Ovarian Sarcoma

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief:  Maneesha Nandimandalam, M.B.B.S.[2]

## Overview[edit | edit source]

Ovarian carcinosarcoma, which is also known as a malignant mixed mullerian tumor (MMMT) of the ovary, is a rare, aggressive cancer of the ovary with two distinct characteristic cancer types i.e carcinoma and sarcoma. Primary ovarian sarcomas occur as pure sarcomas or mixed mullerian tumors (MMTs). Ovarian sarcoma is one of the least common gynecologic malignancy, constituting approximately 1% of all ovarian malignancies. Prognosis is generally poor, and the 5-year survival rate of patients with ovarian sarcoma is approximately 28.2%. Most of the women are asymptomatic, when present, symptoms may include, pain in the abdomen or pelvic area, bloating or swelling of the abdomen, quickly feeling full when eating, other digestive problems. An elevated concentration of CA-125 in serum is seen in some patients of ovarian sarcoma. Biopsy is the study of choice. Findings on MRI suggestive of ovarian sarcoma include the following. Surgery is the mainstay of treatment for ovarian sarcoma.Among all chemotherapeutic regimens that are being used to treat ovarian sarcoma, they are divided into two groups like platinum containing regimens and non-platinum regimens. Cisplatin, carboplatin are commonly used.

## Historical Perspective[edit | edit source]

There is limited information available about the historical perspective of ovarian sarcoma

## Classification[edit | edit source]

* There is no established system for the classification of ovarian sarcoma.[1][2][3]

* Primary ovarian sarcomas occur as pure sarcomas or mixed mullerian tumors (MMTs).
* Pure sarcomas are comprised of a single malignant mesenchymal element and are further categorized as:
* Stromal cell sarcomas
* Fibrosarcomas
* Leiomyosarcomas
* Neurofibrosarcomas
* Rhabdomyosarcomas
* Chondrosarcomas
* Angiosarcomas
* Liposarcomas
* On the other hand mixed mullerian tumors(MMTs) are defined by the presence of both carcinomatous and sarcomatous elements and are more common than pure sarcomas.
* Ovarian MMTs can be further classified as homologous or heterologous on the basis of the tissue components present.
* Homologous tumors contain elements that are native to the ovary whereas heterologous tumors contain elements that normally are not present in the ovary.

The staging of [malignancy name] is based on the [staging system].

There is no established system for the staging of [malignancy name].

## Pathophysiology[edit | edit source]

* The exact pathogenesis of ovarian sarcoma is not fully understood[4][3]
* Clonal loss of the wild-type BRCA2 allele as well as the same somatic mutation of the TP53 gene was evident in histologic components

Types of ovarian cancer according to origin,Vargas AN. Natural history of ovarian cancer. Ecancermedicalscience. 2014;8:465. Published 2014 Sep 25. doi:10.3332/ecancer.2014.465,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4176445/

## Causes[edit | edit source]

The exact causes of ovarian sarcoma have not been identified.

## Differentiating ovarian sarcoma from Other Diseases[edit | edit source]

On the basis of age of onset, vaginal discharge, and constitutional symptoms, ovarian cancer must be differentiated from tubo-ovarian abscess, ectopic pregnancy, hydrosalpinx, salpingitis, fallopian tube carcinoma, uterine leiomyoma, choriocarcinoma, leiomyosarcoma, pregnancy, appendiceal abscess, appendiceal neoplasm, diverticular abscess, colorectal cancer, pelvic kidney, advanced bladder cancer, and retroperitoneal sarcoma.

