) | |
| Echogenicity of tumor | |||
| Hypoechoic | 61 (92.42%) | 14 (93.33%) | .62 |
| Mixed echoic | 4 (6.06%) | 1 (6.67%) | |
| Anechoic | 1 (1.52%) | 0 | |
| Acoustic attenuation | 23 (34.85%) | 4 (26.67%) | .76 |
| Doppler flow signal | |||
| None | 34 (51.52%) | 3 (20.00%) | <.001 |
| Minimal | 24 (36.36%) | 5 (33.33%) | |
| Moderate | 8 (12.12%) | 3 (20.00%) | |
| Abundant | 0 | 4 (26.67%) | |
| Ascites | 1 (1.52%) | 4 (26.67%) | .004 |
| Meigs syndrome | 0 | 1 (6.67%) | .19 |
| Elevated serum CA125 | 4 (6.06%) | 8 (53.33%) | <.001 |
| Surgical procedures | |||
| Tumorectomy | 48 (72.73%) | 5 (33.33%) | .01 |
| USO | 17 (25.75%) | 9 (60.00%) | |
| BSO | 1 (1.52%) | 1 (6.67%) | |
| Operating time, min | 87.62 ± 34.63 | 115.67 ± 42.08 | .59 |
| Intraoperative bleeding, mL | 22.50 ± 27.43 | 50.00 ± 50.82 | .014 |
| Hospital stay, d | 3.31 ± 1.21 (1–7) | 5.33 ± 1.68 (3–9) | .024 |
BSO = bilateral salpingo-oophorectomy, CA125 = cancer antigen 125, USO = unilateral salpingo-oophorectomy.
Among patients with unexpected ovarian fibroma/fibrothecoma, the mean tumor diameter was 0.76 cm (0.2–2.3 cm) and 85.37% (70/82) lesions were on the ovarian surface. Premenopausal women accounted for 80.49% (66/82) and all underwent tumorectomy due to the tumor on the surface. After a mean follow-up of 43.24 months (12–109 months), patients were all alive with no recurrence after tumorectomy. The clinical characteristics of all premenopausal patients is shown in Table 4. Other information of patients with preoperative diagnosis of pelvic mass and unexpected fibroma/fibrothecoma is summarized in the Table, Supplemental Content 1, Supplemental Digital Content, https://links.lww.com/MD/Q56.
Table 4.
The clinical characteristics of premenopausal patients with preoperative diagnosis of pelvic mass and unexpected fibroma/fibrothecoma.
| Premenopausal patients with preoperative diagnosis of pelvic mass (n = 81) | Premenopausal patients with unexpected fibroma/fibrothecoma (n = 66) | P value | |
|---|---|---|---|
| Age, yrs | 36.77 ± 8.63 (17–52) | 30.50 ± 7.68 (14–49) | .067 |
| Gravidity | 1.99 ± 1.71 (0–8) | 1.18 ± 1.36 (0–5) | .187 |
| Parity | 0.93 ± 0.72 (0–2) | 0.64 ± 0.89 (0–3) | .009 |
| Body mass index, kg/m2 | 22.22 ± 3.30 | 22.17 ± 3.15 | .75 |
| Diameter of tumor, cm | 4.78 ± 2.72 (1.2–13.9) | 0.69 ± 0.44 (0.2–2.3) | <.001 |
| Location | |||
| Left | 44 (54.32%) | 38 (57.58%) | .13 |
| Right | 37 (45.68%) | 25 (37.88%) | |
| Bilateral | 0 | 3 (4.54%) | |
| Gross morphology | |||
| Calcification | 3 (3.70%) | 0 | .253 |
| Cystic change | 10 (12.35%) | 0 | .002 |
| Hemorrhage | 1 (1.23%) | 0 | >.99 |
| Firmness | |||
| Hard | 65 (80.25%) | 59 (89.39%) | |
| Moderate | 14 (17.28%) | 7 (10.61%) | .21 |
| Soft | 2 (2.47%) | 0 | |
| Color | |||
| White | 67 (82.72%) | 63 (95.45%) | .019 |
| Light yellow/yellow | 14 (17.28%) | 3 (4.55%) | |
| Surgical procedures | |||
| Tumorectomy | 53 (65.43%) | 66 (100.00%) | <.001 |
| USO | 26 (32.10.%) | 0 | |
| BSO | 2 (2.47%) | 0 |
BSO = bilateral salpingo-oophorectomy, USO = unilateral salpingo-oophorectomy.
