title: 2022 24 Hours of Le Mans

text: As night fell, Pla lost control of the third-place No. 708 Glickenhaus and damaged its left rear suspension on the right guardrail leaving the Tertre Rouge corner after he struck the kerb. Pla drove the vehicle slowly to the pit lane for repairs, relinquishing the car's hold on third to Mailleux's sister Glickenhaus. The No. 7 Toyota had a slow pit stop for a tyre change and driver switch (from Kobayashi to Conway), and Buemi's No. 8 Toyota retook the lead. Conway then reclaimed the lead, passing Buemi into the Daytona Chicane on the Mulsanne Straight. Buemi returned the No. 8 Toyota to the overall lead ahead of Conway's No. 7 entry to begin the ninth hour, extending the car's lead to half a minute when a slow zone was imposed to dry a coolant spill between the Tertre Rouge turn and the first Mulsanne Straight chicane. The No. 709 LMGTE Am-class D'Station Racing Aston Martin of Charlie Fagg retired with chassis and wishbone damage. The category became a two-car battle for the lead between the No. 79 WeatherTech Porsche and the No. 33 TF Sport Aston Martin, driven by Marco Sørensen, after Sørensen lapped faster than Paul Dalla Lana's No. 98 Northwest entry.


title: 2022 24 Hours of Le Mans

text: The No. 31 WRT Oreca recovered from its early stop-and-go penalty to move to second in LMP2 after a quick stint by Frijns before Delétraz's No. 9 Prema passed Frijns' co-driver Gelael on the main straight by forcing Gelael towards the pit-lane barrier. Hirakawa's No. 8 Toyota led López's No. 7 car by almost 19 seconds at half distance, and both cars were two laps ahead of Briscoe's third-place No. 709 Glickenhaus. Jota's No. 38 Oreca, driven by Félix da Costa, still led LMP2 with a one-lap advantage over Prema's No. 9 entry of Delétraz due to the No. 38 team's fast pace and slow zones. Porsche's No. 92 team led the No. 64 Corvette by 100 seconds in LMGTE Pro. TF Sport's No. 33 Aston Martin, driven by Chaves, took the LMGTE Am lead from WeatherTech's No. 79 Porsche when driver Cooper MacNeil lost a minute in one lap for a pit stop just before half distance. The No. 8 Toyota lost the lead it had held for 86 laps when a slow zone was deployed to recover West's retired LMGTE Am-category No. 59 Inception Ferrari from the Mulsanne Straight, catching Buemi off-guard and allowing Conway's No. 7 car to pass during a pit-stop cycle. Porsche brought the No. 92 car into the garage for routine brake disc and pad switches, and lost the LMGTE Pro lead it had held for 104 laps to Pier Guidi's No. 51 AF Corse Ferrari.


title: 2022 24 Hours of Le Mans

text: LMGTE Pro became a close battle between Milner's No. 64 Corvette and Pier Guidi's No. 51 AF Corse Ferrari, with both drivers close for multiple laps with Porsche's No. 92 RSR (driven by Christensen). Milner drafted past Pier Guidi on the Mulsanne Straight and the outside of the Daytona chicane to return to the category lead. The No. 92 Porsche left the battle for the class lead when Christensen understeered into the gravel at the Mulsanne corner. Christensen had a right-front puncture when he built up speed on the approach to the Indianapolis corner, and heavy damage to the car's front required him to drive slowly to the pit lane for repairs. This moved Sims' No. 64 Corvette back into the category lead, with Daniel Serra's No. 51 AF Corse Ferrari second. Before the 16th hour ended, López stopped the No. 7 Toyota at the exit of the right-hand Arnage corner with a front-axle motor–generator issue that made him perform a power cycle to restart the car and return to the pit lane for further troubleshooting; he lost a lap and the lead to Hartley's No. 8 sister Toyota. Brendan Iribe was caught off-guard under braking for the Daytona chicane and struck the left-side Armco barrier with the front of the No. 56 Team Project 1 Porsche hard enough to retire the car, which was third in LMGTE Am. Iribe was unhurt and extricated himself from the car.


title: 2022 24 Hours of Le Mans

text: In the 18th hour, just after the No. 63 Corvette was retired with rear-end mechanical damage, François Perrodo's No. 83 AF Corse Oreca was sandwiched between Sims' No. 64 Corvette and John Falb's No. 47 Algarve Pro Oreca on the Mulsanne Straight after the first chicane when he veered left. Perrodo made slight left-side contact with Sims, who was sent into the left-side barrier at high speed; the damaged No. 64 Corvette was retired. Perrodo, who received a three-minute stop-and-go penalty for causing the crash, slowly entered the pit lane for rear-suspension repairs; Calado's No. 51 AF Corse Ferrari took the LMGTE Pro lead, with Makowiecki's No. 91 Porsche second. Frijns lost control of the No. 31 WRT Oreca, going onto the gravel at the exit of Indianapolis turn and crashing into the left-side Armco barrier. Since the blue impact light came on, Frijns was transported to the medical centre; he was unhurt. The accident forced the No. 31 car's retirement and the safety car's only deployment, to enable repairs to the Armco wall. The safety cars were recalled after fifteen minutes, and the first two cars in LMGTE Pro were together; Pier Guidi lost the No. 51 AF Corse Ferrari's advantage to Makowiecki's No. 91 Porsche. Pier Guidi had a right-rear puncture entering the Porsche Curves which forced an unscheduled pit stop, promoting the No. 91 Porsche to the LMGTE Pro lead. The safety-car period reduced the LMP2-leading No. 38 Jota Oreca's gap from one lap to a half-lap, because it had to remain in the pit lane and wait for the nearest safety car.


title: 2022 24 Hours of Le Mans

text: Claudio Schiavoni, in the No. 85 Iron Lynx Ferrari, collided with an LMP2 entry and struck the left tyre barrier leaving the Porsche Curves with four minutes left in the 21st hour. Schiavoni was unhurt, but the Ferrari was retired. The second-place No. 9 Prema car of Colombo and (later) Kubica in LMP2 closed the gap to Roberto González's class-leading No. 38 Jota car, while the No. 28 sister Jota entry of Aberdein in third made an unscheduled pit stop to repair a slow puncture. Sebastian Priaulx brought the No. 77 Dempsey-Proton Porsche into the pit lane from third in LMGTE Am to repair a failed lower front wishbone, losing his position to David Pittard's No. 98 Aston Martin. Thomas Merrill miscalculated entering the Porsche Curves in WeatherTech's No. 79 Porsche and entered the gravel trap; he avoided striking the barriers, and continued without relinquishing his car's hold on second in LMGTE Am.


title: 2022 24 Hours of Le Mans

text: Hartley maintained the overall lead his No. 8 Toyota had held for the previous 125 laps, and finished first after 380 laps; it was Buemi's fourth Le Mans victory, Hartley's third, Hirakawa's first and Toyota's fifth in succession. They finished two minutes and 1.222 seconds ahead of No. 7 sister Toyota; Glickenhaus made the overall Le Mans podium for the first time in third, with its No. 709 car five laps down. Jota's No. 38 Oreca won LMP2, leading for all but 15 laps to finish two minutes and 21 seconds ahead of the debuting second-place No. 9 Prema car. It was Jota's third category victory (their first since ) and the maiden LMP2 Le Mans win for Félix da Costa, González and Stevens. The No. 28 sister Jota car completed the LMP2 podium in third. The No. 45 Algarve Pro team of James Allen, René Binder and Thomas won the LMP2 Pro/Am subclass by one lap over the No. 24 Nielsen Racing car driven by Matt Bell, Ben Hanley and Rodrigo Sales. In the final LMGTE Pro race at Le Mans, Porsche had their first class victory since with the No. 91 RSR leading the No. 51 AF Corse Ferrari by 42.684 seconds. Aston Martin won LMGTE Am, with the No. 33 TF Sport car leading for the final 105 laps in the first category victory for Chaves, Ben Keating and Sørensen. WeatherTech Racing placed second in the class, 44.446 seconds behind. A record 53 of the 62 starting cars finished the race.


title: 2022 24 Hours of Le Mans

text: The top three teams in each of the four classes appeared on the podium to collect their trophies and spoke to the media at individual press conferences. Hirakawa said that he did not expect to win the race in his first year with Toyota, and his next objective was to win as many as possible. Hartley admitted being emotional about winning and said it was an "amazing race because we were pushing each other so hard. We were giving it everything: there was nothing left on the table because it was so evenly matched." López said that making a car run perfectly was difficult. Toyota's technical director, Pascal Vasselon, called the speed of the Glickenhaus cars "remarkable" given the team's inexperience. Briscoe called Glickenhaus' podium finish "a massive accomplishment", but was disappointed at not matching Toyota's pace. Westbrook said that finishing third felt like a victory, and Mailleux described a podium result as "so unreal".


title: 2022 24 Hours of Le Mans

text: Félix da Costa said about the LMP2 win, "The win is special but the way to get there takes a lot. It's a collective victory." González said it was Jota's dream to win, something they had prepared for for the previous three years. Bruni said that luck was a factor in winning LMGTE Pro when the Corvette and the No. 92 Porsche encountered issues: "This is part of racing. Sometimes it works well, other times it works bad. For sure they were not lucky, Corvette was unlucky. In the end Le Mans chooses [whether] you win or not. This is the special thing of Le Mans. Sometimes she recognises you, other times not." Lietz said a lot of misfortune and difficulty in the preceding two years prevented Porsche from achieving a decent result and that it felt good for them to be lucky again. Keating said that his LMGTE Am win gave him a "little bit of vindication" after a 2019 post-race fuel disqualification from first place: "Somebody asked me what it feels like to win Le Mans, I told them this is my second! Everyone knows we won it in 2019, the difference is this one will be in the record books. There's something special about that".


title: 2022 24 Hours of Le Mans

text: Perrodo and AF Corse team principal Amato Ferrari visited Corvette Racing's garage to apologise for the accident which caused the No. 64 car's retirement. Perrodo said that he had no excuse: "I made a terrible mistake. It's like a small movement with huge consequences. So I had to apologise to Corvette. It's the least I can do. I know that nothing will make them feel better at this stage. It's horrible. It's horrible for me, for them, but of course particularly for them." Sims said, "It's never nice when things happen outside of your control, but we're on track with 60 other cars and people make mistakes. I'm sure Perrodo didn't plan it, we were just in the wrong place, wrong time." Owen believed that Rast was overly aggressive on the first lap: "That's how you cause accidents, honestly. I couldn't even react fast enough before I hit the blue car on my left and was just in the gravel. Of course, it took five or six minutes to get the car unstuck. That was quite a setback." Rast thought that the cars behind him jumped the start, and he followed the race director's instructions: "Everybody who knows me knows that I'm a fair and hard driver, but I'm not taking somebody out on purpose. So yeah, it was the drivers behind me just jumping the start and I got the penalty for it."


