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Ovarian Cancer 
Ziyad Salih 
6th stage 
Collage of Medicine – Al-Qadisiya University
Index :- 
 Introduction 
 Risk factors 
 Pathology and pathogenesis 
 Diagnosis 
 Screening 
 Staging 
 Mangment
Introduction 
 Ovarian cancer accounts for 3–4% of cancer in women 
 And is the fourth most frequent cause of cancer-rel...
Risk Factors 
Family 
History 
Ethnicity Reproducti 
on others
Family History 
 The strongest risk factor 
 A women with a single first-degree relative with ov.Ca has a 
relative risk...
Family History 
 Three familial ovarian cancer syndromes:- 
1- The site specific ovarian ov.ca syndrome 
# only ov.ca is ...
Ethnicity 
 Higher in white women 
 Higher in north America and northern Europe than Japan 
 Difference related to gene...
Reproduction factors 
 Nulliparous 
 First childbirth after age 35 years 
 Involuntary infertility 
 Late menopause an...
Others 
 Exogenous hormones :- HRT 
 Dietary factors , Diets high in saturated animal fats seem to 
confer an increased ...
Protective Factors 
 Multiparity: First pregnancy before age 30 
 Oral contraceptives: 5 years of use cuts risk nearly i...
Pathology 
 Ovarian cancer can be divided into three major categories 
based on the cell type of origin . 
 The ovary ma...
Pathology 
 Major Histopathologic Categories of Ovarian Cancer 
1- Epithelial 
Serous, mucinous, endometrioid, clear cell...
Pathology 
 Major Histopathologic Categories of Ovarian Cancer 
4- Neoplasms Metastatic to the Ovary 
Breast, colon, stom...
Pathogenesis 
 Ovarian carcinogenesis can be divided into two broad 
phases: 
1- malignant transformation 
Benign border...
Pathogenesis 
New model of ovarian carcinogenesis :- 
Surface epithelial tumors divides into two broad categories: 
Type I...
Pathogenesis 
Type 1 Type 2 
Low grade High grade 
Arise from precursor lesion in a stepwise Arise “de novo” 
fashion 
- C...
Diagnosis and Clinical Evaluation 
 Ovarian cancer typically develops as an insidious disease, 
with few warning signs or...
Diagnosis and Clinical Evaluation 
 Rarely, an ovarian tumor may become incarcerated in the 
cul-de-sac and cause severe ...
Diagnosis and Clinical Evaluation 
 On Physical Examination ,, 
1. General examination 
2. Abdominal examination :- Abdom...
Diagnosis and Clinical Evaluation 
 On Physical Examination ,, 
4. Pelvic examination :- A careful and thorough pelvic 
e...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Tumor Markers :- 
an antigenic determinant on a high-molecular-wei...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Tumor Markers :- 
 CA125 can be elevated :- 
1. less frequently e...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Tumor Markers :- 
 One of the limitations of CA125 is that 15% to...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
 Initial imaging modality of choice 
# for benign vs malignant 
...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
benign :- smooth, thin walls; few, thin septations; 
absence of so...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
 mural nodules, mural thickening or irregularity, 
solid componen...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
TVS is significantly more accurate
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Computed Tomography 
 Not the study of choice to 
evaluate a susp...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Computed Tomography 
 On CT, ovarian cancer demonstrates varied m...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Magnetic Resonance Imaging 
 Complementary to US in the evaluatio...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Magnetic Resonance Imaging 
 Several studies have compared MRI to...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Magnetic Resonance Imaging 
 MRI was shown to be the most efficie...
Diagnosis and Clinical Evaluation 
 Investigations ,, 
Positron Emission Tomography 
 little clinical role in the primar...
Staging … 
 According to International Federation of Gynecology and 
Obstetrics (FIGO) Staging of Ovarian Neoplasms :- 
...
Staging …
Staging … 
 Stage II. Extension of the neoplasm from the ovary to the 
pelvis 
IIa—extension to the uterus or fallopian t...
Staging …
Staging … 
 Stage III. Disease extension to the abdominal cavity 
IIIa—abdominal peritoneal surfaces with microscopic 
me...