Diseases  | Clinical manifestations | Para-clinical findings  | Gold standard | Additional findings

|
|
|
|

Age of onset | Symptoms | Physical examination
Lab Findings  | Imaging  | Immunohistopathology
pelvic/abdominal pain or pressure  | vaginal bleeding/discharge  | GI dysturbance  | Fever | Tenderness  | CT scan/US  | MRI
Gynecologic
Ovarian | Follicular cysts
[5] |

* Women in reproductive age (15 -45 y/o)

| +/–  | –  | –  | –  | +/–  |

* High level of estrogen +/–

* In US we may see a >3 cm simple cyst with no internal echo and with posterior acoustic enhancement

* simple cyst with no internal echo or septa

* NA

* History/
imaging

* It is associated with hyperestrogenism and endometrial hyperplasia

Theca lutein cysts
[6][7][8] |

* Women in reproductive age (15 -45 y/o)

| +/–  | –  | –  | –  | +/–  |

* Depends on the underlying etiology

* In US we may see bilaterally enlarged ovaries with multiple cysts

* Multiple bilateral cysts

* Theca interna cell Hyperplasia

* History/
imaging

* It is associated with hydatidiform moles, choriocarcinoma, diabetes mellitus and clomiphene intake (ovulation induction)

Serous cystadenoma/carcinoma
[9][10][11][12] |

* >55 y/o

| +/–  | –  | –  | –  | +/–  |

* Elevated levels of serum cancer antigen-125

* In US we may see simple or multiloculated cyst
* In serous cystadenocarcinoma we may see papillary projection inside the cyst
* In serous cystadenocarcinoma we may see ascites

* In Serous cystadenoma we may see a simple cyst with beak sign, hypointense on T1 and hyperintense on T2
* In serous cystadenocarcinoma we may see some Solid malignant components inside the cyst with intermediate signal on T1 and T2

* Cyst wall consist of benign/malignant Fallopian epithelial layer

* Psammoma body
* In serous cystadenocarcinoma we may see papillary projection inside the cyst

* Biopsy

* Most common ovarian neoplasm

Mucinous cystadenoma/carcinoma
[13][14][15] |

* >55 y/o

| +/–  | –  | –  | –  | +/–  |

* Elevated levels of serum cancer antigen-125

* In US we may see large simple cyst with septation
* In mucinous cystadenocarcinoma we may see thickened internal septation with solid components inside the cyst

* Stained glass appearance due to variable signal intensity on T1 and T2
* The more mucin we have, there is more intensity on T1
* and less intensity on T2

* Cyst wall consist of columnar endocervical epithelium
* We may see gelatinous mucin inside the cyst

* Biopsy

* It may cause pseudomyxoma peritonei

Endometrioma
[16][17][18] |

* Women in reproductive age (15 -45 y/o)

| \+  | \+  | +/–  | –  | \+  |

* Iron deficiency anemia

* Elevated levels of serum cancer antigen-125
* Increased levels of interleukin 1, chemoattractant protein-1, and interferon gamma

* Complex mass on US
* Increased Doppler flow because of increased vascularture
* It may present with catamenial pneumothorax, hemothorax, and lung nodules in CT scan.

* hyperintensity on T1-weighted images and a hypointensity on T2-weighted images
* Powder burn hemorrhages

* Chocolate cyst

* Laparoscopy

* It may cause infertility

Teratoma
[19][20][21][22]

* 10-30 y/o

| +/–  | –  | –  | –  | +/–  |

* High level of HCG and LDH

* In US we may see cystic adnexal mass with mural components and echogenic lesion due to calcification
* The iceberg sign
* Dot-dash pattern

* We may see evidence of fat components

* All three germ layers cell

* Biopsy

* It may cause ovarian torsion

* May content thyroid tissue and cause hyperthyroidism
* In plane radiography we may see calcification due to the presence of tooth in the tumor

Dysgerminoma
[23][24] |

* in the second to third decade of life

| \+  | +/–  | –  | –  | +/–  |

* High level of HCG and LDH
* Hypercalcemia

* Multilobulated solid masses

* We may see ovarian mass with septation which are hyperintense on T1 and hypo or isointense on T2 imaging

* Sheets fried egg appearance cells

* Biopsy

* Same as male seminoma

Yolk sac tumor
[25][26][27] |

* Young children
* Male infants

| \+  | –  | –  | –  | \+  |

* High levels of AFP

* In US we may see a combination of echogenic and hypoechoic components

* Ovarian mass with hemorrhagic areas

* Yellow appearance

* Hemorrhagic

* Schiller-Duval bodies (glomeruli like structures)

