Ovarian cancer differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Fahimeh Shojaei, M.D. Huda A. Karman, M.D.

## Overview

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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.

## Differentiating ovarian cancer from other Diseases

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### Differentiating ovarian cancer from other diseases on the basis of age of onset, vaginal discharge and constitutional symptoms

[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.[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81]

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
[1] |

* 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
[2][3][4] |

* 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
[5][6][7][8] |

* >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

* We may see a simple cyst with beak sign, hypointense on T1 and hyperintense on T2
* 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
* We may see papillary projection inside the cyst

* Biopsy

* Most common ovarian neoplasm

Mucinous cystadenoma/carcinoma
[9][10][11] |

* >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
[12][13][14] |

* 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
[15][16][17][18] |

* 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
[19][20] |

* 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
[21][22][23] |

* 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
[24][25][26] |

* >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
[27][28][29] |

* >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
[30][31][32][33] |

* 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
[34][35] |

* 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
[36][37] |

* >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
[38][39] |

* >55 y/o

| +/–  | –  | +/–

Based on underlying malignancy

| –  | –  |

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

* 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
[40][41][42][43] |

* 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
[44] |

* 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
[45][46][47] |

* 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
[48] |

* 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
[49] |

* >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
[50][51] |

* 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
[52][53][54][55] |

* 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
[56][57][58][59][60] |

* >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
[61] |

* 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
[62] |

* 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
[63][64][65][66][67] |

* 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

Diverticular abscess
[72] |

* >50 y/o

| \+  | –  | \+  | +/–  | \+  |

* Leukocytosis

* Ill-defined lesion with air and fluid inside
* Adjacent bowel loop wall thickening
* Smudged mesenteric fat

* We may see a lesion with air and fluid inside

* NA

* Imaging/
history

* Diverticular abscess happens in almost 30-40% of patients with diverticulitis
* It may cause pleural effusion

Colorectal cancer
[68][69][70][71] |

* >50 y/o

| \+  | –  | \+  | –  | +/–  |

* Anemia
* Positive Fecal occult blood test
* High levels of CEA and CA 19-9

* In CT scan we may see luminal narrowing, intestinal wall thickening,intussusception, bowel obstruction, hepatic metastases, intestinal perforation,enlarged lymph nodes

* We may see tumor mass and the extension of tumor to other structures

* We may see metastasis to the liver, lung and brain

* Based on the sub-type we may have different histopathological feature (for more information click here)

* Biopsy

* It is associated with smoking, positive family history, processed meat, low fiber diet, lynch Syndrome and familial adenomatous polyposis
* They have apple core lesion on barium enema xray

Renal

Bladder

| Pelvic kidney
[73][74] |

* NA

| −/+

In case of sever hydronephrosis or renal stone we may have pelvic pain

| –  | −  | −  | −  | −  |

* In sonography we may see normal appearing kidney in pelvic position

* We may see renal calculi

* We may see normal kidney structure

* Renal calculi

* NA

* Imaging

* It may cause hypertension

* It may cause tract infection (UTI), obstruction, and renal calculi.
* It may be associated with RCC

Bladder cancer
[75][76][77] |

* ≥65 y/o

| \+  | –  | –  | –  | –  |

* Low red blood cell count
* Elevated alkaline phosphatase
* Positive tumor markers such as BTA, NMP, and CEA

* In CT scan we may see masses protruding into the bladder lumen or asymmetric thickening of the bladder
* calcifications
* Nodal metastases

* isointense compared to muscle in T1

* slightly hyperintense compared to muscle in T2

* Based on the sub-type we may have different histopathological feature (for more information click here)

* Biopsy

* It may presents with hematuria

Others  | Retroperitoneal sarcoma
[78][79][80][81] |

* 40-50 y/o

| \+  | –  | \+  | −  | −  |

* Mild leukocytosis.
* It may cause hypoglycemia because of production of insulinlike substances

* We may see irregular solid, semisolid, liquefactive areas and patchy necrosis on CT scan

* We may see retroperitoneal involvement and degree of tumor extension
* We may see liver and lung metastasis

* There are two types: liposarcoma and leiomyosarcoma
* In liposarcomas we may see background of adipocytes with scattered lipoblasts, and inflammatory cell infiltrate
* In leiomyosarcoma we may see smooth muscle cells

