History

Fact Explanation
Dyspepsia, early satiety, abdominal discomfort,fullness, heaviness, bloating sensation, indigestion Ovarian cancer is one of the main gynecological cancers with an increased mortality. [1] Usually the disease is advanced at the time of diagnosis. [4] Ovarian cancer may be either primary or secondary. Primary cancers consist of epithelial ovarian carcinoma (70% of ovarian malignancies), germ-cell, sex-cord stromal tumors, and other types. Epithelial ovarian cancer is the leading type among these. Ovarian carcinomas are classified by cell type into serous, mucinous, endometrioid, clear cell, and Brenner (transitional) tumors. [4] Metastatic cancers are due to the spread from the other sites such as endometrium, breast, colon, stomach, and cervix. Overall 5-year survival rate of ovarian cancer is about 30%. If the disease is confined to the ovary (stage I) 5-year survival is more than 90%. [4]
Abdominal mass and pain Person may be having an abdominal mass which may be noticed by her self. Dull lower abdominal pain will be a mode of presentation. This may radiate to lower back and thighs. [4]
Constipation, frequent micturition Constipation is due to the pressure effects on the bladder and rectum. [2] Patients often have peritoneal disease that involves the surfaces of the bowel. [6] Pressure on the bladder causes need to urinate more frequently or difficulty emptying the bladder completely.
Weight loss, loss apetite Is associated with malignancy. [7]
Dyspareunia Pelvic pain during intercourse is known as deep dyspareunia. This is common with large cysts that displace the ovary and compress during intercourse. [5]
Family history of breast or ovarian cancer Family history of breast and ovarian is a most important risk factor for ovarian cancer This is associated with a germline mutation that increases the risk of the disease. These mutations occurs in the cancer susceptibility genes, BRCA1 and BRCA2. [1,4]
History of colorectal, endometrial, ovarian, gastric, small bowel, biliary/pancreatic, urothelial, skin and central nervous system cancers Hereditary ovarian cancer is also related to the Lynch syndrome which is an autosomal dominant disorder. This makes the individual vulnerable for the colorectal, endometrial, ovarian, gastric, small bowel, biliary/pancreatic, urothelial, skin and central nervous system cancers. [1]
History of endometriosis 1% of ovarian endometriosis can give rise to malignant ovarian yumours. [2]
Parity There is increased estrogen and progestin during pregnancy and oral contraceptive use. Therefore high parity is a protective factor for the ovarian cancer. [2,4]
Use of contraceptives Progestin only oral contraceptives are protective, where the estrogen only or sequential estrogen plus progestin increases the risk of ovarian cancer. [2]
Menstrual history Early menarche and late menopause increase the risk of ovarian cancer [2].
Age Incidence of epithelial ovarian cancer is high among the postmenopausal women where as malignant epithelial tumors are common between 40 and 60 years of age. [4]
References
  1. TOSS A, DE MATTEIS E, ROSSI E, CASA LD, IANNONE A, FEDERICO M, CORTESI L. Ovarian Cancer: Can Proteomics Give New Insights for Therapy and Diagnosis? Int J Mol Sci [online] , 14(4):8271-8290 [viewed 23 August 2014] Available from: doi:10.3390/ijms14048271
  2. MENG Q, SUN W, JIANG J, FLETCHER NM, DIAMOND MP, SAED GM. Identification of common mechanisms between endometriosis and ovarian cancer J Assist Reprod Genet [online] 2011 Sep, 28(10):917-923 [viewed 23 August 2014] Available from: doi:10.1007/s10815-011-9573-1
  3. A SPENCER J. Ovarian cancer: what's new, where next? Cancer Imaging [online] , 4(1):19-21 [viewed 23 August 2014] Available from: doi:10.1102/1470-7330.2003.0030
  4. YONEDA A, LENDORF ME, COUCHMAN JR, MULTHAUPT HA. Breast and Ovarian Cancers: A Survey and Possible Roles for the Cell Surface Heparan Sulfate Proteoglycans J Histochem Cytochem [online] 2012 Jan, 60(1):9-21 [viewed 24 August 2014] Available from: doi:10.1369/0022155411428469
  5. CHETTIER R, WARD K, ALBERTSEN HM. Endometriosis is associated with rare copy number variants. PLoS One [online] 2014, 9(8):e103968 [viewed 04 August 2014] Available from: doi:10.1371/journal.pone.0103968
  6. TWU C, HAN ES. Clinical utility of targeted treatments in the management of epithelial ovarian cancer Biologics [online] 2012:233-244 [viewed 24 August 2014] Available from: doi:10.2147/BTT.S29356
  7. HIPPISLEY-COX J, COUPLAND C. Identifying women with suspected ovarian cancer in primary care: derivation and validation of algorithm BMJ [online] 2012:d8009 [viewed 19 September 2014] Available from: doi:10.1136/bmj.d8009