* Biopsy

* The other name is ovarian endodermal sinus tumor

Fibroma
[28][29][30] |

* >50 y/o

* Pulling sensation in the groin

| –  | –  | –  | +/–  |

* High levels of CA-125

* In CT scan we may see a unilateral mass with poor contrast enhancement

* Low signal intensity on T1 and T2

* We may see scattered hyperintense areas due to edema or cystic degeneration

* Spindle-shaped fibroblast

* Biopsy

* It may cause Meigs syndrome (ovarian fibroma, ascites, and hydrothorax)
* It may cause ovarian torsion
* It may cause pleural effusion

Thecoma
[31][32][33] |

* >50 y/o

| +/–  |

* Postmenopausal bleeding

| –  | –  | –  |

* High level of estrogen

* In US we may see non-specific ovarian mass

* We may see evidence of endometrial hyperplasia due to increased level of estrogen

* Hyperintense on T2
* T1 intensity depends on the amount of fibrous tissue (fibrous tissue lead to hypointensity)

* Lipid-laden stromal cells with pale, vaculolated cytoplasm

* Biopsy

* We may see endometrial cancer as e result of hyper-estrogenism
* We may see ovarian fibrothecoma (mixture of fibroma and thecoma)

Granulosa cell tumor
[34][35][36][37] |

* 50-60 y/o

| \+  |

* Postmenopausal bleeding

| +/–  | –  | –  |

* High level of estrogen and progesteron
* We may see inhibin, calretinin, and Ki-67 on the surface of granulosa tumor cells

* In US we may see solid, cystic, or multiloculated solid and cystic mass

* We may see solid, cystic, or multiloculated solid and cystic mass

* Call-Exner bodies

* Biopsy

* In postmenopausal women may cause breast tenderness

Sertoli-leydig cell tumor
[38][39] |

* 15 to 35 y/o

| +/–  | –  | –  | –  | –  |

* Elevated serum testosterone level
* Elevated alpha-fetoprotein

* In US we may see unilateral Well-defined hypoechoic lesion

* Low T2 signal intensity
* areas of high signal intensity

* Lydig cells (Polygonal pink cells with eosinophilic cytoplasm

* Sertoli cells (clear vacuolated cytoplasm)

* Biopsy

* It may cause virilization symptoms and amenorrhea

Brenner tumor
[40][41] |

* >55 y/o

| +/–  | –  | –  | –  | –  | –  |

* In US we may see hypoechoic solid mass and calcification

* Hypointense on T2 because of fibrous content

* Yellow/pale appearance
* Transitional cell tumor (resembles bladder)
* Coffee bean nuclei on H&E

* Biopsy

* Most of the times it's an accidental finding

Krukenberg tumor
[42][43] |

* >55 y/o

| +/–  | –  | +/–

Based on underlying malignancy

| –  | –  |

* In case of metastatic GI cancers we may see iron deficiency anemia

* Mostly bilateral, complex ovarian lesion
* In CT scan we may see evidence of concurrent malignancy in other organs

* Mostly bilateral, complex ovarian lesion with solid components
* Internal hyperintensity on T1 and T2 weighted MR images because of mucin
* Evidence of concurrent malignancy in other organs

* Mucin-secreting signet cell

* Imaging/
biopsy

* The most common primary tumor is in colon, stomach, breast, lung, and contralateral ovary
* Based on underlying malignancy it may cause pleural effusion

Tubal | tubo-ovarian abscess
[44][45][46][47] |

* Young women (15-30 y/o

| \+  | \+  | –  | \+  | \+  |

* High levels of inflammatory markers
* Leukocytosis

* In US we may see multilocular complex lesion mostly bilateral with debry inside

* We may see a pelvic mass filled with fluid with thick walls

* hypointense in T1 and heterogeneous in T2

* In abscess aspiration we may see anaerobic organisms

* History/
imaging

* The most common risk factors are previous PID, diabetes mellitus, intrauterine device and history of uterine surgery

Ectopic pregnancy
[48] |

* Women in reproductive age (15 -45 y/o)

| \+  | \+  | +/–  | –  | \+  |

* High level of BhCG
* Progesterone level ≤5 ng/ml

* In US we may see empty uterine cavity, tubal ring sign, ring of fire sign (Doppler), extra-uterine fetal heart rate

