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INTRODUCTION 1. Ovarian tumour is one of the major gynaecological disease and is a frequent site for primary and metastatic tumours. Due to its complex structure, primary ovarian neoplasm are of diverse histological types. Ovarian cancer accounts for 25% of all gynaecologic malignancies and 3rd commonest cause of death due to

malignancies of female genital tract in western world1. Ovaries are subjected to monthly endocrine and traumatic insult during ovulatory cycle and prime site for tumour genesis. The primary and secondary carcinoma of ovary are frequent with variety of pathologic pattern, which is seen in all ages2. Histological classification of ovarian tumours along with clinical stage forms an integral part of evaluation of optimum mode of therapy. AIM 2. To present a case of Ovarian Carcinoma, study the various histomorphological features of the ovarian tumours and their pattern of occurrence in relation to age and type diagnosed at in last one year.

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CASE STUDY 3. Bio Data of Patient a. Name b. Age c. Sex d. Residence e. Marital Status f. Education XYZ 55 years Female Chakwal Married Illiterate 8 yrs 18th March, 2011

g. Menopause h. Date of Admission

4. Presenting Complaints a. She presented as a known case of moderately differentiated Adenocarcinoma. b. Pain lower abdomen c. Dyspepsia d. Weakness 5. History of Presenting Illness. The patient had consistent pain lower abdomen for 3 months, which was dull in nature and associated with weakness, nausea and weight loss. There were no aggravating or relieving factors. No history of urinary or bowel complaints. Consulted a civil hospital. Laparotomy was done,
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3 months

differentiated adenocarcinoma. Menstrual History a. P7 . Ca Ovary. HTNº. 6. Asthmaº. Menopause ± 50 yrs of age 9. Menarche . Menopause for 8 yrs 8.SVD c.DMº. Ca Endometrium b.13 yrs of age b. Married for 30 yrs b. a. Past History. Family History a. her sister having TB RESTRICTED . Both parents were Hypertensive c. Cystectomy was revealed moderately done. Her staging laparotomy was planned on 29th Mar 2011. No H/O Ca Breast. Obstetrical History a. Personal History.3 RESTRICTED bilateral ovarian cysts Histopathology report were found. Huqqa Smoker b. IHDº 10. After this procedure the patient reported to MH along with histopathology report for consultation. Not Significant 7.

Speculum Examination (1) (2) (3) (4) Vulva Vagina distribution ± Hypoestrogenized. Belongs to a middle class family. Weight 50 Kgs 13. 12.4 RESTRICTED 11. Scanty hair Cervix normal looking No Vaginal discharge No local lesion b. Gynaecological Examination a. Bimanual Vaginal Examination (1) Uterus Normal in size (postmenopausal). Breasts h. BP b. Cyanosis i.6 º F Positive Not Palpable Not Enlarged Normal Bilaterally g. Pulse c. Temp d. General Physical Examination. Pallor e. Mobile RESTRICTED . Thyroid 100/70mm of Hg 92 b/min 98. Lymph Nodes f. Jaundice Edema Absent k. j. Socio Economic History. a. thin and lean looking pale and lethargic. Well oriented lady.

Digital Rectum Examination .Positive b. Urine for Biochemistry/Microscopy RESTRICTED . BSR d.4 x 10^9/L 24 U/ml 4. Investigation a. Respiratory System c.1 g/dl 370 x 10^9/L 9. CNS NAD 15. CA-125 12. Systemic Examination a.Normal 14.Positive (6) No mass Palpable (7) Ascites . non tender (3) Liver ± lower border Palpable (4) Spleen ± Not Palpable (5) BS . Abdomen (1) Protuberant (2) Soft. CVS d.5 RESTRICTED (2) Fullness of all fornices c.6 mmol/l WNL c. Blood CP (1) Hb (2) Plateletes (3) TLC b.

g. h. k. bleed to touch & adherent to ureter Omentum Healthy looking Peritoneum Unhealthy looking RESTRICTED . Counselling High risk consent taken Cross match sent 03 units RCC arranged Gut preparation done DJ Stenting done on 24th Mar 2011 Staging Laparotomy done on 29th Mar 2011 (1) (2) (3) (4) Uterus Atrophic. d.6 RESTRICTED e. HBSAg/Anti HCV f. Diagnosis. c. Management a. adherent to large gut & peritoneum on lt side Rt Adenexal friable mass (3 x 4 cm). LFTs RFTs Urea/Creatinine/Na+/K+ Chest X-Ray ECG USG Abdomen/Pelvis CT Scan WNL Normal Bilateral Adnexal masses  Bilateral Adnexal masses  Pelvic ascites  Mild hepatomegaly 16. b. i. Moderately Differentiated Adenocarcinoma 17. l. g. f. j. e.