title: 2022 24 Hours of Le Mans

text: The result kept Lapierre, Negrão and Vaxivière atop the Hypercar Drivers' Championship with 81 points; race winners Buemi, Hartley and Hirakawa moved from third to second, three points behind. With 69 points, Dumas and Pla fell from second to third. Bruni's and Lietz's LMGTE Pro win placed them atop the GTE Drivers' Championship with 84 points, ahead of teammates Christensen and Estre by three points. Toyota and Porsche left Le Mans as the Hypercar and GTE Manufacturers' Championship leaders, respectively, with three rounds of the season left.


title: 2022 24 Hours of Le Mans

text: The minimum number of laps for classification at the finish (70 per cent of the overall race winner's distance) was 266 laps. Class winners are denoted in bold and with .


title: User experience design

text: User experience design (UX design, UXD, UED, or XD) is the process of defining the experience a user would go through when interacting with a digital product or website. Design decisions in UX design are often driven by research, data analysis, and test results rather than aesthetic preferences and opinions. Unlike user interface design, which focuses solely on the design of a computer interface, UX design encompasses all aspects of a user's perceived experience with a product or website, such as its usability, usefulness, desirability, brand perception, and overall performance. UX design is also an element of the customer experience (CX), which encompasses all aspects and stages of a customer's experience and interaction with a company.


title: User experience design

text: The field of user experience design is a conceptual design discipline and has its roots in human factors and ergonomics, a field that, since the late 1940s, has focused on the interaction between human users, machines, and the contextual environments to design systems that address the user's experience. With the proliferation of workplace computers in the early 1990s, user experience started to become a positive insight for designers. Donald Norman, a professor and researcher in design, usability, and cognitive science, coined the term "user experience," and brought it to a wider audience.


title: User experience design

text: There is a debate occurring in the experience design community regarding its focus, provoked in part by design scholar and practitioner, Don Norman. Norman claims that when designers describe people only as customers, consumers, and users, designers risk diminishing their ability to do good design.


title: User experience design

text: User experience design draws from design approaches like human-computer interaction and user-centered design, and includes elements from similar disciplines like interaction design, visual design, information architecture, user research, and others.


title: User experience design

text: The second part of the research is understanding the end-user and the purpose of the application. Though this might seem clear to the designer, stepping back and empathizing with the user will yield the best results.


title: User experience design

text: It helps to identify and prove or disprove my assumptions, find commonalities across target audience members, and recognize their needs, goals, and mental models.


title: User experience design

text: Visual design, also commonly known as graphic design, user interface design, communication design, and visual communication, represents the aesthetics or look-and-feel of the front end of any user interface. Graphic treatment of interface elements is often perceived as the visual design. The purpose of visual design is to use visual elements like colors, images, and symbols to convey a message to its audience. Fundamentals of Gestalt psychology and visual perception give a cognitive perspective on how to create effective visual communication.


title: User experience design

text: Information architecture is the art and science of structuring and organizing the information in products and services to support usability and findability.


title: User experience design

text: In the context of information architecture, information is separate from both knowledge and data, and lies nebulously between them. It is information about objects. The objects can range from websites, to software applications, to images et al. It is also concerned with metadata: terms used to describe and represent content objects such as documents, people, process, and organizations. Information architecture also encompasses how the pages and navigation are structured.


title: User experience design

text: It is well recognized that the component of interaction design is an essential part of user experience (UX) design, centering on the interaction between users and products. The goal of interaction design is to create a product that produces an efficient and delightful end-user experience by enabling users to achieve their objectives in the best way possible


title: User experience design

text: The current high emphasis on user-centered design and the strong focus on enhancing user experience have made interaction designers critical in conceptualizing products to match user expectations and meet the standards of the latest UI patterns and components.


title: User experience design

text: In the last few years, the role of interaction designer has shifted from being just focused on specifying UI components and communicating them to the engineers to a situation in which designers have more freedom to design contextual interfaces based on helping meet the user's needs. Therefore, User Experience Design evolved into a multidisciplinary design branch that involves multiple technical aspects from motion graphics design and animation to programming.


title: User experience design

text: Usability is the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use.


title: User experience design

text: Usability is attached to all tools used by humans and is extended to both digital and non-digital devices. Thus, it is a subset of user experience but not wholly contained. The section of usability that intersects with user experience design is related to humans' ability to use a system or application. Good usability is essential to positive user experience but does not alone guarantee it.


title: User experience design

text: Accessibility of a system describes its ease of reach, use, and understanding. In terms of user experience design, it can also be related to the overall comprehensibility of the information and features. It helps shorten the learning curve associated with the system. Accessibility in many contexts can be related to the ease of use for people with disabilities and comes under usability. In addition, accessible design is the concept of services, products, or facilities in which designers should accommodate and consider for the needs of people with disabilities. According to the Web Content Accessibility Guidelines (WCAG), all content must follow by the four main principles of POUR: Perceivable, Operable, Understandable and Robust.


title: User experience design

text: Web Content Accessibility Guidelines (WCAG) 2.0 covers a wide range of recommendations for making Web content more accessible. This makes web content more usable to users in general. Making content more usable and readily accessible to all types of users enhances a user's overall user experience.


title: User experience design

text: Human–computer interaction is concerned with the design, evaluation and implementation of interactive computing systems for human use and with the study of major phenomena surrounding them.


title: User experience design

text: After research, the designer uses the modeling of the users and their environments. User modeling or personas are composite archetypes based on behavior patterns uncovered during research. Personas provide designers a precise way of thinking and communicating about how groups of users behave, how they think, what they want to accomplish and why. Once created, personas help the designer to understand the users' goals in specific contexts, which is particularly useful during ideation and for validating design concepts. Other types of models include workflow models, artifact models, and physical models.


title: User experience design

text: When the designer has a firm grasp on the user's needs and goals, they begin to sketch out the interaction framework (also known as wireframes). This stage defines the high-level structure of screen layouts, as well as the product's flow, behavior, and organization. There are many kinds of materials that can be involved during this iterative phase, from whiteboards to paper prototypes. As the interaction framework establishes an overall structure for product behavior, a parallel process focused on the visual and industrial designs. The visual design framework defines the experience attributes, visual language, and the visual style.


title: User experience design

text: Once a solid and stable framework is established, wireframes are translated from sketched storyboards to full-resolution screens that depict the user interface at the pixel level. At this point, it is critical for the programming team to collaborate closely with the designer. Their input is necessary to create a finished design that can and will be built while remaining true to the concept.


title: User experience design

text: Usability testing is carried out by giving users various tasks to perform on the prototypes. Any issues or problems faced by the users are collected as field notes and these notes are used to make changes in the design and reiterate the testing phase. Aside from monitoring issues, questions asked by users are also noted in order to identify potential points of confusion. Usability testing is, at its core, a means to "evaluate, not create".


title: User experience design

text: UX designers perform a number of different tasks and therefore use a range of deliverables to communicate their design ideas and research findings to stakeholders. Regarding UX specification documents, these requirements depend on the client or the organization involved in designing a product. The four major deliverables are: a title page, an introduction to the feature, wireframes, and a version history. Depending on the type of project, the specification documents can also include flow models, cultural models, personas, user stories, scenarios and any prior user research.


title: User experience design

text: The deliverables that UX designers will produce as part of their job include wireframes, prototypes, user flow diagrams, specification and tech docs, websites and applications, mockups, presentations, personas, user profiles, videos, and to a lesser degree reports. Documenting design decisions, in the form of annotated wireframes, gives the developer the necessary information they may need to successfully code the project.


title: User experience design

text: A user experience designer is considered a UX practitioner, along with the following job titles: user experience researcher, information architect, interaction designer, human factors engineer, business analyst, consultant, creative director, interaction architect, and usability specialist.


title: User experience design

text: Interaction designers (IxD) are responsible for understanding and specifying how the product should behave. This work overlaps with the work of both visual and industrial designers in a couple of important ways. When designing physical products, interaction designers must work with industrial designers early on to specify the requirements for physical inputs and to understand the behavioral impacts of the mechanisms behind them. Interaction designers cross paths with visual designers throughout the project. Visual designers guide the discussions of the brand and emotive aspects of the experience, Interaction designers communicate the priority of information, flow, and functionality in the interface.


title: User experience design

text: Historically, technical and professional communication (TPC) has been as an industry that practices writing and communication. However, recently UX design has become more prominent in TPC as companies look to develop content for a wide range of audiences and experiences. It is now an expectation that technical and professional skills should be coupled with UX design. According to Verhulsdonck, Howard, and Tham, "...it is not enough to write good content. According to industry expectations, next to writing good content, it is now also crucial to design good experiences around that content." Technical communicators must now consider different platforms such as social media and apps, as well as different channels like web and mobile.


title: User experience design

text: User interface (UI) design is the process of making interfaces in software or computerized devices with a focus on looks or style. Designers aim to create designs users will find easy to use and pleasurable. UI design typically refers to graphical user interfaces but also includes others, such as voice-controlled ones.


title: User experience design

text: The visual designer ensures that the visual representation of the design effectively communicates the data and hints at the expected behavior of the product. At the same time, the visual designer is responsible for conveying the brand ideals in the product and for creating a positive first impression; this responsibility is shared with the industrial designer if the product involves hardware. In essence, a visual designer must aim for maximum usability combined with maximum desirability. Visual designer need not be good in artistic skills but must deliver the theme in a desirable manner.


title: User experience design

text: Video games are run by user experience design tactics and are key in their success. User experience has improved in gaming by providing people with a higher picture and resolution quality. In the past, the original Nintendo gaming systems had very blurry and distorted graphics and did not provide users with clear on-screen graphical content. Users and game developers wanted more than just a distorted image to control in a 2D platform. With new desires to give gamers a better user experience and user interface, the creation of new 3D game designing came about. The addition of a 3D imagery systems gave designers new usability options and allowed players of 3D games to explore around a 3D virtual map, like in "Mario Bros." This new 3D animation was just the spark that would light the fire for the advancement of graphical content to come and also resulted in more realistic and real-world oriented game imaging.


