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Ovarian germ cell tumor

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

Overveiw

Ovarian germ cell tumors is a disease in which malignancy originates from the germ cells of the ovary. Ovarian germ cell tumors are rare, accounting for 2% to 3% of all ovarian cancers. The median age for diagnosis differs for each sub-type of germ cell tumor. World health organization (WHO) classified germ cell tumors into 7 types based on histology. The most common ovarian germ cell tumor is called dysgerminoma. Abnormal gonads (due to gonadal dysgenesis and androgen insensitivity syndrome) have a high risk of developing a dysgerminoma. Ovarian germ cell tumors must be differentiated from other neoplastic ovarian masses that can present with similar complaints non-neoplastic ovarian mass, and adnexal mass. Symptoms of ovarian germ cell tumors include abdominal distention, acute/ subacute abdominal pain, menstrual irregularities, and precocious puberty. The laboratory findings associated with ovarian germ cell tumors include rise in serum lactate dehydrogenase (LDH), human chorionic gonadotropin (HCG), CA-125, and alpha-fetoprotein (AFP). Depending on the extent of the tumor at the time of diagnosis, the prognosis may vary. CT, MRI, and ultrasound are used in combination with biopsy not only to distinguish between the subtypes of ovarian germ cell tumors but also for diagnosis confirmation. Surgery along with chemotherapy are the mainstay of treatment depending on the staging of the tumor.

Historical Perspective

There is limited information about the historical perspective of ovarian germ cell tumors.

Classification

Ovarian germ cell tumor may be benign or malignant. Each category sub classified to different types based on histologic features.

Pathophysiology

The pathophysiology of ovarian germ cell tumors depends on the histological subtype. Their common origin is believed to be from the primordial germ cells that transformed pathologically in different stages of development. It is difficult to distinguish subtypes of ovarian germ cell tumor on gross pathology alone. The majority of ovarian germ cell tumors have a solid and cystic appearance with areas of hemorrhage and necrosis. On microscopic pathology, ovarian germ cell tumors may be characterized by a uniform “fried egg” appearance (dysgerminoma), presence of Schiller-Duval bodies (yolk sac tumor), presence of embryonic-like neural, gastrointestinal, and/or cartilaginous tissue (teratoma), or mixed histopathological features (embryonal cell carcinoma).

Epidemiology and Demographics

In USA, the age-adjusted incidence of malignant ovarian germ cell tumor is 0.41 per 100,000 women. Incidence of these tumors increases from 5 years of age, although it may be present during infancy, and this increase continues to peak between the age of 15 to 19 years which is approximately 1.2 per 100,000 women. Another peak incidence of these tumors has been reported among those aged 65 years old or older where teratoma is the most common type observed. The incidence is higher among non-white ethnicity (other than black, especially Hispanic and Asians) followed by white and black individuals. Females are more commonly affected by germ cell tumors than males. These tumors also account for a greater proportion of ovarian tumors in the Asia and Africa.

Risk Factors

Gonadal dysgenesis and androgen insensitivity syndrome are known risk factors for the development of ovarian germ cell tumors. There are also other maternal factors that have been observed to be associated with increased risk of the development of these tumors in daughters. Factors such as maternal use of exogenous hormones, maternal elevated body mass index, and reproductive factors.

Differentiating From Ovarian Germ Cell Tumor Other Diseases

Ovarian germ cell tumor must be differentiated from other diseases that cause ovarian mass, such as Stein-Leventhal syndrome, ovarian teratoma, tubal pregnancy, ovarian epithelial tumors, ovarian sex-cord stromal tumors, and tubo-ovarian abscess.

Prognosis

The prognosis of germ cells of the ovary depends on the type of the tumor and its malignant potentials. Possible complications of benign teratomas are a rupture and ovarian torsion also malignant transformation. Prognosis is generally excellent in the mature teratoma, but in case of simultaneous malignant transformation, the 5-year survival rate of patients is approximately [15-30]%. The 5-year survival rate of the patient even with disseminated dysgerminoma at the time of diagnosis is above 90%. The overall 5-year survival rate for yolk sac tumor, embryonal carcinoma and choriocarcinoma are approximately 80%.


Diagnosis

Staging

According to the FIGO and TNM cancer staging system, there are 4 stages of ovarian germ cell tumor. Surgery is the mainstay of staging for ovarian germ cell tumors.

History and Symptoms

The clinical manifestations of patients with ovarian germ cell tumors depend on the type of the tumor and its potential to produce hormonal materials. Usually, they present with abdominal pain or distention, menstrual irregularities, symptoms of virilization, rapidly growing abdominal/pelvic mass, acute abdominal pain from complications such as necrosis, capsular distention, rupture or torsion and or simply they can be asymptomatic.

Ovarian Germ Cell Tumor Physical Examination

Patients with germ cells of the ovary usually appear normal. Physical examination of these patients is usually unremarkable and the tumors tend to be discovered incidentally or during imaging workups for another reason. When symptomatic, the physical examination may be remarkable for Abdominal/pelvic mass and/or signs of virilization, precocious puberty, and pregnancy depending on the capacity of the tumor for the production of hormones.

Ovarian germ cell tumor Laboratory Findings

The laboratory findings associated with ovarian germ cell tumor are the following: elevated serum level of lactate dehydrogenase (LDH), human chorionic gonadotropin (HCG), CA-125, and alpha-fetoprotein (AFP).

CT

It is difficult to distinguish ovarian germ cell tumors on CT alone, however, pelvic/abdominal CT scan may be helpful in the diagnosis. Sensitive findings on CT scan for the diagnosis of mature teratoma include Fat attenuation, presence or absence of calcification in the cyst wall, palm-tree like protrusion, and fat–fluid levels. Presence of cauliflower appearance with irregular borders may warrant the necessity to search for malignant transformation of these tumors. CT scan findings characteristics of immature teratoma include A large, irregular solid mass, presence of coarse calcification, small foci of fat, and Hemorrhage. CT findings associated with other ovarian germ cell tumors are not specific, but may be helpful.

MRI

Abdominal/pelvic MRI may be helpful in the diagnosis of ovarian germ cell tumors. Findings on MRI suggestive of ovarian germ cell tumors include masses with a cystic and solid component and may contain fat, calcification, fat–fluid level, Tuft\Hairs, Palm tree-like protrusion, and Dermoid nipples-like elements (Rokitansky nodules). The majority of ovarian germ cell tumors have a solid and cystic appearance with areas of hemorrhage and necrosis. The predominance of cystic or solid component differs for each tumor.

Ultrasound

It is difficult to distinguish ovarian germ cell tumors on ultrasound alone. Both solid and cystic lesions with calcification may be present. Dysgerminoma often appears as a hypoechoic mass while other ovarian germ cell tumors often have variable echogenicity. Ovarian teratoma may be further characterized by the presence of sebaceous and hair components arising from the Rokitansky protuberance.