* NA

* NA

* History/
imaging

* Any women in reproductive age presenting with abdominal pain or amenorrhea should be screened for ectopic pregnancy

Hydrosalpinx
[49][50][51] |

* NA

| \+  | –  | –  | –  | +/–  | –  |

* In US we may see tubal longitudinal folds thickening (cogwheel appearance)
* In CT scan we may see tubular adnexal lesion with fluid attenuation

* Dilated Fallopian tube with fluid signal intensity

* NA

* Imaging

* It is associated with endometriosis (haematosalpinx), ovulation induction, pelvic inflammatory disease, post-hysterectomy, tubal ligation, and tubal malignancy

* It may cause infertility

Salpingitis
[52] |

* Women of reproductive age

| \+  | \+  | –  | \+  | \+  |

* Leukocytosis

* In US we may see , edematous and thickened endosalpingeal folds

* NA

* NA

* History/
physical
exam

* It may cause infertility

Fallopian tube carcinoma
[53] |

* >60 y/o

| \+  | \+  | \+  | –  | +/–  |

* High levels of CA125

* US findings are non specific (complex mass on Fallopian tube

* We may see papillary projections

* Low signal on T1

* In case of hemorrhage inside the tumor we may see high signal intensity on T1

* Low or of intermediate signal on T2

* In case of serous fluid inside the tumor we may see high signal intensity on T2

* Based on the tumor type we may have different biopsy finding

* Biopsy

* We may see Latzko triad (abdominal pain, vaginal discgarge, pelvic mass)
* It may cause pleural effusion

Uterine | Leiomyoma
[54][55] |

* Women of reproductive age

| \+  | \+  | –  | –  | +/–  |

* In chronic cases, we may see mild anemia

* In US we may see hypoechoic mass with calcification and cystic areas of necrosis or degeneration may

* Low to intermediate signal intensity on T1 and T2
* In case of necrosis inside the mass, there might be some high signal lesions on T2

* Smooth muscle

* Imaging

* It may cause infertility

Choriocarcinoma
[56][57][58][59] |

* Women in reproductive age (15 -45 y/o)

| \+  | \+  | +/–  | –  | \+  |

* High level of B-hCG

* In US we may see heterogeneous mass infiltrating myometrium
* Enlarged uterus
* Necrosis +
* Hemorrhage +
* In CT scan we may see evidence of metastasis to brain, lung and other organs

* We may see an infiltrative uterine mass and thickening of uterine wall

* Trophoblastic tissue origin
* columns and sheets of trophoblastic tissue invading uterine muscle and blood vessels

* Biopsy

|  |

* It is associated with bilateral theca lutein cysts
* Cannonball metastases to the lungs
* May cause hemoptysis
* We may see passing of grapes like tissue from the vagina

Leiomyosarcoma
[60][61][62][63][64] |

* >55 y/o

| \+  | \+  | –  | –  | +/–  |

* In some cases we may see elevated levels of CA-125 lactate dehydrogenase

* Heterogeneous mass with central low attenuation (necrosis) and calcification.

* Increased uterine size
* Irregular central zones of low signal intensity (tumor necrosis)

* We may see atypical cells, high mitotic rate, geographic areas of coagulative necrosis separated from viable neoplasm

* Biopsy

* In case of rapid uterine growth in post menopausal women we may suspect uterine sarcoma

Pregnancy
[65] |

* Women in reproductive age (15 -45 y/o)

| +/−  | +/−  | +/−  | –  | –  |

* High level of BhCG

* In US we may see ​gestational sac, yolk sac, double bleb sign and fetal pore
* In CT scan we may see cystic structure filled with fluid, curvilinear enhancing structure (placenta) and fetal pore

* Cystic structure filled with fluid
* Curvilinear enhancing structure (placenta)
* Fetal pore

* NA

* History/
laboratory
findings

* We do not perform CT scan and MRI in pregnancy but We may unintentionally image the pregnancy with CT scan and MRI.