* Biopsy

* May cause lower extremity edema, Serous ascites
* we should perform chest CT scan to rule out pulmonary metastases

ABBREVIATIONS

BTA=Bladder tumor associated antigen, NMP= Nuclear matrix proteins, CEA= Carcinoembryonic antigen, US= Ultrasound, HCG= Human chorionic gonadotropin, LDH= Lactate dehydrogenase, AFP= Alpha fitoprotein, CA125= Cancer antigen 125, H&E= Hematoxylin and eosin, MRI= Magnetic resonance imaging, GI= Gastrointestinal tract, PID= Pelvic inflammatory disease, CA19-9= Carbohydrate antigen 19-9, 5HIAA= 5-hydroxyindoleacetic acid, MEN syndrome= Multiple endocrine neoplasia syndrome, HNPCC= Hereditary nonpolyposis colorectal cancer, UTI= Urinary tract infection, RCC= Renal cell carcinoma

## References

[edit | edit source]

1. ↑ 1.0 1.1 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.
2. ↑ 2.0 2.1 Montz FJ, Schlaerth JB, Morrow CP (August 1988). "The natural history of theca lutein cysts". Obstet Gynecol. 72 (2): 247–51. PMID 2455880.
3. ↑ 3.0 3.1 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.
4. ↑ 4.0 4.1 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.
5. ↑ 5.0 5.1 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.
6. ↑ 6.0 6.1 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.
7. ↑ 7.0 7.1 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.
8. ↑ 8.0 8.1 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.
9. ↑ 9.0 9.1 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.
10. ↑ 10.0 10.1 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.
11. ↑ 11.0 11.1 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.
12. ↑ 12.0 12.1 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.
13. ↑ 13.0 13.1 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.
14. ↑ 14.0 14.1 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.
15. ↑ 15.0 15.1 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.
16. ↑ 16.0 16.1 Dunzendorfer, Thomas; deLAS MORENAS, ANTONIO; Kalir, Tamara; Levin, Robert M. (1999). "Struma Ovarii and Hyperthyroidism". Thyroid. 9 (5): 499–502. doi:10.1089/thy.1999.9.499. ISSN 1050-7256.
17. ↑ 17.0 17.1 Outwater, Eric K.; Siegelman, Evan S.; Hunt, Jennifer L. (2001). "Ovarian Teratomas: Tumor Types and Imaging Characteristics". RadioGraphics. 21 (2): 475–490. doi:10.1148/radiographics.21.2.g01mr09475. ISSN 0271-5333.
18. ↑ 18.0 18.1 Saba, Luca; Guerriero, Stefano; Sulcis, Rosa; Virgilio, Bruna; Melis, GianBenedetto; Mallarini, Giorgio (2009). "Mature and immature ovarian teratomas: CT, US and MR imaging characteristics". European Journal of Radiology. 72 (3): 454–463. doi:10.1016/j.ejrad.2008.07.044. ISSN 0720-048X.
19. ↑ 19.0 19.1 Dgani, R.; Shoham(Schwartz), Z.; Czernobilsky, B.; Kaftori, A.; Borenstein, R.; Lancet, M. (1988). "Lactic dehydrogenase, alkaline phosphatase and human chorionic gonadotropin in a pure ovarian dysgerminoma". Gynecologic Oncology. 30 (1): 44–50. doi:10.1016/0090-8258(88)90044-3. ISSN 0090-8258.