Treatment

Chemotherapy

Adjuvant Chemotherapy is recommended for all the patients with diagnosed malignant ovarian germ cell tumor, except those with stage 1a, stage 1a, 1b dysgerminoma, and grade 1 immature teratomas. The platinum-based regimen is currently the most effective management.

Radiotherapy

Among ovarian germ cell tumors, only dysgerminoma is radiosensitive. Radiotherapy is not anymore the first option of treatment for dysgerminoma considering its association with ovarian failure development.

Surgery

Surgical intervention is the mainstay of management of ovarian germ cell tumors. Surgery must be done for the purpose of staging and maybe treatment according to the stage of the tumor. Surgical management of the ovarian germ cell tumors, for the purpose of treatment, classified to two categories according to the preference of the patient to preserve the ovary or not. Surgery is the mainstay of treatment for mature teratoma.

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Historical Perspective

Historical Perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2]

Overview

There is limited information about the historical perspective of ovarian germ cell tumors.

Historical Perspective

Discovery

References

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Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

Ovarian germ cell tumor may be benign or malignant. Each category sub classified to different types based on histologic features.

Classification

Ovarian germ cell tumor may be classified into two subtypes of benign and malignant tumors. Benign tumors are comprised of only teratoma, however, the malignant germ cell tumors may be classified to different types according to the histologic features.

WHO Classification of Ovarian Tumors

WHO classifies ovarian germ cell tumors as follows:[2]

References

  1. ↑ Outwater EK, Siegelman ES, Hunt JL (2001). “Ovarian teratomas: tumor types and imaging characteristics”. Radiographics. 21 (2): 475–90. doi:10.1148/radiographics.21.2.g01mr09475. PMID 11259710.
  2. ↑ Meinhold-Heerlein I, Fotopoulou C, Harter P, Kurzeder C, Mustea A, Wimberger P, Hauptmann S, Sehouli J (April 2016). “The new WHO classification of ovarian, fallopian tube, and primary peritoneal cancer and its clinical implications”. Arch. Gynecol. Obstet. 293 (4): 695–700. doi:10.1007/s00404-016-4035-8. PMID 26894303.

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

Overveiw

The pathophysiology of ovarian germ cell tumors depends on the histological subtype. However, their origin is the primordial germ cells that transformed pathologically in different stages of development.

Pathophysiology

Pathogenesis


 
 
 
 
 
 
 
Germ cell
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pathogenesis
 
 
 
 
 
 
 
Malignant transformation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mature teratoma
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tumors esxpressing transcription factors of pluripotency
 
Tumors with primitive embryonic ectoderm, mesoderm, and/or endoderm differentiation
 
Tumors with extraembroyonic differentiation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dysgerminoma/Embryonal carcinoma
 
Immature teratoma
 
Yolk sac tumor/Choriocarcinoma
 

Mature teratoma

Dysgerminoma

  • Bilateral invovlement occurs in 10% to 15% of the cases.
  • In < 15% of the affected cases, elements of other germ cell tumors can also be found.[6]

Yolk sac tumor

Genetics

Associated Conditions

Conditions associated with mature teratoma include:

Polyembryoma may be associated with Klinefelter syndrome.[13]

Gross Pathology

Ovarian germ cell tumor subtype Features on Gross Pathology
Dysgerminonma
  • Unilateral (bilateral in 10% to 20% of the cases)[14]
  • more common on the right side
  • Solid, white or grayish-withe tumors
Embryonal Carcinoma
Endodermal sinus tumor or yolk sac tumors
Mixed germ cell tumors
Polyembryoma
Teratoma

Teratoma-mature

  • The majority are 5 to 10 cm in diameter.[16]
  • Unilocular in the majority of cases (88%)
  • Predominantly cystic
  • Cystic content may contain sebaceous material that is semi-liquid in room temperature
  • Teeth may be found in Rokitansky’s protuberance – a well-defined, nipple-like structure covered with hair

Teratoma-immature

Teratoma-monodermal

Microscopic Pathology

Ovarian germ cell tumor subtype Features on Histopathological Microscopic Analysis Image
Dysgerminomas
Contributed by CoRus13 in wikimedia.commons
Embryonal carcinoma
Contributed by Nephron in wikimedia.commons
Endodermal sinus tumor or yolk sac tumors
  • Schiller-Duval bodies (resemble renal glomeruli) – key feature [8]
Micrograph showing the yolk sac component of a mixed germ cell tumor. Contributed by Nephrone in wikimedia.commons
Polyemryoma
Micrograph showing the embryoma component of a mixed germ cell tumor. Attributed by “courtesy of PathologyOutlines.com”
Teratoma

Mature teratoma

Immature teratoma

  • Tissues originating from the two or three embryonal layers are present.[8]
  • There is a mixture of mature and immature tissue (primitive cells).
  • The presence of primitive elements is necessary to make the diagnosis.
Mature cystic teratoma of the ovary: Bone Tissue Pathological and histological images courtesy of Ed Uthman at flickr. Contributed by wikimedia commons

