Ovarian Sarcoma: Difference between revisions

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==Differentiating ovarian sarcoma from Other Diseases==
==Differentiating ovarian sarcoma from Other Diseases==
[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! colspan="2" rowspan="4" |Diseases
| colspan="6" |'''Clinical manifestations'''
! colspan="4" rowspan="2" |Para-clinical findings
| colspan="1" rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Gold standard'''
! rowspan="4" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Additional findings
|-
| rowspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Age of onset'''
| colspan="3" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Symptoms'''
! colspan="2" rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Physical examination
|-
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Lab Findings
! colspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Imaging
! rowspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Immunohistopathology
|-
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |pelvic/abdominal pain or pressure
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |vaginal bleeding/discharge
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |GI dysturbance
! colspan="1" rowspan="1" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Fever'''
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Tenderness
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |CT scan/US
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |MRI
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Serous cystadenoma/carcinoma<br><ref name="JungLee20022">{{cite journal|last1=Jung|first1=Seung Eun|last2=Lee|first2=Jae Mun|last3=Rha|first3=Sung Eun|last4=Byun|first4=Jae Young|last5=Jung|first5=Jung Im|last6=Hahn|first6=Seong Tai|title=CT and MR Imaging of Ovarian Tumors with Emphasis on Differential Diagnosis|journal=RadioGraphics|volume=22|issue=6|year=2002|pages=1305–1325|issn=0271-5333|doi=10.1148/rg.226025033}}</ref><ref name="ImaiKiyozuka1990">{{cite journal|last1=Imai|first1=Shunsuke|last2=Kiyozuka|first2=Yasuhiko|last3=Maeda|first3=Hiroko|last4=Noda|first4=Tuneo|last5=Hosick|first5=Howard L.|title=Establishment and Characterization of a Human Ovarian Serous Cystadenocarcinoma Cell Line That Produces the Tumor Markers CA-125 and Tissue Polypeptide Antigen|journal=Oncology|volume=47|issue=2|year=1990|pages=177–184|issn=0030-2414|doi=10.1159/000226813}}</ref><ref name="pmid15087669">{{cite journal |vauthors=Malpica A, Deavers MT, Lu K, Bodurka DC, Atkinson EN, Gershenson DM, Silva EG |title=Grading ovarian serous carcinoma using a two-tier system |journal=Am. J. Surg. Pathol. |volume=28 |issue=4 |pages=496–504 |date=April 2004 |pmid=15087669 |doi= |url=}}</ref><ref name="pmid22405464">{{cite journal |vauthors=Li J, Fadare O, Xiang L, Kong B, Zheng W |title=Ovarian serous carcinoma: recent concepts on its origin and carcinogenesis |journal=J Hematol Oncol |volume=5 |issue= |pages=8 |date=March 2012 |pmid=22405464 |doi=10.1186/1756-8722-5-8 |url=}}</ref>
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* >55 y/o
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px;" |
* Elevated levels of [[CA-125|serum cancer antigen-125]]
| style="background: #F5F5F5; padding: 5px;" |
* In [[Ultrasound|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]]
| style="background: #F5F5F5; padding: 5px;" |
* 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
| style="background: #F5F5F5; padding: 5px;" |
* [[Cyst]] wall consist of [[benign]]/[[malignant]] [[Fallopian tube|Fallopian]] [[Epithelium|epithelial]] layer
* [[Psammoma body]]
* In serous cystadenocarcinoma we may see [[papillary]] projection inside the [[cyst]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