Ovaries ± Papillary Adenocarcinoma 20. Namely Surface germinal epithelium. It relied primarily on the recognition of cell types and pattern of growth3. Immediate Postoperative care a. Papillary Adenocarcinoma CLASSIFICATION & STAGING OF OVARIAN TUMORS 23. Peritoneal washing cytology showed no malignant cells 21. The World Health Organization classification (WHO) was introduced in 1973 based on four major types of tissues. All these can give rise to a variety of neoplasms. Given I/V antibiotics & I/V fluids c.7 RESTRICTED (5) (6) Ascitic fluid taken for cytology Omentum and Uterus sent for histopathology Postoperative Management 18. Omentum . Sex cords. Kept under high nursing care b. RESTRICTED .no evidence of malignancy seen b. Chemotherapy was started on 13th April 2011 22. Histopathological Reports a. Final Diagnosis. Postoperative recovery was smooth 19. Germ cells and Specialized ovarian stroma.

Adenofibroma and cystadenofibroma (b) Malignant i. Adenofibroma and cystadenofibroma (b) Borderline malignancy (low malignant potential) i. Cystic tumor and papillary cystic tumor ii. Adenofibroma and cystadenofibroma with squamous differentiation RESTRICTED . Adenofibroma and cystadenofibroma iii. Cystadenoma with squamous differentiation ii. Adenofibroma and cystadenofibroma (c) Malignant i. Modified WHO scheme of classification in 1995 a. Adenocarcinofibroma and cystadenofibroma. Adenocarcinoma and cystadenocarcinoma ii Adenocarcinofibroma & cystadenocarcinofibroma (3) Endometrioid tumors (a) Benign i. Surface papillary adenocarcinoma iii. Surface epithelial tumours (1) Serous tumours (a) Benign i. Cystadenoma and papillary cystadenoma ii.8 RESTRICTED 24. Surface papillary tumor iii. papillary adenocarcinom and papillary cystadenoma ii. Surface pailloma iii. Cystadenoma ii. Adenocarcinoma. (2) Mucinuous tumors (endocervical like and intestinal type) (a) Benign i.

Stroma sarcoma. Adenocarcinoma ii. Undifferentiated carcinoma Unclassified Sex-cord Stromal Tumours RESTRICTED . homologous and heterologous ii. Adenofibroma and cystadenofibroma with squamous differentiation iii. Adenocarcinofibroma and cystadenofibroma (5) Transitional cell tumours (a) (b) (c) (e) (6) (7) Brenner tumour Brenner tumor of borderline malignancy/ proliferating Malignant Brenner tumour Transitional cell carcinoma (non-Brenner type) Squamous cell tumour Mixed epithelial tumour (specific types) (a) Benign (b) Of borderline malignancy/ or low malignant potential (c) Malignant (8) (9) b. Cyst adenoma ii. Mesodermal (Mullerian) mixed tumor (carcinosarcoma) homologous and heterologous iii. (4) Clear cell tumour (a) Benign i.9 RESTRICTED (b) Malignant i. Adenocarcinoma and cystadenocarcinoma ii. Adenofibroma and cystadenofibroma (b) Malignant i. Adenocarcinofibroma & cystadenocarcinofibroma iv. Adenosarcoma. Adenocarcinofibroma & cystadenocarcinofibroma with squamous differentiation (c) Epithelial (endometrioid) stromal and (endometrioid) stroma i.

Strauma carcinoid vii. Trabecular vi. Germ cell tumours (1) Dysgerminoma (a) Variant with syncytiotrophoblast cells (2) Yolk sac tumour (endodermal sinus tumor) (a) Variant Polyvesicular vitelline tumor (b) Hepatoid (c) Glandular (3) (4) (5) (6) Embryonal carcinoma Polyembryoma Choriocarcinoma Teratoma (a) Premature (b) Mature i. Insular v. Fetiform (Homunculus) (c) Monodermal and highly specialized i.10 RESTRICTED (1) Granulosa cell tumour (a) Juvenile (b) Adult c. Others RESTRICTED . Carcinoid iv. Mucinous carcicoid viii. Solid ii. Cystic (dermoid cyst) iii. Sebaceous tumours x. Ariant with thyroid tumour (specify type) iii. Strauma ovary ii. With secondary tumour formation (specify types) iv. Neuroectodermal tumours ix.

