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Ovarian tumors

Last updated: December 17, 2020

Summary

Ovarian cancer is the most deadly gynecological neoplasm in the United States. Risk factors for developing ovarian cancer include genetic predisposition (e.g., BRCA1/BRCA2 mutation) and hormonal factors (e.g., increased number of lifetime ovulations). The ovaries consist of different types of tissue (epithelial, germ cells, and sex cord tissue), which may give rise to benign or malignant tumors. Symptoms depend on the type of tissue affected and range from local abdominal discomfort to endocrinological phenomena caused by hormone-producing tumors. Metastases of other tumors and lymphomas may also affect the ovaries. The most common malignant tumor of the ovaries is serous ovarian cancer, which primarily affects older women (median age of diagnosis is 63 years). The lack of early symptoms of ovarian cancer often delays diagnosis, resulting in an unfavorable prognosis. Ovarian cancers primarily metastasize intraperitoneally and later become noticeable mostly due to increasing abdominal girth caused by malignancy-related ascites. Treatment generally involves radical surgical removal of the tumor and chemotherapy.

Epidemiology

  • Ovarian tumors are the most common ovarian mass in women > 55 years of age.
  • Lifetime prevalence of malignant ovarian cancer: 1–2% [1]
  • Ovarian cancer is the second most common gynecological cancer (after endometrial cancer) but causes the most deaths (with endometrial cancer causing the second most). [2]
  • Median age at diagnosis of ovarian cancer: 63 years [1][3]
  • Incidence rates highest in non-Hispanic white women [4]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Risk factors [5]

Protective factors

Overview of ovarian tumors

Classification of ovarian tumors

  • Epithelial ovarian tumors
  • Germ cell ovarian tumors
    • Arise from the primordial germ cells (e.g., oocytes)
    • Can be benign or malignant
    • Subtypes are determined by structural differentiation
  • Sex cord and stromal ovarian tumors
    • Arise from sex cord cells (e.g., Sertoli or granulosa cells) or stromal cells (e.g., fibroblasts or primitive gonadal stroma)
    • May be benign or malignant

Epithelial ovarian tumors [18][19]

  • Histological classification
    • Benign: lack hyperproliferative and invasive behavior
    • Borderline ovarian tumors: a histopathological term that describes an ovarian tumor of low malignant potential that expresses cytologic features of malignancy without frank invasion
    • Malignant: evidence of invasion
  • Clinicopathological classification [20]
    • Type I ovarian tumors: low-grade, indolent tumors that typically manifest as large, unilateral, cystic neoplasms
    • Type II ovarian tumors: high-grade, aggressive tumors that typically involve both ovaries and are diagnosed at an advanced stage
      • Histologic subtypes include high-grade serous, carcinosarcoma, and undifferentiated carcinoma
      • Account for ∼ 90% of ovarian cancer deaths
      • Associated with high levels of chromosomal instability
      • p53 mutations are common
  • Frequency [4]
    • Most common benign and malignant ovarian tumor subtype
    • Epithelial tumors account for ∼ 90% of all ovarian malignancies
Types of epithelial ovarian tumors
Type Classification Epidemiology Characteristic features Tumor marker
Serous Cystadenoma
  • Benign
  • Most common benign ovarian tumor
Cystadenocarcinoma
  • Malignant
  • Most common malignant ovarian tumor
Mucinous Cystadenoma
  • Benign
  • Second most common benign ovarian tumor
Brenner tumor
  • Benign
  • Rare
  • Most common in women 40–60 years of age
  • Encapsulated, pale yellow solid tumor
  • Similar to transitional cells of the bladder (urothelium)
  • Circular patches of cells with coffee bean nuclei
Cystadenocarcinoma
  • Malignant
Endometrioid carcinoma
  • Malignant
Clear cell tumors
  • Malignant

CA-125 is used as a tumor marker for epithelial ovarian cancer but can also be elevated in endometriosis, uterine leiomyoma, cirrhosis, and other malignancies.

Most ovarian tumors are benign, not malignant.