* Most common [[ovarian neoplasm]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Mucinous cystadenoma]]/carcinoma<br><ref name="pmid9850171">{{cite journal |vauthors=Hoerl HD, Hart WR |title=Primary ovarian mucinous cystadenocarcinomas: a clinicopathologic study of 49 cases with long-term follow-up |journal=Am. J. Surg. Pathol. |volume=22 |issue=12 |pages=1449–62 |date=December 1998 |pmid=9850171 |doi= |url=}}</ref><ref name="pmid11075847">{{cite journal |vauthors=Lee KR, Scully RE |title=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' |journal=Am. J. Surg. Pathol. |volume=24 |issue=11 |pages=1447–64 |date=November 2000 |pmid=11075847 |doi= |url=}}</ref><ref name="JungLee2002">{{cite journal|last1=Jung|first1=Seung Eun|last2=Lee|first2=Jae Mun|last3=Rha|first3=Sung Eun|last4=Byun|first4=Jae Young|last5=Jung|first5=Jung Im|last6=Hahn|first6=Seong Tai|title=CT and MR Imaging of Ovarian Tumors with Emphasis on Differential Diagnosis|journal=RadioGraphics|volume=22|issue=6|year=2002|pages=1305–1325|issn=0271-5333|doi=10.1148/rg.226025033}}</ref>
| style="background: #F5F5F5; padding: 5px;" |
* >55 y/o
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px;" |
* Elevated levels of [[CA-125|serum cancer antigen-125]]
| style="background: #F5F5F5; padding: 5px;" |
* In [[Ultrasound|US]] we may see large simple [[cyst]] with septation
* In [[mucinous cystadenocarcinoma]] we may see thickened internal septation with solid components inside the [[Cyst of urachus|cyst]]
| style="background: #F5F5F5; padding: 5px;" |
* 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
| style="background: #F5F5F5; padding: 5px;" |
* [[Cyst]] wall consist of [[Columnar epithelia|columnar]] [[Endocervix|endocervical]] [[epithelium]]
* We may see gelatinous [[mucin]] inside the [[cyst]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
* It may cause [[pseudomyxoma peritonei]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Endometrioma]]<br><ref name="pmid9848302">{{cite journal |vauthors=Mol BW, Bayram N, Lijmer JG, Wiegerinck MA, Bongers MY, van der Veen F, Bossuyt PM |title=The performance of CA-125 measurement in the detection of endometriosis: a meta-analysis |journal=Fertil. Steril. |volume=70 |issue=6 |pages=1101–8 |date=December 1998 |pmid=9848302 |doi= |url=}}</ref><ref name="KinkelFrei2005">{{cite journal|last1=Kinkel|first1=Karen|last2=Frei|first2=Kathrin A.|last3=Balleyguier|first3=Corinne|last4=Chapron|first4=Charles|title=Diagnosis of endometriosis with imaging: a review|journal=European Radiology|volume=16|issue=2|year=2005|pages=285–298|issn=0938-7994|doi=10.1007/s00330-005-2882-y}}</ref><ref name="de ZieglerBorghese2010">{{cite journal|last1=de Ziegler|first1=Dominique|last2=Borghese|first2=Bruno|last3=Chapron|first3=Charles|title=Endometriosis and infertility: pathophysiology and management|journal=The Lancet|volume=376|issue=9742|year=2010|pages=730–738|issn=01406736|doi=10.1016/S0140-6736(10)60490-4}}</ref>
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* [[Women's College Hospital|Women]] in [[reproductive]] age (15 -45 y/o)
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
* [[Iron deficiency anemia]] 
* Elevated levels of [[CA-125|serum cancer antigen-125]]
* Increased levels of [[interleukin 1]], [[chemoattractant]] protein-1, and [[Interferon-gamma|interferon gamma]]
| style="background: #F5F5F5; padding: 5px;" |
* Complex [[mass]] on [[Ultrasound|US]]
* Increased [[Doppler ultrasound|Doppler]] flow because of increased vascularture
* It may present with [[catamenial pneumothorax]], [[hemothorax]], and [[lung]] [[nodules]] in [[CT scan]].
| style="background: #F5F5F5; padding: 5px;" |
* hyperintensity on T1-weighted images and a hypointensity on T2-weighted [[images]]
* Powder burn [[hemorrhages]]
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* [[Chocolate cyst]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Laparoscopy]]
| style="background: #F5F5F5; padding: 5px;" |
* It may cause [[infertility]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Teratoma]]<br><ref name="KawaiKano1992">{{cite journal|last1=Kawai|first1=Michiyasu|last2=Kano|first2=Takeo|last3=Kikkawa|first3=Fumitaka|last4=Morikawa|first4=Yoshimitsu|last5=Oguchi|first5=Hidenori|last6=Nakashima|first6=Nobuo|last7=Ishizuka|first7=Takao|last8=Kuzuya|first8=Kazuo|last9=Ohta|first9=Masahiro|last10=Arii|first10=Yoshitaro|last11=Tomoda|first11=Yutaka|title=Seven tumor markers in benign and malignant germ cell tumors of the ovary|journal=Gynecologic Oncology|volume=45|issue=3|year=1992|pages=248–253|issn=00908258|doi=10.1016/0090-8258(92)90299-X}}</ref><ref name="DunzendorferdeLAS MORENAS1999">{{cite journal|last1=Dunzendorfer|first1=Thomas|last2=deLAS MORENAS|first2=ANTONIO|last3=Kalir|first3=Tamara|last4=Levin|first4=Robert M.