20. ↑ 20.0 20.1 Tanaka YO, Kurosaki Y, Nishida M, Michishita N, Kuramoto K, Itai Y, Kubo T (1994). "Ovarian dysgerminoma: MR and CT appearance". J Comput Assist Tomogr. 18 (3): 443–8. PMID 8188914.
21. ↑ 21.0 21.1 Yang, Grace C.H. (2000). "Fine-needle aspiration cytology of Schiller-Duval bodies of yolk-sac tumor". Diagnostic Cytopathology. 23 (4): 228–232. doi:10.1002/1097-0339(200010)23:4<228::AID-DC2>3.0.CO;2-M. ISSN 8755-1039.
22. ↑ 22.0 22.1 Levitin, A; Haller, K D; Cohen, H L; Zinn, D L; O'Connor, M T (1996). "Endodermal sinus tumor of the ovary: imaging evaluation". American Journal of Roentgenology. 167 (3): 791–793. doi:10.2214/ajr.167.3.8751702. ISSN 0361-803X.
23. ↑ 23.0 23.1 Talerman, A.; Haije, W. G. (1974). "Alpha-fetoprotein and germ cell tumors: A possible role of yolk sac tumor in production of alpha-fetoprotein". Cancer. 34 (5): 1722–1726. doi:10.1002/1097-0142(197411)34:5<1722::AID-CNCR2820340521>3.0.CO;2-F. ISSN 0008-543X.
24. ↑ 24.0 24.1 MEIGS JV (May 1954). "Fibroma of the ovary with ascites and hydrothorax; Meigs' syndrome". Am. J. Obstet. Gynecol. 67 (5): 962–85. PMID 13148256.
25. ↑ 25.0 25.1 Sivanesaratnam, V.; Dutta, R.; Jayalakshmi, P. (1990). "Ovarian fibroma - clinical and histopathological characteristics". International Journal of Gynecology & Obstetrics. 33 (3): 243–247. doi:10.1016/0020-7292(90)90009-A. ISSN 0020-7292.
26. ↑ 26.0 26.1 Abad, Antonio; Cazorla, Eduardo; Ruiz, Fernando; Aznar, Ismael; Asins, Enrique; Llixiona, Joaquin (1999). "Meigs' syndrome with elevated CA125: case report and review of the literature". European Journal of Obstetrics & Gynecology and Reproductive Biology. 82 (1): 97–99. doi:10.1016/S0301-2115(98)00174-2. ISSN 0301-2115.
27. ↑ 27.0 27.1 Yaghoobian, Jahanguir; Pinck, Robert L. (1983). "Ultrasound findings in thecoma of the ovary". Journal of Clinical Ultrasound. 11 (2): 91–93. doi:10.1002/jcu.1870110207. ISSN 0091-2751.
28. ↑ 28.0 28.1 Li, Xinchun; Zhang, Weidong; Zhu, Guangbin; Sun, Congpeng; Liu, Qingyu; Shen, Yuechun (2012). "Imaging Features and Pathologic Characteristics of Ovarian Thecoma". Journal of Computer Assisted Tomography. 36 (1): 46–53. doi:10.1097/RCT.0b013e31823f6186. ISSN 0363-8715.
29. ↑ 29.0 29.1 Proctor, Francis E.; Greeley, Joseph P.; Rathmell, Thomas K. (1951). "Malignant thecoma of the ovary". American Journal of Obstetrics and Gynecology. 62 (1): 185–192. doi:10.1016/0002-9378(51)91109-X. ISSN 0002-9378.
30. ↑ 30.0 30.1 Pectasides D, Pectasides E, Psyrri A (February 2008). "Granulosa cell tumor of the ovary". Cancer Treat. Rev. 34 (1): 1–12. doi:10.1016/j.ctrv.2007.08.007. PMID 17945423.
31. ↑ 31.0 31.1 Stenwig, Jan Trygve; Hazekamp, Johan The.; Beecham, Jackson B. (1979). "Granulosa cell tumors of the ovary. A clinicopathological study of 118 cases with long-term follow-up". Gynecologic Oncology. 7 (2): 136–152. doi:10.1016/0090-8258(79)90090-8. ISSN 0090-8258.
32. ↑ 32.0 32.1 Morikawa K, Hatabu H, Togashi K, Kataoka ML, Mori T, Konishi J (1997). "Granulosa cell tumor of the ovary: MR findings". J Comput Assist Tomogr. 21 (6): 1001–4. PMID 9386298.