Ovarian germ cell tumors [18]

  • Frequency: ∼ 5% of all ovarian tumors [4]
Types of ovarian germ cell tumors
Type Classification Epidemiology Characteristic features Tumor markers
Teratoma

Dermoid cysts

(mature teratoma)

  • Benign
  • None
Struma ovarii (mature teratoma)
  • Benign
  • None
Immature
  • Malignant and aggressive
  • Rare
  • Most commonly occurs in women < 20 years of age [25]
Dysgerminoma
  • Malignant
  • Rapid growth; acute onset of symptoms (pelvic mass and pain)
  • A less common female histological equivalent to the male seminoma
  • Histopathologic evaluation shows fried egg cells
Yolk sac tumor of the ovary (endodermal sinus tumor)
  • Malignant and aggressive
  • Rapid growth; acute onset of symptoms (pelvic mass and pain)
  • Mass appears yellow and friable (due to hemorrhage) on gross examination.
  • Characteristic Shiller-Duval bodies, which resemble glomeruli on microscopy [28]

Nongestational choriocarcinoma
  • Malignant
  • Extremely aggressive

Sex cord-stromal tumors of the ovary [18]

  • Frequency: < 5% of all ovarian tumors [31]
Types of sex cord-stromal tumors of the ovary
Type Classification Epidemiology Characteristic features Diagnostic markers
Granulosa cell tumor
  • Malignant
  • Most common type of sex cord-stromal malignancy (∼ 90%) [32]
  • Peak incidence in women between 50–55 years of age
Theca cell tumor (thecoma)
  • Benign
  • Can produce estrogen, which leads to abnormal postmenstrual bleeding
  • Solid yellow-orange tumor on gross examination
  • Ovarian stromal cells filled with lipids on microscopy
  • None
Sertoli-Leydig cell tumor
  • Usually benign
  • Rare tumor
  • Primarily affects women 30–40 years of age [33]
  • None
Ovarian fibroma
  • Benign
  • No hormonal activity
  • Clusters of spindle-shaped cells (fibroblasts)
  • May be associated with Meigs syndrome: ascites and pleural effusion in association with a benign ovarian tumor [37]
    • The cause is unknown.
    • Surgical removal of the tumor leads to complete resolution of symptoms.
  • Often manifests with lower abdominal discomfort and/or a “pulling” sensation in the inguinal area
  • None

Call-Exner bodies are characteristic of Granulosa cell tumors: “Call your Ex and Grandparents!”

Subtypes and variants

Clinical features

Overview [39][40]

  • Traditionally, ovarian cancer was considered an asymptomatic “silent killer.”
  • However, up to ∼ 90% of patients do present with symptoms before diagnosis. [39][41]

Subacute symptoms [40][41]

Ovarian cancer most commonly manifests with subacute symptoms, which occur in women with early-stage disease. These symptoms are nonspecific and often difficult to attribute to ovarian cancer.

Acute presentations and symptoms of metastatic disease [40]

Acute symptoms typically occur in patients with advanced disease and are an indication for immediate evaluation and treatment.

The first symptom of ovarian cancer is often increasing abdominal girth (clothes no longer fit at the waist).

Diagnostics

Imaging

Pelvic ultrasound [46]

  • Imaging test of choice for evaluation of adnexal masses and suspected ovarian cancer. [47]
  • Both transabdominal and transvaginal modalities should be utilized.
  • Ultrasound examination should assess the following:
    • Size and structural characteristics
    • Laterality
    • Mass margins
    • Vascularity
    • Pelvic fluid
Ultrasound workup of ovarian masses
Benign Malignant
Internal structure Uniform, thin walls Irregularly thickened septa
Margins Smooth Indistinct borders; papillary projections
Echogenicity Anechoic Hypoechoic, anechoic, and hyperechoic components
Content Cystic Cystic or solid components
Vascularization Unremarkable Possible central vascularization
Pouch of Douglas Unremarkable Possible free fluid (ascites)

Pelvic ultrasonography should be the first step in evaluating women with suspicious ovarian masses.