Examination

Fact Explanation
Pallor Malignant conditions are associated with anaemia. Malnutrition due to poor intake associated with early satiety, loss of appetite may also contribute. [4]
Jaundice Spread to the liver may cause jaundice. [5]
Vulval and leg oedema Impaired venous drainage due to the abdominal mass. [6]
Obesity, hirsuitism, acne, alopecia Higher levels of androgens are found in those with polycystic ovarian syndrome, and is known to be associated with ovarian cancer [2].
Lymphadenopathy Cancer can be spread via the lymphatics involving the pelvic and para-aortic lymph nodes. This occurs in 20% of early stage cancers and the majority of advanced-stage cancers. [2]
Abdominal lump Ovarian lump may be palpated per abdomen. Examiner can get below the lump. Examination can be combined with vaginal examination, and moving the cervix upwards will not move the lump in same direction. Stage I tumor is limited to the ovaries, stage II tumor involves either one ovary or both of them with pelvic extension, stage III tumor involves one ovary or both of them with peritoneal metastasis outside the pelvis and/or regional lymph node metastasis, and stage IV tumor is distant metastasis. [2]
Abdominal distension, flank dullness, shifting dullness, horseshoe dullness and fluid thrill Ovarian lump can cause gradual abdominal distention. Ascites can be due to the peritoneal dissemination of tumor cells throughout the peritoneal cavity. [2]
Pelvic examination Per vaginal discharge/ bleeding, cervical excitation, adnexal mass/ tenderness, may be evident. Bi manual examination will help to differentiate ovarian mass from a uterine lump.[3]
Pleural effusion: reduced chest expansion, stony dull percussion, reduced vocal fremitus, reduced breath sounds Pleural disease does occur with ovarian cancer. [7]
References
  1. A SPENCER J. Ovarian cancer: what's new, where next? Cancer Imaging [online] , 4(1):19-21 [viewed 23 August 2014] Available from: doi:10.1102/1470-7330.2003.0030
  2. YONEDA A, LENDORF ME, COUCHMAN JR, MULTHAUPT HA. Breast and Ovarian Cancers: A Survey and Possible Roles for the Cell Surface Heparan Sulfate Proteoglycans J Histochem Cytochem [online] 2012 Jan, 60(1):9-21 [viewed 24 August 2014] Available from: doi:10.1369/0022155411428469
  3. SHUSHAN A, PERETZ T, MOR-YOSEF S. Therapeutic approach to ovarian cysts in tamoxifen-treated women with breast cancer. Int J Gynaecol Obstet [online] 1996 Mar, 52(3):249-53 [viewed 04 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8775677
  4. FOX H. Ovarian Tumors--Histogenesis and Systemic Effects Calif Med [online] 1968 Oct, 109(4):295-300 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1503271
  5. GUPTA A, NOBA AL, GUPTA S, ARORA VK, RATHI V, KUMAR S. Papillary Cystadenocarcinoma of Ovary Presenting as Obstructive Jaundice: A Rare Presentation Oman Med J [online] 2012 Mar, 27(2):159-160 [viewed 19 September 2014] Available from: doi:10.5001/omj.2012.32
  6. LIM MC, LEE JS, NAM BH, SEO SS, KANG S, PARK SY. Lower extremity edema in patients with early ovarian cancer J Ovarian Res [online] :28 [viewed 19 September 2014] Available from: doi:10.1186/1757-2215-7-28
  7. KIM KH, BYUN JW, KWON GM, SHIM JH. Massive pleural effusion in ovarian tumor patient during laparoscopic surgery Korean J Anesthesiol [online] 2013 Dec, 65(6 Suppl):S145-S146 [viewed 19 September 2014] Available from: doi:10.4097/kjae.2013.65.6S.S145