Adenomatoid tumour ii. (1) Corpus luteum cyst (2) Pregnancy luteoma RESTRICTED . Adenoma and cystadenoma ii. Others (d) Tumours of uncertain origin i. Tumour of probable Wolffian origin iii. Small cell carcinoma ii.11 RESTRICTED (7) Mixed (specify types) (a) Gonadoblastoma i. Hyper-rectio luteinalis (multiple leutinized follicle cysts) ± variant with corpora lutea. Carcinoma (c) Mesothelial tumours i. Solitary follicle cyst ii. Hepatoid carcinoma iv. Large solitary leuteivized follicle cysts of pregnancy and puerperium e. Oncocytoma (e) Gestational trophoblastic diseases (f) Soft tissue tumours specific to ovary (g) Malignant lymphomas (h) Unclassified tumours (i) Secondary (metastatic) tumours (j) Tumour like lesions i. Variant with dysgerminoma or other germ cell tumor (b) Tumours of rete ovari i. Multiple follicle cyst (polycystic disease) (sclero cystic ovaries) d.

12 RESTRICTED (3) Ectopic pregnancy (4) Hyperplasia of stroma (5) Stromal hyperthecosis (6) Massive edema (7) Fibromatosis (8) Fibromatosis (9) (10) f. the ovary capsule is intact y No tumour is detected on the surface of the ovary y Malignant cells are not detected in ascites or peritoneal washings Ib y y y Both ovaries are affected by the tumour. the ovary capsule is intact No tumour is detected on the surface of the ovaries Malignant cells are not detected in ascites or peritoneal RESTRICTED . Endometriosis Cyst. unclassified (simple cyst) Inflammatory lesions (1) (2) (3) Xanthogranuloma Malakoplakia Other 25. Histologic Staging/Classification (FIGO.Tumour is confined to the ovary / ovaries Ia y Only one ovary is affected by the tumour. 1971) STAGE I .

13 RESTRICTED washings Ic The tumour is limited to one or both ovaries. with any of the following: y y y The ovary capsule is ruptured The tumour is detected on the ovary surface Positive malignant cells are detected in the ascites or peritoneal washings STAGE II ± Tumour involves one or both ovaries and has extended into the pelvis IIa y The tumour has extended and/or implanted into the uterus and/or the fallopian tubes. IIIa y Microscopic peritoneal metastasis beyond the pelvis IIIb y Microscopic peritoneal metastasis beyond the pelvis 2 cm or less in greatest dimension Microscopic peritoneal metastasis beyond the pelvis RESTRICTED IIIc y . y Malignant cells are not detected in ascites or peritoneal washings IIb y y The tumour has extended to another organ in the pelvis Malignant cells are not detected in ascites or peritoneal washingss Tumours are as defined in 2A/B. Includes liver capsule metastasis. and malignant cells are detected in the ascites or peritoneal washings IIc y STAGE III ± The tumour involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis and/or regional lymph node metastasis.

Foci of necrosis and hemorrhage are common in serous carcinoma. It exhibits a mixture of cystic. Mucinous Tumours. borderline or malignant. Are derived from the surface epithelium of the ovary and are further classified as benign. Mucinous carcinoma is typically large. Serous Tumours: Serous tumours are the most common epithelial tumours (40-50%). And.14 RESTRICTED more than 2 cm in greatest dimension and/or regional lymph nodes metastasis STAGE: IV ± Distant metastasis beyond the peritoneal cavity. Epithelial Tumours. unilateral and composed of irregular cysts and glands lined by RESTRICTED . and solid growth patterns. papillary. a. liver parenchymal metastasis. Epithelial tumours account for 60-65 % of all Ovarian tumours and approximately 90% of those that are malignant5. HIS TO GE NE SI S 26. Serous carcinoma is usually large and is often bilateral. according to cell type and behavior4. b. Microscopically it has a papillary pattern and some times shows areas of calcification. which is called Psammoma bodies. The carcinoma often invades through the ovarian capsule and grows on the surface of the ovary.

