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Ovarian cancer
Classification and external resources
ICD-10 C56., D27.
ICD-9 183, 220
ICD-O: varied
DiseasesDB 9418
MedlinePlus 000889
eMedicine med/1698 

Ovarian cancer is a malignant tumor, of any histology, arising from an ovary. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The International Classification of Diseases for Oncology (ICD-O is a domain specific extension of the International Statistical Classification of Diseases and Related Health Problems The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Malignant (from the Latin roots mal- = "bad" and -genus = "born" is a medical term used to describe a severe and progressively worsening disease See also Cancer A tumor or tumour is the name for a swelling or lesion formed by an abnormal growth of cells (termed neoplastic Histology (from the Greek = 'tissue' is the study of the microscopic anatomy of cells and tissues of Plants and "Ovaria" redirects here This is also a proposed section and a Synonym of Solanum.

Contents

Epidemiology

Ovarian cancer is the fifth leading cause of cancer deaths in women, the leading cause of death from gynecological malignancy, and the second most commonly diagnosed gynecologic malignancy. Epidemiology is the study of factors affecting the Health and Illness of populations and serves as the foundation and Logic of interventions made in the Cancer (medical term Malignant Neoplasm) is a class of Diseases in which a group of cells display uncontrolled Gynaecology or gynecology (see spelling differences) refers to the surgical specialty dealing with health of the female reproductive system ( Uterus [1] According to the American Cancer Society, there is no true test for ovarian cancer. The American Cancer Society ( ACS) is the "nationwide community-based voluntary health organization dedicated to "Several large studies are in progess to learn how best to find ovarian cancer in its earliest stage. "[1] Since there is no accurate screening test, "an exploratory surgical procedure called laparotomy is generally required for the definitive diagnosis of ovarian cancer. During this procedure, cysts or other suspicious areas must be removed and biopsied. After the incision is made, the surgeon assesses the fluid and cells in the abdominal cavity. If the lesion is cancerous, the surgeon continues with a process called surgical staging to ascertain how far the cancer has spread. " [2]

The exact cause is usually unknown. The disease is more common in industrialized nations, with the exception of Japan. For a topic outline on this subject see List of basic Japan topics. In the United States, females have a 1. The United States of America —commonly referred to as the 4% to 2. 5% (1 out of 40-60 women) lifetime chance of developing ovarian cancer. Older women are at highest risk. More than half of the deaths from ovarian cancer occur in women between 55 and 74 years of age and approximately one quarter of ovarian cancer deaths occur in women between 35 and 54 years of age.

The risk of developing ovarian cancer appears to be affected by several factors. The more children a woman has, the lower her risk of ovarian cancer. Early age at first pregnancy, older ages of final pregnancy and the use of low dose hormonal contraception have also been shown to have a protective effect. Hormonal contraception refers to Birth control methods that act on the hormonal system Ovarian cancer is reduced in women after tubal ligation. Tubal ligation (informally known as getting one's "tubes tied" is a permanent form of female sterilization, in which the Fallopian tubes are severed

The relationship between use of oral contraceptives and ovarian cancer was shown in a summary of results of 45 case-control and prospective studies. Cumulatively these studies show a protective effect for ovarian cancers. Women who used oral contraceptives for 10 years had about a 60% reduction in risk of ovarian cancer. (risk ratio . 42 with statistical significant confidence intervals given the large study size, not unexpected). This means that if 250 women took oral contraceptives for 10 years, 1 ovarian cancer would be prevented. This is by far the largest epidemiological study to date on this subject (45 studies, over 20,000 women with ovarian cancer and about 80,000 controls). [2]

The link to the use of fertility medication, such as Clomiphene citrate, has been controversial. Fertility medication is medication that enhances Fertility. For women fertility medication is used to stimulate follicle development of the Ovary. Clomifene ( INN) or clomiphene ( USAN and former BAN) or Clomid or Clomifert is a Selective estrogen receptor modulator (SERM An analysis in 1991 raised the possibility that use of drugs may increase the risk of ovarian cancer. Year 1991 ( MCMXCI) was a Common year starting on Tuesday (link will display full calendar of the Gregorian Calendar. Several cohort studies and case-control studies have been conducted since then without providing conclusive evidence for such a link. Case-control is a type of Epidemiological Study design. Case-control studies are used to identify factors that may contribute to a medical condition by comparing subjects [3] It will remain a complex topic to study as the infertile population differs in parity from the "normal" population. For other uses of the term in other fields see Parity. In Medicine, parity is a technical term that refers to the number of times