Staging …
Staging … 
 Stage IV. Distant metastatic disease 
Malignant pleural effusion 
Pulmonary parenchymal metastases 
Liver or ...
Metastasis … 
 Typical spread– omentum, peritoneal surfaces such as 
undersurface of diaphragm, paracolic gutters and bow...
Screening … 
 5-year survival rates for 
stage I and stage II ovarian cancer are 80% to 90% and 
70%, respectively ; 
f...
Screening … 
 Unfortunately, there are no good screening methods for 
ovarian cancer at present; 
most use a combination ...
Screening … 
 Risk of Malignancy Index (RMI) 
Most valuable clinical tool by combining serum CA125 values 
with ultrasoun...
Management … 
 Complete surgical staging 
 Optimal reductive surgery 
 Chemotherapy 
 Clinical Trials
Management … 
 The treatment of ovarian cancer is based on the stage of the 
disease which is a reflection of the extent ...
Management … 
 Surgery 
 Surgery is the mainstay of both the diagnosis and the 
treatment of ovarian cancer. 
 A vertic...
Management … 
 Surgery 
I. Complete hysterectomy & removal of tubes and ovaries 
II. •Lymph node evaluation 
III. •Omente...
Management … 
 Surgery 
1. in a young , nulliparous woman with unilateral tumour and no 
ascites ( stage Ia ), unilateral...
Management … 
 Chemotherapy 
 Women with stage Ia or Ib and well or moderately 
differentiated tumours will not require ...
Management … 
Radiation Therapy 
 Currently, radiation therapy plays 
a limited role in the treatment of 
patients with e...
Management … 
Alternative Therapies 
A number of alternative therapies have been applied for the 
treatment of epithelial ...
Management … 
Alternative Therapies 
 Recently, antibodies against vascular epithelial growth factor 
(VEGF) have shown e...
Prognosis … 
The prognosis for patients with ovarian cancer is primarily 
related to the stage of disease. 
 germ cell tu...
Prognosis … 
 Embryonal carcinoma, choriocarcinoma, and polyembryoma 
are very rare lesions, and it is difficult to asses...
100 
95 
90 
85 
80 
75 
70 
65 
60 
55 
50 
45 
40 
35 
30 
25 
20 
15 
10 
Five years survival rates 
dysgerminoma Immat...
Ovarian cancer
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a nice presentation about the Ovarian Cancer its include an introduction with brief notes about the epidemiology and risk factors then shift to pathology and pathogenesis and diagnosis with signs , symptoms and lab tests with imaging modules , screening , management

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Ovarian cancer

  1. 1. Ovarian Cancer Ziyad Salih 6th stage Collage of Medicine – Al-Qadisiya University
  2. 2. Index :-  Introduction  Risk factors  Pathology and pathogenesis  Diagnosis  Screening  Staging  Mangment
  3. 3. Introduction  Ovarian cancer accounts for 3–4% of cancer in women  And is the fourth most frequent cause of cancer-related death in females in the United States  In the year 2005, an estimated 22,000 new ovarian cancer cases were diagnosed in the United States and 16,000 patients succumbed to the disease.  Ovarian cancer is the second most common gynecologic malignancy, endometrial cancer being the most common, but is the most common cause of death among women who develop a gynecologic malignancy.  In general, ovarian cancer is a disease of the postmenopausal woman, with the highest incidence among patients ages 65–74 year .