title: User experience design

text: As more consoles are released the user interface of graphics greatly increases. Consoles such as PlayStation 4 and Xbox One are the latest next-generation consoles that portray realistic graphics that results in giving players a more exciting user experience. Games that include high level graphics are "Grand Theft Auto V", "NBA 2K19", and "Madden NFL 19". In "Madden" and "NBA" users can play with their real-life favorite sports players that almost look exactly the same. The picture for the games even captures tattoos and certain distinct facial features found on videogame characters' real-life version. Furthermore, storyline enhancements have resulted in the user interfaces of video games gaining popular feedback from fans and contribute to the achievement of the game as a whole. According to Robin Burks, "playing a video game involves more interaction than watching a film or television series. For example, scenes pause as players are forced to decide who lives and who dies: and sometimes, players must make that choice quickly. This interaction means that the player becomes part of the story and not just an inactive participant." The quick decision making and on edge approach to video game storylines impact the way players shape their own user experience. In some circumstances, users could be faced with choosing life or death between two of their favorite characters. For players who become emotionally invested in their games this spices things up for them and leaves them with a tough decision.


title: User experience design

text: Usability testing is the most common method used by designers to test their designs. The basic idea behind conducting a usability test is to check whether the design of a product or brand works well with the target users. While carrying out usability testing, two things are being tested for: whether the design of the product is successful and if it is not successful, how can it be improved.


title: User experience design

text: While designers are testing, they are testing the design and not the user. Also, every design is evolving. The designers carry out usability testing at every stage of the design process and as early and often as possible.


title: Bird's eye chili

text: Bird's eye chili or Thai chili (Thai: "prik ki nu", พริกขี้หนู, literally "mouse dung chili" owing to its shape) is a chili pepper, a variety from the species "Capsicum annuum" native to Mexico. Cultivated across Southeast Asia, it is used extensively in many Asian cuisines. It may be mistaken for a similar-looking chili derived from the species "Capsicum frutescens", the cultivar "siling labuyo". "Capsicum frutescens" fruits are generally smaller and characteristically point upwards.


title: Bird's eye chili

text: The bird's eye chili plant is a perennial with small, tapering fruits, often two or three, at a node. The fruits are very pungent.


title: Bird's eye chili

text: The bird's eye chili is small, but is quite hot. It measures around 100,000 - 225,000 Scoville units, which is at the lower half of the range for the hotter habanero, but still much hotter than a common jalapeño.


title: Bird's eye chili

text: All chilis found around the world today have their origins in Mexico, Central America, and South America. They were spread by Spanish and Portuguese colonists, missionaries, and traders, together with many other now common crops such as maize, tomatoes and pineapples through the Columbian Exchange. The chili varieties found in Southeast Asia today were brought there in the 16th or 17th century.


title: Bird's eye chili

text: In Vietnamese cuisine, these chilis are used in soups, salads, and stir-fried dishes. They are also put in a wide variety of sauces, pastes, and marinades, used as a condiment or eaten raw, both fresh and dried.


title: Bird's eye chili

text: In Thai cuisine, these chilis are highly valued for their fruity taste and extreme spiciness. They are extensively used in many Thai dishes, such as in Thai curries and in Thai salads, green as well as the ripe red chilis; or they can just be eaten raw on the side, with for instance, "khao kha mu" (stewed pork trotter served with rice).


title: Bird's eye chili

text: The more decorative, but slightly less pungent chili, sometimes known as "Thai ornamental", has peppers that point upward on the plant, and range from green to yellow, orange, and then red. It is the basis for the hybrid cultivar "Numex twilight", essentially the same, but less pungent, and starting with purple fruit, creating a rainbow effect. These peppers can grow wild in places such as Saipan and Guam.


title: Ovarian cancer

text: Ovarian cancer is a cancerous tumor of an ovary. It may originate from the ovary itself or more commonly from communicating nearby structures such as fallopian tubes or the inner lining of the abdomen. The ovary is made up of three different cell types including epithelial cells, germ cells, and stromal cells. When these cells become abnormal, they have the ability to divide and form tumors. These cells can also invade or spread to other parts of the body. When this process begins, there may be no or only vague symptoms. Symptoms become more noticeable as the cancer progresses. These symptoms may include bloating, vaginal bleeding, pelvic pain, abdominal swelling, constipation, and loss of appetite, among others. Common areas to which the cancer may spread include the lining of the abdomen, lymph nodes, lungs, and liver.


title: Ovarian cancer

text: The risk of ovarian cancer increases with age. Most cases of ovarian cancer develop after menopause. It is also more common in women who have ovulated more over their lifetime. This includes those who have never had children, those who began ovulation at a younger age and those who reach menopause at an older age. Other risk factors include hormone therapy after menopause, fertility medication, and obesity. Factors that decrease risk include hormonal birth control, tubal ligation, pregnancy, and breast feeding. About 10% of cases are related to inherited genetic risk; women with mutations in the genes "BRCA1" or "BRCA2" have about a 50% chance of developing the disease. Some family cancer syndromes such as hereditary nonpolyposis colon cancer and Peutz-Jeghers syndrome also increase the risk of developing ovarian cancer. Epithelial ovarian carcinoma is the most common type of ovarian cancer, comprising more than 95% of cases. There are five main subtypes of ovarian carcinoma, of which high-grade serous carcinoma (HGSC) is the most common. Less common types of ovarian cancer include germ cell tumors and sex cord stromal tumors. A diagnosis of ovarian cancer is confirmed through a biopsy of tissue, usually removed during surgery.


title: Ovarian cancer

text: Screening is not recommended in women who are at average risk, as evidence does not support a reduction in death and the high rate of false positive tests may lead to unneeded surgery, which is accompanied by its own risks. Those at very high risk may have their ovaries removed as a preventive measure. If caught and treated in an early stage, ovarian cancer is often curable. Treatment usually includes some combination of surgery, radiation therapy, and chemotherapy. Outcomes depend on the extent of the disease, the subtype of cancer present, and other medical conditions. The overall five-year survival rate in the United States is 49%. Outcomes are worse in the developing world.


title: Ovarian cancer

text: In 2020, new cases occurred in approximately 313,000 women. In 2019 it resulted in 13,445 deaths in the United States. Death from ovarian cancer increased globally between 1990 to 2017 by 84.2%. Ovarian cancer is the second-most common gynecologic cancer in the United States. It causes more deaths than any other cancer of the female reproductive system. Among women it ranks fifth in cancer-related deaths. The typical age of diagnosis is 63. Death from ovarian cancer is more common in North America and Europe than in Africa and Asia. In the United States, it is more common in White and Hispanic women than Black or American Indian women.


title: Ovarian cancer

text: Early signs and symptoms of ovarian cancer may be absent or subtle. In most cases, symptoms exist for several months before being recognized and diagnosed. Symptoms can often be misdiagnosed as irritable bowel syndrome. The early stages of ovarian cancer tend to be painless which makes it difficult to detect it early on. Symptoms can vary based on the subtype. Ovarian borderline tumors, also known as low malignant potential (LMP) ovarian tumors, do not cause an increase in CA125 levels and are not identifiable with an ultrasound. The typical symptoms of an LMP tumor can include abdominal distension or pelvic pain. Particularly large masses tend to be benign or borderline.


title: Ovarian cancer

text: The most typical symptoms of ovarian cancer include bloating, abdominal or pelvic pain or discomfort, back pain, irregular menstruation or postmenopausal vaginal bleeding, pain or bleeding after or during sexual intercourse, loss of appetite, fatigue, diarrhea, indigestion, heartburn, constipation, nausea, feeling full, and possibly urinary symptoms (including frequent urination and urgent urination).


title: Ovarian cancer

text: Later symptoms of ovarian cancer are due to the growing mass causing pain by pressing on other abdominopelvic organs or from metastases. Because of the anatomic location of the ovaries deep in the pelvis, most masses are large and advanced at the time of diagnosis. The growing mass may cause pain if ovarian torsion develops. If these symptoms start to occur more often or more severely than usual, especially after no significant history of such symptoms, ovarian cancer is considered. Metastases may cause a Sister Mary Joseph nodule. Rarely, teratomas can cause growing teratoma syndrome or peritoneal gliomatosis. Some experience menometrorrhagia and abnormal vaginal bleeding after menopause in most cases. Other common symptoms include hirsutism, abdominal pain, virilization, and an adnexal mass.


title: Ovarian cancer

text: In adolescents or children with ovarian tumors, symptoms can include severe abdominal pain, irritation of the peritoneum, or bleeding. Sex cord stromal tumors produce hormones which can lead to the premature development of secondary sex characteristics. Sex cord-stromal tumors in prepubertal children may be manifested by signs of early puberty; abdominal pain and distension are also common. Adolescents with sex cord-stromal tumors may experience amenorrhea. As the cancer becomes more advanced, it can cause an accumulation of fluid in the abdomen and lead to distension. If the malignancy has not been diagnosed by the time it causes ascites, it is typically diagnosed shortly thereafter. Advanced cancers can also cause abdominal masses, lymph node masses, or pleural effusion.


title: Ovarian cancer

text: There are many known risk factors that may increase a women's risk of developing ovarian cancer. The risk of developing ovarian cancer is related to the amount of time a woman spends ovulating. Factors that increase the number of ovulatory cycles a women undergoes may increase the risk of developing ovarian cancer. During ovulation, cells are stimulated to divide. If this division is abnormally regulated, tumors may form which can be malignant. Early menarche and late menopause increase the number of ovulatory cycles a woman undergoes in her lifetime and so increases the risk of developing ovarian cancer. Since ovulation is suppressed during pregnancy, not having children also increases the risk of ovarian cancer. Therefore, women who have not borne children are at twice the risk of ovarian cancer than those who have. Both obesity and hormone replacement therapy also raise the risk.


title: Ovarian cancer

text: The risk of developing ovarian cancer is less for women who have fewer menstrual cycles, no menstrual cycles, breast feeding, take oral contraceptives, have multiple pregnancies, and have a pregnancy at an early age. The risk of developing ovarian cancer is reduced in women who have had tubal ligation (colloquially known as having one's "tubes tied"), both ovaries removed, or hysterectomy (an operation in which the uterus is removed). Age is also a risk factor. Non-genetic factors such as diabetes mellitus, high body mass index, tobacco, and alcohol use are also risk factors for ovarian cancer.


title: Ovarian cancer

text: The use of fertility medication may contribute to ovarian borderline tumor formation, but the link between the two is disputed and difficult to study. Fertility drugs may be associated with a higher risk of borderline tumors. Those who have been treated for infertility but remain nulliparous are at higher risk for epithelial ovarian cancer due to hormonal exposure that may lead to proliferation of cells. However, those who are successfully treated for infertility and subsequently give birth are at no higher risk. This may be due to shedding of precancerous cells during pregnancy, but the cause remains unclear. The risk factor may instead be infertility itself, not the treatment.