Differential Diagnoses

Fact Explanation
Benign ovarian cysts [4] These also present with the same features of ovarian malignancy, [4] Nulliparity and infertility are associated with an increased risk, and multiparity with a reduced risk of benign ovarian conditions. [4] Imaging such as ultrasound scan is helpful to define the characteristics of cyst such as unilateral/bilateral, single/multiple, unilocular/ multilocular, site, size, shape, consistency, thickness of the septae etc. Presence of ascites, and peritoneal metastases will favour malignancy. CA125 is also normal or slightly elevate din benign cysts.
Endometriosis Endometriosis is ectopic location and growth of endometrial glands and stroma [1]. CA 125 will be elevate din endometriosis but not as high in malignant ovarian cysts. Hemorrhagic cysts, and endometriomas are evident on ultrasound scan.
Pedunculated fibroid [2] This may also present with similar pressure symptoms and pelvic mass. [3] But patient is more ill with ascites and wasting in ovarian cancers. Bimanual palpation will help to differentiate this mass arise from uterus.
References
  1. MENG Q, SUN W, JIANG J, FLETCHER NM, DIAMOND MP, SAED GM. Identification of common mechanisms between endometriosis and ovarian cancer J Assist Reprod Genet [online] 2011 Sep, 28(10):917-923 [viewed 23 August 2014] Available from: doi:10.1007/s10815-011-9573-1
  2. KATSUMORI T, AKAZAWA K, MIHARA T. Uterine artery embolization for pedunculated subserosal fibroids. AJR Am J Roentgenol [online] 2005 Feb, 184(2):399-402 [viewed 04 August 2014] Available from: doi:10.2214/ajr.184.2.01840399
  3. EZEAMA C, IKECHEBELU J, OBIECHINA N, EZEAMA N. Clinical Presentation of Uterine Fibroids in Nnewi, Nigeria: A 5-year Review Ann Med Health Sci Res [online] 2012, 2(2):114-118 [viewed 19 September 2014] Available from: doi:10.4103/2141-9248.105656
  4. BOOTH M, BERAL V, MACONOCHIE N, CARPENTER L, SCOTT C. A case-control study of benign ovarian tumours. J Epidemiol Community Health [online] 1992 Oct, 46(5):528-531 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1059646

Investigations - for Diagnosis

Fact Explanation
Tumor markers (eg, CA125, beta-human chorionic gonadotropin, alpha-fetoprotein, lactate dehydrogenase) [4] CA 125 (Cancer antigen 125), a protein expressed on the cell membrane of both normal ovarian tissue and carcinomas. Serum level less than 35U/mL is considered as normal. More than 80% of epithelial ovarian carcinomas will have elevated CA125 levels. This is not specific to ovarian malignancies as it can also be elevated in peritonitis, hemorrhage, cyst rupture, and infection, menstruation, fibroids, and endometriosis. If the symptoms are suggestive of ovarian cancer CA125 needs to be done.[6] If serum CA125 is 35 IU/ml or greater, ultrasound scan of the abdomen and pelvis is needed to evaluate the presence of ovarian malignancy. Other tumor markers like Alpha fetoprotein, human chorionic gonadotropin will be elevated in germ cell tumours and LDH, inhibin and oestradiol in sex cord stromal tumours. These needs to be be considered in young women with a solid mass. CA19-9- may be elevated in mucinous tumours and teratomas. [5]
Abdominal and pelvic ultrasonography Ultrasound scan is helpful [1,2] to define the characteristics of cyst such as unilateral/bilateral, single/multiple, unilocular/ multilocular, site, size, shape, consistency, thickness of the septae etc. Presence of ascites, and peritoneal metastases will favour malignancy. Large cysts with associated features such as multilocular, thick walled, projections into the lumen or on the surface, solid and cystic areas within the cyst contents are more likely to be malignant.
Diagnostic laparoscopy[3] Performing diagnostic laparoscopy [3] may sometimes be necessary to inspect the mass. There is a possibility of missing an intraovarian malignancy.
References
  1. KNUDSEN UB, TABOR A, MOSGAARD B, ANDERSEN ES, KJER JJ, HAHN-PEDERSEN S, TOFTAGER-LARSEN K, MOGENSEN O. Management of ovarian cysts. Acta Obstet Gynecol Scand [online] 2004 Nov, 83(11):1012-21 [viewed 04 August 2014] Available from: doi:10.1111/j.0001-6349.2004.00607.x
  2. GOFFINET F. [Ovarian cysts and pregnancy]. J Gynecol Obstet Biol Reprod (Paris) [online] 2001 Nov, 30(1 Suppl):S100-8 [viewed 04 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11917371
  3. CHAPRON C, DUBUISSON JB, FRITEL X, RAMBAUD D. Diagnosis and management of organic ovarian cysts: indications and procedures for laparoscopy. Hum Reprod Update [online] 1996 Sep-Oct, 2(5):435-46 [viewed 04 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15717442
  4. MUKHOPADHYAY M, SHUKLA RM, MUKHOPADHYAY B, MANDAL KC, RAY A, SISODIYA N, PATRA MP. Ovarian cysts and tumors in infancy and childhood J Indian Assoc Pediatr Surg [online] 2013, 18(1):16-19 [viewed 04 August 2014] Available from: doi:10.4103/0971-9261.107010
  5. CHO HY, KIM K, JEON YT, KIM YB, NO JH. CA19-9 elevation in ovarian mature cystic teratoma: Discrimination from ovarian cancer - CA19-9 level in teratoma Med Sci Monit [online] :230-235 [viewed 19 September 2014] Available from: doi:10.12659/MSM.883865
  6. MACDONALD F, BIRD R, STOKES H, RUSSELL B, CROCKER J. Expression of CEA, CA125, CA19-9 and human milk fat globule membrane antigen in ovarian tumours. J Clin Pathol [online] 1988 Mar, 41(3):260-264 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1141420