Immunohistochemistry

Dysgerminoma

Embryonal carcinoma

Endodermal sinus tumor

Non-gestational chriocarcinoma

Polyembryoma

Teratoma

References

  1. ↑ 1.0 1.1 El-Maarri, Osman; Rijlaarsdam, Martin A.; Tax, David M. J.; Gillis, Ad J. M.; Dorssers, Lambert C. J.; Koestler, Devin C.; de Ridder, Jeroen; Looijenga, Leendert H. J. (2015). “Genome Wide DNA Methylation Profiles Provide Clues to the Origin and Pathogenesis of Germ Cell Tumors”. PLOS ONE. 10 (4): e0122146. doi:10.1371/journal.pone.0122146. ISSN 1932-6203.
  2. ↑ Carcangiu, M. L. (2014). WHO Classification of Tumours of Female Reproductive Organs. Lyon: International Agency for Research on Cancer. ISBN 978-92-832-4487-5.
  3. ↑ 3.0 3.1 Vural, F.; Vural, B.; Paksoy, N. (2015). “Vaginal teratoma: A case report and review of the literature”. Journal of Obstetrics and Gynaecology. 35 (7): 757–758. doi:10.3109/01443615.2015.1004525. ISSN 0144-3615.
  4. ↑ Linder, David; McCaw, Barbara Kaiser; Hecht, Frederick (1975). “Parthenogenic Origin of Benign Ovarian Teratomas”. New England Journal of Medicine. 292 (2): 63–66. doi:10.1056/NEJM197501092920202. ISSN 0028-4793.
  5. ↑ AL Husaini, Hamed; Soudy, Hussein; Darwish, Alaa El Din; Ahmed, Mohamed; Eltigani, Amin; AL Mubarak, Mustafa; Sabaa, Amal Abu; Edesa, Wael; AL-Tweigeri, Taher; Al-Badawi, Ismail A. (2012). “Pure dysgerminoma of the ovary: a single institutional experience of 65 patients”. Medical Oncology. 29 (4): 2944–2948. doi:10.1007/s12032-012-0194-z. ISSN 1357-0560.
  6. ↑ Gordon A, Lipton D, Woodruff JD (October 1981). “Dysgerminoma: a review of 158 cases from the Emil Novak Ovarian Tumor Registry”. Obstet Gynecol. 58 (4): 497–504. PMID 7279343.
  7. ↑ Young, Robert H. (2014). “The Yolk Sac Tumor”. International Journal of Surgical Pathology. 22 (8): 677–687. doi:10.1177/1066896914558265. ISSN 1066-8969.
  8. ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 Shaaban, Akram M.; Rezvani, Maryam; Elsayes, Khaled M.; Baskin, Henry; Mourad, Amr; Foster, Bryan R.; Jarboe, Elke A.; Menias, Christine O. (2014). “Ovarian Malignant Germ Cell Tumors: Cellular Classification and Clinical and Imaging Features”. RadioGraphics. 34 (3): 777–801. doi:10.1148/rg.343130067. ISSN 0271-5333.
  9. ↑ 9.0 9.1 Kojimahara, Takanobu; Nakahara, Kenji; Takano, Tadao; Yaegashi, Nobuo; Nishiyama, Hiroshi; Fujimori, Keiya; Sato, Naoki; Terada, Yukihiro; Tase, Toru; Yokoyama, Yoshihito; Mizunuma, Hideki; Shoji, Tadahiro; Sugiyama, Toru; Kurachi, Hirohisa (2013). “Yolk Sac Tumor of the Ovary: A Retrospective Multicenter Study of 33 Japanese Women by Tohoku Gynecologic Cancer Unit (TGCU)”. The Tohoku Journal of Experimental Medicine. 230 (4): 211–217. doi:10.1620/tjem.230.211. ISSN 1349-3329.
  10. ↑ 10.0 10.1 10.2 Kraggerud SM, Szymanska J, Abeler VM, Kaern J, Eknaes M, Heim S, Teixeira MR, Tropé CG, Peltomäki P, Lothe RA (June 2000). “DNA copy number changes in malignant ovarian germ cell tumors”. Cancer Res. 60 (11): 3025–30. PMID 10850452.
  11. ↑ Dalmau, Josep; Gleichman, Amy J; Hughes, Ethan G; Rossi, Jeffrey E; Peng, Xiaoyu; Lai, Meizan; Dessain, Scott K; Rosenfeld, Myrna R; Balice-Gordon, Rita; Lynch, David R (2008). “Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies”. The Lancet Neurology. 7 (12): 1091–1098. doi:10.1016/S1474-4422(08)70224-2. ISSN 1474-4422.
  12. ↑ 12.0 12.1 Kallenberg, GA; Pesce, CM; Norman, B; Ratner, RE; Silverberg, SG (1991). “Ectopic hyperprolactinemia resulting from an ovarian teratoma”. International Journal of Gynecology & Obstetrics. 34 (2): 194–195. doi:10.1016/0020-7292(91)90266-8. ISSN 0020-7292.
  13. ↑ Beresford L, Fernandez CV, Cummings E, Sanderson S, Ming-Yu W, Giacomantonio M (April 2003). “Mediastinal polyembryoma associated with Klinefelter syndrome”. J. Pediatr. Hematol. Oncol. 25 (4): 321–3. PMID 12679648.
  14. ↑ Chen VW, Ruiz B, Killeen JL, Coté TR, Wu XC, Correa CN (May 2003). “Pathology and classification of ovarian tumors”. Cancer. 97 (10 Suppl): 2631–42. doi:10.1002/cncr.11345. PMID 12733128.
  15. ↑ Oliva, Esther; Young, Robert H. (2014). “Germ cell tumours of the ovary: selected topics”. Diagnostic Histopathology. 20 (9): 364–375. doi:10.1016/j.mpdhp.2014.07.003. ISSN 1756-2317.
  16. ↑ Yayla Abide, Çiğdem; Bostancı Ergen, Evrim (2018). “Retrospective analysis of mature cystic teratomas in a single center and review of the literature”. Journal of Turkish Society of Obstetric and Gynecology. 15 (2): 95–98. doi:10.4274/tjod.86244. ISSN 1307-699X.
  17. ↑ 17.0 17.1 17.2 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. ↑ Mature teratoma. http://librepathology.org/wiki/index.php/Teratoma#Mature_teratoma. URL Accessed on November 12, 2015
  19. ↑ Ulbright TM (February 2005). “Germ cell tumors of the gonads: a selective review emphasizing problems in differential diagnosis, newly appreciated, and controversial issues”. Mod. Pathol. 18 Suppl 2: S61–79. doi:10.1038/modpathol.3800310. PMID 15761467.
  20. ↑ 20.0 20.1 Pectasides, D.; Pectasides, E.; Kassanos, D. (2008). “Germ cell tumors of the ovary”. Cancer Treatment Reviews. 34 (5): 427–441. doi:10.1016/j.ctrv.2008.02.002. ISSN 0305-7372.
  21. ↑ Cao, Dengfeng; Guo, Shuangping; Allan, Robert W.; Molberg, Kyle H.; Peng, Yan (2009). “SALL4 Is a Novel Sensitive and Specific Marker of Ovarian Primitive Germ Cell Tumors and Is Particularly Useful in Distinguishing Yolk Sac Tumor From Clear Cell Carcinoma”. The American Journal of Surgical Pathology. 33 (6): 894–904. doi:10.1097/PAS.0b013e318198177d. ISSN 0147-5185.
  22. ↑ Ordi J, Romagosa C, Tavassoli FA, Nogales F, Palacin A, Condom E, Torné A, Cardesa A (February 2003). “CD10 expression in epithelial tissues and tumors of the gynecologic tract: a useful marker in the diagnosis of mesonephric, trophoblastic, and clear cell tumors”. Am. J. Surg. Pathol. 27 (2): 178–86. PMID 12548163.
  23. ↑ Banet, Natalie; Gown, Allen M.; Shih, Ie-Ming; Kay Li, Qing; Roden, Richard B.S.; Nucci, Marisa R.; Cheng, Liang; Przybycin, Christopher G.; Nasseri-Nik, Niloofar; Wu, Lee-Shu-Fune; Netto, George J.; Ronnett, Brigitte M.; Vang, Russell (2015). “GATA-3 Expression in Trophoblastic Tissues”. The American Journal of Surgical Pathology. 39 (1): 101–108. doi:10.1097/PAS.0000000000000315. ISSN 0147-5185.
  24. ↑ Miettinen, Markku; Wang, Zengfeng; McCue, Peter A.; Sarlomo-Rikala, Maarit; Rys, Janusz; Biernat, Wojciech; Lasota, Jerzy; Lee, Yi-Shan (2014). “SALL4 Expression in Germ Cell and Non–Germ Cell Tumors”. The American Journal of Surgical Pathology. 38 (3): 410–420. doi:10.1097/PAS.0000000000000116. ISSN 0147-5185.
  25. ↑ Niehans GA, Manivel JC, Copland GT, Scheithauer BW, Wick MR (September 1988). “Immunohistochemistry of germ cell and trophoblastic neoplasms”. Cancer. 62 (6): 1113–23. PMID 2457424.
  26. ↑ Preda, Ovidiu; Nicolae, Alina; Aneiros-Fernández, José; Borda, Angela; Nogales, Francisco F (2011). “Glypican 3 is a sensitive, but not a specific, marker for the diagnosis of yolk sac tumours”. Histopathology. 58 (2): 312–314. doi:10.1111/j.1365-2559.2010.03735.x. ISSN 0309-0167.
  27. ↑ Takayama, Yoshiyasu; Matsumura, Nozomi; Nobusawa, Sumihito; Ikota, Hayato; Minegishi, Takashi; Yokoo, Hideaki (2015). “Immunophenotypic features of immaturity of neural elements in ovarian teratoma”. Virchows Archiv. 468 (3): 337–343. doi:10.1007/s00428-015-1891-8. ISSN 0945-6317.