Non-gynecologic
GIT | Appendiceal abscess
[66] |

* NA

| \+  | –  | \+  | +/–  | \+  |

* Leukocytosis

* Fluid collection in the appendicular region

* appendicolith may be visualized.

* Fluid collection in the appendicular region

* appendicolith may be visualized.

* NA

* Imaging/
history

* The most common complication of acute appendicitis
* It may cause pleural effusion

Appendiceal neoplasm
[67][68][69][70][71] |

* 60-70 y/o for adenocarcinoma,
* 30-50 y/o for carcinoid tumors

| \+  | –  | \+  | –  | +/–  |

* In adenocarcinoma type we may have high levels of CEA and CA 19-9
* In carcinoid type we may see high levels of chromogranin A, 5-HIAA and Ki67

* In CT scan we may see:
* Soft tissue thickening and Cystic lesion with Internal septation
* Wall irregularity
* Calcification
* Peri-appendiceal fat stranding

* Soft tissue mass in the appendix
* We may see invasion to other structures

* Gray/yellowi color

* Cystic structures with angiolymphatic invasion

* Biopsy

* It is associated with:
* MEN1 syndrome
* Ulcerative colitis
* Neurofibromatosis type 1
* HNPCC
* Smoking
* It may cause pleural effusion

## Epidemiology and Demographics[edit | edit source]

* Ovarian sarcoma is one of the least common gynecologic malignancy, constituting approximately 1% of all ovarian malignancies.[1][72][73][74][75][76]
* In 2012, approximately 239,000 women were diagnosed with ovarian cancer worldwide, and 152,000 died of the disease.
* Patients of all age groups may develop sarcoma of the ovary both postmenopausal and premenopausal women.
* The incidence of ovarian Sarcoma increases with age; the median age at diagnosis is 50-60 years.
* There is no racial predilection to ovarian Sarcoma

## Risk Factors[edit | edit source]

There are no established risk factors for ovarian sarcoma

## Screening[edit | edit source]

There is insufficient evidence to recommend routine screening for ovarian sarcoma.

## Natural History, Complications, and Prognosis[edit | edit source]

* Ovarian carcinosarcomas follow a distinct natural history compared to other more common epithelial carcinomas[77][3][78][79]
* Ovarian carcinosarcomas are aggressive neoplasms with a predilection towards early dissemination.
* Prognostic factors for this tumor type remain unclear because of its rarity.
* Prognosis is generally poor, and the 5-year survival rate of patients with ovarian sarcoma is approximately 28.2%.
* Some possible factors such as age and menopausal status have been proposed.

## Diagnostic Study of Choice[edit | edit source]

* There are no established criteria for the diagnosis of ovarian sarcoma
* Biopsy is the study of choice

## History and Symptoms[edit | edit source]

Most of the women are asymptomatic, when present, symptoms may include:[80][81][82]

* Pain in the abdomen or pelvic area
* Bloating or swelling of the abdomen
* Quickly feeling full when eating
* Other digestive problems

## Physical Examination[edit | edit source]

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

## Laboratory Findings[edit | edit source]

* An elevated concentration of CA-125 in serum is seen in some patients of ovarian sarcoma.[83][84][85]
* There are no diagnostic laboratory findings associated with ovarian sarcoma.

## Electrocardiogram[edit | edit source]

There are no ECG findings associated with ovarian sarcoma.

## X-ray[edit | edit source]

There are no x-ray findings associated with ovarian Sarcoma.

## Echocardiography or Ultrasound[edit | edit source]

There are no echocardiography/ultrasound findings associated with ovarian Sarcoma.

## CT scan[edit | edit source]

* CT scan may be helpful in the diagnosis of ovarian sarcoma . Findings on CT scan suggestive of ovarian sarcoma include:[86][87][88]

## MRI[edit | edit source]

* MRI may be helpful in the diagnosis of ovarian sarcoma. Findings on MRI suggestive of ovarian sarcoma include the following:[89][86][88][90][87]

## Other Imaging Findings[edit | edit source]

There are no other imaging findings associated with ovarian sarcoma

## Other Diagnostic Studies[edit | edit source]

There are no other diagnostic studies associated with [disease name].