Investigations - Fitness for Management

Fact Explanation
Haemoglobin level Anaemia can be seen in patients with malignancies.[2]
Urinalysis Abdominal and pelvic pain may be presenting features. Therefore excluding the urinary tract infections is important in the management. [4]
OVA-1 test This is an immunoassay-based test, used preoperatively, to assess the the risk of ovarian cancer in persons with pelvic masses. [1]
CT scan of the abdomen and pelvis Extent of involvement of the peritoneum, omentum and retroperitoneum prior to surgery is done using CT scan. [3]
References
  1. TOSS A, DE MATTEIS E, ROSSI E, CASA LD, IANNONE A, FEDERICO M, CORTESI L. Ovarian Cancer: Can Proteomics Give New Insights for Therapy and Diagnosis? Int J Mol Sci [online] , 14(4):8271-8290 [viewed 23 August 2014] Available from: doi:10.3390/ijms14048271
  2. FOX H. Ovarian Tumors--Histogenesis and Systemic Effects Calif Med [online] 1968 Oct, 109(4):295-300 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1503271
  3. CHANG CF, LIN CK. A case of recurrent, bilateral ovarian mature teratoma in a young woman BMC Womens Health [online] :57 [viewed 19 September 2014] Available from: doi:10.1186/1472-6874-14-57
  4. HONKINEN O, LEHTONEN OP, RUUSKANEN O, HUOVINEN P, MERTSOLA J. Cohort study of bacterial species causing urinary tract infection and urinary tract abnormalities in children BMJ [online] 1999 Mar 20, 318(7186):770-771 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27791