Magnetic resonance imaging (MRI) [46]

  • Not routinely recommended for evaluation of suspected ovarian cancer
  • May be helpful in determining the origin of pelvic masses that are not clearly arising from the ovary
  • Useful for assessing the feasibility of surgical resection

Computed tomography (CT)

  • Not recommended in the initial evaluation of adnexal masses
  • Useful for determining the extent of ovarian metastases (e.g., omental, liver, and lung lesions)

Tumor markers

Serum markers of germ cell tumors

Type of tumor

 Tumor marker
Dysgerminoma
Yolk sac tumor
Immature teratoma
Choriocarcinoma
Embryonal carcinoma

Tissue diagnosis

  • Noninvasive biopsy: not recommended due to the risk of tumor seeding and, as a result, advancing the stage of disease [49]
  • Surgical evaluation
    • Recommended method for diagnosing ovarian cancer [50]
    • Should only be utilized in patients with a high probability of a malignant ovarian mass
    • If a malignancy is found, it can be staged and cytoreduction can be performed (see “Surgery” in “Treatment” below).

Fine needle aspiration is absolutely contraindicated in ovarian tumors because it may directly spread tumor cells to the peritoneum!

Differential diagnoses

Gynecologic [46]

Nongynecologic [46]

The differential diagnoses listed here are not exhaustive.

Stages

Staging of epithelial ovarian cancer including fallopian tube cancer and primary peritoneal cancer [18]

Staging is based on the 2017 International Federation of Gynecology and Obstetrics (FIGO) and the Tumor, Node, Metastasis (TNM) classification systems.

Management approach

 FIGO Stage

TNM

 Description
Curative
  • Stage IA
  • T1a, N0, M0
  • Stage IB
  • T1b, N0, M0
  • Stage IC
  • T1c, N0, M0
  • Stage IIA
  • T2a, N0, M0
  • Stage IIB
  • T2b, N0, M0
  • Tumor extension to or implants on other pelvic tissues
  • Stage IIIA1
  • T1–T2, N1, M0
  • Stage IIIA2
  • T3a, N0–N1, M0
  • Stage IIIB
  • T3b, N0–N1, M0
  • Stage IIIC
  • T3c, N0–N1, M0
Palliative
  • Stage IVA
  • T1–T3, N0-N1, M1a
  • Stage IVB
  • T1–T3, N0-N1, M1b

Treatment

Surgery [51][52]

For the best patient outcomes, surgical staging and debulking should be performed by expert gynecological oncologists.

Chemotherapy [52]

Targeted molecular therapy

Radiation therapy [65]

  • Not the preferred treatment modality for ovarian cancer
  • Reserved as symptomatic treatment for recurrent or metastatic disease

Prognosis

Outcomes for epithelial ovarian cancer [1]

  • Very poor overall prognosis as a result of late diagnosis
  • 5-year survival rate of all stages: ∼ 50%
FIGO Anatomic extension 5-year survival rate
I Limited to one or both ovaries 80–90%
II Infiltration of the lesser pelvis 50–70%
III Extension outside pelvis 30–40%
IV Distant metastases 10–20%

Prevention

Ovarian cancer screening [18]

  • Indications
    • Routine screening with CA-125 or transvaginal ultrasound is not recommended in patients with an average risk of ovarian cancer. [66][67]
    • Routine screening is also not recommended in patients with a known, high-risk genetic predisposition (e.g., BRCA mutation carrier or strong family history).
      • Alternatively, high-risk patients may undergo risk-reducing salpingo-oophorectomy (rrBSO) if no future pregnancies are desired. [13]
      • Intensive and regular screening with pelvic ultrasound (e.g., every 6 months after age 35) is an alternative to rrBSO. [68]
  • Potential benefits
    • Reduction in mortality
    • Diagnosis of ovarian cancer at an earlier stage
  • Potential harms

Strategies to reduce the risk of ovarian cancer

See “Protective factors” in “Etiology” above.