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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2]

Overview

There are no established causes for ovarian germ cell tumors. However, there are certain risk factors that predispose to increased risk of ovarian germ cell tumors.

Causes

There are no established causes for ovarian germ cell tumors. However, there are certain risk factors that predispose to increased risk of ovarian germ cell tumors. For more information on risk factors, click here.

References

Epidemiology and Demographics

Epidemiology and Demographics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

In USA, the age-adjusted incidence of malignant ovarian germ cell tumor is 0.41 per 100,000 women. Incidence of these tumors increases from 5 years of age, although it may be present during infancy, and this increase continues to peak between the age of 15 to 19 years which is approximately 1.2 per 100,000 women. Another peak incidence of these tumors has been reported among those aged 65 years old or older where teratoma is the most common type observed. The incidence is higher among non-white ethnicity (other than black, especially Hispanic and Asians) followed by white and black individuals. Females are more commonly affected by germ cell tumors than males. These tumors also account for a greater proportion of ovarian tumors in the Asia and Africa.

Epidemiology

Incidence

Incidence of Ovarian germ cell tumors
Mature teratoma
Dysgerminoma
Yolk sac tumor Age-adjusted incidence of this tumor is 0.048 per 100,000 women-year.[6]
Embryonal carcinoma Age-adjusted incidence of this tumor is 0.014 per 100,000 women-year.[6]
Choriocarcinom Age-adjusted incidence of this tumor is 0.008 per 100,000 women-year.[6]

Prevalence

Prevalence of Ovarian germ cell tumors
Mature teratoma Mature teratoma is the most common ovarian germ cell tumor and accounts for 95% of ovarian teratomas.[8]
Dysgerminoma
Mixed germ cell tumor
Embryonal carcinoma These tumors are very rare, comprising only 1% of ovarian germ cell tumors, and usually are a component of mixed germ cell tumors.[11]
Endodermal sinus tumor The pure form of these tumors are the third most common ovarian tumors.[10]
Non-gestational choriocarcinoma These tumors comprised less than 1% of malignant ovarian germ cell tumors.[12]

Demographics

Age

Age
Mature teratoma Patients of all age groups may develop mature teratoma. However, they tend to present between 20 to 30 years of age at a greater extent.[14]
Immature teratoma Immature teratoma tends to affect younger patient than mature teratomas (usually the first 2 decades of life).[15]
Dysgerminoma
  • Dysgerminoma commonly affects individuals younger than 30 years of age in 85% of cases.[9]
  • The median age at the time of diagnosis is approximately 19 to 23 years, although it may happen at any age.[16]
  • The tumor is uncommon prepubertal or postmenopausal.
Yolk sac tumor They are most common in women in the second and third decades of life and rarely happens after the age 40.[17]
Embryonal carcinoma They affect primarily children and young adults.[16]
Choriocarcinoma