title: Ovarian cancer

text: Hormonal conditions such as polycystic ovary syndrome and endometriosis are associated with ovarian cancer, but the link is not completely confirmed. Postmenopausal hormone replacement therapy (HRT) with estrogen likely increases the risk of ovarian cancer. The association has not been confirmed in a large-scale study, but notable studies including the Million Women Study have supported this link. Postmenopausal HRT with combined estrogen and progesterone may increase contemporaneous risk if used for over 5 years, but this risk returns to normal after cessation of therapy. Estrogen HRT with or without progestins increases the risk of endometrioid and serous tumors but lowers the risk of mucinous tumors. Higher doses of estrogen increase this risk. Endometriosis is another risk factor for ovarian cancer, as is pain with menstruation. Endometriosis is associated with clear-cell and endometrioid subtypes, low-grade serous tumors, stage I and II tumors, grade 1 tumors, and lower mortality.


title: Ovarian cancer

text: Before menopause, obesity can increase a person's risk of ovarian cancer, but this risk is not present after menopause. This risk is also relevant in those who are both obese and have never used HRT. A similar association with ovarian cancer appears in taller women.


title: Ovarian cancer

text: A family history of ovarian cancer is a risk factor for ovarian cancer. Women with hereditary nonpolyposis colon cancer (Lynch syndrome), and those with BRCA-1 and BRCA-2 genetic abnormalities are at increased risk.


title: Ovarian cancer

text: The major genetic risk factor for ovarian cancer is a mutation in "BRCA1" or "BRCA2" genes, or in DNA mismatch repair genes, which is present in 10% of ovarian cancer cases. Only one allele needs to be mutated to place a person at high risk. The gene can be inherited through either the maternal or paternal line, but has variable penetrance. Though mutations in these genes are usually associated with increased risk of breast cancer, they also carry a substantial lifetime risk of ovarian cancer, a risk that peaks in a person's 40s and 50s. The lowest risk cited is 30% and the highest 60%. Mutations in BRCA1 have a lifetime risk of developing ovarian cancer of 15–45%. Mutations in "BRCA2" are less risky than those with "BRCA1", with a lifetime risk of 10% (lowest risk cited) to 40% (highest risk cited). On average, BRCA-associated cancers develop 15 years before their sporadic counterparts because people who inherit the mutations on one copy of their gene only need one mutation to start the process of carcinogenesis, whereas people with two normal genes would need to acquire two mutations.


title: Ovarian cancer

text: In the United States, five of 100 women with a first-degree relative with ovarian cancer will eventually get ovarian cancer themselves, placing those with affected family members at triple the risk of women with unaffected family members. Seven of 100 women with two or more relatives with ovarian cancer will eventually get ovarian cancer. In general, 5–10% of ovarian cancer cases have a genetic cause. BRCA mutations are associated with high-grade serous nonmucinous epithelial ovarian cancer.


title: Ovarian cancer

text: A strong family history of endometrial cancer, colon cancer, or other gastrointestinal cancers may indicate the presence of a syndrome known as hereditary nonpolyposis colorectal cancer (also known as Lynch syndrome), which confers a higher risk for developing a number of cancers, including ovarian cancer. Lynch syndrome is caused by mutations in mismatch repair genes, including "MSH2, MLH1, MLH6, PMS1", and "PMS2". The risk of ovarian cancer for an individual with Lynch syndrome is between 10 and 12 percent. Women of Icelandic descent, European Jewish descent/Ashkenazi Jewish descent, and Hungarian descent are at higher risk for epithelial ovarian cancer. Estrogen receptor beta gene (ESR2) seems to be a key to pathogenesis and response to therapy. Other genes that have been associated with ovarian cancer are "BRIP1", "MSH6", "RAD51C" and "RAD51D". "CDH1", "CHEK2", "PALB2" and "RAD50" have also been associated with ovarian cancer.


title: Ovarian cancer

text: Several rare genetic disorders are associated with specific subtypes of ovarian cancer. Peutz–Jeghers syndrome, a rare genetic disorder, also predisposes women to sex cord tumour with annular tubules. Ollier disease and Maffucci syndrome are associated with granulosa cell tumors in children and may also be associated with Sertoli-Leydig tumors. Benign fibromas are associated with nevoid basal cell carcinoma syndrome.


title: Ovarian cancer

text: The American Cancer Society recommends a healthy eating pattern that includes plenty of fruits, vegetables, whole grains, and a diet that avoids or limits red and processed meats and processed sugar. High consumption of total, saturated and trans-fats increases ovarian cancer risk. A 2021 umbrella review found that coffee, egg, and fat intake significantly increases the risk of ovarian cancer. There is mixed evidence from studies on ovarian cancer risk and consumption of dairy products.


title: Ovarian cancer

text: Industrialized nations, with the exception of Japan, have high rates of epithelial ovarian cancer, which may be due to diet in those countries. White women are at a 30–40% higher risk for ovarian cancer when compared to Black women and Hispanic women, likely due to socioeconomic factors; white women tend to have fewer children and different rates of gynecologic surgeries that affect risk for ovarian cancer.


title: Ovarian cancer

text: Tentative evidence suggests that talc, pesticides, and herbicides increase the risk of ovarian cancer. The American Cancer Society notes that as of now, no study has been able to accurately link any single chemical in the environment, or in the human diet, directly to mutations that cause ovarian cancer.


title: Ovarian cancer

text: Other factors that have been investigated, such as smoking, low levels of vitamin D in the blood, presence of inclusion ovarian cysts, and infection with human papilloma virus (the cause of some cases of cervical cancer), have been disproven as risk factors for ovarian cancer. The carcinogenicity of perineal talc is controversial, because it can act as an irritant if it travels through the reproductive tract to the ovaries. Case-control studies have shown that use of perineal talc does increase the risk of ovarian cancer, but using talc more often does not create a greater risk. Use of talc elsewhere on the body is unrelated to ovarian cancer. Sitting regularly for prolonged periods is associated with higher mortality from epithelial ovarian cancer. The risk is not negated by regular exercise, though it is lowered.


title: Ovarian cancer

text: Increased age (up to the 70s) is a risk factor for epithelial ovarian cancer because more mutations in cells can accumulate and eventually cause cancer. Those over 80 are at slightly lower risk.


title: Ovarian cancer

text: Smoking tobacco is associated with a higher risk of mucinous ovarian cancer; after smoking cessation, the risk eventually returns to normal. Higher levels of C-reactive protein are associated with a higher risk of developing ovarian cancer.


title: Ovarian cancer

text: Suppression of ovulation, which would otherwise cause damage to the ovarian epithelium and, consequently, inflammation, is generally protective. This effect can be achieved by having children, taking combined oral contraceptives, and breast feeding, all of which are protective factors. A longer period of breastfeeding correlates with a larger decrease in the risk of ovarian cancer. Each birth decreases risk of ovarian cancer more, and this effect is seen with up to five births. Combined oral contraceptives reduce the risk of ovarian cancer by up to 50%, and the protective effect of combined oral contraceptives can last 25–30 years after they are discontinued. Regular use of aspirin or acetaminophen (paracetamol) may be associated with a lower risk of ovarian cancer; other NSAIDs do not seem to have a similar protective effect.


title: Ovarian cancer

text: Tubal ligation is protective because carcinogens are unable to reach the ovary and fimbriae via the vagina, uterus, and Fallopian tubes. Tubal ligation is also protective in women with the BRCA1 mutation, but not the BRCA2 mutation. Hysterectomy reduces the risk, and removal of both Fallopian tubes and ovaries (bilateral salpingo-oophorectomy) dramatically reduces the risk of not only ovarian cancer but breast cancer as well. This is still a topic of research, as the link between hysterectomy and lower ovarian cancer risk is controversial. The reasons that hysterectomy may be protective have not been elucidated as of 2015.


title: Ovarian cancer

text: A diet that includes large amounts of carotene, fiber, and vitamins with low amounts of fat—specifically, a diet with non-starchy vegetables (e.g. broccoli and onions) may be protective. Dietary fiber is associated with a significant reduced risk of ovarian cancer. A 2021 review found that green leafy vegetables, allium vegetables, fiber, flavanoids and green tea intake can significantly reduce ovarian cancer risk.


title: Ovarian cancer

text: Ovarian cancer forms when errors in normal ovarian cell growth occur. Usually, when cells grow old or get damaged, they die, and new cells take their place. Cancer starts when new cells form unneeded, and old or damaged cells do not die as they should. The buildup of extra cells often forms a mass of tissue called an ovarian tumor or growth. These abnormal cancer cells have many genetic abnormalities that cause them to grow excessively. When an ovary releases an egg, the egg follicle bursts open and becomes the corpus luteum. This structure needs to be repaired by dividing cells in the ovary. Continuous ovulation for a long time means more repair of the ovary by dividing cells, which can acquire mutations in each division.


title: Ovarian cancer

text: Overall, the most common gene mutations in ovarian cancer occur in "NF1, BRCA1, BRCA2, "and "CDK12". Type I ovarian cancers, which tend to be less aggressive, tend to have microsatellite instability in several genes, including both oncogenes (most notably "BRAF" and "KRAS") and tumor suppressors (most notably "PTEN"). The most common mutations in Type I cancers are "KRAS, BRAF, ERBB2, PTEN, PIK3CA," and "ARID1A." Type II cancers, the more aggressive type, have different genes mutated, including "p53, BRCA1", and "BRCA2". Low-grade cancers tend to have mutations in KRAS, whereas cancers of any grade that develop from low malignant potential tumors tend to have mutations in p53. Type I cancers tend to develop from precursor lesions, whereas Type II cancers can develop from a serous tubal intraepithelial carcinoma. Serous cancers that have BRCA mutations also inevitably have p53 mutations, indicating that the removal of both functional genes is important for cancer to develop.


title: Ovarian cancer

text: In 50% of high-grade serous cancers, homologous recombination DNA repair is dysfunctional, as are the notch and FOXM1 signaling pathways. They also almost always have p53 mutations. Other than this, mutations in high-grade serous carcinoma are hard to characterize beyond their high degree of genomic instability. "BRCA1" and "BRCA2" are essential for homologous recombination DNA repair, and germline mutations in these genes are found in about 15% of women with ovarian cancer. The most common mutations in BRCA1 and BRCA2 are the frameshift mutations that originated in a small founding population of Ashkenazi Jews.