Endometrioid carcinomas histologically resemble the usual adenocarcinoma of the endometrium. These tumours are solid masses with a soft. Endometrioid Tumours. or fibrous consistency. 15 % cases of endometrioid carcinoma of ovary are associated with endometrial carcinoma. only intestinal-type mucinous cells. d. or a combination of the two. These cysts are usually filled with chocolatecoloured fluid. They contain only endocervical-type cells. which often are stratified into four or more cell layers. Clear Cell Tumours. The inner surface has polypoidal projection. They are often predominantly cystic and contain soft or firm solid nodular masses. c. The main criterion of invasive mucinous carcinoma is the presence of obvious stromal invasion. These are commonly unilateral. firm. but are usually composed of cells that are not specifically suggestive of either endocervical. The tumor is predominantly cystic which is unilocular and contains brown fluid.15 RESTRICTED atypical mucinous cells. Dissection of mucin into the stroma is especially common and extensive in cases of pseudomyoma peritonei and is designated pseudomyxoma ovarii2. The characteristic microscopic appearance is called ³Hob Nail´ RESTRICTED .or intestinal-type mucinous cells.

atypical nuclei. Almost all combinations of mixed epithelial tumors have been encountered. The cysts contain papillary or polypoid masses or solid nodules in their walls.16 RESTRICTED appearance. g. Admixtures of the various subtypes of the surface epithelial. Malignant transitional cell tumours (Brenner tumours) have both solid and cystic components. Transitional Cell Tumours (Brenner Tumours). Mixed epithelial tumors. which suggests that it may be a variant of endometriod tumor. e. f. The presence of soft masses or foci of necrosis may suggest malignancy. Clear cell carcinoma frequently co exist with ovarian endometriosis and endometriod carcinoma of ovary . Malignant transitional cell tumors (Brenner tumors) resemble a high-grade transitional cell carcinoma of the bladder5. Undifferentiated Tumour. The tumor cells have pleomorphic. Undifferentiated carcinoma is one that shows no differentiation or contains only rare.stromal category often occur. The WHO limits their identification to those neoplasms in which one or more components other than the predominant component account for at least 10% of the tumor on microscopic examination. and the malignant transitional cells obviously infiltrate the stroma. minor areas of RESTRICTED .

Tubal ligation and hysterectomy (with ovarian conservation) is associated with a decrease risk of ovarian cancer [C] b. Women from families with hereditary ovarian cancer syndromes may reduce their risk of developing ovarian cancer by ever use of the combined oral contraceptive pills[C] d. Marked cellular atypia. with increasing duration of use increasing the level of protection afforded [C] c. Factors which reduce ovulation are associated with a reduced risk of ovarian cancer. bizarre giant cells.17 RESTRICTED differentiation according to the WHO. and has the poorest prognosis of any epithelial carcinoma adenocarcinoma. and atypical mitoses are frequent. RESTRICTED . AETIOLOGY OF OVARIAN CANCER 27. Undifferentiated carcinoma grows rapidly. The cause of Ovarian Cancer is unknown but some of the aetiological factors of ovarian cancer are a. the use of combined oral contraceptive pills appears protective. usually exhibits extra ovarian spread.

gas or bloating b. j. Pelvic Irradiation. Bilateral salpingo-oopherectomy is protective in BRCA mutation carriers [B] h. g. dull ache in the lower back d.18 RESTRICTED e. f. Drugs used for ovulation induction suggested being associated with subsequent increase risk of ovarian carcinoma. or frequent need to urinate c. Hereditary ovarian cancers represent fewer than 10% of all ovarian cancers. Infertility Treatment. pain during sexual intercourse RESTRICTED . difficulty urinating. Indigestion. Symptoms of ovarian cysts and tumours include a. SYMPTOMS 28. Evidence of causal association between the use of ovulatory stimulants and the subsequent development of epithelial ovarian tumours is inconclusive. HNPCC has an association with cancers of the ovary and endometrium4 i. Pelvic irradiation increases the risk of pelvic cancers including ovarian cancers.

Laparoscopy. endometriotic cyst or dermoid cyst). Tests that look for ovarian cysts or tumours include a. Ultrasound. used for the treatment of ovarian cysts. painful menstruation and abnormal bleeding f. magnetic resonance imaging (MRI). Computed tomography (CT).19 RESTRICTED e. and positron emission tomography (PET) are highly detailed imaging scans to find ovarian tumours and see whether and how far they have spread.g. RESTRICTED . DIAGNOSIS 29. Pelvic pain radiating down the inner aspect of the leg is a common presenting symptom. c. Rupture of a large cyst may produce signs of peritonitis. and the patient may be shocked in cases of extensive rupture or continuing haemorrhage. b. swelling and/or pain in the abdomen g. particularly if the cyst contents are irritant (e. To determine the size and location of the cyst or tumour. and torsion classically presents as severe pain associated with vomiting h. Imaging tests.