4. Discussion
Ovarian fibroma/fibrothecoma is the most common benign solid tumor of the ovary. To the best of our knowledge, this is the largest report describing the clinical characteristics of ovarian fibroma/fibrothecoma in premenopausal women, which may provide information for further studies.
Previous studies have suggested that ovarian fibroma/fibrothecoma often occurs in older perimenopausal and postmenopausal women.[3,5,6] In agreement with previous reports, we found that the average age of patients with preoperative diagnosis of pelvic mass was 52.12 years (17–89 years). Among these patients, 24.5% women were 21 to 40 years old and 65% were 41 to 70 years old. In contrast, the average age of patients with unexpected fibroma/fibrothecoma was 36.82 years (14–75 years), significantly younger than that of patients with preoperative diagnosis. Meanwhile, approximately 65% patients with unexpected tumor were between 21 and 40 years old. When combining these 2 groups of patients, the proportion of patients appeared similar across all age decades from 21 to 70, and approximately half of patients aged 50 years or younger, which suggested that the ovarian fibroma/fibrothecoma might occur at a younger age than previously believed. Cho et al reported that, of 97 patients with fibroma/fibrothecoma, 49.5% were < 40 years old.[10]
Among those with unexpected ovarian fibroma/fibrothecoma, 80.49% were premenopausal and 85.37% lesions were on the ovarian surface. The average diameter of tumor was 0.76 cm. When it is small, the tumor is inconspicuous and presents a challenge in differentiation from the surrounding normal tissue intraoperatively. Therefore, the real incidence is probably underestimated in premenopausal women. A thorough and meticulous intraoperative examination of the pelvic cavity is essential to identify and remove the mass on the ovarian surface.
Most of ovarian fibroma/fibrothecoma are asymptomatic and often detected incidentally by routine pelvic examination, ultrasound (Fig. 4), computed tomography and magnetic resonance imaging (Fig. 5).[2,3] Ultrasound is a preferred initial imaging modality for women with pelvic mass. Although some of them contained cystic areas, the major of ovarian fibroma/fibrothecoma were completely solid.[3] Paladini et al reported that cystic-solid lesions were observed in about 20% to 22% patients with fibroma/fibrothecoma.[3] In current study, cystic-solid mass was significantly more common in postmenopausal women than in premenopausal women (17.89% vs 6.17%). Meanwhile, the tumor size in postmenopausal women was significantly larger than that in premenopausal women. With the growth of tumor, cystic degeneration and internal hemorrhage may occur and induce corresponding ultrasonographic appearance.
Figure 4.
Grayscale transvaginal ultrasound shows oval solid tumors with regular internal echogenicity and acoustic attenuation, (A) fibrothecoma; (B) fibroma.
Figure 5.
A 17-year-old female patient with left ovarian fibrothecoma. T2-weighted MR images show a solid mass (M) with low signal intensity. Abutting and normal-appearing ipsilateral left ovary (O) is noted.
Ovarian torsion is one of the common complications caused by ovarian tumors, which requires urgent exploratory surgery.[12,13] However, it is difficult to quote an incidence for this acute complication in ovarian fibroma/fibrothecoma, as they are rare and most are described as cases or small series in the literature.[3,14–16] In our study, the overall incidence of ovarian torsion was 5.88% (12/204), which was in accordance with the previous studies of Paladini et al and Son et al.[3,8] Large size is one of the risk factors associated with ovarian torsion, especially those larger than 5 cm.[17–20] In current study, the tumor size in postmenopausal women was significantly larger than that in premenopausal women (7.21 cm vs 4.78 cm), which might increase the risk of ovarian torsion in postmenopausal women. Although without significant difference, the incidence of ovarian torsion in premenopausal women was lower than that in postmenopausal women (2.47% vs 8.13%).