There is good evidence that in some women genetic factors are important. Carriers of certain mutations of the BRCA1 or the BRCA2 gene. BRCA1 ( Breast cancer 1 early onset is a Human Gene, some mutations of which are associated with a significant increase in the risk of Breast cancer BRCA2 (Breast Cancer Type 2 susceptibility protein is a Human Gene that is involved in the repair of chromosomal History See also History of genetics The existence of genes was first suggested by Gregor Mendel (1822-1884 who in the 1860s studied inheritance The BRCA1 and BRCA2 gene account for 5%-13% of ovarian cancers[3] and certain populations (e. g. Ashkenazi Jewish women) are at a higher risk of both breast cancer and ovarian cancer, often at an earlier age than the general population. Ashkenazi Jews, also known as Ashkenazic Jews or Ashkenazim ( Hebrew: אַשְׁכֲּנָזִים, ˌaʃkəˈnazim sing Breast cancer is a Cancer that starts in the cells of the Breast in women and men Patients with a personal history of breast cancer or a family history of breast and/or ovarian cancer, especially if at a young age, may have an elevated risk.

A strong family history of uterine cancer, colon cancer, or other gastrointestinal cancers may indicate the presence of a syndrome known as hereditary nonpolyposis colorectal cancer (HNPCC, also known as Lynch II syndrome), which confers a higher risk for developing ovarian cancer. The term uterine cancer may refer to any of several different types of Cancer which occur in the Uterus, namely Uterine sarcomas Colorectal cancer, also called colon cancer or large bowel cancer, includes Cancerous growths in the colon, Rectum and Gastrointestinal cancer refers to Malignant conditions of the Gastrointestinal tract, including the esophagus stomach liver biliary system pancreas bowels and Hereditary nonpolyposis colorectal cancer (HNPCC also known as Lynch syndrome, is characterised by a risk of Colorectal cancer and other cancers of the endometrium Hereditary nonpolyposis colorectal cancer (HNPCC also known as Lynch syndrome, is characterised by a risk of Colorectal cancer and other cancers of the endometrium Patients with strong genetic risk for ovarian cancer may consider the use of prophylactic i. Prophylaxis ( Greek "προφυλάσσω" to guard or prevent beforehand) is any medical or Public health procedure whose purpose e. preventative oophorectomy after completion of childbearing. Oophorectomy (or ovariectomy) is the surgical removal of an Ovary or ovaries

A Swedish study, which followed more than 61,000 women for 13 years, has found a significant link between milk consumption and ovarian cancer. According to the BBC, "[Researchers] found that milk had the strongest link with ovarian cancer - those women who drank two or more glasses a day were at double the risk of those who did not consume it at all, or only in small amounts. " [4] Recent studies have shown that women in sunnier countries have a lower rate of ovarian cancer, which may have some kind of connection with exposure to Vitamin D. Vitamin D is a group of fat-soluble Prohormones, the two major forms of which are vitamin D2 (or Ergocalciferol) and vitamin D3 (or

Other factors that have been investigated, such as talc use, asbestos exposure, high dietary fat content, and childhood mumps infection, are controversial and have not been definitively proven. Talc (derived from the Persian via Arabic talq) is a Mineral composed of Hydrated Magnesium Silicate with Asbestos is a group of Minerals with long thin fibrous Crystals The word "asbestos" (῾ἀσβεστος is derived from a Greek adjective Mumps or epidemic Parotitis is a Viral disease of the Human species

"Associations were also found between alcohol consumption and cancers of the ovary and prostate, but only for 50 g and 100 g a day. "[5]

Classification

A germ cell tumor of the ovary, discovered during a C-section; this is a 4 cm teratoma
A germ cell tumor of the ovary, discovered during a C-section; this is a 4 cm teratoma