Special patient groups

Pregnant women

  • Pregnancy luteoma [69]
    • Definition: rare, benign tumors that arise in response to elevated hormone levels (e.g., β-hCG) during pregnancy
    • Clinical features
      • The majority of patients are asymptomatic.
      • Occasionally, they are functionally active (i.e., cause androgen hypersecretion) and manifest with symptoms of virilization of the mother or the fetus.
    • Diagnostics
      • Pelvic ultrasound
        • Solid adnexal mass
        • Can be unilateral or bilateral
        • Significant venous or arterial flow
        • 4–10 cm in diameter
      • Luteomas are often diagnosed incidentally during cesarean delivery.
    • Treatment
      • Observation
      • Most regress spontaneously postpartum.
  • Theca lutein cysts (see “Overview” in “Ovarian cysts”)

If surgical removal of an ovarian tumor is indicated during pregnancy, surgery should, if possible, be scheduled for after the 10th week of gestation, as the secretion of progesterone by the corpus luteum is essential for the maintenance of the pregnancy. The placenta takes over this function from approximately the 10th week of pregnancy onwards.

References

  1. Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Carcinoma Version 1.2020. https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf. Updated: March 11, 2020. Accessed: September 6, 2020.
  2. Meinhold-Heerlein I, Fotopoulou C, Harter P, et al. The new WHO classification of ovarian, fallopian tube, and primary peritoneal cancer and its clinical implications.. Arch Gynecol Obstet. 2016; 293 (4): p.695-700. doi: 10.1007/s00404-016-4035-8 . | Open in Read by QxMD
  3. Kurman RJ, Shih IeM. The Dualistic Model of Ovarian Carcinogenesis: Revisited, Revised, and Expanded.. Am J Pathol. 2016; 186 (4): p.733-47. doi: 10.1016/j.ajpath.2015.11.011 . | Open in Read by QxMD
  4. Torre LA, Trabert B, DeSantis CE, et al.. Ovarian cancer statistics, 2018. CA Cancer J Clin. 2018; 68 (4): p.284-296. doi: 10.3322/caac.21456 . | Open in Read by QxMD
  5. Smith JW, Kemeny N, Caldwell C, Banner P, Sigurdson E, Huvos A. Pseudomyxoma peritonei of appendiceal origin. The memorial sloan-kettering cancer center experience. Cancer. 1992; 70 (2): p.396-401. doi: 10.1002/1097-0142(19920715)70:2<396::aid-cncr2820700205>3.0.co;2-a . | Open in Read by QxMD
  6. Wentzensen N, Poole EM, Trabert B, et al. Ovarian Cancer Risk Factors by Histologic Subtype: An Analysis From the Ovarian Cancer Cohort Consortium. J Clin Oncol. 2016; 34 (24): p.2888-2898. doi: 10.1200/jco.2016.66.8178 . | Open in Read by QxMD
  7. Comerci JT Jr, Licciardi F, Bergh PA, Gregori C, Breen JL. Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature.. Obstet Gynecol. 1994; 84 (1): p.22-8.
  8. Park J-Y, Kim D-Y, Kim J-H, Kim Y-M, Kim Y-T, Nam J-H. Malignant transformation of mature cystic teratoma of the ovary: Experience at a single institution. Eur J Obstet Gynecol Reprod Biol. 2008; 141 (2): p.173-178. doi: 10.1016/j.ejogrb.2008.07.032 . | Open in Read by QxMD
  9. M.Roth L, Talerman A. The enigma of struma ovarii. Pathology. 2007; 39 (1): p.139-146. doi: 10.1080/00313020601123979 . | Open in Read by QxMD