  4. 4. Risk Factors Family History Ethnicity Reproducti on others
  5. 5. Family History  The strongest risk factor  A women with a single first-degree relative with ov.Ca has a relative risk (RR) of approximately 3.6 for developing ov.ca compared with general population  Her life time risk approx. 5%  5-10% of ov.ca are linked to identifiable, inherited mutations in certain genes  Families in which three or more first-degree relatives have ovarian or ovarian plus breast cancer are likley to have a cancer-susceptibility genetic mutation that is transmitted in an autosomal-dominant inheritance pattern
  6. 6. Family History  Three familial ovarian cancer syndromes:- 1- The site specific ovarian ov.ca syndrome # only ov.ca is seen # account for 10-15% of hereditary ov.ca. 2- The hereditary breast/ovarian cancer syndrome #associated with 65-75% of hereditary ov.ca. 3- the hereditary nonpolyposis colorectal cancer syndrome (HNPCC), affected individuals may have colon, endometrial, breast, ovarian or other cancers
  7. 7. Ethnicity  Higher in white women  Higher in north America and northern Europe than Japan  Difference related to genetics, diet, or environmental exposure or a combination  BRCA1 and BRCA2 genes are more common among white women of Ashkenazi descent  Incidence of ov.ca is higher in countries with higher in countries with higher per capita consumption of animal fat
  8. 8. Reproduction factors  Nulliparous  First childbirth after age 35 years  Involuntary infertility  Late menopause and early menarche  Pts. With prolonged period or uninterrupted ovulation
  9. 9. Others  Exogenous hormones :- HRT  Dietary factors , Diets high in saturated animal fats seem to confer an increased risk by unknown mechanisms … Japanese women who move to the United States have an increased ovarian cancer risk. # Japanese women who move to the United States have an increased ovarian cancer risk. <<<<<<<<<<<<<<<<
  10. 10. Protective Factors  Multiparity: First pregnancy before age 30  Oral contraceptives: 5 years of use cuts risk nearly in half  Tubal ligation  Hysterectomy  Bilateral oopherectomy  Lactation  Epidemiologic and laboratory evidence suggest a potential role for retinoids , vitamin D, NSAIDs as preventive agents for ovarian cancer
  11. 11. Pathology  Ovarian cancer can be divided into three major categories based on the cell type of origin .  The ovary may also be the site of metastatic disease by primary cancer from another organ site.  Unlike carcinomas of the cervix and endometrium, precursor lesions of ovarian carcinoma have not been defined.
  12. 12. Pathology  Major Histopathologic Categories of Ovarian Cancer 1- Epithelial Serous, mucinous, endometrioid, clear cell, transitional cell (Brenner), undifferentiated 2- Germ Cell Dysgerminoma, endodermal sinus tumor, teratoma (immature, mature, specialized), embryonal carcinoma, choriocarcinoma, gonadoblastoma, mixed germ cell, polyembryona 3- Sex Cord and Stromal Granulosa cell tumor, bibroma, thecoma Sertoli-Leydig cell, gynandroblastoma
  13. 13. Pathology  Major Histopathologic Categories of Ovarian Cancer 4- Neoplasms Metastatic to the Ovary Breast, colon, stomach, endometrium, lymphoma
  14. 14. Pathogenesis  Ovarian carcinogenesis can be divided into two broad phases: 1- malignant transformation Benign borderline  malignant ovarian tumors. 2- peritoneal dissemination ** Now do not appear to be valid for the majority of ovarian cancers
  15. 15. Pathogenesis New model of ovarian carcinogenesis :- Surface epithelial tumors divides into two broad categories: Type I and Type II based on their clinico-pathologic features and characteristic molecular genetic changes
  16. 16. Pathogenesis Type 1 Type 2 Low grade High grade Arise from precursor lesion in a stepwise Arise “de novo” fashion - Cystadenoma - Borderline tumor Typically present in stage I Typically present in advanced stage Slow growing, indolent Rapid growing, aggressive Often remains low grade E.g. High grade serous E.g. Low grade micropapillary Mucinous Clear cell endometroid
  17. 17. Diagnosis and Clinical Evaluation  Ovarian cancer typically develops as an insidious disease, with few warning signs or symptoms. Most neoplastic ovarian tumors produce few symptoms until the disease is widely disseminated throughout the abdominal cavity.  A history of nonspecific gastrointestinal complaints, including : nausea, dyspepsia, and altered bowel habits, is particularly common  abdominal distention as a result of ascites are generally signs of advanced disease.  A change in bowel habits, such as constipation and decreased stool caliber, is occasionally noted. Large tumors may cause a sensation of pelvic weight or pressure.