Ovarian cancer is classified according to the histology of the tumor, obtained in a pathology report. A Caesarean section (or Cesarean section in American English) also known as C-section, is a form of Childbirth in which a surgical A teratoma is a type of neoplasm. The word teratoma comes from Greek and means roughly "monstrous tumor" Histology (from the Greek = 'tissue' is the study of the microscopic anatomy of cells and tissues of Plants and Pathology (from Greek grc πάθος pathos, "fate harm" and grc -λογία -logia) is the study and Histology dictates many aspects of clinical treatment, management, and prognosis. Prognosis (older Greek πρόγνωσις modern Greek πρόγνωση - literally fore-knowing foreseeing) is a medical term denoting the

Ovarian cancer can also be a secondary cancer, the result of metastasis from a primary cancer elsewhere in the body. Metastasis ( Greek: displacement μετά=next + στάσις=placement, plural metastases) sometimes abbreviated mets, Common primary cancers are breast cancer and gastrointestinal cancer (in which case the ovarian cancer is a Krukenberg cancer). Breast cancer is a Cancer that starts in the cells of the Breast in women and men Gastrointestinal cancer refers to Malignant conditions of the Gastrointestinal tract, including the esophagus stomach liver biliary system pancreas bowels and A Krukenberg tumor, also Krukenberg tumour, classically refers to a secondary ovarian malignancy whose primary site arose in the gastrointestinal tract Surface epithelial-stromal tumor can originate in the peritoneum (the lining of the abdominal cavity), in which case the ovarian cancer is secondary to primary peritoneal cancer, but treatment is basically the same as for primary surface epithelial-stromal tumor involving the peritoneum. In higher Vertebrates the peritoneum is the Serous membrane that forms the lining of the abdominal cavity &mdash it covers most of the intra-abdominal Primary peritoneal cancer or carcinoma ("PPCa" is a Cancer of the cells lining the Peritoneum, or abdominal cavity

Symptoms

Studies on the accuracy of symptoms

Two case-control studies, both subject to results being inflated by spectrum bias, have been reported. Case-control is a type of Epidemiological Study design. Case-control studies are used to identify factors that may contribute to a medical condition by comparing subjects Initially identified in 1978 spectrum bias refers to evaluating the ability of a diagnostic test in a biased group of patients which leads to an overestimation of the sensitivity and The first found that women with ovarian cancer had symptoms of increased abdominal size, bloating, urge to pass urine and pelvic pain. [6] The smaller, second study found that women with ovarian cancer had pelvic/abdominal pain, increased abdominal size/bloating, and difficulty eating/feeling full. [7] The latter study created a symptom index that was considered positive if any of the six (6) symptoms "occurred >12 times per month but were present for <1 year". They reported a sensitivity of 57% for early-stage disease and specificity 87% to 90%.

Ovarian Cancer Symptoms Consensus Statement

In 2007, the Gynecologic Cancer Foundation, Society of Gynecologic Oncologists and American Cancer Society originated the following consensus statement regarding the symptoms of ovarian cancer. [8]

Ovarian cancer is called a “silent killer” because symptoms were not thought to develop until the disease had advanced and the chance of cure or remission poor. However, the following symptoms are much more likely to occur in women with ovarian cancer than women in the general population. These symptoms include:

Women with ovarian cancer report that symptoms are persistent and represent a change from normal for their bodies. The frequency and/or number of such symptoms are key factors in the diagnosis of ovarian cancer. Several studies show that even early stage ovarian cancer can produce these symptoms. Women who have these symptoms almost daily for more than a few weeks should see their doctor, preferably a gynecologist. Prompt medical evaluation may lead to detection at the earliest possible stage of the disease. Early stage diagnosis is associated with an improved prognosis.

Several other symptoms have been commonly reported by women with ovarian cancer. These symptoms include fatigue, indigestion, back pain, pain with intercourse, constipation and menstrual irregularities. However, these other symptoms are not as useful in identifying ovarian cancer because they are also found in equal frequency in women in the general population who do not have ovarian cancer.

Diagnosis

Ovarian cancer at its early stages(I/II) is difficult to diagnose until it spreads and advances to later stages (III/IV). This is due to the fact that most of the common symptoms are non-specific.