Chemotherapy may also be used to treat borderline tumours that appear to have more aggressive features (such as recurring after surgery). Following surgery.women with ovarian cancer. such as whether it has spread beyond the ovaries. CA-125. TREATMENT 30. to look for a protein called CA-125. This test is mainly used in women over age 35. Surgery is usually recommended to remove these tumours. In general. Surgery is the main treatment for ovarian cancer. Stages range from I to IV based on the cancer's specific characteristics. These tumours are often referred to as carcinomas of low malignant potential because they rarely metastasize or cause death. the course of treatment is determined by the stage of the cancer. RESTRICTED . women with higher-stage tumours may receive chemotherapy. About 10 . who are at slightly higher risk for ovarian cancer.15% of epithelial ovarian tumours are referred to as "borderline´ because their appearance and behaviour under the microscope is between benign and malignant.20 RESTRICTED d. tend to be higher in some -. Borderline ovarian tumours are most often seen in younger women with epithelial ovarian cancer.but not all -.

Chemotherapy.) b. Treatment Options for Stage III and Stage IV Ovarian Cancer. the fatty layer that covers and pads organs in the abdomen(omentectomy). usually do not need further therapy after surgery. Treatment options for stage I and stage II ovarian cancer may include: a.21 RESTRICTED 31. However. 32. Surgery. higher risk patients (stage IC. (Carefully selected premenopausal women in Stage I with the lowest-grade tumors in one ovary may sometimes be treated only with the removal of the diseased ovary and tube in order to preserve fertility. removal of both ovaries and fallopian tubes (bilateral salpingooophorectomy). and surgical staging of the lymph nodes and other tissues in the pelvis and abdomen. partial removal of the omentum. stage I/grade 3) are usually treated with platinum-based chemotherapy to reduce their risk of subsequent relapse. Treatment Options for Stage I and Stage II Ovarian Cancer. Patients with stage IA or B disease. Removal of the uterus (total hysterectomy). grade 1 (or sometimes grade 2). Treatment options for stage III and stage IV ovarian cancer may include RESTRICTED .

and chemotherapy5. cyclopthosphamide) b. The chemotherapeutic agents have been used in a number of combinations but the combinations RESTRICTED . Clinical trial options include additional surgical debulking. Surgery. Chemotherapy. If ovarian cancer returns or persists after treatment. Combination chemotherapy with a platinumbased drug and a taxane drug delivered intraperitoneally (through the abdominal cavity) 33. total abdominal hysterectomy. Removal of the tumour (debulking). Taxanes (eg. chemotherapy is the mainstay of treatment.22 RESTRICTED a. Combination chemotherapy. Alkylaking agents (eg. 34. epirubicin) d. Treatment Options for Recurrent Ovarian Cancer. Single chemotherapeutic agents active in epithelial ovarian cancer include6 a. omentectomy b. Chemotherapy. although it is not generally curative in the setting of relapsed disease. Platinum Compounds (cisplatin and carboplatin) c. paclitaxel and docetaxel) 35. and biologic therapy combined with bilateral salpingo-oopherectomy. Anthracyclenes (eg.

The prognosis of epithelial ovarian tumours is determined by the following factors a. CA-125.23 RESTRICTED containing cisplatin or carboplatin have shown higher response rate than others but without improving the survival rate. Radiotherapy. Positive retroperitoneal nodes d. FOLLOW UP 37. Size of residual tumour bulk c. Persistent or rising levels of CA-125 indicate drug resistance or recurrence. The stage wise survival is as under RESTRICTED . Histological subtype and grading of tumour 39. It is not needed in stage Ia disease and is not effective in patients with stage IV carcinoma of the ovary. The patients receiving chemotherapy are followed with regular estimation of CA-125. 36. A rapid fall in its level indicates chemosensitivity of the tumour. PROGNOSIS 38. It can be used as an alternative to chemotherapy in patients with stage Ib-IIIa. Extent of disease at diagnosis b. The overall 5 year survival is approximately 35% in all epithelial ovarian tumours.