title: Ovarian cancer

text: Almost 100% of rare mucinous carcinomas have mutations in "KRAS" and amplifications of "ERBB2" (also known as "Her2/neu"). Overall, 20% of ovarian cancers have mutations in "Her2/neu".


title: Ovarian cancer

text: Serous carcinomas may develop from serous tubal intraepithelial carcinoma, rather than developing spontaneously from ovarian tissue. Other carcinomas develop from cortical inclusion cysts, which are groups of epithelial ovarian cells inside the stroma.


title: Ovarian cancer

text: Diagnosis of ovarian cancer starts with a physical examination (including a pelvic examination), a blood test (for CA-125 and sometimes other markers), and transvaginal ultrasound. Sometimes a rectovaginal examination is used to help plan a surgery. The diagnosis must be confirmed with surgery to inspect the abdominal cavity, take biopsies (tissue samples for microscopic analysis), and look for cancer cells in the abdominal fluid. This helps to determine if an ovarian mass is benign or malignant.


title: Ovarian cancer

text: Ovarian cancer's early stages (I/II) are difficult to diagnose because most symptoms are nonspecific and thus of little use in diagnosis; as a result, it is rarely diagnosed until it spreads and advances to later stages (III/IV). Additionally, symptoms of ovarian cancer may appear similar to irritable bowel syndrome. In women in whom pregnancy is a possibility, BHCG level can be measured during the diagnosis process. Serum alpha-fetoprotein, neuron-specific enolase, and lactate dehydrogenase can be measured in young girls and adolescents with suspected ovarian tumors as younger women with ovarian cancer are more likely to have malignant germ cell tumors.


title: Ovarian cancer

text: A physical examination, including a pelvic examination, and a pelvic ultrasound (transvaginal or otherwise) are both essential for diagnosis: physical examination may reveal increased abdominal girth and/or ascites (fluid within the abdominal cavity), while pelvic examination may reveal an ovarian or abdominal mass. An adnexal mass is a significant finding that often indicates ovarian cancer, especially if it is fixed, nodular, irregular, solid, and/or bilateral. 13–21% of adnexal masses are caused by malignancy; however, there are other benign causes of adnexal masses, including ovarian follicular cyst, leiomyoma, endometriosis, ectopic pregnancy, hydrosalpinx, tuboovarian abscess, ovarian torsion, dermoid cyst, cystadenoma (serous or mucinous), diverticular or appendiceal abscess, nerve sheath tumor, pelvic kidney, ureteral or bladder diverticulum, benign cystic mesothelioma of the peritoneum, peritoneal tuberculosis, or paraovarian cyst. Ovaries that can be felt are also a sign of ovarian cancer in postmenopausal women. Other parts of a physical examination for suspected ovarian cancer can include a breast examination and a digital rectal exam. Palpation of the supraclavicular, axillary, and inguinal lymph nodes may reveal lymphadenopathy, which can be indicative of metastasis. Another indicator may be the presence of a pleural effusion, which can be noted on auscultation.


title: Ovarian cancer

text: When an ovarian malignancy is included in a list of diagnostic possibilities, a limited number of laboratory tests are indicated. A complete blood count and serum electrolyte test is usually obtained; when an ovarian cancer is present, these tests often show a high number of platelets (20–25% of patients) and low blood sodium levels due to chemical signals secreted by the tumor. A positive test for inhibin A and inhibin B can indicate a granulosa cell tumor.


title: Ovarian cancer

text: A blood test for a marker molecule called CA-125 is useful in differential diagnosis and in follow up of the disease, but it by itself has not been shown to be an effective method to screen for early-stage ovarian cancer due to its unacceptable low sensitivity and specificity. CA-125 levels in premenopausal women over 200 U/mL may indicate ovarian cancer, as may any elevation in CA-125 above 35 U/mL in post-menopausal women. CA-125 levels are not accurate in early stage ovarian cancer, as half of stage I ovarian cancer patients have a normal CA-125 level. CA-125 may also be elevated in benign (non-cancerous) conditions, including endometriosis, pregnancy, uterine fibroids, menstruation, ovarian cysts, systemic lupus erythematosus, liver disease, inflammatory bowel disease, pelvic inflammatory disease, and leiomyoma. HE4 is another candidate for ovarian cancer testing, though it has not been extensively tested. Other tumor markers for ovarian cancer include CA19-9, CA72-4, CA15-3, immunosuppressive acidic protein, haptoglobin-alpha, OVX1, mesothelin, lysophosphatidic acid, osteopontin, and fibroblast growth factor 23.


title: Ovarian cancer

text: Use of blood test panels may help in diagnosis. The OVA1 panel includes CA-125, beta-2 microglobulin, transferrin, apolipoprotein A1, and transthyretin. OVA1 above 5.0 in premenopausal women and 4.4 in postmenopausal women indicates a high risk for cancer. A different set of laboratory tests is used for detecting sex cord-stromal tumors. High levels of testosterone or dehydroepiandrosterone sulfate, combined with other symptoms and high levels of inhibin A and inhibin B can be indicative of an SCST of any type.


title: Ovarian cancer

text: Current research is looking at ways to consider tumor marker proteomics in combination with other indicators of disease (i.e. radiology and/or symptoms) to improve diagnostic accuracy. The challenge in such an approach is that the disparate prevalence of ovarian cancer means that even testing with very high sensitivity and specificity will still lead to a number of false positive results, which in turn may lead to issues such as performing surgical procedures in which cancer is not found intraoperatively. Genomics approaches have not yet been developed for ovarian cancer.


title: Ovarian cancer

text: CT scanning is preferred to assess the extent of the tumor in the abdominopelvic cavity, though magnetic resonance imaging can also be used. CT scanning can also be useful for finding omental caking or differentiating fluid from solid tumor in the abdomen, especially in low malignant potential tumors. However, it may not detect smaller tumors. Sometimes, a chest x-ray is used to detect metastases in the chest or pleural effusion. Another test for metastatic disease, though it is infrequently used, is a barium enema, which can show if the rectosigmoid colon is involved in the disease. Positron emission tomography, bone scans, and paracentesis are of limited use; in fact, paracentesis can cause metastases to form at the needle insertion site and may not provide useful results. However, paracentesis can be used in cases where there is no pelvic mass and ascites is still present. A physician suspecting ovarian cancer may also perform mammography or an endometrial biopsy (in the case of abnormal bleeding) to assess the possibility of breast malignancies and endometrial malignancy, respectively. Vaginal ultrasonography is often the first-line imaging study performed when an adnexal mass is found. Several characteristics of an adnexal mass indicate ovarian malignancy; they usually are solid, irregular, multilocular, and/or large; and they typically have papillary features, central vessels, and/or irregular internal septations. However, SCST has no definitive characteristics on radiographic study.


title: Ovarian cancer

text: To definitively diagnose ovarian cancer, a surgical procedure to inspect the abdomen is required. This can be an open procedure (laparotomy, incision through the abdominal wall) or keyhole surgery (laparoscopy). During this procedure, suspicious tissue is removed and sent for microscopic analysis. Usually, this includes a unilateral salpingo-oophorectomy, removal of a single affected ovary and Fallopian tube. Fluid from the abdominal cavity can also be analyzed for cancerous cells. If cancer is found, this procedure can also be used to determine the extent of its spread (which is a form of tumor staging).


title: Ovarian cancer

text: Pafolacianine is indicated for use in adults with ovarian cancer to help identify cancerous lesions during surgery. It is a diagnostic agent that is administered in the form of an intravenous injection prior to surgery.


title: Ovarian cancer

text: A widely recognized method of estimating the risk of malignant ovarian cancer is the risk of malignancy index (RMI), calculated based on an initial workup. An RMI score of over 200 or 250 is generally felt to indicate high risk for ovarian cancer.


title: Ovarian cancer

text: Two methods can be used to determine the ultrasound score and menopausal score, with the resultant scores being referred to as RMI 1 and RMI 2, respectively, depending on what method is used.


title: Ovarian cancer

text: Another method for quantifying risk of ovarian cancer is the Risk of Ovarian Cancer Algorithm (ROCA), which observes levels over time and determines if they are increasing rapidly enough to warrant transvaginal ultrasound. The Risk of Ovarian Malignancy algorithm uses CA-125 levels and HE4 levels to calculate the risk of ovarian cancer; it may be more effective than RMI. The IOTA models can be used to estimate the probability that an adnexal tumor is malignant. They include LR2 risk model, The Simple Rules risk (SRrisk) calculation and Assessment of Different Neoplasias in the Adnexa (ADNEX) model that can be used to assess risk of malignancy in an adnexal mass, based on its characteristics and risk factors. The QCancer (Ovary) algorithm is used to predict likelihood of ovarian cancer from risk factors.


title: Ovarian cancer

text: Ovarian cancers are classified according to the microscopic appearance of their structures (histology or histopathology). Histology dictates many aspects of clinical treatment, management, and prognosis. The gross pathology of ovarian cancers is very similar regardless of histologic type: ovarian tumors have solid and cystic masses. According to SEER, the types of ovarian cancers in women age 20 and over are:


title: Ovarian cancer

text: Ovarian cancers are histologically and genetically divided into type I or type II. Type I cancers are of low histological grade and include endometrioid, mucinous, and clear-cell carcinomas. Type II cancers are of higher histological grade and include serous carcinoma and carcinosarcoma.


title: Ovarian cancer

text: Epithelial ovarian cancer typically presents at an advanced stage and is derived from the malignant transformation of the epithelium of the ovarian surface, peritoneum, or fallopian tube. It is the most common cause of gynecologic cancer death. There are various types of epithelial ovarian cancer, including serous tumor, endometrioid tumor, clear cell tumor, mucinous tumor, and undifferentiated or unclassified tumors. Annually worldwide, 230,000 women will be diagnosed and 150,000 will die. It has a 46% 5 year survival rate after diagnosis because of the advanced stage of the disease at the time of diagnosis. Typically, around 75% of patients are diagnosed as having an advanced stage of the disease because of the asymptomatic nature of its presentation. There is a genomic predisposition to epithelial ovarian cancer and the BRCA1 and BRCA2 genes have been found to be the causative genes in 65-75% of hereditary epithelial ovarian cancer.