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

## Treatment[edit | edit source]

## Medical Therapy[edit | edit source]

There is no medical treatment for ovarian sarcoma, the mainstay of therapy is surgery and chemotherapy.

## Surgery[edit | edit source]

* Surgery is the mainstay of treatment for ovarian sarcoma.
* The management is similar to that of epithelial carcinoma of ovary, consisting of cytoreductive surgery followed by adjuvant chemotherapy.

## Chemotherapy[edit | edit source]

* Chemotherapy with various regimens has been used in different centers without defined conclusions on efficacy[81][82][91][92][93]
* Multiple chemotherapeutic regimens have been evaluated with modest response rates ranging from 12% to 100%.
* Among all chemotherapeutic regimens that are being used, they are divided into two groups like platinum containing regimens and non-platinum regimens.
* Platinum containing chemotherapy regimens

1. Carboplatin and ifosfamide (Carbo-I)
2. Carboplatin (Carbo)
3. Cyclophosphamide, adriamycin and cisplatin (CAP)
4. Carboplatin and cyclophosphamide (Carbo-C)
5. Epirubicin, carboplatin and 5FU (E-Carbo-F)
6. Epirubicin, cisplatin and 5FU (ECF)
7. Taxol and Carboplatin (T-Carbo)

* Other chemotherapy regimens

1. Doxorubicin (A)
2. Doxorubicin and cyclophosphamide (AC)
3. Cyclophosphamide (IV)
4. Cyclophosphamide (oral)
5. Melphalan

## Primary Prevention[edit | edit source]

There are no established measures for the primary prevention of ovarian sarcoma.

## Secondary Prevention[edit | edit source]

There are no established measures for the secondary prevention of ovarian sarcoma.