  10. Smith HO, Berwick M, Verschraegen CF, et al. Incidence and Survival Rates for Female Malignant Germ Cell Tumors. Obstet Gynecol. 2006; 107 (5): p.1075-1085. doi: 10.1097/01.aog.0000216004.22588.ce . | Open in Read by QxMD
  11. Ihara T, Ohama K, Satoh H, Fujii T, Nomura K, Fujiwara A. Histologic grade and karyotype of immature teratoma of the ovary. Cancer. 1984; 54 (12): p.2988-2994. doi: 10.1002/1097-0142(19841215)54:12<2988::aid-cncr2820541229>3.0.co;2-u . | Open in Read by QxMD
  12. Levato F, Martinello R, Campobasso C, Porto S. LDH and LDH isoenzymes in ovarian dysgerminoma.. Eur J Gynaecol Oncol. 1995; 16 (3): p.212-5.
  13. Kurman RJ, Norris HJ. Endodermal sinus tumor of the ovary.A clinical and pathologic analysis of 71 cases. Cancer. 1976; 38 (6): p.2404-2419. doi: 10.1002/1097-0142(197612)38:6<2404::aid-cncr2820380629>3.0.co;2-3 . | Open in Read by QxMD
  14. Gershenson DM, Del Junco G, Herson J, Rutledge FN. Endodermal sinus tumor of the ovary: the M. D. Anderson experience.. Obstet Gynecol. 1983; 61 (2): p.194-202.
  15. Kawai M, Kano T, Kikkawa F, et al. Seven tumor markers in benign and malignant germ cell tumors of the ovary. Gynecol Oncol. 1992; 45 (3): p.248-253. doi: 10.1016/0090-8258(92)90299-x . | Open in Read by QxMD
  16. Quirk JT, Natarajan N. Ovarian cancer incidence in the United States, 1992–1999. Gynecol Oncol. 2005; 97 (2): p.519-523. doi: 10.1016/j.ygyno.2005.02.007 . | Open in Read by QxMD
  17. Young RH. Sex cord-stromal tumors of the ovary and testis: their similarities and differences with consideration of selected problems. Mod Pathol. 2005; 18 (S2): p.S81-S98. doi: 10.1038/modpathol.3800311 . | Open in Read by QxMD
  18. Lim D, Oliva E. Ovarian sex cord-stromal tumours: an update in recent molecular advances. Pathology. 2018; 50 (2): p.178-189. doi: 10.1016/j.pathol.2017.10.008 . | Open in Read by QxMD
  19. Tanaka YO, Tsunoda H, Kitagawa Y, Ueno T, Yoshikawa H, Saida Y. Functioning Ovarian Tumors: Direct and Indirect Findings at MR Imaging. RadioGraphics. 2004; 24 (suppl_1): p.S147-S166. doi: 10.1148/rg.24si045501 . | Open in Read by QxMD
  20. Zanotti KM. The clinical manifestations and diagnosis of Sertoli-Leydig cell tumors of the ovary.. CME Journal of Gynecologic Oncology. 2002; 7 : p.129-133.
  21. Young RH, Scully RE. Ovarian Sertoli - Leydig cell tumors. Am J Surg Pathol. 1985; 9 (8): p.543-569. doi: 10.1097/00000478-198508000-00001 . | Open in Read by QxMD
  22. Brun J-L. Demons syndrome revisited: A review of the literature. Gynecol Oncol. 2007; 105 (3): p.796-800. doi: 10.1016/j.ygyno.2007.01.050 . | Open in Read by QxMD
  23. Kubeček O, Laco J, Špaček J, et al. The pathogenesis, diagnosis, and management of metastatic tumors to the ovary: a comprehensive review. Clin Exp Metastasis. 2017; 34 (5): p.295-307. doi: 10.1007/s10585-017-9856-8 . | Open in Read by QxMD
  24. Cancer Stat Facts: Ovarian Cancer. https://seer.cancer.gov/statfacts/html/ovary.html. Updated: November 1, 2016. Accessed: February 21, 2018.
  25. Ovarian Cancer Statistics. https://www.cdc.gov/cancer/ovarian/statistics/index.htm. Updated: June 8, 2020. Accessed: September 5, 2020.
  26. Kuchenbaecker KB, Hopper JL, Barnes DR, et al. Risks of Breast, Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers. JAMA. 2017; 317 (23): p.2402. doi: 10.1001/jama.2017.7112 . | Open in Read by QxMD