  18. 18. Diagnosis and Clinical Evaluation  Rarely, an ovarian tumor may become incarcerated in the cul-de-sac and cause severe pain, urinary retention, rectal discomfort, and bowel obstruction.  Menstrual abnormalities may be noted in as many as 15% of reproductive-age patients with an ovarian neoplasm  vaginal bleeding may occur in patients with ovarian cancer in the presence of a synchronous endometrial carcinoma or as a consequence of metastatic disease to the lower genital tract.  Ovarian stromal hyperplasia or hyperthecosis also may be associated with excess androgen production, which alters the normal menstrual cycle.
  19. 19. Diagnosis and Clinical Evaluation  On Physical Examination ,, 1. General examination 2. Abdominal examination :- Abdominal distention is one of the more common findings. The presence of flank fullness and shifting dullness implies the presence of ascites or a large pelvic-abdominal mass , Recent eversion of the umbilicus 3. Lymph Node examination :- the supraclavicular and inguinal areas , Sister Mary Joseph's nodule refers to a metastatic implant in the umbilicus.
  20. 20. Diagnosis and Clinical Evaluation  On Physical Examination ,, 4. Pelvic examination :- A careful and thorough pelvic examination provides many helpful clues regarding the etiology of a pelvic mass. # Benign mass :- Mobile , smooth , cystic , unilateral #malignant mass :- fixed , irregular , sold or firm , bilateral.  If I find a mass …. What could be else !!!! Endometrioma , Fibroid , Functional cyst , Ectopic pregnancy , Dermoid tumor (younger women)
  21. 21. Diagnosis and Clinical Evaluation  Investigations ,, Tumor Markers :- an antigenic determinant on a high-molecular-weight glycoprotein recognized by the murine monoclonal antibody OC-125  upper limit of normal- 35 U/mL.  In postmenopausal women :- lower cutoffs, 20 U/mL  85% of patients with epithelial ovarian cancer have >35 U/mL.
  22. 22. Diagnosis and Clinical Evaluation  Investigations ,, Tumor Markers :-  CA125 can be elevated :- 1. less frequently elevated in mucinous, clear cell, and borderline tumors compared to serous tumors. 2. in other malignancies (pancreas, breast, colon, and lung cancer) 3. in benign conditions and physiological states such as pregnancy, endometriosis, and menstruation. Many of these nonmalignant conditions are not found in postmenopausal women, improving the diagnostic accuracy of elevated CA125 in this population.
  23. 23. Diagnosis and Clinical Evaluation  Investigations ,, Tumor Markers :-  One of the limitations of CA125 is that 15% to 20% of ovarian cancers do not express the antigen.  Though FDA approved, NCCN does not recommend use of biomarkers including CA-125 for estimating risk of cancer in case of pelvic mass.  LDH (lactate dehydrogenase)— dysgerminoma  HCG (human chorionic gonadotropin)– choriocarcinoma.  AFP (alpha fetal protein)-- endodermal sinus tumors  Other routine tests ( CBC , LFT , RFT , CXR )
  24. 24. Diagnosis and Clinical Evaluation  Investigations ,,  Initial imaging modality of choice # for benign vs malignant  that US detects more stage I ovarian carcinomas than CA125 levels and physical examination
  25. 25. Diagnosis and Clinical Evaluation  Investigations ,, benign :- smooth, thin walls; few, thin septations; absence of solid components or mural nodularity.
  26. 26. Diagnosis and Clinical Evaluation  Investigations ,,  mural nodules, mural thickening or irregularity, solid components, thick septations (3 mm) and associated findings such as ascites, peritoneal implants, and/or hydronephrosis suggest malignancy
  27. 27. Diagnosis and Clinical Evaluation  Investigations ,, TVS is significantly more accurate
  28. 28. Diagnosis and Clinical Evaluation  Investigations ,, Computed Tomography  Not the study of choice to evaluate a suspected ovarian lesion.  the sensitivity, specificity, and accuracy of CT for characterizing benign versus malignant lesions are reported to be 89%, 96% to 99%, and 92% to 94%, respectively.
  29. 29. Diagnosis and Clinical Evaluation  Investigations ,, Computed Tomography  On CT, ovarian cancer demonstrates varied morphologic patterns, including a multilocular cyst with thick internal septations and solid mural or septal components, a partially cystic and solid mass, and a lobulated, papillary solid mass.