A correct preoperative diagnosis is usually difficult because of its infrequency and solid nature. Color Doppler sonography facilitates differentiating ovarian tumor from subserosal leiomyoma. A well-vascularized solid pelvic mass with high-speed flow is suggestive of subserosal leiomyoma, while a less vascularized mass with low-speed flow indicates ovarian tumor.[21] Due to the solid nature of the mass, the associated hydrothorax/ascites and elevated levels of CA125, fibromas/fibrothecomas are often misdiagnosed as ovarian malignancy before surgery. Therefore, carefully intraoperative evaluation and frozen section should be considered before more radical surgery, especially in young patients.
There are 2 clinical associations worth mentioning. The 1st association is called Meigs syndrome (ovarian fibroma/fibrothecoma, hydrothorax/pleural effusion, and ascites), which is observed in 1% to 10% of ovarian fibromas/fibrothecomas.[22] In current study, only one was reported in premenopausal patients. The 2nd is called Gorlin-Goltz syndrome or basal cell nevus syndrome (bilateral ovarian fibromas/fibrothecomas, multiple basal cell carcinomas of the skin, odontogenic keratocysts, and other abnormalities), which is an autosomal dominant disorder that occurs usually in women aged younger than 30 years.[23–25] In our series, no endocrine manifestations, no cutaneous lesions, and no Gorlin-Goltz syndrome had been observed.
With respect to the solid structure, surgery is the treatment of choice, even for tumors smaller than 3 cm. The surgical treatment is different between premenopausal and postmenopausal patients. In general, the prognosis of ovarian fibroma/fibrothecoma is presumed to be good.[2,3,9,26] With the recent trend of postponement of childbearing age and high requirement of postoperative quality of life, there has been an increased demand for ovarian-sparing surgery to conserve fertility and ovarian function. For patients with conception requirement or at reproductive age, tumorectomy remains the preferred surgery. Meanwhile, USO can be considered for perimenopausal women, and bilateral salpingo-oophorectomy is preferred for postmenopausal women. In current study, USO and bilateral salpingo-oophorectomy were performed in 7 (5.69%) and 115 (93.50%) postmenopausal patients, respectively. Cho et al reported that tumorectomy was performed in 54.79% (40/73) premenopausal patients, among whom 90% cases underwent laparoscopy.[10] In our study, tumorectomy was performed in 53 (65.43%) premenopausal patients with preoperative diagnosis, including 48 (90.57%) cases of laparoscopy and 5 (9.43%) cases of laparotomy. After a mean follow-up of 51.10 months, patients were all alive with no recurrence. In addition, 66 premenopausal patients were diagnosed with unexpected ovarian fibroma/fibrothecoma intraoperatively, and all underwent tumorectomy, among whom recurrence was not observed after a mean follow-up of 43.24 months.
In the present study, among premenopausal women, the tumor size in the laparotomy group was significantly larger than that in the laparoscopy group, meanwhile, a moderate or abundant blood flow signal, the presence of ascites and elevated CA125 were significantly more common in the laparotomy group, which might lead to the difficulty in preoperative differential diagnosis of malignancy and result in the choice of laparotomy for such patients.
On the other hand, 66 (81.48%) premenopausal patients underwent laparoscopy with significantly less intraoperative bleeding and shorter hospital stay. Conversions to laparotomy or perioperative complications were not observed. Compared to laparotomy, laparoscopy is considered as a minimally invasive and feasible alternative, resulting in less operation time, smaller intraoperative bleeding, reduced postoperative pain, shorter recovery time and a smaller scar.[8–10,27,28]
There are several limitations in our study. First, the major limitation is the retrospective nature of the clinical data. Second, sample size was limited and all patients came from 1 medical center. Third, medical data was analyzed without blind fashion.
In conclusion, ovarian fibroma/fibrothecoma may occur at an earlier age than conventionally estimated. The overall incidence of ovarian torsion is low in premenopausal women. Laparoscopic tumorectomy remains the preferred surgery for patients with conception requirement or at reproductive age. A thorough and meticulous intraoperative examination is essential to identify and remove the early-stage lesion on the ovarian surface.