33. ↑ 33.0 33.1 Ko SF, Wan YL, Ng SH, Lee TY, Lin JW, Chen WJ, Kung FT, Tsai CC (May 1999). "Adult ovarian granulosa cell tumors: spectrum of sonographic and CT findings with pathologic correlation". AJR Am J Roentgenol. 172 (5): 1227–33. doi:10.2214/ajr.172.5.10227493. PMID 10227493.
34. ↑ 34.0 34.1 Lantzsch, T.; Stoerer, S.; Lawrenz, K.; Buchmann, J.; Strauss, H.-G.; Koelbl, H. (2001). "Sertoli-Leydig cell tumor". Archives of Gynecology and Obstetrics. 264 (4): 206–208. doi:10.1007/s004040000114. ISSN 0932-0067.
35. ↑ 35.0 35.1 Jung, Seung Eun; Rha, Sung Eun; Lee, Jae Mun; Park, Soo Youn; Oh, Soon Nam; Cho, Kyoung Sik; Lee, Eun Ju; Byun, Jae Young; Hahn, Seong Tai (2005). "CT and MRI Findings of Sex Cord–Stromal Tumor of the Ovary". American Journal of Roentgenology. 185 (1): 207–215. doi:10.2214/ajr.185.1.01850207. ISSN 0361-803X.
36. ↑ 36.0 36.1 Shevchuk, Maria M.; Fenoglio, Cecilia M.; Richart, Ralph M. (1980). "Histogenesis of brenner tumors, I: Histology and ultrastructure". Cancer. 46 (12): 2607–2616. doi:10.1002/1097-0142(19801215)46:12<2607::AID-CNCR2820461213>3.0.CO;2-Q. ISSN 0008-543X.
37. ↑ 37.0 37.1 Outwater, Eric K; Siegelman, Evan S; Kim, Bohyun; Chiowanich, Peerapod; Blasbalg, Roberto; Kilger, Alex (1998). "Ovarian Brenner tumors: MR imaging characteristics". Magnetic Resonance Imaging. 16 (10): 1147–1153. doi:10.1016/S0730-725X(98)00136-2. ISSN 0730-725X.
38. ↑ 38.0 38.1 Kim SH, Kim WH, Park KJ, Lee JK, Kim JS (1996). "CT and MR findings of Krukenberg tumors: comparison with primary ovarian tumors". J Comput Assist Tomogr. 20 (3): 393–8. PMID 8626898.
39. ↑ 39.0 39.1 Al-Agha OM, Nicastri AD (November 2006). "An in-depth look at Krukenberg tumor: an overview". Arch. Pathol. Lab. Med. 130 (11): 1725–30. doi:10.1043/1543-2165(2006)130[1725:AILAKT]2.0.CO;2. PMID 17076540.
40. ↑ 40.0 40.1 Landers, D. V.; Sweet, R. L. (1983). "Tubo-ovarian Abscess: Contemporary Approach to Management". Clinical Infectious Diseases. 5 (5): 876–884. doi:10.1093/clinids/5.5.876. ISSN 1058-4838.
41. ↑ 41.0 41.1 Stewart Taylor, E.; McMillan, James H.; Greer, Benjamin E.; Droegemueller, William; Thompson, Horace E. (1975). "The intrauterine device and tubo-ovarian abscess". American Journal of Obstetrics and Gynecology. 123 (4): 338–348. doi:10.1016/S0002-9378(16)33434-2. ISSN 0002-9378.
42. ↑ 42.0 42.1 Ha, H. K.; Lim, G. Y.; Cha, E. S.; Lee, H. G.; Ro, H. J.; Kim, H. S.; Kim, H. H.; Joo, S. W.; Jee, M. K. (1995). "MR Imaging of Tubo-Ovarian Abscess". Acta Radiologica. 36 (5): 510–514. doi:10.1080/02841859509173418. ISSN 0284-1851.
43. ↑ 43.0 43.1 Varras M, Polyzos D, Perouli E, Noti P, Pantazis I, Akrivis C (2003). "Tubo-ovarian abscesses: spectrum of sonographic findings with surgical and pathological correlations". Clin Exp Obstet Gynecol. 30 (2–3): 117–21. PMID 12854857. Vancouver style error: initials (help)
44. ↑ 44.0 44.1 Barnhart, Kurt T. (2009). "Ectopic Pregnancy". New England Journal of Medicine. 361 (4): 379–387. doi:10.1056/NEJMcp0810384. ISSN 0028-4793.