  30. 30. Diagnosis and Clinical Evaluation  Investigations ,, Magnetic Resonance Imaging  Complementary to US in the evaluation of a suspected ovarian lesion.  As with CT, disease metastatic to the ovary is often indistinguishable from primary ovarian cancer on MRI scans  both the colon and the stomach should be examined as potential primary tumor sites if an ovarian mass is detected.
  31. 31. Diagnosis and Clinical Evaluation  Investigations ,, Magnetic Resonance Imaging  Several studies have compared MRI to CT and US for characterizing adnexal masses, with mixed results  Both TVS and MRI have high sensitivity (97% and 100%, respectively) in the identification of solid components within an adnexal mass. MRI, however, shows higher specificity (98% vs. 46%)
  32. 32. Diagnosis and Clinical Evaluation  Investigations ,, Magnetic Resonance Imaging  MRI was shown to be the most efficient second test when an indeterminate ovarian mass was detected at US.  high cost of MRI precludes its use as a screening modality.
  33. 33. Diagnosis and Clinical Evaluation  Investigations ,, Positron Emission Tomography  little clinical role in the primary detection of a pelvic mass  Appears to be promising for its potential to detect tumor prior to significant morphologic changes.  US, CT, MRI, and FDG-PET all have a role to play in the accurate staging of ovarian cancer.  These modalities also play a role in the monitoring of therapy and detection of recurrent disease.
  34. 34. Staging …  According to International Federation of Gynecology and Obstetrics (FIGO) Staging of Ovarian Neoplasms :-  Stage I. Growth limited to the ovaries Ia —one ovary involved Ib —both ovaries involved Ic —Ia or Ib and ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology positive for malignant cells
  35. 35. Staging …
  36. 36. Staging …  Stage II. Extension of the neoplasm from the ovary to the pelvis IIa—extension to the uterus or fallopian tube IIb—extension to other pelvic tissues IIc—IIa or b and ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology positive for malignant cells
  37. 37. Staging …
  38. 38. Staging …  Stage III. Disease extension to the abdominal cavity IIIa—abdominal peritoneal surfaces with microscopic metastases IIIb—tumor metastases < 2 cm in size IIIc—tumor metastases > 2 cm in size or metastatic disease in the pelvic, paraaortic, or inguinal lymph nodes
  39. 39. Staging …
  40. 40. Staging …  Stage IV. Distant metastatic disease Malignant pleural effusion Pulmonary parenchymal metastases Liver or splenic parenchymal metastases (not surface implants) Metastases to the supraclavicular lymph nodes or skin
  41. 41. Metastasis …  Typical spread– omentum, peritoneal surfaces such as undersurface of diaphragm, paracolic gutters and bowel serosa  Lymphatics– follows bld supply thru infundibulopelvic lig to nodes in para aortic region  Drainage thru broad lig and parametrium– involves ext iliac, obturator and hypogastric regions  Along round lig– involves inguinal nodes  Extra abd mets– pleura, liver , spleen, lung, bone and CNS
  42. 42. Screening …  5-year survival rates for stage I and stage II ovarian cancer are 80% to 90% and 70%, respectively ; for stages III and IV ranges from 5% to 30%.  Only 25% diagnosed in Stage I  In 1994, a NIH recommended that screening be offered to women with ≥ 2 first-degree relatives with ovarian carcinoma.  In practice, many women with a single first-degree relative are enrolled in screening programs
  43. 43. Screening …  Unfortunately, there are no good screening methods for ovarian cancer at present; most use a combination of physical exam, CA125 levels, and TVS.  No role of routine screening in general population . Some follow women with high risk factors (e.g., family history, BRCA mutation) using CA-125 and TVS.
  44. 44. Screening …  Risk of Malignancy Index (RMI) Most valuable clinical tool by combining serum CA125 values with ultrasound findings and menopausal status to calculate a Risk of Malignancy Index (RMI). RMI = U x M x CA125 1. ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. 2. menopausal status is scored as 1 = pre-menopausal and 3 = post-menopausal 3. Serum CA125 in IU/ml and can vary between 0 and hundreds or even thousands of units.