Out of these histopathologically about 67 cases were malignant and 197 were benign cases.7% CLINICOPATHOLOGICAL REVIEW OF OVARIAN TUMOURS IN RAWALPINDI 40. Ovarian tumours pertaining to the cases diagnosed. of Cases 08 08 Percentage 11. total 264 cases of ovarian tumours were diagnosed. a.91 11. histopathologically at ______________ Laboratory. During this period.5% 4. Age Table-1: Age Distribution in 67 Malignant Cases Age (years) 11 ± 20 21 ± 30 No.91 RESTRICTED . The result pattern in relation to age and type diagnosed is summarized as under.24 RESTRICTED Stage I II III IV 5 yrs survival 60-70% 43-51% 17. for the period from January 2010 to December 2010.

59 39.38 8.25 RESTRICTED 31 ± 40 41 ± 50 51 ± 60 61 ± 70 > 70 years Total 09 19 15 06 02 67 13.98 100.03 2.05 12.00 RESTRICTED .00 Table-2: Age Distribution in 197 Benign Cases Age (years) 11 ± 20 21 ± 30 31 ± 40 41 ± 50 51 ± 60 61 ± 70 > 70 years Total No.35 22.43 28.59 37.03 100. of Cases 13 78 73 25 04 04 197 Percentage 6.95 2.69 2.

47 4.46 04 04 03 03 03 02 02 02 5.43 10.47 4.91 13.95 7.98 2. Histological Diagnosis Table-3: Histological typing of 67 ovarian cancers Cancers Serous Cyst Adenocarcinoma Mucinous Adenocarcinoma Granulosa Cell Tumour Endometriod Adenocarcinoma Adenocarcinoma (moderately differentiated) Mucinous Borderline Tumour Yolk Sac Tumour Serous Borderline Tumour Clear Cell Carcinoma Immature Teratoma Poorly Differentiated Carcinoma Dysgerminoma Metastatic Signet Ring Cell Adenocarcinoma No of Cases Percentage 12 09 07 06 05 17.98 RESTRICTED .98 2.97 4.26 RESTRICTED b.47 2.97 5.44 8.

61 3.55 3.04 100 RESTRICTED .61 7.24 7.49 100 Table-4:Histological typing of 197 Benign Tumours Tumours Luteal cyst Follicular cyst Mucinous cyst adenoma Serous cyst adenoma Endometriod cyst Dermoid Cyst Total No of Cases Percentage 122 32 15 15 07 06 197 61.49 1.49 1.27 RESTRICTED Carcinoid Tumor Transitional Cell Carcinoma Mixed Sex Cord Stromal Tumour Diffused Large B-Cell Lymphoma Total 02 01 01 01 67 2.92 16.98 1.

91%) followed by Mucinous Adenocarcinoma (13.43%). Unilateral/Bilateral ovarian tumours Table-5: ovarian cancer Unilateral No of cases Percentage 57 85.07 Bilateral 10 14.77 Total 197 100 CONCLUSION 41. Amongst the malignant tumours the highest number of cases seen were of Serous Cyst Adenocarcinoma (17.23 Bilateral 35 17.93 Total 67 100 Table-6: Benign ovarian tumours Unilateral No of cases Percentage 162 82.28 RESTRICTED c. Ovarian tumours occurred in all age group. Most of the tumours were unilateral. RESTRICTED . In Benign tumours most of the tumours were in the age group of 21-30 and 31-40. But majority of malignant cases were in the age group of 41-50 and 51-60 years.

du Bois A. Stoler MH Obstetrics & Gynecology by David M Luesely and Phillip N Baker. 4th edn. 2 Robert E Scully. Hahman M et al. P. 365-413. Saunders: 1997. page 814. Gershenson DM (1999) Ovarian carcinomas with transitional cell carcinoma pattern. 13: 1702-10 Silva EG. In: Sternberg Diagnostic Surgical Pathology. Smith TL. second edition. Jones HW. Ovarian tumours. Greenson JK. Reuter VE. Lippincott Williams & Wilkins: Mills SE. Jones GS. Philips B Clement. Philadelphia. 3.29 RESTRICTED REFERANCES 1 Novak ER. Robert H Young. 6th Edition. Vol. Robey-Cafferty SS. Ovarian surface epithelial-stromal tumours. Obserman HA. 4 3 Ibid 5 Harter P. Am J Clin Pathol 93:457±465 6 RESTRICTED . In: Gynaecological and Obstetrical Pathology. Cartes D. Surgery in recurrent ovarian cancer: the Arbeitsgemeinschaft Gynaekologische Onkologie 2006. Philadelphia.