When an ovarian malignancy is included in the list of diagnostic possibilities, a limited number of laboratory tests are indicated. A complete blood count (CBC) and serum electrolyte test should be obtained in all patients.

The serum BHCG level should be measured in any female in whom pregnancy is a possibility. Human chorionic gonadotropin ( hCG) is a Glycoprotein Hormone produced in Pregnancy that is made by the Embryo soon after conception In addition, serum alpha-fetoprotein (AFP) and lactate dehydrogenase (LDH) should be measured in young girls and adolescents with suspected ovarian tumors because the younger the patient, the greater the likelihood of a malignant germ cell tumor. Alpha-fetoprotein ( AFP) is a molecule produced in the developing Embryo

A blood test called CA-125 is useful in differential diagnosis and in follow up of the disease, but it has not been shown to be an effective method to screen for early-stage ovarian cancer due to its unacceptable low sensitivity and specificity. CA-125, also known as CA125 is an abbreviation for cancer Antigen 125 However, this is the only available, widely-used marker currently.

Current research is looking at ways to combine tumor markers proteomics along with other indicators of disease (i. Proteomics is the large-scale study of Proteins particularly their structures and functions. e. radiology and/or symptoms) to improve accuracy. The challenge in such an approach is that the very low population prevalence of ovarian cancer means that even testing with very high sensitivity and specificity will still lead to a number of false positive results (i. e. performing surgical procedures in which cancer is not found intra-operatively). However, the contributions of proteomics are still in the early stages and require further refining. Proteomics is the large-scale study of Proteins particularly their structures and functions. Current studies on proteomics mark the beginning of a paradigm shift towards individually tailored therapy.

A pelvic examination and imaging including CT scan and trans-vaginal ultrasound are essential. Physical examination may reveal increased abdominal girth and/or ascites (fluid within the abdominal cavity). In Medicine ( Gastroenterology) ascites (also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more Pelvic examination may reveal an ovarian or abdominal mass. The pelvic examination can include a rectovaginal component for better palpation of the ovaries. For very young patients, magnetic resonance imaging may be preferred to rectal and vaginal examination.

Staging

Ovarian cancer staging is by the FIGO staging system and uses information obtained after surgery, which can include a total abdominal hysterectomy, removal of (usually) both ovaries and fallopian tubes, (usually) the omentum, and pelvic (peritoneal) washings for cytology. The International Federation of Gynecology and Obstetrics, usually just FIGO as the acronym of its French name Fédération Internationale de Gynécologie et d'Obstétrique A hysterectomy (from Greek hystera "womb" is the surgical removal of the Uterus, usually performed by a gynecologist. The AJCC stage is the same as the FIGO stage. The American Joint Committee on Cancer (AJCC is an organization best known for defining and popularizing Cancer staging standards officially the AJCC staging system

Para-aortic lymph node metastases are considered regional lymph nodes (Stage IIIC). In Medicine ( Gastroenterology) ascites (also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more

Treatment

Surgical treatment may be sufficient for malignant tumors that are well-differentiated and confined to the ovary. Addition of chemotherapy may be required for more aggressive tumors that are confined to the ovary. For patients with advanced disease a combination of surgical reduction with a combination chemotherapy regimen is standard. Borderline tumors, even following spread outside of the ovary, are managed well with surgery, and chemotherapy is not seen as useful.

Surgery is the preferred treatment and is frequently necessary to obtain a tissue specimen for differential diagnosis via its histology. Surgery (from the χειρουργική cheirourgikē, via chirurgiae meaning "hand work" is a medical specialty that uses operative manual and instrumental Diagnosis is the identification by Process of elimination, of the nature of anything Histology (from the Greek = 'tissue' is the study of the microscopic anatomy of cells and tissues of Plants and Surgery performed by a specialist in gynecologic oncology usually results in an improved result. Gynecologic oncology is a specialized field of medicine that focuses only on cancers of the female reproductive system notably Ovarian cancer, Cervical cancer, Improved survival is attributed to more accurate staging of the disease and a higher rate of aggressive surgical excision of tumor in the abdomen by gynecologic oncologists as opposed to general gynecologists and general surgeons.