|title=Struma Ovarii and Hyperthyroidism|journal=Thyroid|volume=9|issue=5|year=1999|pages=499–502|issn=1050-7256|doi=10.1089/thy.1999.9.499}}</ref><ref name="OutwaterSiegelman2001">{{cite journal|last1=Outwater|first1=Eric K.|last2=Siegelman|first2=Evan S.|last3=Hunt|first3=Jennifer L.|title=Ovarian Teratomas: Tumor Types and Imaging Characteristics|journal=RadioGraphics|volume=21|issue=2|year=2001|pages=475–490|issn=0271-5333|doi=10.1148/radiographics.21.2.g01mr09475}}</ref><ref name="SabaGuerriero2009">{{cite journal|last1=Saba|first1=Luca|last2=Guerriero|first2=Stefano|last3=Sulcis|first3=Rosa|last4=Virgilio|first4=Bruna|last5=Melis|first5=GianBenedetto|last6=Mallarini|first6=Giorgio|title=Mature and immature ovarian teratomas: CT, US and MR imaging characteristics|journal=European Journal of Radiology|volume=72|issue=3|year=2009|pages=454–463|issn=0720048X|doi=10.1016/j.ejrad.2008.07.044}}</ref>
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* 10-30 y/o
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px;" |
* High level of [[HCG]] and [[LDH]]
| style="background: #F5F5F5; padding: 5px;" |
* In [[Ultrasound|US]] we may see [[cystic]] [[adnexal]] [[mass]] with mural components and echogenic [[lesion]] due to [[calcification]]
* The iceberg [[sign]]
* Dot-dash pattern
| style="background: #F5F5F5; padding: 5px;" |
* We may see evidence of [[fat]] components
| style="background: #F5F5F5; padding: 5px;" |
* All three [[Germ layer|germ layers]] [[Cell (biology)|cell]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Biopsy]]
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* 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]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Granulosa cell tumour|Granulosa cell tumor]]<br><ref name="pmid17945423">{{cite journal |vauthors=Pectasides D, Pectasides E, Psyrri A |title=Granulosa cell tumor of the ovary |journal=Cancer Treat. Rev. |volume=34 |issue=1 |pages=1–12 |date=February 2008 |pmid=17945423 |doi=10.1016/j.ctrv.2007.08.007 |url=}}</ref><ref name="StenwigHazekamp1979">{{cite journal|last1=Stenwig|first1=Jan Trygve|last2=Hazekamp|first2=Johan The.|last3=Beecham|first3=Jackson B.|title=Granulosa cell tumors of the ovary. A clinicopathological study of 118 cases with long-term follow-up|journal=Gynecologic Oncology|volume=7|issue=2|year=1979|pages=136–152|issn=00908258|doi=10.1016/0090-8258(79)90090-8}}</ref><ref name="pmid9386298">{{cite journal |vauthors=Morikawa K, Hatabu H, Togashi K, Kataoka ML, Mori T, Konishi J |title=Granulosa cell tumor of the ovary: MR findings |journal=J Comput Assist Tomogr |volume=21 |issue=6 |pages=1001–4 |date=1997 |pmid=9386298 |doi= |url=}}</ref><ref name="pmid10227493">{{cite journal |vauthors=Ko SF, Wan YL, Ng SH, Lee TY, Lin JW, Chen WJ, Kung FT, Tsai CC |title=Adult ovarian granulosa cell tumors: spectrum of sonographic and CT findings with pathologic correlation |journal=AJR Am J Roentgenol |volume=172 |issue=5 |pages=1227–33 |date=May 1999 |pmid=10227493 |doi=10.2214/ajr.172.5.10227493 |url=}}</ref>
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* 50-60 y/o
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
* [[Postmenopausal bleeding]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px;" |
* High level of [[estrogen]] and [[Progesterone|progesteron]]
* We may see [[inhibin]], [[calretinin]], and [[Ki-67]] on the surface of [[Granulosa cell|granulosa]] [[tumor]] [[Cell (biology)|cells]]
| style="background: #F5F5F5; padding: 5px;" |
* In [[Ultrasound|US]] we may see solid, [[cystic]], or multiloculated solid and [[cystic]] [[mass]]
| style="background: #F5F5F5; padding: 5px;" |
* We may see solid, [[Cystic Cytoplasm|cystic]], or multiloculated solid and [[cystic]] [[mass]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Call-Exner bodies]]
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* [[Biopsy]]