45. ↑ 45.0 45.1 Kim, Mi Young; Rha, Sung Eun; Oh, Soon Nam; Jung, Seung Eun; Lee, Young Joon; Kim, You Sung; Byun, Jae Young; Lee, Ahwon; Kim, Mee-Ran (2009). "MR Imaging Findings of Hydrosalpinx: A Comprehensive Review". RadioGraphics. 29 (2): 495–507. doi:10.1148/rg.292085070. ISSN 0271-5333.
46. ↑ 46.0 46.1 Atri M, Nazarnia S, Bret PM, Aldis AE, Kintzen G, Reinhold C (July 1994). "Endovaginal sonographic appearance of benign ovarian masses". Radiographics. 14 (4): 747–60, discussion 761–2. doi:10.1148/radiographics.14.4.7938766. PMID 7938766.
47. ↑ 47.0 47.1 Chanelles, Olivier; Ducarme, Guillaume; Sifer, Christophe; Hugues, Jean-Noel; Touboul, Cyril; Poncelet, Christophe (2011). "Hydrosalpinx and infertility: what about conservative surgical management?". European Journal of Obstetrics & Gynecology and Reproductive Biology. 159 (1): 122–126. doi:10.1016/j.ejogrb.2011.07.004. ISSN 0301-2115.
48. ↑ 48.0 48.1 Czerwenka K, Heuss F, Hosmann J, Manavi M, Jelincic D, Kubista E (October 1994). "Salpingitis caused by Chlamydia trachomatis and its significance for infertility". Acta Obstet Gynecol Scand. 73 (9): 711–5. PMID 7976247.
49. ↑ 49.0 49.1 Niloff, Jonathan M.; Klug, Thomas L.; Schaetzl, Elena; Zurawski, Vincent R.; Knapp, Robert C.; Bast, Robert C. (1984). "Elevation of serum CA125 in carcinomas of the fallopian tube, endometrium, and endocervix". American Journal of Obstetrics and Gynecology. 148 (8): 1057–1058. doi:10.1016/S0002-9378(84)90444-7. ISSN 0002-9378.
50. ↑ 50.0 50.1 Bulletti, Carlo; De Ziegler, Dominique; Polli, Valeria; Flamigni, Carlo (1999). "The role of leiomyomas in infertility". The Journal of the American Association of Gynecologic Laparoscopists. 6 (4): 441–445. doi:10.1016/S1074-3804(99)80008-5. ISSN 1074-3804.
51. ↑ 51.0 51.1 Murase, Eiko; Siegelman, Evan S.; Outwater, Eric K.; Perez-Jaffe, Liza A.; Tureck, Richard W. (1999). "Uterine Leiomyomas: Histopathologic Features, MR Imaging Findings, Differential Diagnosis, and Treatment". RadioGraphics. 19 (5): 1179–1197. doi:10.1148/radiographics.19.5.g99se131179. ISSN 0271-5333.
52. ↑ 52.0 52.1 Seckl, Michael J; Fisher, Rosemary A; Salerno, Giovanni; Rees, Helene; Paradinas, Fernando J; Foskett, Marianne; Newlands, Edward S (2000). "Choriocarcinoma and partial hydatidiform moles". The Lancet. 356 (9223): 36–39. doi:10.1016/S0140-6736(00)02432-6. ISSN 0140-6736.
53. ↑ 53.0 53.1 Nishikawa, Yoshiki; Kaseki, Shigeaki; Tomoda, Yutaka; Ishizuka, Takao; Asai, Yasumasa; Suzuki, Toshio; Ushijima, Hiroshi (1985). "Histopathologic classification of uterine choriocarcinoma". Cancer. 55 (5): 1044–1051. doi:10.1002/1097-0142(19850301)55:5<1044::AID-CNCR2820550520>3.0.CO;2-7. ISSN 0008-543X.
54. ↑ 54.0 54.1 Libshitz HI, Baber CE, Hammond CB (April 1977). "The pulmonary metastases of choriocarcinoma". Obstet Gynecol. 49 (4): 412–6. PMID 558566.