The type of surgery depends upon how widespread the cancer is when diagnosed (the cancer stage), as well as the presumed type and grade of cancer. The surgeon may remove one (unilateral oophorectomy) or both ovaries (bilateral oophorectomy), the fallopian tubes (salpingectomy), and the uterus (hysterectomy). For some very early tumors (stage 1, low grade or low-risk disease), only the involved ovary and fallopian tube will be removed (called a "unilateral salpingo-oophorectomy," USO), especially in young females who wish to preserve their fertility.

In advanced malignancy, where complete resection is not feasible, as much tumor as possible is removed (debulking surgery). Cancer (medical term Malignant Neoplasm) is a class of Diseases in which a group of cells display uncontrolled In cases where this type of surgery is successful (i. e. < 1 cm in diameter of tumor is left behind ["optimal debulking"]), the prognosis is improved compared to patients where large tumor masses (> 1 cm in diameter) are left behind. Minimally invasive surgical techniques may facilitate the safe removal of very large (greater than 10 cm) tumors with fewer complications of surgery. Minimally invasive surgical procedures avoid open invasive surgery in favor of closed or local surgery with less trauma [9]

Chemotherapy has been a general standard of care for ovarian cancer for decades, although with highly variable protocols. Chemotherapy, in its most general sense refers to treatment of disease by chemicals that kill cells specifically those of micro-organisms or Cancer. For the English law, see Standard of care in English law. In Tort law, the standard of care is the degree of prudence and caution [10] Chemotherapy is used after surgery to treat any residual disease, if appropriate. This depends on the histology of the tumor; some kinds of tumor (particularly teratoma) are not sensitive to chemotherapy. Histology (from the Greek = 'tissue' is the study of the microscopic anatomy of cells and tissues of Plants and A teratoma is a type of neoplasm. The word teratoma comes from Greek and means roughly "monstrous tumor" In some cases, there may be reason to perform chemotherapy first, followed by surgery.

Currently for Stage IIIC ovarian adenocarcinomas after optimal debulking, median time for survival is statistically significantly longer for patient receiving intraperitoneal (IP) chemotherapy. Patients in this clinical trial did report less compliance with IP chemotherapy, and fewer than half of the patients received all six cycles of IP chemotherapy. Despite this high "drop-out" rate, the group as a whole (including the patients that didn't complete IP chemotherapy treatment) survived longer on average than patients who received intravenous chemotherapy alone.

Some specialists believe the toxicities and other complications of IP chemotherapy will be unnecessary with improved IV chemotherapy drugs currently being developed.

Although IP chemotherapy has been recommended as a standard of care for the first-line treatment of ovarian cancer, the basis for this recommendation has been challenged. For the English law, see Standard of care in English law. In Tort law, the standard of care is the degree of prudence and caution [11]

Radiation therapy is not effective for advanced stages because when vital organs are in the radiation field, a high dose cannot be safely delivered. Radiation therapy (or radiotherapy) is the medical use of Ionizing radiation as part of Cancer treatment to control Malignant

Prognosis

Ovarian cancer usually has a poor prognosis. Prognosis (older Greek πρόγνωσις modern Greek πρόγνωση - literally fore-knowing foreseeing) is a medical term denoting the It is disproportionately deadly because it lacks any clear early detection or screening test, meaning that most cases are not diagnosed until they have reached advanced stages. More than 60% of patients presenting with this cancer already have stage III or stage IV cancer, when it has already spread beyond the ovaries. Ovarian cancers shed cells into the naturally occurring fluid within the abdominal cavity. These cells can implant on other abdominal (peritoneal) structures, included the uterus, urinary bladder, bowel and the lining of the bowel wall (omentum). The uterus (from the Latin word for womb) is the major Female reproductive organ of most Mammals including Humans One end the In Anatomy, the urinary bladder is a hollow muscular, and distensible (or elastic organ that sits on the Pelvic floor in Mammals It is the In Anatomy, the intestine is the segment of the alimentary canal extending from the Stomach to the Anus and in humans and other mammals consists These cells can begin forming new tumor growths before cancer is even suspected.

