Register / Log in

Trusted medical expertise in seconds.

Access 1,000+ clinical and preclinical articles. Find answers fast with the high-powered search feature and clinical tools.

Try free for 5 days
Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer.

Ovarian tumors

Last updated: August 7, 2021

Summarytoggle arrow icon

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.

Epidemiological data refers to the US, unless otherwise specified.

Risk factors [5]

Protective factors

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]
  • 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 Cystadenoma Brenner tumor [21] Cystadenocarcinoma Endometrioid carcinoma [4][22] Clear cell tumors [4][23]
Serous Mucinous Serous Mucinous [24]
Classification
  • Benign
  • Malignant
Epidemiology
  • Most (serous) and second most common (mucinous) benign ovarian tumor
  • Rare
  • Peak age: 40–60 years
  • Most common malignant ovarian tumor
Clinical features
  • Typically asymptomatic
  • Symptoms of abdominal displacement may be present (e.g., pain, ↑ urinary frequency)
  • Pelvic pain
  • Symptoms of abdominal displacement may be present (e.g., pain, ↑ urinary frequency)
  • Abnormal vaginal bleeding
Ultrasound appearance
  • Unilocular cystic mass
  • Absent flow on Doppler
  • Large, multilocular cystic tumor
  • Mostly small tumors with a solid component and calcifications
  • Absent or only minimal flow on Doppler
  • Mostly large, unilateral, solid or multilocular-solid tumor with papillary projections
  • Large (up to 30 cm in diameter), cystic/solid unilateral masses
  • Tumor with mixed cystic/solid components and heterogeneous texture
  • May contain papillary projections and/or thick septations
  • Similar to mucinous cystadenoma
  • Additional solid components and signs of malignancy (e.g., invasion of adjacent structures) may be present
  • Mural thickening

Pathology

 Gross examination
  • Cysts with watery fluid
  • Smooth or bosselated appearance
  • Cyst is loculated; loculi contain gelatinous material
  • Encapsulated, pale yellow solid tumor
  • Cysts filled with mucoid material, cellular debris, and/or blood
  • Possible appearances are:
    • Smooth surface with cystic spaces filled with blood-stained fluid
    • Completely solid with necrosis/hemorrhage
  • Endometriosis-associated tumors are filled with chocolate-colored fluid
Histology
  • Cystic or colloid type, depending on intracellular or extracellular mucin deposition
    • Cystic type: > 50% of intracellular mucin in ≥ 90% of tumor cells
    • Colloid type: large quantities of extracellular mucin (≥ 50% of tumor volume)
  • Characteristic confluent glandular/expansile pattern
    • Tightly packed, back-to-back glands lined with tumor cells
    • Absent intervening stroma
  • Variable appearance: tubulocystic, papillary, and solid
Tumor marker

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

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 Teratoma Yolk sac tumor of the ovary (endodermal sinus tumor) [26] Dysgerminoma [27] Nongestational choriocarcinoma [28]
Dermoid cysts (mature cystic teratoma) Struma ovarii (mature teratoma) [29] Immature teratoma [30]
Classification
  • Benign
  • Malignant, aggressive
Epidemiology
  • Most common of all germ cell tumors (90% of all cases)
  • Most common ovarian tumor in women < 30 years [31]
  • Rare
  • Peak age: women < 20 years of age [33]
Clinical features
  • Mostly asymptomatic
  • Unspecific symptoms, including:
  • Rapid growth; acute onset of symptoms (pelvic mass and pain)
  • Larger tumors may cause:
    • ↑ Abdominal girth
    • Pressure symptoms (e.g., ↑ urinary frequency)
    • Lower abdominal pain
Ultrasound appearance
  • Heterogeneous mass
  • Hyperechoic nodule
  • Echogenic shadowing
  • Absent internal vascularity and/or fluid-fluid levels
  • Multilocular solid appearance
  • Struma pearl may be present.
  • Large tumor with a solid component
  • Solid component arises from the wall of the cyst and makes up ≥ 15% of total cyst size; contains smaller, fluid-filled cysts (e.g., blood, mucus).
  • Small areas of calcification
  • Well vascularized tumor
  • Contains a slightly hyperechoic solid component with an irregular, but still fine-textured appearance
  • No acoustic shadowing
  • Large, solid, well- vascularized, multilobulated tumor that is well-defined relative to its surroundings
  • Heterogeneous internal echogenicity
  • Well-vascularized mass with inhomogeneous texture
  • Irregular contour
  • Ovarian crescent sign may be present
Histopathology
Tumor markers
  • None
  • LDH (rare) [35]
Risk of malignant transformation
  • N/A