Race

Gender

Region

References

  1. ↑ 1.0 1.1 Quirk, Jeffrey T.; Natarajan, Nachimuthu; Mettlin, Curtis J. (2005). “Age-specific ovarian cancer incidence rate patterns in the United States”. Gynecologic Oncology. 99 (1): 248–250. doi:10.1016/j.ygyno.2005.06.052. ISSN 0090-8258.
  2. ↑ 2.0 2.1 Møller H, Evans H (January 2003). “Epidemiology of gonadal germ cell cancer in males and females”. APMIS. 111 (1): 43–6, discussion 46–8. PMID 12752232.
  3. ↑ 3.0 3.1 3.2 dos Santos Silva I, Swerdlow AJ (May 1991). “Ovarian germ cell malignancies in England: epidemiological parallels with testicular cancer”. Br. J. Cancer. 63 (5): 814–8. PMC 1972374. PMID 1645564.
  4. ↑ 4.0 4.1 Pectasides, D.; Pectasides, E.; Kassanos, D. (2008). “Germ cell tumors of the ovary”. Cancer Treatment Reviews. 34 (5): 427–441. doi:10.1016/j.ctrv.2008.02.002. ISSN 0305-7372.
  5. ↑ Westhoff C, Pike M, Vessey M (July 1988). “Benign ovarian teratomas: a population-based case-control study”. Br. J. Cancer. 58 (1): 93–8. PMC 2246492. PMID 3166898.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Smith, Harriet O.; Berwick, Marianne; Verschraegen, Claire F.; Wiggins, Charles; Lansing, Letitia; Muller, Carolyn Y.; Qualls, Clifford R. (2006). “Incidence and Survival Rates for Female Malignant Germ Cell Tumors”. Obstetrics & Gynecology. 107 (5): 1075–1085. doi:10.1097/01.AOG.0000216004.22588.ce. ISSN 0029-7844.
  7. ↑ Shaaban, Akram M.; Rezvani, Maryam; Elsayes, Khaled M.; Baskin, Henry; Mourad, Amr; Foster, Bryan R.; Jarboe, Elke A.; Menias, Christine O. (2014). “Ovarian Malignant Germ Cell Tumors: Cellular Classification and Clinical and Imaging Features”. RadioGraphics. 34 (3): 777–801. doi:10.1148/rg.343130067. ISSN 0271-5333.
  8. ↑ 8.0 8.1 Ulbright, Thomas M (2005). “Germ cell tumors of the gonads: a selective review emphasizing problems in differential diagnosis, newly appreciated, and controversial issues”. Modern Pathology. 18: S61–S79. doi:10.1038/modpathol.3800310. ISSN 0893-3952.
  9. ↑ 9.0 9.1 Vicus, Danielle; Beiner, Mario E.; Klachook, Shany; Le, Lisa W.; Laframboise, Stephane; Mackay, Helen (2010). “Pure dysgerminoma of the ovary 35 years on: A single institutional experience”. Gynecologic Oncology. 117 (1): 23–26. doi:10.1016/j.ygyno.2009.12.024. ISSN 0090-8258.
  10. ↑ 10.0 10.1 Tewari, K (2000). “Malignant germ cell tumors of the ovary”. Obstetrics & Gynecology. 95 (1): 128–133. doi:10.1016/S0029-7844(99)00470-6. ISSN 0029-7844.
  11. ↑ Cheng, Liang; Zhang, Shaobo; Talerman, Aleksander; Roth, Lawrence M. (2010). “Morphologic, immunohistochemical, and fluorescence in situ hybridization study of ovarian embryonal carcinoma with comparison to solid variant of yolk sac tumor and immature teratoma”. Human Pathology. 41 (5): 716–723. doi:10.1016/j.humpath.2009.10.016. ISSN 0046-8177.
  12. ↑ Jiao, Lan-zhou; Xiang, Yang; Feng, Feng-zhi; Wan, Xi-run; Zhao, Jun; Cui, Quan-cai; Yang, Xiu-yu (2010). “Clinical Analysis of 21 Cases of Nongestational Ovarian Choriocarcinoma”. International Journal of Gynecological Cancer. 20 (2): 299–302. doi:10.1111/IGC.0b013e3181cc2526. ISSN 1048-891X.
  13. ↑ Brookfield, Kathleen F.; Cheung, Michael C.; Koniaris, Leonidas G.; Sola, Juan E.; Fischer, Anne C. (2009). “A Population-Based Analysis of 1037 Malignant Ovarian Tumors in the Pediatric Population”. Journal of Surgical Research. 156 (1): 45–49. doi:10.1016/j.jss.2009.03.069. ISSN 0022-4804.
  14. ↑ Yayla Abide, Çiğdem; Bostancı Ergen, Evrim (2018). “Retrospective analysis of mature cystic teratomas in a single center and review of the literature”. Journal of Turkish Society of Obstetric and Gynecology. 15 (2): 95–98. doi:10.4274/tjod.86244. ISSN 1307-699X.
  15. ↑ 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.
  16. ↑ 16.0 16.1 16.2 16.3 AL Husaini, Hamed; Soudy, Hussein; Darwish, Alaa El Din; Ahmed, Mohamed; Eltigani, Amin; AL Mubarak, Mustafa; Sabaa, Amal Abu; Edesa, Wael; AL-Tweigeri, Taher; Al-Badawi, Ismail A. (2012). “Pure dysgerminoma of the ovary: a single institutional experience of 65 patients”. Medical Oncology. 29 (4): 2944–2948. doi:10.1007/s12032-012-0194-z. ISSN 1357-0560.
  17. ↑ Kurman RJ, Norris HJ (December 1976). “Endodermal sinus tumor of the ovary: a clinical and pathologic analysis of 71 cases”. Cancer. 38 (6): 2404–19. PMID 63318.
  18. ↑ Smith HO, Berwick M, Verschraegen CF, Wiggins C, Lansing L, Muller CY, Qualls CR (May 2006). “Incidence and survival rates for female malignant germ cell tumors”. Obstet Gynecol. 107 (5): 1075–85. doi:10.1097/01.AOG.0000216004.22588.ce. PMID 16648414.

Template:WikiDoc Sources

Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

Gonadal dysgenesis and androgen insensitivity syndrome are known risk factors for the development of ovarian germ cell tumors. There are also other maternal factors that have been observed to be associated with increased risk of the development of these tumors in daughters. Factors such as maternal use of exogenous hormones, maternal elevated body mass index, and reproductive factors.

Risk Factors

Mature teratoma

Dysgerminoma

References

  1. ↑ Pleskacova, J.; Hersmus, R.; Oosterhuis, J.W.; Setyawati, B.A.; Faradz, S.M.; Cools, M.; Wolffenbuttel, K.P.; Lebl, J.; Drop, S.L.; Looijenga, L.H. (2010). “Tumor Risk in Disorders of Sex Development”. Sexual Development. 4 (4–5): 259–269. doi:10.1159/000314536. ISSN 1661-5433.
  2. ↑ Sharpe, Richard M.; Skakkebaek, Niels E. (2008). “Testicular dysgenesis syndrome: mechanistic insights and potential new downstream effects”. Fertility and Sterility. 89 (2): e33–e38. doi:10.1016/j.fertnstert.2007.12.026. ISSN 0015-0282.
  3. ↑ Skakkebæk, N.E.; Rajpert-De Meyts, E.; Main, K.M. (2001). “Testicular dysgenesis syndrome: an increasingly common developmental disorder with environmental aspects: Opinion”. Human Reproduction. 16 (5): 972–978. doi:10.1093/humrep/16.5.972. ISSN 1460-2350.
  4. ↑ Walker AH, Ross RK, Haile RW, Henderson BE (April 1988). “Hormonal factors and risk of ovarian germ cell cancer in young women”. Br. J. Cancer. 57 (4): 418–22. PMC 2246577. PMID 3390378.
  5. ↑ Hackethal A, Brueggmann D, Bohlmann MK, Franke FE, Tinneberg HR, Münstedt K (December 2008). “Squamous-cell carcinoma in mature cystic teratoma of the ovary: systematic review and analysis of published data”. Lancet Oncol. 9 (12): 1173–80. doi:10.1016/S1470-2045(08)70306-1. PMID 19038764.
  6. ↑ Park, Jeong-Yeol; Kim, Dae-Yeon; Kim, Jong-Hyeok; Kim, Yong-Man; Kim, Young-Tak; Nam, Joo-Hyun (2008). “Malignant transformation of mature cystic teratoma of the ovary: Experience at a single institution”. European Journal of Obstetrics & Gynecology and Reproductive Biology. 141 (2): 173–178. doi:10.1016/j.ejogrb.2008.07.032. ISSN 0301-2115.
  7. ↑ Kliegman, Robert (2011). Nelson textbook of pediatrics. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1-4377-0755-7.

Template:WikiDoc Sources

Screening

Screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2]

Overview

According to the US preventive services task force, screening for ovarian cancer is not recommended in asymptomatic women.