Author contributions
Conceptualization: Jiaren Zhang, Jianmin Chen.
Data curation: Jiaren Zhang, Rong Zhu, Yana Ma.
Formal analysis: Jiaren Zhang, Rong Zhu, Yana Ma.
Funding acquisition: Jiaren Zhang.
Project administration: Jiaren Zhang, Rong Zhu, Yana Ma.
Writing – original draft: Jiaren Zhang.
Writing – review & editing: Jianmin Chen.
Supplementary Material
Abbreviations:
- CA125
- cancer antigen 125
- USO
- unilateral salpingo-oophorectomy
JZ is currently receiving a grant (No. LQ20H040011) from Zhejiang Provincial Natural Science Foundation of China, and a grant (2021KY181) from Zhejiang Province Medical Science and Technology Plan Project.
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Supplemental Digital Content is available for this article.
How to cite this article: Zhang J, Zhu R, Ma Y, Chen J. The clinical characteristics and surgical management experience of ovarian fibroma/fibrothecoma in premenopausal women. Medicine 2025;104:38(e44615).
Contributor Information
Jiaren Zhang, Email: 3316027@zju.edu.cn.
Yana Ma, Email: 22118417@zju.edu.cn.
References
- [1].Numanoglu C, Kuru O, Sakinci M, Akbayir O, Ulker V. Ovarian fibroma/fibrothecoma: retrospective cohort study shows limited value of risk of malignancy index score. Aust N Z J Obstet Gynaecol. 2013;53:287–92. [DOI] [PubMed] [Google Scholar]
- [2].Sivanesaratnam V, Dutta R, Jayalakshmi P. Ovarian fibroma–clinical and histopathological characteristics. Int J Gynaecol Obstet. 1990;33:243–7. [DOI] [PubMed] [Google Scholar]
- [3].Paladini D, Testa A, Holsbeke C, Mancari R, Timmerman D, Valentin L. Imaging in gynecological disease (5): clinical and ultrasound characteristics in fibroma and fibrothecoma of the ovary. Ultrasound Obstet Gynecol. 2009;34:188–95. [DOI] [PubMed] [Google Scholar]
- [4].Chechia A, Attia L, Temime RB, Makhlouf T, Koubaa A. Incidence, clinical analysis, and management of ovarian fibromas and fibrothecomas. Am J Obstet Gynecol. 2008;199:473.e1–4. [DOI] [PubMed] [Google Scholar]
- [5].Chen H, Liu Y, Shen LF, Jiang MJ, Yang ZF, Fang GP. Ovarian thecoma-fibroma groups: clinical and sonographic features with pathological comparison. J Ovarian Res. 2016;9:81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Genç M, Solak A, Genç B, et al. A diagnostic dilemma for solid ovarian masses: the clinical and radiological aspects with differential diagnosis of 23 cases. Eur J Gynaecol Oncol. 2015;36:186–91. [PubMed] [Google Scholar]
- [7].Scully R, Sobin L. Histological typing of ovarian tumours. Vol. 9. Springer; 1999. [Google Scholar]
- [8].Son CE, Choi JS, Lee JH, Jeon SW, Hong JH, Bae JW. Laparoscopic surgical management and clinical characteristics of ovarian fibromas. JSLS. 2011;15:16–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [9].Cho YJ, Lee HS, Kim JM, et al. Ovarian-sparing local mass excision for ovarian fibroma/fibrothecoma in premenopausal women. Eur J Obstet Gynecol Reprod Biol. 2015;185:78–82. [DOI] [PubMed] [Google Scholar]
- [10].Cho YJ, Lee HS, Kim JM, Joo KY, Kim ML. Clinical characteristics and surgical management options for ovarian fibroma/fibrothecoma: a study of 97 cases. Gynecol Obstet Invest. 2013;76:182–7. [DOI] [PubMed] [Google Scholar]
- [11].Zhao C, Vinh TN, McManus K, Dabbs D, Barner R, Vang R. Identification of the most sensitive and robust immunohistochemical markers in different categories of ovarian sex cord-stromal tumors. Am J Surg Pathol. 2009;33:354–66. [DOI] [PubMed] [Google Scholar]