title: Ovarian cancer

text: Serous ovarian cancer is the most common type of epithelial ovarian cancer and it accounts for about two-thirds of cases of epithelial ovarian cancer. Low-grade serous carcinoma is less aggressive than high-grade serous carcinomas, though it does not typically respond well to chemotherapy or hormonal treatments. Serous carcinomas are thought to begin in the Fallopian tube. High grade serous carcinoma accounts for 75% of all epithelial ovarian cancer. About 15-20% of high grade serous carcinoma have germline BRCA1 and BRCA2 mutations. Histologically, the growth pattern of high grade serous carcinoma is heterogenous and has some papillary or solid growth patterns. The tumor cells are atypical with large, irregular nuclei. It has a high proliferation rate. 50% of the time, serous carcinomas are bilateral, and in 85% of cases, they have spread beyond the ovary at the time of diagnosis.


title: Ovarian cancer

text: Serous Tubal Intraepithelial Carcinoma (STIC) is now recognized to be the precursor lesion of most so-called ovarian high-grade serous carcinomas.


title: Ovarian cancer

text: Small-cell ovarian carcinoma is rare and aggressive, with two main subtypes: hypercalcemic and pulmonary. This rare malignancy most commonly affects young women under the age of 40 years old with a range between 14 months to 58 years. The mean age of diagnosis of 24 years. Approximately two-thirds of patients will present with paraneoplastic hypercalcemia meaning they have high blood calcium levels for an unknown reason. The tumor secretes Parathyroid hormone related protein which acts similarly to PTH and binds PTH receptors in the bone and kidney causing hypercalcemia. Recent research has found an inactivating germline and somatic mutation of "SMARCA4" gene. The hypercalcemic subtype is very aggressive and has a overall survival rate of 16% with a recurrence rate of 65% in patients who receive treatment. Patients who have spread of the disease to other parts of the body tend to die 2 years after the diagnosis. Extra-ovarian spread is involved in 50% of cases and lymph node spread is present in 55% of cases. The most common initial presentation is a rapidly growing unilateral pelvic mass with a mean size of 15 cm. Histologically, it is characterized by many sheets of small, round, tightly packed cells with clusters, nests, and cords. Immunohistochemistry is typically positive for vimentin, cytokeratin, CD10, p53, and WT-1.


title: Ovarian cancer

text: Small cell ovarian carcinoma of the pulmonary subtype presents differently from the hypercalcemic subtype. Typically, pulmonary small cell ovarian cancer usually affects both ovaries of older women and looks like oat-cell carcinoma of the lung. The average age of disease onset is 59 years old and approximately 45% of cases are bilateral for the pulmonary subtype. Additionally, several hormones can be elevated in the pulmonary subtype including serotonin, somatostatin, insulin, gastrin, and calcitonin.


title: Ovarian cancer

text: Primary peritoneal carcinomas develop from the peritoneum, a membrane that covers the abdominal cavity that has the same embryonic origin as the ovary. They are often discussed and classified with ovarian cancers when they affect the ovary. They can develop even after the ovaries have been removed and may appear similar to mesothelioma.


title: Ovarian cancer

text: Clear cell ovarian carcinoma is a rare subtype of epithelial ovarian cancer. Those diagnosed with clear cell ovarian carcinoma are typically younger at the age of diagnosis and diagnosed at earlier stages than other subtypes of epithelial ovarian cancer. The highest incidence of clear cell carcinoma of the ovary have been observed among young Asian women, especially those of Korean, Taiwanese, and Japanese background. Endometriosis has been linked to being the main risk factor for the development of clear cell carcinoma of the ovary and has been found to be present in 50% of women diagnosed with clear cell carcinoma of the ovary. The development of clots in the legs such as deep vein thromboembolism or in the lungs with pulmonary embolism is reported to be 40% higher in patients with clear cell carcinoma than other epithelial ovarian cancer subtypes. Mutations in molecular pathways such as ARID1A, PIK3, and PIK3CA have been found to be linked to clear cell carcinoma. They typically present as a large, unilateral mass, with a mean size between 13–15 cm. 90% of cases are unilateral. Clear-cell ovarian carcinomas do not typically respond well to chemotherapy due to intrinsic chemoresistance therefore treatment is typically with aggressive cytoreductive surgery and platinum-based chemotherapy.


title: Ovarian cancer

text: Clear-cell adenocarcinomas are histopathologically similar to other clear cell carcinomas, with clear cells and hobnail cells. They represent approximately 5–10% of epithelial ovarian cancers and are associated with endometriosis in the pelvic cavity. They are typically early-stage and therefore curable by surgery, but advanced clear-cell adenocarcinomas (approximately 20%) have a poor prognosis and are often resistant to platinum chemotherapy.


title: Ovarian cancer

text: Endometrioid adenocarcinomas make up approximately 13-15% of all ovarian cancers. Because they are typically low-grade, endometrioid adenocarcinomas have a good prognosis. The median age of diagnosis is around 53 years of age. These tumors frequently co-occur with endometriosis or endometrial cancer. Cancer antigen 125 levels are typically elevated and a family history of a first degree relative with endometrioid ovarian cancer is associated with increased risk of developing endometrioid ovarian cancer. The average tumor size is larger than 10 cm.


title: Ovarian cancer

text: Mixed müllerian tumors make up less than 1% of ovarian cancer. They have epithelial and mesenchymal cells visible and tend to have a poor prognosis.


title: Ovarian cancer

text: Mucinous adenocarcinomas make up 5–10% of epithelial ovarian cancers. Histologically, they are similar to intestinal or cervical adenocarcinomas and are often actually metastases of appendiceal or colon cancers. Advanced mucinous adenocarcinomas have a poor prognosis, generally worse than serous tumors, and are often resistant to platinum chemotherapy, though they are rare.


title: Ovarian cancer

text: "Pseudomyxoma peritonei" refers to a collection of encapsulated mucous or gelatinous material in the abdominopelvic cavity, which is very rarely caused by a primary mucinous ovarian tumor. More commonly, it is associated with ovarian metastases of intestinal cancer.


title: Ovarian cancer

text: Undifferentiated cancers - those where the cell type cannot be determined - make up about 10% of epithelial ovarian cancers and have a comparatively poor prognosis. When examined under the microscope, these tumors have very abnormal cells that are arranged in clumps or sheets. Usually there are recognizable clumps of serous cells inside the tumor.


title: Ovarian cancer

text: Malignant Brenner tumors are rare. Histologically, they have dense fibrous stroma with areas of transitional epithelium and some squamous differentiation. To be classified as a malignant Brenner tumor, it must have Brenner tumor foci and transitional cell carcinoma. The transitional cell carcinoma component is typically poorly differentiated and resembles urinary tract cancer.


title: Ovarian cancer

text: Transitional cell carcinomas represent less than 5% of ovarian cancers. Histologically, they appear similar to bladder carcinoma. The prognosis is intermediate - better than most epithelial cancers but worse than malignant Brenner tumors.


title: Ovarian cancer

text: Sex cord-stromal tumor, including estrogen-producing granulosa cell tumor, the benign thecoma, and virilizing Sertoli-Leydig cell tumor or arrhenoblastoma, accounts for 7% of ovarian cancers. They occur most frequently in women between 50 and 69 years of age but can occur in women of any age, including young girls. They are not typically aggressive and are usually unilateral; they are therefore usually treated with surgery alone. Sex cord-stromal tumors are the main hormone-producing ovarian tumors.


title: Ovarian cancer

text: Several different cells from the mesenchyme can give rise to sex-cord or stromal tumors. These include fibroblasts and endocrine cells. The symptoms of a sex-cord or stromal ovarian tumor can differ from other types of ovarian cancer. Common signs and symptoms include ovarian torsion, hemorrhage from or rupture of the tumor, an abdominal mass, and hormonal disruption. In children, isosexual precocious pseudopuberty may occur with granulosa cell tumors since they produce estrogen. These tumors cause abnormalities in menstruation (excessive bleeding, infrequent menstruation, or no menstruation) or postmenopausal bleeding. Because these tumors produce estrogen, they can cause or occur at the same time as endometrial cancer or breast cancer. Other sex-cord/stromal tumors present with distinct symptoms. Sertoli-Leydig cell tumors cause virilization and excessive hair growth due to the production of testosterone and androstenedione, which can also cause Cushing's syndrome in rare cases. Also, sex-cord stromal tumors occur that do not cause a hormonal imbalance, including benign fibromas, which cause ascites and hydrothorax. With germ cell tumors, sex cord-stromal tumors are the most common ovarian cancer diagnosed in women under 20.


title: Ovarian cancer

text: Granulosa cell tumors are the most common sex-cord stromal tumors, making up 70% of cases, and are divided into two histologic subtypes: adult granulosa cell tumors, which develop in women over 50, and juvenile granulosa tumors, which develop before puberty or before the age of 30. Both develop in the ovarian follicle from a population of cells that surrounds germinal cells.


title: Ovarian cancer

text: Adult granulosa cell tumors are characterized by later onset (30+ years, 50 on average). These tumors produce high levels of estrogen, which causes its characteristic symptoms: menometrorrhagia; endometrial hyperplasia; tender, enlarged breasts; postmenopausal bleeding; and secondary amenorrhea. The mass of the tumor can cause other symptoms, including abdominal pain and distension, or symptoms similar to an ectopic pregnancy if the tumor bleeds and ruptures.


title: Ovarian cancer

text: Sertoli-Leydig tumors are most common in women before the age of 30, and particularly common before puberty.


title: Ovarian cancer

text: Germ cell tumors of the ovary develop from the ovarian germ cells. Germ cell tumor accounts for about 30% of ovarian tumors, but only 5% of ovarian cancers, because most germ-cell tumors are teratomas and most teratomas are benign. Malignant teratomas tend to occur in older women, when one of the germ layers in the tumor develops into a squamous cell carcinoma. Germ-cell tumors tend to occur in young women (20s–30s) and girls, making up 70% of the ovarian cancer seen in that age group. Germ-cell tumors can include dysgerminomas, teratomas, yolk sac tumors/endodermal sinus tumors, and choriocarcinomas, when they arise in the ovary. Some germ-cell tumors have an isochromosome 12, where one arm of chromosome 12 is deleted and replaced with a duplicate of the other. Most germ-cell cancers have a better prognosis than other subtypes and are more sensitive to chemotherapy. They are more likely to be stage I at diagnosis. Overall, they metastasize more frequently than epithelial ovarian cancers. In addition, the cancer markers used vary with tumor type: choriocarcinomas are monitored with beta-HCG and endodermal sinus tumors with alpha-fetoprotein.