Investigations - Followup

Fact Explanation
CA 125 level It is better to do annual CA125 in high-risk women. [3]
Ultrasoud scan Annual ultrasonographic examinations is required in high risk people. [4]
HE4 HE4 is used to monitor recurrence or progression of epithelial ovarian cancer. [1]
CT scan abdomen and pelvis Baseline CT after chemotherapy is taken and it is compared with a CT in a relapse. [2] Post-surgical patient will have no omentum and omental cakes. Recurrence may involve other peritoneal recesses and reflections such as supracolic compartment around the spleen and stomach.
References
  1. TOSS A, DE MATTEIS E, ROSSI E, CASA LD, IANNONE A, FEDERICO M, CORTESI L. Ovarian Cancer: Can Proteomics Give New Insights for Therapy and Diagnosis? Int J Mol Sci [online] , 14(4):8271-8290 [viewed 23 August 2014] Available from: doi:10.3390/ijms14048271
  2. A SPENCER J. Ovarian cancer: what's new, where next? Cancer Imaging [online] , 4(1):19-21 [viewed 23 August 2014] Available from: doi:10.1102/1470-7330.2003.0030
  3. TUXEN MK, SöLéTORMOS G, DOMBERNOWSKY P. Serum tumour marker CA 125 in monitoring of ovarian cancer during first-line chemotherapy Br J Cancer [online] 2001 May, 84(10):1301-1307 [viewed 19 September 2014] Available from: doi:10.1054/bjoc.2001.1787
  4. MARCUS CS, MAXWELL GL, DARCY KM, HAMILTON CA, MCGUIRE WP. Current Approaches and Challenges in Managing and Monitoring Treatment Response in Ovarian Cancer J Cancer [online] , 5(1):25-30 [viewed 19 September 2014] Available from: doi:10.7150/jca.7810

Investigations - Screening/Staging

Fact Explanation
Pelvic and abdominal computed tomography (CT) scanning and magnetic resonance imaging CT is important in staging the disease. [2] CT is better than USS for retroperitoneal assessment, detection of omental and peritoneal disease, assess the extent of involvement of the peritoneum, omentum and retroperitoneum prior to surgery.
Chest radiography/CT chest To exclude the lung metastases. [2]
HE4 HE4 is a secreted glycoprotein , either alone or in combination with CA125, has shown to improve the accuracy of screening for ovarian cancers as it is overexpressed by serous and endometrioid ovarian cancers. [1]
Urinary pregnancy test This should be always performed in all women of childbearing age to exclude the pregnancy. Positive pregnancy test and a ovarian cyst may be due to corpus luteum cyst. [3]
RMI (Risk of Malignancy Index) [4] Serum CA-125 level, menopausal status, and ultrasound score is used to calculate the RMI score. Risk of ovarian carcinoma is low when the RMI score <25, while a moderate risk is present with a score of 25-250 and a high risk is present if the RMI score >250.
References
  1. TOSS A, DE MATTEIS E, ROSSI E, CASA LD, IANNONE A, FEDERICO M, CORTESI L. Ovarian Cancer: Can Proteomics Give New Insights for Therapy and Diagnosis? Int J Mol Sci [online] , 14(4):8271-8290 [viewed 23 August 2014] Available from: doi:10.3390/ijms14048271
  2. A SPENCER J. Ovarian cancer: what's new, where next? Cancer Imaging [online] , 4(1):19-21 [viewed 23 August 2014] Available from: doi:10.1102/1470-7330.2003.0030
  3. ) TAKEDA A, SAKAI K, MITSUI T, NAKAMURA H. Management of ruptured corpus luteum cyst of pregnancy occurring in a 15-year-old girl by laparoscopic surgery with intraoperative autologous blood transfusion. J Pediatr Adolesc Gynecol [online] 2007 Apr, 20(2):97-100 [viewed 04 August 2014] Available from: doi:10.1016/j.jpag.2006.09.017
  4. ) MOOLTHIYA W, YUENYAO P. The risk of malignancy index (RMI) in diagnosis of ovarian malignancy. Asian Pac J Cancer Prev [online] 2009, 10(5):865-8 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20162854

Management - General Measures

Fact Explanation
Patient education This should be a part of the management. Accurate information regarding the condition, treatment, chemotherapy and its side effects should be provided to the patient and family in an empathetic manner. Psychological support is important as they may be psychologically depressed. [3]
Supportive management Management of pain, anaemia nutritional support is needed.
Management of complications They need symptomatic treatment. Pleural effusion needs to be drained. Ascites needs a paracentesis.
Genetic screening for BRCA1 and BRCA2 mutations [1,2] Genetic screening [1,2] should be considered in patients with: two primary cancers (breast and/or ovary) in one 1st /2nd degree relative, three 1st and 2nd degree relatives with any of these cancers- breast, ovarian, colorectal, stomach, endometrial, two 1st or 2nd degree relatives, one with ovarian cancer at any age and one with breast cancer under 50 or two 1st or 2nd degree relatives with ovarian cancer at any age.
References
  1. LOWRY KP, LEE JM, KONG CY, MCMAHON PM, GILMORE ME, COTT CHUBIZ JE, PISANO ED, GATSONIS C, RYAN PD, OZANNE EM, GAZELLE GS. Annual screening strategies in BRCA1 and BRCA2 gene mutation carriers: a comparative effectiveness analysis. Cancer [online] 2012 Apr 15, 118(8):2021-30 [viewed 06 August 2014] Available from: doi:10.1002/cncr.26424
  2. MOYER VA, U.S. PREVENTIVE SERVICES TASK FORCE. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med [online] 2014 Feb 18 [viewed 06 August 2014] Available from: doi:10.7326/M13-2747
  3. RODIN G, KATZ M, LLOYD N, GREEN E, MACKAY JA, WONG RK. Treatment of depression in cancer patients Curr Oncol [online] 2007 Oct, 14(5):180-188 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2002483