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* In [[postmenopausal]] [[women]] may cause [[breast]] [[tenderness]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Sertoli-Leydig cell tumor|Sertoli-leydig cell tumor]]<br><ref name="LantzschStoerer2001">{{cite journal|last1=Lantzsch|first1=T.|last2=Stoerer|first2=S.|last3=Lawrenz|first3=K.|last4=Buchmann|first4=J.|last5=Strauss|first5=H.-G.|last6=Koelbl|first6=H.|title=Sertoli-Leydig cell tumor|journal=Archives of Gynecology and Obstetrics|volume=264|issue=4|year=2001|pages=206–208|issn=0932-0067|doi=10.1007/s004040000114}}</ref><ref name="JungRha2005">{{cite journal|last1=Jung|first1=Seung Eun|last2=Rha|first2=Sung Eun|last3=Lee|first3=Jae Mun|last4=Park|first4=Soo Youn|last5=Oh|first5=Soon Nam|last6=Cho|first6=Kyoung Sik|last7=Lee|first7=Eun Ju|last8=Byun|first8=Jae Young|last9=Hahn|first9=Seong Tai|title=CT and MRI Findings of Sex Cord–Stromal Tumor of the Ovary|journal=American Journal of Roentgenology|volume=185|issue=1|year=2005|pages=207–215|issn=0361-803X|doi=10.2214/ajr.185.1.01850207}}</ref>
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* 15 to 35 y/o
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px;" |
* Elevated [[serum]] [[testosterone]] level
* Elevated [[alpha-fetoprotein]]
| style="background: #F5F5F5; padding: 5px;" |
* In [[Ultrasound|US]] we may see unilateral Well-defined hypoechoic [[lesion]]
| style="background: #F5F5F5; padding: 5px;" |
* Low T2 signal intensity
* areas of high signal intensity
| style="background: #F5F5F5; padding: 5px;" |
* Lydig [[Cell (biology)|cells]] (Polygonal pink [[Cell (biology)|cells]] with [[eosinophilic]] [[cytoplasm]]
* [[Sertoli cell|Sertoli cells]] (clear vacuolated [[cytoplasm]])
| style="background: #F5F5F5; padding: 5px;" |
* [[Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
* It may cause [[virilization]] [[Symptom|symptoms]] and [[amenorrhea]]
|-
| rowspan="5" style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Fallopian tube|Tubal]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[tubo-ovarian abscess]]<br><ref name="LandersSweet1983">{{cite journal|last1=Landers|first1=D. V.|last2=Sweet|first2=R. L.|title=Tubo-ovarian Abscess: Contemporary Approach to Management|journal=Clinical Infectious Diseases|volume=5|issue=5|year=1983|pages=876–884|issn=1058-4838|doi=10.1093/clinids/5.5.876}}</ref><ref name="Stewart TaylorMcMillan1975">{{cite journal|last1=Stewart Taylor|first1=E.|last2=McMillan|first2=James H.|last3=Greer|first3=Benjamin E.|last4=Droegemueller|first4=William|last5=Thompson|first5=Horace E.|title=The intrauterine device and tubo-ovarian abscess|journal=American Journal of Obstetrics and Gynecology|volume=123|issue=4|year=1975|pages=338–348|issn=00029378|doi=10.1016/S0002-9378(16)33434-2}}</ref><ref name="HaLim1995">{{cite journal|last1=Ha|first1=H. K.|last2=Lim|first2=G. Y.|last3=Cha|first3=E. S.|last4=Lee|first4=H. G.|last5=Ro|first5=H. J.|last6=Kim|first6=H. S.|last7=Kim|first7=H. H.|last8=Joo|first8=S. W.|last9=Jee|first9=M. K.|title=MR Imaging of Tubo-Ovarian Abscess|journal=Acta Radiologica|volume=36|issue=5|year=1995|pages=510–514|issn=0284-1851|doi=10.1080/02841859509173418}}</ref><ref name="pmid12854857">{{cite journal |vauthors=Varras M, Polyzos D, Perouli E, Noti P, Pantazis I, Akrivis Ch |title=Tubo-ovarian abscesses: spectrum of sonographic findings with surgical and pathological correlations |journal=Clin Exp Obstet Gynecol |volume=30 |issue=2-3 |pages=117–21 |date=2003 |pmid=12854857 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |
* Young [[women]] (15-30 y/o
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
* High levels of [[Inflammation|inflammatory]] [[Marker|markers]]
* [[Leukocytosis]]
| style="background: #F5F5F5; padding: 5px;" |
* In [[Ultrasound|US]] we may see multilocular complex [[lesion]] mostly [[bilateral]] with debry inside
| style="background: #F5F5F5; padding: 5px;" |
* We may see a [[Pelvic masses|pelvic mass]] filled with [[fluid]] with thick walls
* hypointense in T1 and  heterogeneous in T2
| style="background: #F5F5F5; padding: 5px;" |
* In [[abscess]] [[aspiration]] we may see [[Anaerobic organism|anaerobic organisms]]
| style="background: #F5F5F5; padding: 5px;" |
* [[History and Physical examination|History]]/<br>[[imaging]]
| style="background: #F5F5F5; padding: 5px;" |