- [12].Bayer AI, Wiskind AK. Adnexal torsion: can the adnexa be saved? Am J Obstet Gynecol. 1994;171:1506–10; discussion 1510. [DOI] [PubMed] [Google Scholar]
- [13].Tsafrir Z, Hasson J, Levin I, Solomon E, Lessing JB, Azem F. Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence. Eur J Obstet Gynecol Reprod Biol. 2012;162:203–5. [DOI] [PubMed] [Google Scholar]
- [14].Moro F, Bolomini G, Sibal M, et al. Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion. Ultrasound Obstet Gynecol. 2020;56:934–43. [DOI] [PubMed] [Google Scholar]
- [15].Ozcan A, Mumusoglu S, Gokcu M, et al. Differentiated therapy in pre- and postmenopausal adnexal torsion based on malignancy rates: a retrospective multicentre study over five years. Int J Surg. 2016;29:95–100. [DOI] [PubMed] [Google Scholar]
- [16].Melcer Y, Sarig-Meth T, Maymon R, Pansky M, Vaknin Z, Smorgick N. Similar but different: a comparison of adnexal torsion in pediatric, adolescent, and pregnant and reproductive-age women. J Womens Health (Larchmt). 2016;25:391–6. [DOI] [PubMed] [Google Scholar]
- [17].Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: ovarian torsion. Am J Emerg Med. 2022;56:145–50. [DOI] [PubMed] [Google Scholar]
- [18].Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion-a 15-year review. J Pediatr Surg. 2009;44:1212–6; discussion 1217. [DOI] [PubMed] [Google Scholar]
- [19].Sasaki KJ, Miller CE. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014;21:196–202. [DOI] [PubMed] [Google Scholar]
- [20].Asfour V, Varma R, Menon P. Clinical risk factors for ovarian torsion. J Obstet Gynaecol. 2015;35:721–5. [DOI] [PubMed] [Google Scholar]
- [21].Valentin L. Gray scale sonography, subjective evaluation of the color Doppler image and measurement of blood flow velocity for distinguishing benign and malignant tumors of suspected adnexal origin. Eur J Obstet Gynecol Reprod Biol. 1997;72:63–72. [DOI] [PubMed] [Google Scholar]
- [22].Meigs JV. Pelvic tumors other than fibromas of ovary with ascites and hydrothorax. Obstet Gynecol. 1954;3:471–86. [PubMed] [Google Scholar]
- [23].Gorlin RJ, Vickers RA, Kellen E, Williamson JJ. The multiple basal cell nevi syndrome. Cancer. 1965;18:89–104. [DOI] [PubMed] [Google Scholar]
- [24].Dallay D, Chabrand S, Sonmireu J, et al. Ovarian fibromas and the Gorlin-Goltz syndrome. Rev Fr Gynecol Obstet. 1985;80:873–6. [PubMed] [Google Scholar]
- [25].Gargano G, Zito FA, Catino A, et al. Ovarian fibroma. A report of three cases. Eur J Gynaecol Oncol. 1995;16:509–15. [PubMed] [Google Scholar]
- [26].Kim ET, Song YJ, Park KY, et al. Clinical, radiological, and pathological features of mitotically active cellular fibroma of ovary: a review of cases with literature review. Taiwan J Obstet Gynecol. 2024;63:722–30. [DOI] [PubMed] [Google Scholar]
- [27].Târcoveanu E, Dimofte G, Niculescu D, et al. Ovarian fibroma in the era of laparoscopic surgery: a general surgeon’s experience. Acta Chir Belg. 2007;107:664–9. [DOI] [PubMed] [Google Scholar]
- [28].Macciò A, Madeddu C, Kotsonis P, Pietrangeli M, Paoletti AM. Large twisted ovarian fibroma associated with Meigs’ syndrome, abdominal pain and severe anemia treated by laparoscopic surgery. BMC Surg. 2014;14:38. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.