title: Ovarian cancer

text: Germ-cell tumors are typically discovered when they become large, palpable masses. However, like sex cord tumors, they can cause ovarian torsion or hemorrhage and, in children, isosexual precocious puberty. They frequently metastasize to nearby lymph nodes, especially para-aortic and pelvic lymph nodes. The most common symptom of germ cell tumors is subacute abdominal pain caused by the tumor bleeding, necrotizing, or stretching the ovarian capsule. If the tumor ruptures, causes significant bleeding, or torses the ovary, it can cause acute abdominal pain, which occurs in less than 10% of those with germ-cell tumors. They can also secrete hormones which change the menstrual cycle. In 25% of germ-cell tumors, the cancer is discovered during a routine examination and does not cause symptoms.


title: Ovarian cancer

text: Diagnosing germ cell tumors may be difficult because the normal menstrual cycle and puberty can cause pain and pelvic symptoms, and a young woman may even believe these symptoms to be those of pregnancy, and not seek treatment due to the stigma of teen pregnancy. Blood tests for alpha-fetoprotein, karyotype, human chorionic gonadotropin, and liver function are used to diagnose germ cell tumor and potential co-occurring gonadal dysgenesis. A germ cell tumor may be initially mistaken for a benign ovarian cyst.


title: Ovarian cancer

text: Dysgerminoma accounts for 35% of ovarian cancer in young women and is the most likely germ cell tumor to metastasize to the lymph nodes; nodal metastases occur in 25–30% of cases. These tumors may have mutations in the "KIT" gene, a mutation known for its role in gastrointestinal stromal tumor. People with an XY karyotype and ovaries (gonadal dysgenesis) or an X,0 karyotype and ovaries (Turner syndrome) who develop a unilateral dysgerminoma are at risk for a gonadoblastoma in the other ovary, and in this case, both ovaries are usually removed when a unilateral dysgerminoma is discovered to avoid the risk of another malignant tumor. Gonadoblastomas in people with Swyer or Turner syndrome become malignant in approximately 40% of cases. However, in general, dysgerminomas are bilateral 10–20% of the time.


title: Ovarian cancer

text: They are composed of cells that cannot differentiate further and develop directly from germ cells or from gonadoblastomas. Dysgerminomas contain syncytiotrophoblasts in approximately 5% of cases, and can therefore cause elevated hCG levels. On gross appearance, dysgerminomas are typically pink to tan-colored, have multiple lobes, and are solid. Microscopically, they appear identical to seminomas and very close to embryonic primordial germ cells, having large, polyhedral, rounded clear cells. The nuclei are uniform and round or square with prominent nucleoli and the cytoplasm has high levels of glycogen. Inflammation is another prominent histologic feature of dysgerminomas.


title: Ovarian cancer

text: Choriocarcinoma can occur as a primary ovarian tumor developing from a germ cell, though it is usually a gestational disease that metastasizes to the ovary. Primary ovarian choriocarcinoma has a poor prognosis and can occur without a pregnancy. They produce high levels of hCG and can cause early puberty in children or menometrorrhagia (irregular, heavy menstruation) after menarche.


title: Ovarian cancer

text: Immature, or solid, teratomas are the most common type of ovarian germ cell tumor, making up 40–50% of cases. Teratomas are characterized by the presence of disorganized tissues arising from all three embryonic germ layers: ectoderm, mesoderm, and endoderm; immature teratomas also have undifferentiated stem cells that make them more malignant than mature teratomas (dermoid cysts). The different tissues are visible on gross pathology and often include bone, cartilage, hair, mucus, or sebum, but these tissues are not visible from the outside, which appears to be a solid mass with lobes and cysts. Histologically, they have large amounts of neuroectoderm organized into sheets and tubules along with glia; the amount of neural tissue determines the histologic grade. Immature teratomas usually only affect one ovary (10% co-occur with dermoid cysts) and usually metastasize throughout the peritoneum. They can also cause mature teratoma implants to grow throughout the abdomen in a disease called growing teratoma syndrome; these are usually benign but will continue to grow during chemotherapy, and often necessitate further surgery. Unlike mature teratomas, immature teratomas form many adhesions, making them less likely to cause ovarian torsion. There is no specific marker for immature teratomas, but carcinoembryonic antigen (CEA), CA-125, CA19-9, or AFP can sometimes indicate an immature teratoma.


title: Ovarian cancer

text: Stage I teratomas make up the majority (75%) of cases and have the best prognosis, with 98% of patients surviving 5 years; if a Stage I tumor is also grade 1, it can be treated with unilateral surgery only. Stage II though IV tumors make up the remaining quarter of cases and have a worse prognosis, with 73–88% of patients surviving 5 years.


title: Ovarian cancer

text: Mature teratomas, or dermoid cysts, are rare tumors consisting of mostly benign tissue that develop after menopause. The tumors consist of disorganized tissue with nodules of malignant tissue, which can be of various types. The most common malignancy is squamous cell carcinoma, but adenocarcinoma, basal-cell carcinoma, carcinoid tumor, neuroectodermal tumor, malignant melanoma, sarcoma, sebaceous tumor, and struma ovarii can also be part of the dermoid cyst. They are treated with surgery and adjuvant platinum chemotherapy or radiation.


title: Ovarian cancer

text: Yolk sac tumors, formerly called endodermal sinus tumors, make up approximately 10–20% of ovarian germ cell malignancies, and have the worst prognosis of all ovarian germ cell tumors. They occur both before menarche (in one-third of cases) and after menarche (the remaining two-thirds of cases). Half of the people with yolk sac tumors are diagnosed in stage I. Typically, they are unilateral until metastasis, which occurs within the peritoneal cavity and via the bloodstream to the lungs. Yolk sac tumors grow quickly and recur easily, and are not easily treatable once they have recurred. Stage I yolk sac tumors are highly treatable, with a 5-year disease-free survival rate of 93%, but stage II-IV tumors are less treatable, with survival rates of 64–91%.


title: Ovarian cancer

text: Their gross appearance is solid, friable, and yellow, with necrotic and hemorrhagic areas. They also often contain cysts that can degenerate or rupture. Histologically, yolk sac tumors are characterized by the presence of Schiller-Duval bodies (which are pathognomonic for yolk sac tumors) and a reticular pattern. Yolk sac tumors commonly secrete alpha-fetoprotein and can be immunohistochemically stained for its presence; the level of alpha-fetoprotein in the blood is a useful marker of recurrence.


title: Ovarian cancer

text: Embryonal carcinomas, a rare tumor type usually found in mixed tumors, develop directly from germ cells but are not terminally differentiated; in rare cases, they may develop in dysgenetic gonads. They can develop further into a variety of other neoplasms, including choriocarcinoma, yolk sac tumor, and teratoma. They occur in younger people, with an average age at diagnosis of 14, and secrete both alpha-fetoprotein (in 75% of cases) and hCG.


title: Ovarian cancer

text: Histologically, embryonal carcinoma appears similar to the embryonic disc, made up of epithelial, anaplastic cells in disorganized sheets, with gland-like spaces and papillary structures.


title: Ovarian cancer

text: Polyembryomas, the most immature form of teratoma and very rare ovarian tumors, are histologically characterized by having several embryo-like bodies with structures resembling a germ disk, yolk sac, and amniotic sac. Syncytiotrophoblast giant cells also occur in polyembryomas.


title: Ovarian cancer

text: Primary ovarian squamous cell carcinomas are rare and have a poor prognosis when advanced. More typically, ovarian squamous cell carcinomas are cervical metastases, areas of differentiation in an endometrioid tumor, or derived from a mature teratoma.


title: Ovarian cancer

text: Mixed tumors contain elements of more than one of the above classes of tumor histology. To be classed as a mixed tumor, the minor type must make up more than 10% of the tumor. Though mixed carcinomas can have any combination of cell types, mixed ovarian cancers are typically serous/endometrioid or clear cell/endometrioid. Mixed germ cell tumors make up approximately 25–30% of all germ cell ovarian cancers, with combinations of dysgerminoma, yolk sac tumor, and/or immature teratoma. The prognosis and treatment vary based on the component cell types.


title: Ovarian cancer

text: Ovarian cancer can also be a secondary cancer, the result of metastasis from a primary cancer elsewhere in the body. About 5-30% of ovarian cancers are due to metastases, while the rest are primary cancers. Common primary cancers are breast cancer, colon cancer, appendiceal cancer, and stomach cancer (primary gastric cancers that metastasize to the ovary are called Krukenberg tumors). Krukenberg tumors have signet ring cells and mucinous cells. Endometrial cancer and lymphomas can also metastasize to the ovary.


title: Ovarian cancer

text: Ovarian borderline tumors, sometimes called low malignant potential (LMP) ovarian tumors, have some benign and some malignant features. LMP tumors make up approximately 10%-15% of all ovarian tumors. They develop earlier than epithelial ovarian cancer, around the age of 40–49. They typically do not have extensive invasion; 10% of LMP tumors have areas of stromal microinvasion (<3mm, <5% of tumor). LMP tumors have other abnormal features, including increased mitosis, changes in cell size or nucleus size, abnormal nuclei, cell stratification, and small projections on cells (papillary projections). Serous and/or mucinous characteristics can be seen on histological examination, and serous histology makes up the overwhelming majority of advanced LMP tumors. More than 80% of LMP tumors are Stage I; 15% are stage II and III and less than 5% are stage IV. Implants of LMP tumors are often non-invasive.


title: Ovarian cancer

text: Ovarian cancer is staged using the FIGO staging system and uses information obtained after surgery, which can include a total abdominal hysterectomy via midline laparotomy, removal of (usually) both ovaries and Fallopian tubes, (usually) the omentum, pelvic (peritoneal) washings, assessment of retroperitoneal lymph nodes (including the pelvic and para-aortic lymph nodes), appendectomy in suspected mucinous tumors, and pelvic/peritoneal biopsies for cytopathology. Around 30% of ovarian cancers that appear confined to the ovary have metastasized microscopically, which is why even stage-I cancers must be staged completely. 22% of cancers presumed to be stage I are observed to have lymphatic metastases. The AJCC stage is the same as the FIGO stage. The AJCC staging system describes the extent of the primary tumor (T), the absence or presence of metastasis to nearby lymph nodes (N), and the absence or presence of distant metastasis (M). The most common stage at diagnosis is stage IIIc, with over 70% of diagnoses.


title: Ovarian cancer

text: The AJCC/TNM staging system indicates where the tumor has developed, spread to lymph nodes, and metastasis.


title: Ovarian cancer

text: Grade 1 tumors have well differentiated cells (look very similar to the normal tissue) and are the ones with the best prognosis. Grade 2 tumors are also called moderately well-differentiated and they are made up of cells that resemble the normal tissue. Grade 3 tumors have the worst prognosis and their cells are abnormal, referred to as poorly differentiated.