*The most common [[Risk factor|risk factors]] are previous [[PID]], [[diabetes mellitus]], [[intrauterine device]] and [[History and Physical examination|history]] of [[Uterus|uterine]] [[surgery]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Fallopian tube cancer|Fallopian tube carcinoma]]<br><ref name="NiloffKlug1984">{{cite journal|last1=Niloff|first1=Jonathan M.|last2=Klug|first2=Thomas L.|last3=Schaetzl|first3=Elena|last4=Zurawski|first4=Vincent R.|last5=Knapp|first5=Robert C.|last6=Bast|first6=Robert C.|title=Elevation of serum CA125 in carcinomas of the fallopian tube, endometrium, and endocervix|journal=American Journal of Obstetrics and Gynecology|volume=148|issue=8|year=1984|pages=1057–1058|issn=00029378|doi=10.1016/S0002-9378(84)90444-7}}</ref>
| style="background: #F5F5F5; padding: 5px;" |
* >60 y/o
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | –
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px;" |
* High levels of [[CA-125|CA125]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Ultrasound|US]] findings are non specific (complex [[Mass–energy equivalence|mass]] on [[Fallopian tube]]
* We may see [[papillary]] projections
| style="background: #F5F5F5; padding: 5px;" |
* 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
| style="background: #F5F5F5; padding: 5px;" |
* Based on the [[Tumor suppressor gene|tumor]] type we may have different [[biopsy]] finding
| style="background: #F5F5F5; padding: 5px;" |
* [[Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
* We may see Latzko triad ([[abdominal pain]], [[Vagina|vaginal]] discgarge, [[Pelvic masses|pelvic mass]])
* It may cause [[Pleural effusion (patient information)|pleural effusion]]
|-
| rowspan="4" style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Uterus|Uterine]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Leiomyoma]]<br><ref name="BullettiDe Ziegler1999">{{cite journal|last1=Bulletti|first1=Carlo|last2=De Ziegler|first2=Dominique|last3=Polli|first3=Valeria|last4=Flamigni|first4=Carlo|title=The role of leiomyomas in infertility|journal=The Journal of the American Association of Gynecologic Laparoscopists|volume=6|issue=4|year=1999|pages=441–445|issn=10743804|doi=10.1016/S1074-3804(99)80008-5}}</ref><ref name="MuraseSiegelman1999">{{cite journal|last1=Murase|first1=Eiko|last2=Siegelman|first2=Evan S.|last3=Outwater|first3=Eric K.|last4=Perez-Jaffe|first4=Liza A.|last5=Tureck|first5=Richard W.|title=Uterine Leiomyomas: Histopathologic Features, MR Imaging Findings, Differential Diagnosis, and Treatment|journal=RadioGraphics|volume=19|issue=5|year=1999|pages=1179–1197|issn=0271-5333|doi=10.1148/radiographics.19.5.g99se131179}}</ref>
| style="background: #F5F5F5; padding: 5px;" |
* [[Women]] of [[reproductive]] age
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | –
| style="background: #F5F5F5; padding: 5px; text-align: center;" | –
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px;" |
* In [[chronic]] cases, we may see mild [[anemia]]
| style="background: #F5F5F5; padding: 5px;" |
* In [[Ultrasound|US]] we may see hypoechoic [[Mass-independent fractionation|mass]] with [[calcification]] and [[Cyst|cystic]] areas of [[necrosis]] or [[degeneration]] may
| style="background: #F5F5F5; padding: 5px;" |
* Low to intermediate signal intensity on T1 and T2
* In case of [[necrosis]] inside the [[mass]], there might be some high signal [[Lesion|lesions]] on T2
| style="background: #F5F5F5; padding: 5px;" |
* [[Smooth muscle]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Imaging]]
| style="background: #F5F5F5; padding: 5px;" |
* It may cause  [[infertility]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Choriocarcinoma]]<br><ref name="SecklFisher2000">{{cite journal|last1=Seckl|first1=Michael J|last2=Fisher|first2=Rosemary A|last3=Salerno|first3=Giovanni|last4=Rees|first4=Helene|last5=Paradinas|first5=Fernando J|last6=Foskett|first6=Marianne|last7=Newlands|first7=Edward S|title=Choriocarcinoma and partial hydatidiform moles|journal=The Lancet|volume=356|issue=9223|year=2000|pages=36–39|issn=01406736|doi=10.1016/S0140-6736(00)02432-6}}</ref><ref name="NishikawaKaseki1985">{{cite journal|last1=Nishikawa|first1=Yoshiki|last2=Kaseki|first2=Shigeaki|last3=Tomoda|first3=Yutaka|last4=Ishizuka|first4=Takao|last5=Asai|first5=Yasumasa|last6=Suzuki|first6=Toshio|last7=Ushijima|first7=Hiroshi|title=Histopathologic classification of uterine choriocarcinoma|journal=Cancer|volume=55|issue=5|year=1985|pages=1044–1051|issn=0008-543X|doi=10.1002/1097-0142(19850301)55:5<1044::AID-CNCR2820550520>3.0.CO;2-7}}</ref><ref name="pmid558566">{{cite journal |vauthors=Libshitz HI, Baber CE, Hammond CB |title=The pulmonary metastases of choriocarcinoma |journal=Obstet Gynecol |volume=49 |issue=4 |pages=412–6 |date=April 1977 |pmid=558566 |doi= |url=}}</ref><ref name="pmid16114202">{{cite journal |vauthors=Diouf A, Cissé ML, Laïco A, Ndiaye D, Moreau JC, Diadhiou F |title=[Sonographic features of gestational choriocarcinoma] |language=French |journal=J Radiol |volume=86 |issue=5 Pt 1 |pages=469–73 |date=May 2005 |pmid=16114202 |doi= |url=}}</ref>