55. ↑ 55.0 55.1 Diouf A, Cissé ML, Laïco A, Ndiaye D, Moreau JC, Diadhiou F (May 2005). "[Sonographic features of gestational choriocarcinoma]". J Radiol (in French). 86 (5 Pt 1): 469–73. PMID 16114202.CS1 maint: Unrecognized language (link)
56. ↑ 56.0 56.1 Seki, K.; Hoshihara, T.; Nagata, I. (1992). "Leiomyosarcoma of the Uterus: Ultrasonography and Serum Lactate Dehydrogenase Level". Gynecologic and Obstetric Investigation. 33 (2): 114–118. doi:10.1159/000294861. ISSN 1423-002X.
57. ↑ 57.0 57.1 Juang CM, Yen MS, Horng HC, Twu NF, Yu HC, Hsu WL (2006). "Potential role of preoperative serum CA125 for the differential diagnosis between uterine leiomyoma and uterine leiomyosarcoma". Eur. J. Gynaecol. Oncol. 27 (4): 370–4. PMID 17009628.
58. ↑ 58.0 58.1 Pattani, Sita J.; Kier, Ruben; Deal, Robert; Luchansky, Edward (1995). "MRI of uterine leiomyosarcoma". Magnetic Resonance Imaging. 13 (2): 331–333. doi:10.1016/0730-725X(95)93813-5. ISSN 0730-725X.
59. ↑ 59.0 59.1 McLeod, A J; Zornoza, J; Shirkhoda, A (1984). "Leiomyosarcoma: computed tomographic findings". Radiology. 152 (1): 133–136. doi:10.1148/radiology.152.1.6729102. ISSN 0033-8419.
60. ↑ 60.0 60.1 Robboy, Stanley J.; Bentley, Rex C.; Butnor, Kelly; Anderson, Malcolm C. (2000). "Pathology and Pathophysiology of Uterine Smooth-Muscle Tumors". Environmental Health Perspectives. 108: 779. doi:10.2307/3454306. ISSN 0091-6765.
61. ↑ 61.0 61.1 Cacctatore, Bruno; Tttttnen, Atla; Stenman, Ulf-Hakan; Ylostalo, Pekka (1990). "Normal early pregnancy: serum hCG levels and vaginal ultrasonography findings". BJOG: An International Journal of Obstetrics and Gynaecology. 97 (10): 899–903. doi:10.1111/j.1471-0528.1990.tb02444.x. ISSN 1470-0328.
62. ↑ 62.0 62.1 Pinto Leite N, Pereira JM, Cunha R, Pinto P, Sirlin C (August 2005). "CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings". AJR Am J Roentgenol. 185 (2): 406–17. doi:10.2214/ajr.185.2.01850406. PMID 16037513.
63. ↑ 63.0 63.1 Chapter 5: Tumours of the Appendix - IARC. https://www.iarc.fr/en/publications/pdfs-online/pat-gen/bb2/bb2-chap5.pdf Accessed on January 15, 2019
64. ↑ 64.0 64.1 Goede, A. C.; Caplin, M. E.; Winslet, M. C. (2003). "Carcinoid tumour of the appendix". British Journal of Surgery. 90 (11): 1317–1322. doi:10.1002/bjs.4375. ISSN 0007-1323.
65. ↑ 65.0 65.1 Pablo Carmignani, C.; Hampton, Regina; E. Sugarbaker, Christina; Chang, David; H. Sugarbaker, Paul (2004). "Utility of CEA and CA 19-9 tumor markers in diagnosis and prognostic assessment of mucinous epithelial cancers of the appendix". Journal of Surgical Oncology. 87 (4): 162–166. doi:10.1002/jso.20107. ISSN 0022-4790.
66. ↑ 66.0 66.1 Limsui D, Vierkant RA, Tillmans LS, Wang AH, Weisenberger DJ, Laird PW, Lynch CF, Anderson KE, French AJ, Haile RW, Harnack LJ, Potter JD, Slager SL, Smyrk TC, Thibodeau SN, Cerhan JR, Limburg PJ (July 2010). "Cigarette smoking and colorectal cancer risk by molecularly defined subtypes". J. Natl. Cancer Inst. 102 (14): 1012–22. doi:10.1093/jnci/djq201. PMC 2915616. PMID 20587792.