Sex cord-stromal tumors of the ovary [18]

  • Frequency: < 5% of all ovarian tumors [40]
Types of sex cord-stromal tumors of the ovary
Type

Ovarian fibroma [41]

 Theca cell tumor (thecoma) [42] Sertoli-Leydig cell tumor [43][44][45][46] Granulosa cell tumor [43][47][48]
Classification
  • Benign
  • Usually benign
  • Malignant
Epidemiology
  • Rare
  • Peak age: 30–40 years
  • Most common type of sex cord-stromal malignancy (∼ 90%)
  • Peak age: 50–55 years
Clinical features
  • No hormonal activity
  • Lower abdominal discomfort and/or a pulling-sensation in the inguinal area
  • May be associated with Meigs syndrome: ascites and pleural effusion in association with a benign ovarian tumor; surgical removal of the tumor leads to complete resolution of symptoms. [50]
  • Abnormal postmenstrual bleeding due to estrogen production
Ultrasound appearance
  • Round or oval solid tumor with minimal to moderate vascularization
  • Regular to slightly irregular internal echogenicity
  • Cystic spaces may be present.
  • Most commonly between 5 and 15 cm in diameter
  • Large papillary projections may be visible.
  • Typically, large tumor with multilocular solid appearance with > 10 small locules
  • Typically mixed or low level echogenicity
Pathology Gross examination
  • Smooth, lobulated
  • Cut surface: chalky, firm, yellow-to-white color
  • Solid yellow-orange tumor
  • Small, yellow-brown tumor
  • Tan/yellow color
  • Encapsulated; smooth lobulated surface, possibly with areas of necrosis/hemorrhage
Histology
  • Ovarian stromal cells filled with lipids on microscopy
  • Call-Exner bodies: granulosa cells arranged in clusters surrounding a central cavity with eosinophilic secretions, resembling primordial follicles
Tumor markers
  • None

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

Subtypes and variants

Overview [52][53]

  • Traditionally, ovarian cancer was considered an asymptomatic “silent killer.”
  • However, up to ∼ 90% of patients do present with symptoms before diagnosis. [52][54]

Subacute symptoms [53][54]

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 [53]

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).

Imaging

Pelvic ultrasound [59]

  • Imaging test of choice for evaluation of adnexal masses and suspected ovarian cancer. [60]
  • 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) [59]

  • 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 [62]
  • Surgical evaluation
    • Recommended method for diagnosing ovarian cancer [63]
    • 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!

Gynecologic [59]

Nongynecologic [59]

The differential diagnoses listed here are not exhaustive.

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

Surgery [64][65]

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

Chemotherapy [65]

Targeted molecular therapy

Radiation therapy [78]

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

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%

Ovarian cancer screening [18]

Strategies to reduce the risk of ovarian cancer

See “Protective factors” in “Etiology” above.

Pregnant women

  • Pregnancy luteoma [84]
    • 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
  • Corpus luteum cyst

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.