| style="background: #F5F5F5; padding: 5px;" |
* [[Women]] in [[reproductive]] age (15 -45 y/o)
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px;" |
* High level of [[HCG|B-hCG]]
| style="background: #F5F5F5; padding: 5px;" |
* In [[Ultrasound|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
| style="background: #F5F5F5; padding: 5px;" |
* We may see an infiltrative [[Uterine Cancer|uterine]] mass and  thickening of [[Uterus|uterine]] wall
| style="background: #F5F5F5; padding: 5px;" |
* [[Trophoblast]]<nowiki/>ic [[tissue]] origin
* columns and sheets of [[trophoblast]]<nowiki/>ic tissue invading uterine [[Myotome|muscle]] and [[blood vessels]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
* It is associated with bilateral [[Ovarian cyst|theca lutein cysts]]
* Cannonball [[Metastasis|metastases]] to the [[lungs]]
* May cause [[hemoptysis]]
* We may see passing of grapes like tissue from the [[vagina]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Leiomyosarcoma]]<br><ref name="SekiHoshihara1992">{{cite journal|last1=Seki|first1=K.|last2=Hoshihara|first2=T.|last3=Nagata|first3=I.|title=Leiomyosarcoma of the Uterus: Ultrasonography and Serum Lactate Dehydrogenase Level|journal=Gynecologic and Obstetric Investigation|volume=33|issue=2|year=1992|pages=114–118|issn=1423-002X|doi=10.1159/000294861}}</ref><ref name="pmid17009628">{{cite journal |vauthors=Juang CM, Yen MS, Horng HC, Twu NF, Yu HC, Hsu WL |title=Potential role of preoperative serum CA125 for the differential diagnosis between uterine leiomyoma and uterine leiomyosarcoma |journal=Eur. J. Gynaecol. Oncol. |volume=27 |issue=4 |pages=370–4 |date=2006 |pmid=17009628 |doi= |url=}}</ref><ref name="PattaniKier1995">{{cite journal|last1=Pattani|first1=Sita J.|last2=Kier|first2=Ruben|last3=Deal|first3=Robert|last4=Luchansky|first4=Edward|title=MRI of uterine leiomyosarcoma|journal=Magnetic Resonance Imaging|volume=13|issue=2|year=1995|pages=331–333|issn=0730725X|doi=10.1016/0730-725X(95)93813-5}}</ref><ref name="McLeodZornoza1984">{{cite journal|last1=McLeod|first1=A J|last2=Zornoza|first2=J|last3=Shirkhoda|first3=A|title=Leiomyosarcoma: computed tomographic findings.|journal=Radiology|volume=152|issue=1|year=1984|pages=133–136|issn=0033-8419|doi=10.1148/radiology.152.1.6729102}}</ref><ref name="RobboyBentley2000">{{cite journal|last1=Robboy|first1=Stanley J.|last2=Bentley|first2=Rex C.|last3=Butnor|first3=Kelly|last4=Anderson|first4=Malcolm C.|title=Pathology and Pathophysiology of Uterine Smooth-Muscle Tumors|journal=Environmental Health Perspectives|volume=108|year=2000|pages=779|issn=00916765|doi=10.2307/3454306}}</ref>
| style="background: #F5F5F5; padding: 5px;" |
* >55 y/o
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" |–
| style="background: #F5F5F5; padding: 5px; text-align: center;" | +/–
| style="background: #F5F5F5; padding: 5px;" |
* In some cases we may see elevated levels of [[CA-125]] [[lactate dehydrogenase]]
| style="background: #F5F5F5; padding: 5px;" |
* Heterogeneous mass with central low attenuation ([[necrosis]]) and  [[calcification]].
| style="background: #F5F5F5; padding: 5px;" |
* Increased [[uterine]] size
* Irregular central zones of low signal intensity (tumor [[necrosis]])
| style="background: #F5F5F5; padding: 5px;" |
* We may see [[Atypia|atypical cells]], high [[mitotic]] rate, geographic areas of [[coagulative necrosis]] separated from viable [[neoplasm]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Biopsy]]
| style="background: #F5F5F5; padding: 5px;" |
* In case of rapid [[uterine]] growth in post [[Menopause|menopausal]] [[women]] we may suspect [[uterine sarcoma]]
|}
OR
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Epidemiology and Demographics==
==Epidemiology and Demographics==