title: Ovarian cancer

text: Metastasis in ovarian cancer is very common in the abdomen and occurs via exfoliation, where cancer cells burst through the ovarian capsule and are able to move freely throughout the peritoneal cavity. Ovarian cancer metastases usually grow on the surface of organs rather than the inside; they are also common on the omentum and the peritoneal lining. Cancer cells can also travel through the lymphatic system and metastasize to lymph nodes connected to the ovaries via blood vessels; i.e. the lymph nodes along the infundibulopelvic ligament, the broad ligament, and the round ligament. The most commonly affected groups include the paraaortic, hypogastric, external iliac, obturator, and inguinal lymph nodes. Usually, ovarian cancer does not metastasize to the liver, lung, brain, or kidneys unless it is a recurrent disease; this differentiates ovarian cancer from many other forms of cancer.


title: Ovarian cancer

text: Women with strong genetic risk for ovarian cancer may consider the surgical removal of their ovaries as a preventive measure. This is often done after completion of childbearing years. This reduces the chances of developing both breast cancer (by around 50%) and ovarian cancer (by about 96%) in women at high risk. Women with "BRCA" gene mutations usually also have their Fallopian tubes removed at the same time (salpingo-oophorectomy), since they also have an increased risk of Fallopian tube cancer. However, these statistics may overestimate the risk reduction because of how they have been studied.


title: Ovarian cancer

text: Women with a significant family history for ovarian cancer are often referred to a genetic counselor to see if testing for BRCA mutations would be beneficial. The use of oral contraceptives, the absence of 'periods' during the menstrual cycle, and tubal ligation reduce the risk.


title: Ovarian cancer

text: There may an association of developing ovarian cancer and ovarian stimulation during infertility treatments. Endometriosis has been linked to ovarian cancers. Human papillomavirus infection, smoking, and talc have not been identified as increasing the risk for developing ovarian cancer.


title: Ovarian cancer

text: There is no simple and reliable way to test for ovarian cancer in women who do not have any signs or symptoms. Screening is not recommended in women who are at average risk, as evidence does not support a reduction in death and the high rate of false positive tests may lead to unneeded surgery, which is accompanied by its own risks. Women with high risk of ovarian cancer that are currently identified based on family history and genetic testing may benefit from screening. The Pap test does not screen for ovarian cancer.


title: Ovarian cancer

text: Ovarian cancer is usually only palpable in advanced stages. Screening is not recommended using CA-125 measurements, HE4 levels, ultrasound, or adnexal palpation in women who are at average risk. This high risk group has benefited with earlier detection.


title: Ovarian cancer

text: Ovarian cancer has low prevalence, even in the high-risk group of women from the ages of 50 to 60 (about one in 2000), and screening of women with average risk is more likely to give ambiguous results than detect a problem that requires treatment. Because ambiguous results are more likely than detection of a treatable problem, and because the usual response to ambiguous results is invasive interventions, in women of average risk, the potential harms of having screening without an indication outweigh the potential benefits. The purpose of screening is to diagnose ovarian cancer at an early stage when it is more likely to be treated successfully.


title: Ovarian cancer

text: Screening with transvaginal ultrasound, pelvic examination, and CA-125 levels can be used instead of preventive surgery in women who have BRCA1 or BRCA2 mutations. This strategy has shown some success.


title: Ovarian cancer

text: Screening for CA125, a chemical released by ovarian tumours, with follow-up using ultrasound, was shown to be ineffective in reducing mortality in a large-scale UK study.


title: Ovarian cancer

text: There have been some screening trials that have used age, family history of ovarian cancer, and mutation status to identify target populations for screening.


title: Ovarian cancer

text: Once it is determined that ovarian, fallopian tube or primary peritoneal cancer is present, treatment is scheduled by a gynecologic oncologist (a physician trained to treat cancers of a woman's reproductive system). Gynecologic oncologists can perform surgery on and give chemotherapy to women with ovarian cancer. A treatment plan is developed.


title: Ovarian cancer

text: Treatment usually involves surgery and chemotherapy, and sometimes radiotherapy, regardless of the subtype of ovarian cancer. Surgical treatment may be sufficient for well-differentiated malignant tumors and confined to the ovary. Addition of chemotherapy may be required for more aggressive tumors confined to the ovary. For patients with advanced disease, a combination of surgical reduction with a combination chemotherapy regimen is standard. Since 1980, platinum-based drugs have had an important role in treating ovarian cancer. Borderline tumors, even following spread outside of the ovary, are managed well with surgery, and chemotherapy is not seen as useful. Second-look surgery and maintenance chemotherapy have not been shown to provide benefit.


title: Ovarian cancer

text: Surgery has been the standard of care for decades and may be necessary for obtaining a specimen for diagnosis. The surgery depends upon the extent of nearby invasion of other tissues by the cancer when it is diagnosed. This extent of the cancer is described by assigning it a stage, the presumed type, and the grade of cancer. The gynecological surgeon may remove one (unilateral oophorectomy) or both ovaries (bilateral oophorectomy). The Fallopian tubes (salpingectomy), uterus (hysterectomy), and the omentum (omentectomy) may also be removed. Typically, all of these organs are removed.


title: Ovarian cancer

text: For low-grade, unilateral stage-IA cancers, only the involved ovary (which must be unruptured) and Fallopian tube will be removed. This can be done especially in young people who wish to preserve their fertility. However, a risk of microscopic metastases exists and staging must be completed. If any metastases are found, a second surgery to remove the remaining ovary and uterus is needed. Tranexamic acid can be administered prior to surgery to reduce the need for blood transfusions due to blood loss during the surgery.


title: Ovarian cancer

text: If a tumor in a premenopausal woman is determined to be a low malignant potential tumor during surgery, and it is clearly stage I cancer, only the affected ovary is removed. For postmenopausal women with low malignant potential tumors, hysterectomy with bilateral salpingo-oophorectomy is still the preferred option. During staging, the appendix can be examined or removed. This is particularly important with mucinous tumors. In children or adolescents with ovarian cancer, surgeons typically attempt to preserve one ovary to allow for the completion of puberty, but if the cancer has spread, this is not always possible. Dysgerminomas, in particular, tend to affect both ovaries: 8–15% of dysgerminomas are present in both ovaries. People with low-grade (well-differentiated) tumors are typically treated only with surgery, which is often curative. In general, germ cell tumors can be treated with unilateral surgery unless the cancer is widespread or fertility is not a factor. In women with surgically staged advanced epithelial ovarian cancer (stages III and IV), studies suggest all attempts should be made to reach complete cytoreduction (surgical efforts to remove the bulk of the tumor).


title: Ovarian cancer

text: In advanced cancers, where complete removal is not an option, as much tumor as possible is removed in a procedure called debulking surgery. This surgery is not always successful, and is less likely to be successful in women with extensive metastases in the peritoneum, stage- IV disease, cancer in the transverse fissure of the liver, mesentery, or diaphragm, and large areas of ascites. Debulking surgery has usually only been done once but a recent study has shown a longer overall survival in recurrent ovarian cancer when surgery combined with chemotherapy was performed compared to treatment with chemotherapy alone. Computed tomography (abdominal CT) is often used to assess if primary debulking surgery is possible, but low certainty evidence also suggests fluorodeoxyglucose‐18 (FDG) PET/CT and MRI may be useful as an addition for assessing macroscopic incomplete debulking. More complete debulking is associated with better outcomes: women with no macroscopic evidence of disease after debulking have a median survival of 39 months, as opposed to 17 months with less complete surgery. By removing metastases, many cells that are resistant to chemotherapy are removed, and any clumps of cells that have died are also removed. This allows chemotherapy to better reach the remaining cancer cells, which are more likely to be fast-growing and therefore chemosensitive.


title: Ovarian cancer

text: Interval debulking surgery is another protocol used, where neoadjuvant chemotherapy is given, debulking surgery is performed, and chemotherapy is finished after debulking. Though no definitive studies have been completed, it is shown to be approximately equivalent to primary debulking surgery in terms of survival and shows slightly lower morbidity. Previous studies have shown different results from primary debulking versus interval debulking. Hopefully the ongoing TRUST study will clarify selection criterias for each surgical approach.


title: Ovarian cancer

text: There are several different surgical procedures that can be employed to treat ovarian cancer. For stage I and II cancer, laparoscopic (keyhole) surgery can be used, but metastases may not be found. For advanced cancer, laparoscopy is not used, since debulking metastases requires access to the entire peritoneal cavity. Depending on the extent of the cancer, procedures may include a bilateral salpingo-oophorectomy, biopsies throughout the peritoneum and abdominal lymphatic system, omentectomy, splenectomy, bowel resection, diaphragm stripping or resection, appendectomy, or even a posterior pelvic exenteration.


title: Ovarian cancer

text: To fully stage ovarian cancer, lymphadenectomy can be included in the surgery, but a significant survival benefit to this practice may not happen. This is particularly important in germ cell tumors because they frequently metastasize to nearby lymph nodes.


title: Ovarian cancer

text: If ovarian cancer recurs, secondary surgery is sometimes a treatment option. This depends on how easily the tumor can be removed, how much fluid has accumulated in the abdomen, and overall health. Effectivenes of this surgery depends on surgical technique, completeness of cytoreduction, and extent of disease. It also can be helpful in people who had their first surgery done by a generalist and in epithelial ovarian cancer. Secondary surgery can be effective in dysgerminomas and immature teratomas. Evidence suggests surgery in recurrent epithelial ovarian cancer may be associated with prolonging life in some women with platinum-sensitive disease.


title: Ovarian cancer

text: The major side effect of oophorectomy in younger women is early menopause, which can cause osteoporosis. After surgery, hormone replacement therapy can be considered, especially in younger women. This therapy can consist of a combination of estrogen and progesterone, or estrogen alone. Estrogen alone is safe after hysterectomy; when the uterus is still present, unopposed estrogen dramatically raises the risk of endometrial cancer. Estrogen therapy after surgery does not change survival rates. People having ovarian cancer surgery are typically hospitalized afterwards for 3–4 days and spend around a month recovering at home. Surgery outcomes are best at hospitals that do a large number of ovarian cancer surgeries.


title: Ovarian cancer

text: It is unclear if laparoscopy or laparotomy is better or worse for FIGO stage I ovarian cancer. There is also no apparent difference between total abdominal hysterectomy and supracervical hysterectomy for advanced cancers. Approximately 2.8% of people having a first surgery for advanced ovarian cancer die within two weeks of the surgery (2.8% perioperative mortality rate). More aggressive surgeries are associated with better outcomes in advanced (stage III or IV) ovarian cancer.