  45. 45. Management …  Complete surgical staging  Optimal reductive surgery  Chemotherapy  Clinical Trials
  46. 46. Management …  The treatment of ovarian cancer is based on the stage of the disease which is a reflection of the extent or spread of the cancer to other parts of the body.  There are basically three forms of treatment of ovarian cancer:- 1. The primary one is surgery at which time the cancer is removed from the ovary and from as many other sites as is possible 2. Chemotherapy is the second important modality. 3. radiation treatment, which is used in only certain instances. It utilizes high energy x-rays to kill cancer cells.
  47. 47. Management …  Surgery  Surgery is the mainstay of both the diagnosis and the treatment of ovarian cancer.  A vertical incision is required for an adequate exploration of the upper abdomen.  The pelvis and upper abdomen are explored carefully to identify metastatic disease.  This is usually possible in the majority of stage I and stage II, but impossible in advanced cases.
  48. 48. Management …  Surgery I. Complete hysterectomy & removal of tubes and ovaries II. •Lymph node evaluation III. •Omentectomy IV. •Intestinal resection V. •Peritoneal stripping/Tumor debulking VI. •Conservative management for those desiring to preserve fertility with early stage disease
  49. 49. Management …  Surgery 1. in a young , nulliparous woman with unilateral tumour and no ascites ( stage Ia ), unilateral salpingo-oophorectomy may be done after careful exploration to exclude metastatic disease , and curettage of the uterine cavity to exclude a synchronous endometrial tumour.  If the is subsequently found to be poorly differentiated or if the washings are positive, a second operation to clear the pelvis will be necessary. - For older women who complete her family a total hysterectomy and bilateral salpingo-oophorectomy is usually done.
  50. 50. Management …  Chemotherapy  Women with stage Ia or Ib and well or moderately differentiated tumours will not require further treatment.  All other patient with invasive ovarian carcinoma require chemotherapy (stage II-IV –possibly stage Ic ).  Drugs used are Carboplatin, cisplatin and taxol.
  51. 51. Management … Radiation Therapy  Currently, radiation therapy plays a limited role in the treatment of patients with epithelial ovarian cancer mainly because of radiation damage to the small bowel, liver, and kidneys.  radiation therapy has been used successfully in the treatment of patients with dysgerminoma .
  52. 52. Management … Alternative Therapies A number of alternative therapies have been applied for the treatment of epithelial ovarian cancer.  Cytokines like interleukin-2 and interferon either alone or in combination with chemotherapy have shown some promising effects.  Monoclonal antibodies directed against ovarian cancer-associated antigens, including CA-125, HMFG (human milk-fat globulin)
  53. 53. Management … Alternative Therapies  Recently, antibodies against vascular epithelial growth factor (VEGF) have shown efficacy in patients with ovarian cancer. Anti-VEGF antibodies are currently being tested in combination with carboplatin and paclitaxel in first-line chemotherapy for ovarian cancer patients.  Gene therapy trials have used different antitumor approaches, including the delivery of tumor suppressor gene p53 via recombinant adenovirus into the peritoneal cavities.  The early trials have not shown significant clinical response, mainly as a result of the inefficiency of intraperitoneal and intratumoral gene transfer.
  54. 54. Prognosis … The prognosis for patients with ovarian cancer is primarily related to the stage of disease.  germ cell tumors are associated with better 5-year survival rates than epithelial ovarian neoplasms.  Patients with dysgerminoma have a 5-year survival rate of 95%.  Immature teratomas are associated with 5-year survival rates of 70–80%.  endodermal sinus tumor is associated with a 5-year survival rate of 60–70%.
  55. 55. Prognosis …  Embryonal carcinoma, choriocarcinoma, and polyembryoma are very rare lesions, and it is difficult to assess 5-year survival estimates.  Epithelial ovarian neoplasms of low malignancy potential are characterized by 5-year survival rates of 95%
  56. 56. 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 Five years survival rates dysgerminoma Immature teratomas endodermal sinus tumor Epithelial ovarian neoplasms
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a nice presentation about the Ovarian Cancer its include an introduction with brief notes about the epidemiology and risk factors then shift to pathology and pathogenesis and diagnosis with signs , symptoms and lab tests with imaging modules , screening , management

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