Revision as of 17:15, 19 August 2019


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

Overview

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 müllerian 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

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

Classification

  • There is no established system for the classification of ovarian Sarcoma.[1][2][3]
  • Primary ovarian sarcomas occur as pure sarcomas or mixed müllerian 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].

OR

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

Pathophysiology

  • 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

The exact causes of ovarian sarcoma have not been identified.

Differentiating ovarian sarcoma from Other Diseases

Epidemiology and Demographics

Risk Factors

There are no established risk factors for ovarian sarcoma

Screening

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

Natural History, Complications, and Prognosis

  • Ovarian carcinosarcomas follow a distinct natural history compared to other more common epithelial carcinomas[10][3][11][12]
  • 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

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

History and Symptoms

Most of the women are asymptomatic, when present, symptoms may include:[13][14][15]

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

Physical Examination

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].

OR

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

OR

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

OR

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

Laboratory Findings

  • An elevated concentration of CA-125 in serum is seen in some patients of ovarian sarcoma.[16][17][18]
  • There are no diagnostic laboratory findings associated with ovarian sarcoma.

Electrocardiogram

There are no ECG findings associated with ovarian sarcoma.

X-ray

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

Echocardiography or Ultrasound

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

CT scan

  • CT scan may be helpful in the diagnosis of ovarian sarcoma . Findings on CT scan suggestive of ovarian sarcoma include:[19][20][21]

MRI

  • MRI may be helpful in the diagnosis of ovarian sarcoma. Findings on MRI suggestive of ovarian sarcoma include the following:[22][19][21][23][20]

Other Imaging Findings

There are no other imaging findings associated with ovarian sarcoma

Other Diagnostic Studies

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

OR

[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].

OR

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

Medical Therapy

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

Surgery

  • 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

  • Chemotherapy with various regimens has been used in different centers without defined conclusions on efficacy[14][15][24][25][26]
  • 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