## References[edit | edit source]

1. ↑ 1.0 1.1 Harris, M A; Delap, L M; Sengupta, P S; Wilkinson, P M; Welch, R S; Swindell, R; Shanks, J H; Wilson, G; Slade, R J; Reynolds, K; Jayson, G C (2003). "Carcinosarcoma of the ovary". British Journal of Cancer. 88 (5): 654–657. doi:10.1038/sj.bjc.6600770. ISSN 0007-0920.
2. ↑ Makris GM, Siristatidis C, Battista MJ, Chrelias C (2015). "Ovarian carcinosarcoma: a case report, diagnosis, treatment and literature review". Hippokratia. 19 (3): 256–9. PMC 4938474. PMID 27418786.CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 3.2 Rauh-Hain JA, Growdon WB, Rodriguez N, Goodman AK, Boruta DM, Schorge JO; et al. (2011). "Carcinosarcoma of the ovary: a case-control study". Gynecol Oncol. 121 (3): 477–81. doi:10.1016/j.ygyno.2011.02.023. PMID 21420726.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
4. ↑ Vargas AN (2014). "Natural history of ovarian cancer". Ecancermedicalscience. 8: 465. doi:10.3332/ecancer.2014.465. PMC 4176445. PMID 25371706.
5. ↑ Levine D, Brown DL, Andreotti RF, Benacerraf B, Benson CB, Brewster WR, Coleman B, Depriest P, Doubilet PM, Goldstein SR, Hamper UM, Hecht JL, Horrow M, Hur HC, Marnach M, Patel MD, Platt LD, Puscheck E, Smith-Bindman R (September 2010). "Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement". Radiology. 256 (3): 943–54. doi:10.1148/radiol.10100213. PMID 20505067.
6. ↑ Montz FJ, Schlaerth JB, Morrow CP (August 1988). "The natural history of theca lutein cysts". Obstet Gynecol. 72 (2): 247–51. PMID 2455880.
7. ↑ Southam, Anna L. (1962). "Massive Ovarian Hyperstimulation with Clomiphene Citrate". JAMA: The Journal of the American Medical Association. 181 (5): 443. doi:10.1001/jama.1962.03050310083018b. ISSN 0098-7484.
8. ↑ Nguyen, K T; Reid, R L; Sauerbrei, E (1986). "Antenatal sonographic detection of a fetal theca lutein cyst: a clue to maternal diabetes mellitus". Journal of Ultrasound in Medicine. 5 (11): 665–667. doi:10.7863/jum.1986.5.11.665. ISSN 0278-4297.
9. ↑ Jung, Seung Eun; Lee, Jae Mun; Rha, Sung Eun; Byun, Jae Young; Jung, Jung Im; Hahn, Seong Tai (2002). "CT and MR Imaging of Ovarian Tumors with Emphasis on Differential Diagnosis". RadioGraphics. 22 (6): 1305–1325. doi:10.1148/rg.226025033. ISSN 0271-5333.
10. ↑ Imai, Shunsuke; Kiyozuka, Yasuhiko; Maeda, Hiroko; Noda, Tuneo; Hosick, Howard L. (1990). "Establishment and Characterization of a Human Ovarian Serous Cystadenocarcinoma Cell Line That Produces the Tumor Markers CA-125 and Tissue Polypeptide Antigen". Oncology. 47 (2): 177–184. doi:10.1159/000226813. ISSN 0030-2414.
11. ↑ Malpica A, Deavers MT, Lu K, Bodurka DC, Atkinson EN, Gershenson DM, Silva EG (April 2004). "Grading ovarian serous carcinoma using a two-tier system". Am. J. Surg. Pathol. 28 (4): 496–504. PMID 15087669.
12. ↑ Li J, Fadare O, Xiang L, Kong B, Zheng W (March 2012). "Ovarian serous carcinoma: recent concepts on its origin and carcinogenesis". J Hematol Oncol. 5: 8. doi:10.1186/1756-8722-5-8. PMID 22405464.
13. ↑ Hoerl HD, Hart WR (December 1998). "Primary ovarian mucinous cystadenocarcinomas: a clinicopathologic study of 49 cases with long-term follow-up". Am. J. Surg. Pathol. 22 (12): 1449–62. PMID 9850171.
14. ↑ Lee KR, Scully RE (November 2000). "Mucinous tumors of the ovary: a clinicopathologic study of 196 borderline tumors (of intestinal type) and carcinomas, including an evaluation of 11 cases with 'pseudomyxoma peritonei'". Am. J. Surg. Pathol. 24 (11): 1447–64. PMID 11075847.
15. ↑ Jung, Seung Eun; Lee, Jae Mun; Rha, Sung Eun; Byun, Jae Young; Jung, Jung Im; Hahn, Seong Tai (2002). "CT and MR Imaging of Ovarian Tumors with Emphasis on Differential Diagnosis". RadioGraphics. 22 (6): 1305–1325. doi:10.1148/rg.226025033. ISSN 0271-5333.
16. ↑ Mol BW, Bayram N, Lijmer JG, Wiegerinck MA, Bongers MY, van der Veen F, Bossuyt PM (December 1998). "The performance of CA-125 measurement in the detection of endometriosis: a meta-analysis". Fertil. Steril. 70 (6): 1101–8. PMID 9848302.
17. ↑ Kinkel, Karen; Frei, Kathrin A.; Balleyguier, Corinne; Chapron, Charles (2005). "Diagnosis of endometriosis with imaging: a review". European Radiology. 16 (2): 285–298. doi:10.1007/s00330-005-2882-y. ISSN 0938-7994.
18. ↑ de Ziegler, Dominique; Borghese, Bruno; Chapron, Charles (2010). "Endometriosis and infertility: pathophysiology and management". The Lancet. 376 (9742): 730–738. doi:10.1016/S0140-6736(10)60490-4. ISSN 0140-6736.
19. ↑ Kawai, Michiyasu; Kano, Takeo; Kikkawa, Fumitaka; Morikawa, Yoshimitsu; Oguchi, Hidenori; Nakashima, Nobuo; Ishizuka, Takao; Kuzuya, Kazuo; Ohta, Masahiro; Arii, Yoshitaro; Tomoda, Yutaka (1992). "Seven tumor markers in benign and malignant germ cell tumors of the ovary". Gynecologic Oncology. 45 (3): 248–253. doi:10.1016/0090-8258(92)90299-X. ISSN 0090-8258.
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