Management - Specific Treatments

Fact Explanation
Surgery Stage IA and IB disease with well differentiation or moderately well differentiation can be treated with surgery alone. Surgery includes hysterectomy, bilateral salpingo-oophorectomy, and omentectomy with optimal cytoreduction [3] and debulking. Sampling is done from the potential sites such as peritoneal biopsies, pelvic and para-aortic lymph node biopsies and peritoneal washings. Surgical exploration is also needed for histological confirmation. [1] Target is to resect the tumour completely with optimal tumor debulking, defined as residual tumor of less than 1 cm in diameter. [1] If the person is not suitable for the surgery, neoadjuvant chemotherapy for 3–4 cycles given and then proceed to interval debulking surgery.
Radiotherapy If the tumor is grade III, densely adherent, or stage IC, radiation therapy is recommended. [2,3]
Systemic chemotherapy Systemic chemotherapy based on platinums alone or in combination with alkylating agents are used to treat the ovarian malignancies. Paclitaxel given over one hour from 180 mg/m2 intravenously every 3 weeks to a dose-dense regimen of 80 mg/m2 intravenously once a week. [1] Paclitaxel, 250 mg/m2, and cisplatin, 75 mg/m2, are the maximally tolerated doses These drugs can be associated with toxic effects such as nausea, vomiting, malaise, bone pain, headache, fever, chills, facial flushing and occasionally peripheral neuropathy or myalgias. Neutropenia may be due to the myelosuppression. Intraperitoneal chemotherapy can be used after a negative secondlook laparotomy.
Angiogenesis inhibitors : Bevacizumab, Aflibercept, Sorafenib Angiogenesis(growth and development of new blood vessels) is driven by vascular endothelial growth factor (VEGF). As tumors enlarge, inadequate blood supply will cause hypoxia that further stimulates VEGF production by tumors. Bevacizumab (15 mg/kg intravenously every 3 weeks) is used in patients with recurrent epithelial ovarian cancers and platinum-resistant ovarian cancers. [1]
Tyrosine kinase inhibitors: Erlotinib and gefitinib, Tyrosine kinase is important for the activation of the signal transduction pathways, cell proliferation, angiogenesis, metastasis, and inhibition of apoptosis. Inhibitors for tyrosine kinase is used for the recurrent disease. [1]
Maintenance therapy: maintenance intravenous paclitaxel [1] After the cytoreductive surgrry and chemotherpy [1] , some mode of maintenance treatment is needed for the prevention of recurrances.
References
  1. TWU C, HAN ES. Clinical utility of targeted treatments in the management of epithelial ovarian cancer Biologics [online] 2012:233-244 [viewed 24 August 2014] Available from: doi:10.2147/BTT.S29356
  2. BIETE A, VALDUVIECO I, ROVIROSA A, FARRúS B, CASAS F, CONILL C. Whole abdominal radiotherapy in ovarian cancer Rep Pract Oncol Radiother [online] , 15(2):27-30 [viewed 19 September 2014] Available from: doi:10.1016/j.rpor.2010.02.004
  3. YAHARA K, OHGURI T, IMADA H, YAMAGUCHI S, KAWAGOE T, MATSUURA Y, HACHISUGA T, KOROGI Y. Epithelial ovarian cancer: definitive radiotherapy for limited recurrence after complete remission had been achieved with aggressive front-line therapy J Radiat Res [online] 2013 Mar, 54(2):322-329 [viewed 19 September 2014] Available from: doi:10.1093/jrr/rrs108