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

Secondary Prevention

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

References

  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.
  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.
  4. ↑ Vargas AN (2014). "Natural history of ovarian cancer". Ecancermedicalscience. 8: 465. doi:10.3332/ecancer.2014.465. PMC 4176445. PMID 25371706.
  5. ↑ Ferlay, Jacques; Soerjomataram, Isabelle; Dikshit, Rajesh; Eser, Sultan; Mathers, Colin; Rebelo, Marise; Parkin, Donald Maxwell; Forman, David; Bray, Freddie (2015). "Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012". International Journal of Cancer. 136 (5): E359–E386. doi:10.1002/ijc.29210. ISSN 0020-7136.
  6. ↑ Ferlay, Jacques; Shin, Hai-Rim; Bray, Freddie; Forman, David; Mathers, Colin; Parkin, Donald Maxwell (2010). "Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008". International Journal of Cancer. 127 (12): 2893–2917. doi:10.1002/ijc.25516. ISSN 0020-7136.
  7. ↑ Parkin DM, Bray F, Ferlay J, Pisani P (2005). "Global cancer statistics, 2002". CA Cancer J Clin. 55 (2): 74–108. PMID 15761078.
  8. ↑ Cresanta JL (1992). "Epidemiology of cancer in the United States". Prim Care. 19 (3): 419–41. PMID 1410056.
  9. ↑ Bray, Freddie; Ferlay, Jacques; Soerjomataram, Isabelle; Siegel, Rebecca L.; Torre, Lindsey A.; Jemal, Ahmedin (2018). "Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries". CA: A Cancer Journal for Clinicians. 68 (6): 394–424. doi:10.3322/caac.21492. ISSN 0007-9235.
  10. ↑ Barnholtz-Sloan JS, Morris R, Malone JM, Munkarah AR (2004) Survival of women diagnosed with malignant, mixed mullerian tumors of the ovary (OMMMT). Gynecol Oncol 93 (2):506-12. DOI:10.1016/j.ygyno.2004.02.016 PMID: 15099970
  11. ↑ Sood AK, Sorosky JI, Gelder MS, Buller RE, Anderson B, Wilkinson EJ et al. (1998) Primary ovarian sarcoma: analysis of prognostic variables and the role of surgical cytoreduction. Cancer 82 (9):1731-7. PMID: 9576296
  12. ↑ Cicin İ, Özatlı T, Türkmen E, Özturk T, Özçelik M, Çabuk D et al. (2016) Predictive and Prognostic Factors in Ovarian and Uterine Carcinosarcomas. Balkan Med J 33 (5):517-524. DOI:10.5152/balkanmedj.2016.151268 PMID: 27761279
  13. ↑ Dai Y, Shen K, Lang JH, Huang HF, Pan LY, Wu M; et al. (2011). "Primary sarcoma of the ovary: clinicopathological characteristics, prognostic factors and evaluation of therapy". Chin Med J (Engl). 124 (9): 1316–21. PMID 21740740.
  14. ↑ 14.0 14.1 del Carmen MG, Birrer M, Schorge JO (2012). "Carcinosarcoma of the ovary: a review of the literature". Gynecol Oncol. 125 (1): 271–7. doi:10.1016/j.ygyno.2011.12.418. PMID 22155675.
  15. ↑ 15.0 15.1 Kim HJ, Lee HM, Kim MK, Lee YK, Lee IH, Lee KH; et al. (2017). "Prognostic assessment of sarcomatous histologic subtypes of ovarian carcinosarcoma". Obstet Gynecol Sci. 60 (4): 350–356. doi:10.5468/ogs.2017.60.4.350. PMC 5547082. PMID 28791266.
  16. ↑ Shakuntala P, Umadevi K, Usha A, Abhilasha N, Bafna U (2012). "Primary ovarian adenosarcoma with elevated Ca-125 levels and normal ascitic fluid cytology: a case report and review of literature". Ecancermedicalscience. 6: 284. doi:10.3332/ecancer.2012.284. PMC 3530409. PMID 23304240.
  17. ↑ Mogensen O, Mogensen B, Jakobsen A (1990). "Tumour-associated trypsin inhibitor (TATI) and cancer antigen 125 (CA 125) in mucinous ovarian tumours". Br J Cancer. 61 (2): 327–9. doi:10.1038/bjc.1990.64. PMC 1971406. PMID 2310684.
  18. ↑ Van Gorp T, Cadron I, Despierre E, Daemen A, Leunen K, Amant F; et al. (2011). "HE4 and CA125 as a diagnostic test in ovarian cancer: prospective validation of the Risk of Ovarian Malignancy Algorithm". Br J Cancer. 104 (5): 863–70. doi:10.1038/sj.bjc.6606092. PMC 3048204. PMID 21304524.
  19. ↑ 19.0 19.1 Miccò M, Sala E, Lakhman Y, Hricak H, Vargas HA (2015). "Imaging Features of Uncommon Gynecologic Cancers". AJR Am J Roentgenol. 205 (6): 1346–59. doi:10.2214/AJR.14.12695. PMC 5502476. PMID 26587944.
  20. ↑ 20.0 20.1 Bell DJ, Pannu HK (2011). "Radiological assessment of gynecologic malignancies". Obstet Gynecol Clin North Am. 38 (1): 45–68, vii. doi:10.1016/j.ogc.2011.02.003. PMID 21419327.
  21. ↑ 21.0 21.1 Forstner R, Graf A (1999). "[Diagnostic imaging in staging of gynecologic carcinomas]". Radiologe. 39 (7): 610–8. PMID 10472090.
  22. ↑ Manoharan D, Das CJ, Aggarwal A, Gupta AK (2016). "Diffusion weighted imaging in gynecological malignancies - present and future". World J Radiol. 8 (3): 288–97. doi:10.4329/wjr.v8.i3.288. PMC 4807338. PMID 27027614.
  23. ↑ Alt CD, Brocker KA, Eichbaum M, Sohn C, Arnegger FU, Kauczor HU; et al. (2011). "Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT: Part 2". Strahlenther Onkol. 187 (11): 705–14. doi:10.1007/s00066-011-4002-z. PMID 22037656.
  24. ↑ Brown E, Stewart M, Rye T, Al-Nafussi A, Williams AR, Bradburn M; et al. (2004). "Carcinosarcoma of the ovary: 19 years of prospective data from a single center". Cancer. 100 (10): 2148–53. doi:10.1002/cncr.20256. PMID 15139057.
  25. ↑ Harris MA, Delap LM, Sengupta PS, Wilkinson PM, Welch RS, Swindell R; et al. (2003). "Carcinosarcoma of the ovary". Br J Cancer. 88 (5): 654–7. doi:10.1038/sj.bjc.6600770. PMC 2376340. PMID 12618869.
  26. ↑ Cicin I, Saip P, Eralp Y, Selam M, Topuz S, Ozluk Y; et al. (2008). "Ovarian carcinosarcomas: clinicopathological prognostic factors and evaluation of chemotherapy regimens containing platinum". Gynecol Oncol. 108 (1): 136–40. doi:10.1016/j.ygyno.2007.09.003. PMID 17936342.

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