Screening

According to the US preventive services task force, screening for ovarian cancer is not recommended in asymptomatic women.[1]

References

  1. ↑ Grossman, David C.; Curry, Susan J.; Owens, Douglas K.; Barry, Michael J.; Davidson, Karina W.; Doubeni, Chyke A.; Epling, John W.; Kemper, Alex R.; Krist, Alex H.; Kurth, Ann E.; Landefeld, C. Seth; Mangione, Carol M.; Phipps, Maureen G.; Silverstein, Michael; Simon, Melissa A.; Tseng, Chien-Wen (2018). “Screening for Ovarian Cancer”. JAMA. 319 (6): 588. doi:10.1001/jama.2017.21926. ISSN 0098-7484.
Differentiating Ovarian germ cell tumor from other Diseases

Differentiating Ovarian germ cell tumor from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

Ovarian germ cell tumor must be differentiated from other diseases that cause ovarian mass, such as Stein-Leventhal syndrome, ovarian teratoma, tubal pregnancy, ovarian epithelial tumors, ovarian sex-cord stromal tumors, and tubo-ovarian abscess.

Differentiating Ovarian Germ Cell Tumor From Other Diseases

Ovarian germ cell tumor must be differentiated from other diseases that cause ovarian mass, such as:[1][2]

Dysgerminoma and other ovarian germ cell tumors capable of producing B-hCG must be differentiated from other diseases that cause abdominal/pelvic mass and elevated levels of B-hCG.[3]

Differentiating ovarian germ cell tumors from other diseases on the basis of age of onset, vaginal discharge, and constitutional symptoms

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 Embryonal carcinoma[4][5][6][7][8]
  • Individuals of any age, especially young adults
 +/– +/– _ _ _
Gonadoblastoma
[9][10][11][12][13][14]
  • Individuals of any age,but more common prior to 15 years of age
 +/– +/– _ _ _
  • NA
Follicular cysts
[15] 		+/– – – – +/–
  • 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
Theca lutein cysts
[16][17][18] 		+/– – – – +/–
Serous cystadenoma/carcinoma
[19][20][21][22]
  • >55 y/o
 +/– – – – +/–
  • In US we may see simple or multiloculated cyst
  • In serous cystadenocarcinoma we may see papillary projection inside the cyst
  • In serous cystadenocarcinoma we may see ascites
  • In Serous cystadenoma we may see a simple cyst with beak sign, hypointense on T1 and hyperintense on T2
  • In serous cystadenocarcinoma we may see some Solid malignant components inside the cyst with intermediate signal on T1 and T2
Mucinous cystadenoma/carcinoma
[23][24][25]
  • >55 y/o
 +/– – – – +/–
  • 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
Endometrioma
[26][27][28] 		+ + +/– – +
  • hyperintensity on T1-weighted images and a hypointensity on T2-weighted images
  • Powder burn hemorrhages
Teratoma
[29][30][31][32]
  • 10-30 y/o
 +/– – – – +/–
  • We may see evidence of fat components
Dysgerminoma
[33][34]
  • in the second to third decade of life
 + +/– – – +/–
  • We may see ovarian mass with septation which are hyperintense on T1 and hypo or isointense on T2 imaging
  • Sheets fried egg appearance cells
Yolk sac tumor
[35][36][37] 		+ – – – +
  • High levels of AFP
  • In US we may see a combination of echogenic and hypoechoic components
  • Yellow appearance
  • Schiller-Duval bodies (glomeruli like structures)
Fibroma
[38][39][40]
  • >50 y/o
  • Pulling sensation in the groin
 – – – +/–
  • In CT scan we may see a unilateral mass with poor contrast enhancement
  • Low signal intensity on T1 and T2
Thecoma
[41][42][43]
  • >50 y/o
 +/– – – –
Granulosa cell tumor
[44][45][46][47]
  • 50-60 y/o
 + +/– – –
Sertoli-leydig cell tumor
[48][49]
  • 15 to 35 y/o
 +/– – – – –
  • In US we may see unilateral Well-defined hypoechoic lesion
  • Low T2 signal intensity
  • areas of high signal intensity
Brenner tumor
[50][51]
  • >55 y/o
 +/– – – – – –
  • Hypointense on T2 because of fibrous content
  • Most of the times it’s an accidental finding
Krukenberg tumor
[52][53]
  • >55 y/o
 +/– – +/–

Based on underlying malignancy

– –
Tubal tubo-ovarian abscess
[54][55][56][57] 		+ + – + +
  • hypointense in T1 and heterogeneous in T2
Ectopic pregnancy
[58] 		+ + +/– – +
  • NA
  • NA
Hydrosalpinx
[59][60][61]
  • NA
 + – – – +/– –
  • NA
Salpingitis
[62] 		+ + – + +
  • In US we may see , edematous and thickened endosalpingeal folds
  • NA
  • NA
Fallopian tube carcinoma
[63]
  • >60 y/o
 + + + – +/–
  • 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
  • Based on the tumor type we may have different biopsy finding
Uterine Leiomyoma
[64][65] 		+ + – – +/–
  • 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
Choriocarcinoma
[66][67][68][69] 		+ + +/– – +
  • We may see an infiltrative uterine mass and thickening of uterine wall
Leiomyosarcoma
[70][71][72][73][74]
  • >55 y/o
 + + – – +/–
  • Increased uterine size
  • Irregular central zones of low signal intensity (tumor necrosis)
Pregnancy
[75] 		+/− +/− +/− – –
  • NA
Non-gynecologic
GIT Appendiceal abscess
[76]
  • NA
 + – + +/– +
  • NA
Appendiceal neoplasm
[77][78][79][80][81] 		+ – + – +/–
  • Soft tissue mass in the appendix
  • We may see invasion to other structures
  • Gray/yellowi color
  • Cystic structures with angiolymphatic invasion
    Diverticular abscess
    [82]
    • >50 y/o
    		 + – + +/– +
    • 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
    Colorectal cancer
    [83][84][85][86]
    • >50 y/o
    		 + – + – +/–
    • We may see tumor mass and the extension of tumor to other structures
    Renal

    Bladder

    		Pelvic kidney
    [87][88]
    • NA
    		 −/+

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

    		– − − − −
    • We may see normal kidney structure
    • NA
    • It may cause tract infection (UTI), obstruction, and renal calculi.
    • It may be associated with RCC
    Bladder cancer
    [89][90][91]
    • ≥65 y/o
    		 + – – – –
    • isointense compared to muscle in T1
    • slightly hyperintense compared to muscle in T2
    Others Retroperitoneal sarcoma
    [92][93][94][95]
    • 40-50 y/o
    		 + – + − −