  27. Brett M. R, Brett M. R, Jennifer B. P, Thomas A. S, Jennifer B. P, Thomas A. S. Epidemiology of ovarian cancer: a review. Cancer Biol Med. 2017; 14 (1): p.9-32. doi: 10.20892/j.issn.2095-3941.2016.0084 . | Open in Read by QxMD
  28. Camargo MC, Stayner LT, Straif K, et al. Occupational Exposure to Asbestos and Ovarian Cancer: A Meta-analysis. Environ Health Perspect. 2011; 119 (9): p.1211-1217. doi: 10.1289/ehp.1003283 . | Open in Read by QxMD
  29. Barrow E, Robinson L, Alduaij W, et al.. Cumulative lifetime incidence of extracolonic cancers in Lynch syndrome: a report of 121 families with proven mutations. Clin Genet. 2009; 75 (2): p.141-149. doi: 10.1111/j.1399-0004.2008.01125.x . | Open in Read by QxMD
  30. BANNO K, KISU I, YANOKURA M, et al. Hereditary gynecological tumors associated with Peutz-Jeghers syndrome (Review). Oncol Lett. 2013; 6 (5): p.1184-1188. doi: 10.3892/ol.2013.1527 . | Open in Read by QxMD
  31. Franchini M, Castaman G, Coppola A, et al. Acquired inhibitors of clotting factors: AICE recommendations for diagnosis and management. Blood Transfus. 2015; 13 (3): p.498-513. doi: 10.2450/2015.0141-15 . | Open in Read by QxMD
  32. Tsilidis KK, Allen NE, Key TJ, et al. Oral contraceptive use and reproductive factors and risk of ovarian cancer in the European Prospective Investigation into Cancer and Nutrition. Br J Cancer. 2011; 105 (9): p.1436-1442. doi: 10.1038/bjc.2011.371 . | Open in Read by QxMD
  33. Pearce CL, Templeman C, Rossing MA, et al. Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case–control studies. Lancet Oncol. 2012; 13 (4): p.385-394. doi: 10.1016/s1470-2045(11)70404-1 . | Open in Read by QxMD
  34. Berek JS, Chalas E, Edelson M, et al. Prophylactic and Risk-Reducing Bilateral Salpingo-oophorectomy. Obstet Gynecol. 2010; 116 (3): p.733-743. doi: 10.1097/aog.0b013e3181ec5fc1 . | Open in Read by QxMD
  35. Whittmore AS, Harris R, Itnyre J. Characteristics Relating to Ovarian Cancer Risk: Collaborative Analysis of 12 US Case -Control Studies. Am J Epidemiol. 1992; 136 (10): p.1184-1203. doi: 10.1093/oxfordjournals.aje.a116427 . | Open in Read by QxMD
  36. Narod SA, Sun P, Ghadirian P, et al. Tubal ligation and risk of ovarian cancer in carriers of BRCA1 or BRCA2 mutations: a case-control study.. Lancet. 2001; 357 (9267): p.1467-70. doi: 10.1016/s0140-6736(00)04642-0 . | Open in Read by QxMD
  37. Havrilesky LJ, Moorman PG, Lowery WJ, et al. Oral Contraceptive Pills as Primary Prevention for Ovarian Cancer. Obstet Gynecol. 2013; 122 (1): p.139-147. doi: 10.1097/aog.0b013e318291c235 . | Open in Read by QxMD
  38. Li D-P, Du C, Zhang Z-M, et al. Breastfeeding and Ovarian Cancer Risk: a Systematic Review and Meta-analysis of 40 Epidemiological Studies. Asian Pac J Cancer Prev. 2014; 15 (12): p.4829-4837. doi: 10.7314/apjcp.2014.15.12.4829 . | Open in Read by QxMD
  39. Goff BA, Mandel L, Muntz HG, Melancon CH. Ovarian carcinoma diagnosis. Cancer. 2000; 89 (10): p.2068-2075. doi: 10.1002/1097-0142(20001115)89:10<2068::aid-cncr6>3.0.co;2-z . | Open in Read by QxMD
  40. GOFF B. Symptoms Associated With Ovarian Cancer. Clin Obstet Gynecol. 2012; 55 (1): p.36-42. doi: 10.1097/grf.0b013e3182480523 . | Open in Read by QxMD
  41. Olson S. Symptoms of ovarian cancer. Obstet Gynecol. 2001; 98 (2): p.212-217. doi: 10.1016/s0029-7844(01)01457-0 . | Open in Read by QxMD