  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. Dierickx I, Valentin L, Van Holsbeke C, et al. Imaging in gynecological disease (7): clinical and ultrasound features of Brenner tumors of the ovary. Ultrasound in Obstetrics & Gynecology. 2012; 40 (6): p.706-713. doi: 10.1002/uog.11149 . | Open in Read by QxMD
  6. Moro F, Magoga G, Pasciuto T, et al. Imaging in gynecological disease (13): clinical and ultrasound characteristics of endometrioid ovarian cancer. Ultrasound in Obstetrics & Gynecology. 2018; 52 (4): p.535-543. doi: 10.1002/uog.19026 . | Open in Read by QxMD
  7. Pozzati F, Moro F, Pasciuto T, et al. Imaging in gynecological disease (14): clinical and ultrasound characteristics of ovarian clear cell carcinoma. Ultrasound in Obstetrics & Gynecology. 2018; 52 (6): p.792-800. doi: 10.1002/uog.19171 . | Open in Read by QxMD
  8. Babaier A, Ghatage P. Mucinous Cancer of the Ovary: Overview and Current Status. Diagnostics. 2020; 10 (1): p.52. doi: 10.3390/diagnostics10010052 . | Open in Read by QxMD
  9. 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
  10. 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
  11. Anfelter P, Testa A, Chiappa V, et al. Imaging in gynecological disease (17): ultrasound features of malignant ovarian yolk sac tumors (endodermal sinus tumors). Ultrasound in Obstetrics & Gynecology. 2020; 56 (2): p.276-284. doi: 10.1002/uog.22002 . | Open in Read by QxMD
  12. Guerriero S, Testa AC, Timmerman D, et al. Imaging of gynecological disease (6): clinical and ultrasound characteristics of ovarian dysgerminoma. Ultrasound in Obstetrics & Gynecology. 2011; 37 (5): p.596-602. doi: 10.1002/uog.8958 . | Open in Read by QxMD
  13. Mascilini F, Moro F, Di Grazia FM, et al. Clinical and ultrasound features of non‐gestational ovarian choriocarcinoma. Ultrasound in Obstetrics & Gynecology. 2017; 52 (1): p.121-123. doi: 10.1002/uog.18943 . | Open in Read by QxMD
  14. Weinberger V, Kadlecova J, Minář L, et al. Struma ovarii – ultrasound features of a rare tumor mimicking ovarian cancer. Medical Ultrasonography. 2018; 20 (3): p.355. doi: 10.11152/mu-1526 . | Open in Read by QxMD
  15. Abdullahi Idle S, Hayes K, Ross J. Ultrasound features of immature ovarian teratomas: Case series and review of literature. Ultrasound. 2020; 28 (2): p.82-90. doi: 10.1177/1742271x19895538 . | Open in Read by QxMD
  16. 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.
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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.
  22. 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
  23. 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.
  24. 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
  25. 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
  26. Paladini D, Testa A, Van 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 in Obstetrics and Gynecology. 2009; 34 (2): p.188-195. doi: 10.1002/uog.6394 . | Open in Read by QxMD
  27. Ovarian thecoma. https://radiopaedia.org/articles/ovarian-thecoma. . Accessed: June 23, 2021.
  28. 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
  29. 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.
  30. 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
  31. Demidov VN, Lipatenkova J, Vikhareva O, Van Holsbeke C, Timmerman D, Valentin L. Imaging of gynecological disease (2): clinical and ultrasound characteristics of Sertoli cell tumors, Sertoli–Leydig cell tumors and Leydig cell tumors. Ultrasound in Obstetrics and Gynecology. 2007; 31 (1): p.85-91. doi: 10.1002/uog.5227 . | Open in Read by QxMD
  32. 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
  33. Van Holsbeke C, Domali E, Holland TK, et al. Imaging of gynecological disease (3): clinical and ultrasound characteristics of granulosa cell tumors of the ovary. Ultrasound in Obstetrics and Gynecology. 2008; 31 (4): p.450-456. doi: 10.1002/uog.5279 . | Open in Read by QxMD
  34. 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
  35. 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
  36. 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
  37. Cancer Stat Facts: Ovarian Cancer. https://seer.cancer.gov/statfacts/html/ovary.html. Updated: November 1, 2016. Accessed: February 21, 2018.
  38. Ovarian Cancer Statistics. https://www.cdc.gov/cancer/ovarian/statistics/index.htm. Updated: June 8, 2020. Accessed: September 5, 2020.
  39. 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
  40. 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
  41. 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
  42. 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
  43. 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
  44. 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
  45. 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
  46. 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
  47. 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
  48. 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
  49. 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
  50. 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
  51. 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
  52. 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
  53. 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
  54. 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
  55. 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
  56. 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
  57. 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
  58. 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
  59. 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
  60. 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
  61. 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
  62. 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.
  63. 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
  64. Surgery for ovarian cancer. https://www.cancer.org/cancer/ovarian-cancer/treating/surgery.html. Updated: April 18, 2018. Accessed: September 20, 2020.
  65. Treatment of Invasive Epithelial Ovarian Cancers, by Stage. https://www.cancer.org/cancer/ovarian-cancer/treating/by-stage.html. . Accessed: September 22, 2020.
  66. 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
  67. 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
  68. 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.
  69. 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
  70. 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
  71. 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
  72. 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
  73. 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
  74. 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
  75. 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
  76. 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
  77. 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
  78. 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
  79. 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
  80. 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
  81. Breast and Ovarian Cancer and Family History Risk Categories. https://www.cdc.gov/genomics/disease/breast_ovarian_cancer/risk_categories.htm. Updated: March 25, 2020. Accessed: April 6, 2021.
  82. BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing. Updated: August 20, 2019. Accessed: April 6, 2021.
  83. 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
  84. 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
  85. 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
  86. 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