    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

    1. ↑ 1.0 1.1 Shaaban AM, Rezvani M, Elsayes KM, et al. Ovarian malignant germ cell tumors: cellular classification and clinical and imaging features. Radiographics. 2014;34(3):777-801.http://pubs.rsna.org/doi/pdf/10.1148/rg.343130067
    2. ↑ 2.0 2.1 Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. Radiographics. 2002;22(6):1305-25.http://www.ncbi.nlm.nih.gov/pubmed/12432104
    3. ↑ 3.0 3.1 Rozenholc A, Abdulcadir J, Pelte MF, Petignat P (June 2012). “A pelvic mass on ultrasonography and high human chorionic gonadotropin level: not always an ectopic pregnancy”. BMJ Case Rep. 2012. doi:10.1136/bcr.01.2012.5577. PMID 22669919.
    4. ↑ Krag Jacobsen G, Barlebo H, Olsen J, Schultz HP, Starklint H, Søgaard H; et al. (1984). “Testicular germ cell tumours in Denmark 1976-1980. Pathology of 1058 consecutive cases”. Acta Radiol Oncol. 23 (4): 239–47. PMID 6093440.
    5. ↑ Ishida, M.; Hasegawa, M.; Kanao, K.; Oyama, M.; Nakajima, Y. (2008). “Non-palpable Testicular Embryonal Carcinoma Diagnosed by Ultrasound: A Case Report”. Japanese Journal of Clinical Oncology. 39 (2): 124–126. doi:10.1093/jjco/hyn141. ISSN 0368-2811.
    6. ↑ Stein, Erica B.; Wasnik, Ashish P.; Sciallis, Andrew P.; Kamaya, Aya; Maturen, Katherine E. (2017). “MR Imaging–Pathologic Correlation in Ovarian Cancer”. Magnetic Resonance Imaging Clinics of North America. 25 (3): 545–562. doi:10.1016/j.mric.2017.03.004. ISSN 1064-9689.
    7. ↑ Pectasides, D.; Pectasides, E.; Kassanos, D. (2008). “Germ cell tumors of the ovary”. Cancer Treatment Reviews. 34 (5): 427–441. doi:10.1016/j.ctrv.2008.02.002. ISSN 0305-7372.
    8. ↑ Cao, Dengfeng; Guo, Shuangping; Allan, Robert W.; Molberg, Kyle H.; Peng, Yan (2009). “SALL4 Is a Novel Sensitive and Specific Marker of Ovarian Primitive Germ Cell Tumors and Is Particularly Useful in Distinguishing Yolk Sac Tumor From Clear Cell Carcinoma”. The American Journal of Surgical Pathology. 33 (6): 894–904. doi:10.1097/PAS.0b013e318198177d. ISSN 0147-5185.
    9. ↑ Scully RE (1970). “Gonadoblastoma. A review of 74 cases”. Cancer. 25 (6): 1340–56. PMID 4193741.
    10. ↑ Saia, Philip (2018). Clinical gynecologic oncology. Philadelphia, PA: Elsevier. ISBN 978-0-323-40067-1.
    11. ↑ Esin, Sertac; Baser, Eralp; Kucukozkan, Tuncay; Magden, Hasim Ata (2011). “Ovarian gonadoblastoma with dysgerminoma in a 15-year-old girl with 46, XX karyotype: case report and review of the literature”. Archives of Gynecology and Obstetrics. 285 (2): 447–451. doi:10.1007/s00404-011-2073-9. ISSN 0932-0067.
    12. ↑ Luisiri, A; Vogler, C; Steinhardt, G; Silberstein, M (1991). “Neonatal cystic testicular gonadoblastoma. Sonographic and pathologic findings”. Journal of Ultrasound in Medicine. 10 (1): 59–61. doi:10.7863/jum.1991.10.1.59. ISSN 0278-4297.
    13. ↑ Hatano T, Yoshino Y, Kawashima Y, Shirai H, Iizuka N, Miyazawa Y, Sakata A, Onishi T (March 1999). “Case of gonadoblastoma in a 9-year-old boy without physical abnormalities”. Int. J. Urol. 6 (3): 164–6. PMID 10226831.
    14. ↑ Cools, Martine; Stoop, Hans; Kersemaekers, Anne-Marie F.; Drop, Stenvert L. S.; Wolffenbuttel, Katja P.; Bourguignon, Jean-Pierre; Slowikowska-Hilczer, Jolanta; Kula, Krzysztof; Faradz, Sultana M. H.; Oosterhuis, J. Wolter; Looijenga, Leendert H. J. (2006). “Gonadoblastoma Arising in Undifferentiated Gonadal Tissue within Dysgenetic Gonads”. The Journal of Clinical Endocrinology & Metabolism. 91 (6): 2404–2413. doi:10.1210/jc.2005-2554. ISSN 0021-972X.
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    19. ↑ 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.
    20. ↑ 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.
    21. ↑ 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.
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    25. ↑ 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.
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    29. ↑ 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.
    30. ↑ 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.
    31. ↑ 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.
    32. ↑ 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.
    33. ↑ 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.
    34. ↑ 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.
    35. ↑ 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.
    36. ↑ 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.
    37. ↑ 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.
    38. ↑ MEIGS JV (May 1954). “Fibroma of the ovary with ascites and hydrothorax; Meigs’ syndrome”. Am. J. Obstet. Gynecol. 67 (5): 962–85. PMID 13148256.
    39. ↑ 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.
    40. ↑ 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.
    41. ↑ 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.
    42. ↑ 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.
    43. ↑ 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.
    44. ↑ 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.
    45. ↑ 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.
    46. ↑ 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.
    47. ↑ 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.
    48. ↑ 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.
    49. ↑ 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.
    50. ↑ 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.
    51. ↑ 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.
    52. ↑ 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.
    53. ↑ 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.
    54. ↑ 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.
    55. ↑ 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.
    56. ↑ 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.
    57. ↑ 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)
    58. ↑ Barnhart, Kurt T. (2009). “Ectopic Pregnancy”. New England Journal of Medicine. 361 (4): 379–387. doi:10.1056/NEJMcp0810384. ISSN 0028-4793.
    59. ↑ 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.
    60. ↑ 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.
    61. ↑ 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.
    62. ↑ 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.
    63. ↑ 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.
    64. ↑ 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.
    65. ↑ 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.
    66. ↑ 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.
    67. ↑ 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.
    68. ↑ Libshitz HI, Baber CE, Hammond CB (April 1977). “The pulmonary metastases of choriocarcinoma”. Obstet Gynecol. 49 (4): 412–6. PMID 558566.
    69. ↑ 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.
    70. ↑ 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.
    71. ↑ 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.
    72. ↑ 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.
    73. ↑ 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.
    74. ↑ 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.
    75. ↑ 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.
    76. ↑ 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.
    77. ↑ 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
    78. ↑ 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.
    79. ↑ 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.
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    95. ↑ 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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    Natural History, Complications and Prognosis

    Natural History, Complications and Prognosis

    Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Monalisa Dmello, M.B,B.S., M.D. [3]

    Overview

    The prognosis of germ cells of the ovary depends on the type of the tumor and its malignant potentials. Possible complications of benign teratomas are a rupture and ovarian torsion also malignant transformation. Prognosis is generally excellent in the mature teratoma, but in case of simultaneous malignant transformation, the 5-year survival rate of patients is approximately [15-30]%. The 5-year survival rate of the patient even with disseminated dysgerminoma at the time of diagnosis is above 90%. The overall 5-year survival rate for yolk sac tumor, embryonal carcinoma and choriocarcinoma are approximately 80%.