More than 50% of women with ovarian cancer are diagnosed in the advanced stages of the disease because no cost-effective screening test for ovarian cancer exists. The 5 year survival rate for all stages is only 35% to 38%. If a diagnosis is made early in the disease, five-year survival rates can reach 90% to 98%.

Germ cell tumors of the ovary have a much better prognosis than other ovarian cancers, in part because they tend to grow rapidly to a very large size, hence they are detected sooner. A germ cell tumor ( GCT) is a Neoplasm derived from Germ cells Germ cells normally occur inside the gonads ( Ovary and Testis)

Complications

These cells can implant on other abdominal (peritoneal) structures, including the uterus, urinary bladder, bowel, lining of the bowel wall (omentum) and, less frequently, to the lungs. In Medicine ( Gastroenterology) ascites (also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more

References

  1. ^ Merck Manual of Diagnosis and Therapy Section 18. Gynecology And Obstetrics Chapter 241. Gynecologic Neoplasms
  2. ^ Collaborative Group on Epidemiological Studies of Ovarian Cancer. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23 257 women with ovarian cancer and 87 303 controls. Lancet 2008;371:303-14 doi:10. 1016/S0140-6736(08)60167-1
  3. ^ Brinton, L. A. , Moghissi, K. S. , Scoccia, B. , Westhoff, C. L. , Lamb, E. J. (2005). "Ovulation induction and cancer risk". Fertil. Steril. 83 (2): 261-74; quiz 525-6. doi:10.1016/j.fertnstert.2004.09.016. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15705362.  
  4. ^ BBC News Milk link to ovarian cancer risk 29 November 2004
  5. ^ Alcohol consumption and cancer risk
  6. ^ Goff BA, Mandel LS, Melancon CH, Muntz HG (2004). Events 1777 - San Jose California, is founded as el Pueblo de San José de Guadalupe "MMIV" redirects here For the Modest Mouse album see " Baron von Bullshit Rides Again " "Frequency of symptoms of ovarian cancer in women presenting to primary care clinics". JAMA 291 (22): 2705-12. doi:10.1001/jama.291.22.2705. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15187051.  
  7. ^ Goff BA, Mandel LS, Drescher CW, et al (2007). "Development of an ovarian cancer symptom index: possibilities for earlier detection". Cancer 109 (2): 221-7. doi:10.1002/cncr.22371. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 17154394.  
  8. ^ Ovarian Cancer Symptoms Consensus Statement (pdf). Retrieved on 2007-07-19. Year 2007 ( MMVII) was a Common year starting on Monday of the Gregorian calendar in the 21st century. Events 711 - Muslim forces under Tariq ibn Ziyad defeat the Visigoths led by their king Roderic.
  9. ^ Ehrlich, P. F. , Teitelbaum, D. H. , Hirschl, R. B. , Rescorla, F. (2007). "Excision of large cystic ovarian tumors: combining minimal invasive surgery techniques and cancer surgery--the best of both worlds. ". J. Pediatr. Surg. 42 (5): 890-3. doi:10.1016/j.jpedsurg.2006.12.069. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 17502206.  
  10. ^ McGuire WP, Markman M (December 2003). "Primary ovarian cancer chemotherapy: current standards of care". Br. J. Cancer 89 Suppl 3: S3–8. doi:10.1038/sj.bjc.6601494. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 14661040.  
  11. ^ Swart AM, Burdett S, Ledermann J, Mook P, Parmar MK (April 2008). "Why i.p. therapy cannot yet be considered as a standard of care for the first-line treatment of ovarian cancer: a systematic review". Ann. Oncol. 19 (4): 688–95. doi:10.1093/annonc/mdm518. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 18006894.  


See also

External links

A germ cell tumor ( GCT) is a Neoplasm derived from Germ cells Germ cells normally occur inside the gonads ( Ovary and Testis) Dsrct2jpg|thumb|right||Cell exhibiting blue oval and round shapes of desmoplastic small round blue cell tumor]] Desmoplastic small round cell tumor is classified as a An ovarian cyst is any collection of fluid surrounded by a very thin wall within an Ovary. The Open Directory Project ( ODP) also known as dmoz (from directory
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