  42. Hamilton W, Peters TJ, Bankhead C, Sharp D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ. 2009; 339 (aug25 2): p.b2998-b2998. doi: 10.1136/bmj.b2998 . | Open in Read by QxMD
  43. Shanbhogue AKP, Shanbhogue DKP, Prasad SR, Surabhi VR, Fasih N, Menias CO. Clinical Syndromes Associated with Ovarian Neoplasms: A Comprehensive Review. RadioGraphics. 2010; 30 (4): p.903-919. doi: 10.1148/rg.304095745 . | Open in Read by QxMD
  44. White RH, Chew HK, Zhou H, et al. Incidence of Venous Thromboembolism in the Year Before the Diagnosis of Cancer in 528 693 Adults. Arch Intern Med. 2005; 165 (15): p.1782. doi: 10.1001/archinte.165.15.1782 . | Open in Read by QxMD
  45. Lengyel E. Ovarian Cancer Development and Metastasis. Am J Pathol. 2010; 177 (3): p.1053-1064. doi: 10.2353/ajpath.2010.100105 . | Open in Read by QxMD
  46. R Eskander, M Berman, L Keder. Practice Bulletin No. 174. Obstetrics & Gynecology. 2016; 128 (5): p.e210-e226. doi: 10.1097/aog.0000000000001768 . | Open in Read by QxMD
  47. Van Nagell JR, Miller RW. Evaluation and Management of Ultrasonographically Detected Ovarian Tumors in Asymptomatic Women. Obstet Gynecol. 2016; 127 (5): p.848-858. doi: 10.1097/aog.0000000000001384 . | Open in Read by QxMD
  48. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice.. Committee Opinion No. 477: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer.. Obstet Gynecol. 2011; 117 (3): p.742-6. doi: 10.1097/AOG.0b013e31821477db . | Open in Read by QxMD
  49. Sainz de la Cuesta R, Goff BA, Fuller AF Jr, Nikrui N, Eichhorn JH, Rice LW. Prognostic importance of intraoperative rupture of malignant ovarian epithelial neoplasms.. Obstet Gynecol. 1994; 84 (1): p.1-7.
  50. Webb MJ, Decker DG, Mussey E, Williams TJ. Factor influencing survival in Stage I ovarian cancer.. Am J Obstet Gynecol. 1973; 116 (2): p.222-8. doi: 10.1016/0002-9378(73)91054-5 . | Open in Read by QxMD
  51. Surgery for ovarian cancer. https://www.cancer.org/cancer/ovarian-cancer/treating/surgery.html. Updated: April 18, 2018. Accessed: September 20, 2020.
  52. Treatment of Invasive Epithelial Ovarian Cancers, by Stage. https://www.cancer.org/cancer/ovarian-cancer/treating/by-stage.html. . Accessed: September 22, 2020.
  53. Giede KC, Kieser K, Dodge J, Rosen B. Who should operate on patients with ovarian cancer? An evidence-based review. Gynecol Oncol. 2005; 99 (2): p.447-461. doi: 10.1016/j.ygyno.2005.07.008 . | Open in Read by QxMD
  54. Chi DS, Eisenhauer EL, Zivanovic O, et al. Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Gynecol Oncol. 2009; 114 (1): p.26-31. doi: 10.1016/j.ygyno.2009.03.018 . | Open in Read by QxMD
  55. Schorge JO, McCann C, Del Carmen MG. Surgical debulking of ovarian cancer: what difference does it make?. Rev Obstet Gynecol. undefined; 3 (3): p.111-7.
  56. Chan JK, Tian C, Teoh D, et al. Survival after recurrence in early-stage high-risk epithelial ovarian cancer: A Gynecologic Oncology Group study. Gynecol Oncol. 2010; 116 (3): p.307-311. doi: 10.1016/j.ygyno.2009.10.074 . | Open in Read by QxMD
  57. Elit L, Chambers A, Fyles A, Covens A, Carey M, Kee Fung MF. Systematic review of adjuvant care for women with Stage I ovarian carcinoma. Cancer. 2004; 101 (9): p.1926-1935. doi: 10.1002/cncr.20595 . | Open in Read by QxMD