    Natural History, Complications, and Prognosis

    Natural History

    Dysgerminomas

    Yolk sac tumor

    Embryonal carcinoma

    Choriocarcinoma

    Complications

    Mature teratoma

    Common complications of mature teratoma include:[7]

    Dysgerminoma

    Prognosis

    Prognosis of ovarian germ cell tumors
    Mature teratoma Prognosis is generally excellent in the mature teratoma, but in case of simultaneous malignant transformation, the 5-year survival rate of patients is approximately [15-30]%.[13]
    Immature teratoma The prognosis of immature teratoma is favorable.[14]
    Dysgerminoma
    Yolk sac tumor
    Embryonal carcinoma
    Choriocarcinoma

    References

    1. ↑ Low, Jeffrey J.H.; Ilancheran, Arunachalam; Ng, Joseph S. (2012). “Malignant ovarian germ-cell tumours”. Best Practice & Research Clinical Obstetrics & Gynaecology. 26 (3): 347–355. doi:10.1016/j.bpobgyn.2012.01.002. ISSN 1521-6934.
    2. ↑ Rozenholc A, Abdulcadir J, Pelte MF, Petignat P (2012). “A pelvic mass on ultrasonography and high human chorionic gonadotropin level: not always an ectopic pregnancy”. BMJ Case Rep. 2012. doi:10.1136/bcr.01.2012.5577. PMC 4543203. PMID 22669919.
    3. ↑ Shaaban, Akram M.; Rezvani, Maryam; Elsayes, Khaled M.; Baskin, Henry; Mourad, Amr; Foster, Bryan R.; Jarboe, Elke A.; Menias, Christine O. (2014). “Ovarian Malignant Germ Cell Tumors: Cellular Classification and Clinical and Imaging Features”. RadioGraphics. 34 (3): 777–801. doi:10.1148/rg.343130067. ISSN 0271-5333.
    4. ↑ Stein, Erica B.; Wasnik, Ashish P.; Sciallis, Andrew P.; Kamaya, Aya; Maturen, Katherine E. (2017). “MR Imaging–Pathologic Correlation in Ovarian Cancer”. Magnetic Resonance Imaging Clinics of North America. 25 (3): 545–562. doi:10.1016/j.mric.2017.03.004. ISSN 1064-9689.
    5. ↑ Kurman RJ, Norris HJ (December 1976). “Endodermal sinus tumor of the ovary: a clinical and pathologic analysis of 71 cases”. Cancer. 38 (6): 2404–19. PMID 63318.
    6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Chen VW, Ruiz B, Killeen JL, Coté TR, Wu XC, Correa CN (May 2003). “Pathology and classification of ovarian tumors”. Cancer. 97 (10 Suppl): 2631–42. doi:10.1002/cncr.11345. PMID 12733128.
    7. ↑ 7.0 7.1 Ayhan, Ali; Bukulmez, Orhan; Genc, Cuneyt; Karamursel, Burcu S.; Ayhan, Ayse (2000). “Mature cystic teratomas of the ovary: case series from one institution over 34 years”. European Journal of Obstetrics & Gynecology and Reproductive Biology. 88 (2): 153–157. doi:10.1016/S0301-2115(99)00141-4. ISSN 0301-2115.
    8. ↑ Kim, Min Jae; Kim, Na Young; Lee, Dong-Yun; Yoon, Byung-Koo; Choi, DooSeok (2011). “Clinical characteristics of ovarian teratoma: age-focused retrospective analysis of 580 cases”. American Journal of Obstetrics and Gynecology. 205 (1): 32.e1–32.e4. doi:10.1016/j.ajog.2011.02.044. ISSN 0002-9378.
    9. ↑ Comerci JT, Licciardi F, Bergh PA, Gregori C, Breen JL (July 1994). “Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature”. Obstet Gynecol. 84 (1): 22–8. PMID 8008317.
    10. ↑ Singh P, Yordan EL, Wilbanks GD, Miller AW, Wee A (February 1988). “Malignancy associated with benign cystic teratomas (dermoid cysts) of the ovary”. Singapore Med J. 29 (1): 30–4. PMID 2841767.
    11. ↑ AL Husaini, Hamed; Soudy, Hussein; Darwish, Alaa El Din; Ahmed, Mohamed; Eltigani, Amin; AL Mubarak, Mustafa; Sabaa, Amal Abu; Edesa, Wael; AL-Tweigeri, Taher; Al-Badawi, Ismail A. (2012). “Pure dysgerminoma of the ovary: a single institutional experience of 65 patients”. Medical Oncology. 29 (4): 2944–2948. doi:10.1007/s12032-012-0194-z. ISSN 1357-0560.
    12. ↑ Smith, Harriet O.; Berwick, Marianne; Verschraegen, Claire F.; Wiggins, Charles; Lansing, Letitia; Muller, Carolyn Y.; Qualls, Clifford R. (2006). “Incidence and Survival Rates for Female Malignant Germ Cell Tumors”. Obstetrics & Gynecology. 107 (5): 1075–1085. doi:10.1097/01.AOG.0000216004.22588.ce. ISSN 0029-7844.
    13. ↑ Park, Jeong-Yeol; Kim, Dae-Yeon; Kim, Jong-Hyeok; Kim, Yong-Man; Kim, Young-Tak; Nam, Joo-Hyun (2008). “Malignant transformation of mature cystic teratoma of the ovary: Experience at a single institution”. European Journal of Obstetrics & Gynecology and Reproductive Biology. 141 (2): 173–178. doi:10.1016/j.ejogrb.2008.07.032. ISSN 0301-2115.
    14. ↑ 14.0 14.1 14.2 “HarvardKey Login”.
    15. ↑ Vicus, Danielle; Beiner, Mario E.; Klachook, Shany; Le, Lisa W.; Laframboise, Stephane; Mackay, Helen (2010). “Pure dysgerminoma of the ovary 35 years on: A single institutional experience”. Gynecologic Oncology. 117 (1): 23–26. doi:10.1016/j.ygyno.2009.12.024. ISSN 0090-8258.
    Diagnosis

    Diagnosis

    Staging | History and Symptoms | Physical Examination | Laboratory Findings | Chest X Ray | CT | MRI | Ultrasound | Other Imaging Findings | Other Diagnostic Studies

    Treatment

    Treatment

    Chemotherapy and Radiotherapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

    Case Studies

    Case Studies

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