67. ↑ 67.0 67.1 Duh QY, Hybarger CP, Geist R, Gamsu G, Goodman PC, Gooding GA, Clark OH (July 1987). "Carcinoids associated with multiple endocrine neoplasia syndromes". Am. J. Surg. 154 (1): 142–8. PMID 2886072.
68. ↑ 68.0 68.1 Zhu, Amy; Kaneshiro, Marc; Kaunitz, Jonathan D. (2010). "Evaluation and Treatment of Iron Deficiency Anemia: A Gastroenterological Perspective". Digestive Diseases and Sciences. 55 (3): 548–559. doi:10.1007/s10620-009-1108-6. ISSN 0163-2116.
69. ↑ 69.0 69.1 Macdonald JS (1999). "Carcinoembryonic antigen screening: pros and cons". Semin Oncol. 26 (5): 556–60. PMID 10528904.
70. ↑ 70.0 70.1 Haggar FA, Boushey RP (November 2009). "Colorectal cancer epidemiology: incidence, mortality, survival, and risk factors". Clin Colon Rectal Surg. 22 (4): 191–7. doi:10.1055/s-0029-1242458. PMC 2796096. PMID 21037809.
71. ↑ 71.0 71.1 Taylor AJ, Youker JE (1991). "Imaging in colorectal carcinoma". Semin Oncol. 18 (2): 99–110. PMID 2014406.
72. ↑ 72.0 72.1 Hulnick, D H; Megibow, A J; Balthazar, E J; Naidich, D P; Bosniak, M A (1984). "Computed tomography in the evaluation of diverticulitis". Radiology. 152 (2): 491–495. doi:10.1148/radiology.152.2.6739821. ISSN 0033-8419.
73. ↑ 73.0 73.1 Weizer, Alon Z.; Springhart, W. Patrick; Ekeruo, Wesley O.; Matlaga, Brian R.; Tan, Yeh H.; Assimos, Dean G.; Preminger, Glenn M. (2005). "Ureteroscopic management of renal calculi in anomalous kidneys". Urology. 65 (2): 265–269. doi:10.1016/j.urology.2004.09.055. ISSN 0090-4295.
74. ↑ 74.0 74.1 Ross, Jonathan H.; Kay, Robert (1998). "URETEROPELVIC JUNCTION OBSTRUCTION IN ANOMALOUS KIDNEYS". Urologic Clinics of North America. 25 (2): 219–225. doi:10.1016/S0094-0143(05)70010-0. ISSN 0094-0143.
75. ↑ 75.0 75.1 Barentsz JO, Jager GJ, Witjes JA, Ruijs JH (1996). "Primary staging of urinary bladder carcinoma: the role of MRI and a comparison with CT". Eur Radiol. 6 (2): 129–33. PMID 8797968.
76. ↑ 76.0 76.1 Shariat SF, Karam JA, Lotan Y, Karakiewizc PI (2008). "Critical evaluation of urinary markers for bladder cancer detection and monitoring". Rev Urol. 10 (2): 120–35. PMC 2483317. PMID 18660854.
77. ↑ 77.0 77.1 Metts MC, Metts JC, Milito SJ, Thomas CR (June 2000). "Bladder cancer: a review of diagnosis and management". J Natl Med Assoc. 92 (6): 285–94. PMC 2640522. PMID 10918764.
78. ↑ 78.0 78.1 Storm FK, Mahvi DM (July 1991). "Diagnosis and management of retroperitoneal soft-tissue sarcoma". Ann. Surg. 214 (1): 2–10. PMC 1358407. PMID 2064467.
79. ↑ 79.0 79.1 Francis IR, Cohan RH, Varma DG, Sondak VK (August 2005). "Retroperitoneal sarcomas". Cancer Imaging. 5: 89–94. doi:10.1102/1470-7330.2005.0019. PMID 16154826.
80. ↑ 80.0 80.1 Silverstein, Murray N.; Wakim, Khalil G.; Bahn, Robert C. (1964). "Hypoglycemia associated with neoplasia". The American Journal of Medicine. 36 (3): 415–423. doi:10.1016/0002-9343(64)90168-8. ISSN 0002-9343.
81. ↑ 81.0 81.1 Storm FK, Mahvi DM (July 1991). "Diagnosis and management of retroperitoneal soft-tissue sarcoma". Ann. Surg. 214 (1): 2–10. PMC 1358407. PMID 2064467.

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