  58. Seagle B-LL, Butler SK, Strohl AE, Nieves-Neira W, Shahabi S. Chemotherapy delay after primary debulking surgery for ovarian cancer. Gynecol Oncol. 2017; 144 (2): p.260-265. doi: 10.1016/j.ygyno.2016.11.022 . | Open in Read by QxMD
  59. Kyrgiou M, Salanti G, Pavlidis N, Paraskevaidis E, Ioannidis JPA. Survival Benefits With Diverse Chemotherapy Regimens for Ovarian Cancer: Meta-analysis of Multiple Treatments. JNCI: Journal of the National Cancer Institute. 2006; 98 (22): p.1655-1663. doi: 10.1093/jnci/djj443 . | Open in Read by QxMD
  60. Tewari D, Java JJ, Salani R, et al. Long-term survival advantage and prognostic factors associated with intraperitoneal chemotherapy treatment in advanced ovarian cancer: a gynecologic oncology group study.. J Clin Oncol. 2015; 33 (13): p.1460-6. doi: 10.1200/JCO.2014.55.9898 . | Open in Read by QxMD
  61. Konstantinopoulos PA, Norquist B, Lacchetti C, et al. Germline and Somatic Tumor Testing in Epithelial Ovarian Cancer: ASCO Guideline. J Clin Onc. 2020; 38 (11): p.1222-1245. doi: 10.1200/jco.19.02960 . | Open in Read by QxMD
  62. Moore K, Colombo N, Scambia G, et al. Maintenance Olaparib in Patients with Newly Diagnosed Advanced Ovarian Cancer. N Engl J Med. 2018; 379 (26): p.2495-2505. doi: 10.1056/nejmoa1810858 . | Open in Read by QxMD
  63. González-Martín A, Pothuri B, Vergote I, et al. Niraparib in Patients with Newly Diagnosed Advanced Ovarian Cancer. N Engl J Med. 2019; 381 (25): p.2391-2402. doi: 10.1056/nejmoa1910962 . | Open in Read by QxMD
  64. Coleman RL, Fleming GF, Brady MF, et al. Veliparib with First-Line Chemotherapy and as Maintenance Therapy in Ovarian Cancer. N Engl J Med. 2019; 381 (25): p.2403-2415. doi: 10.1056/nejmoa1909707 . | Open in Read by QxMD
  65. Fields EC, McGuire WP, Lin L, Temkin SM. Radiation Treatment in Women with Ovarian Cancer: Past, Present, and Future. Frontiers in Oncology. 2017; 7 . doi: 10.3389/fonc.2017.00177 . | Open in Read by QxMD
  66. Pinsky PF, Yu K, Kramer BS, et al. Extended mortality results for ovarian cancer screening in the PLCO trial with median 15 years follow-up. Gynecol Oncol. 2016; 143 (2): p.270-275. doi: 10.1016/j.ygyno.2016.08.334 . | Open in Read by QxMD
  67. Jacobs IJ, Menon U, Ryan A, et al. Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial. Lancet. 2016; 387 (10022): p.945-956. doi: 10.1016/s0140-6736(15)01224-6 . | Open in Read by QxMD
  68. Smith RA, Manassaram-Baptiste D, Brooks D, et al. Cancer screening in the United States, 2015: A review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2015; 65 (1): p.30-54. doi: 10.3322/caac.21261 . | Open in Read by QxMD
  69. Masarie K, Katz V, Balderston K. Pregnancy luteomas. Obstet Gynecol Surv. 2010; 65 (9): p.575-582. doi: 10.1097/ogx.0b013e3181f8c41d . | Open in Read by QxMD
  70. Prat J. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet. 2013; 124 (1): p.1-5. doi: 10.1016/j.ijgo.2013.10.001 . | Open in Read by QxMD
  71. Khosla D, Dimri K, Pandey A, Mahajan R, Trehan R. Ovarian granulosa cell tumor: Clinical features, treatment, outcome, and prognostic factors. North American Journal of Medical Sciences. 2014; 6 (3): p.133. doi: 10.4103/1947-2714.128475 . | Open in Read by QxMD