- Email: [email protected]
Ovarian Serous Papillary Cystadenocarcinoma Stage IIIC in a 19-Year-Old
GYNECOLOGIC ONCOLOGY ARTICLE NO.
64, 279–281 (1997)
GO964562
CASE REPORT Ovarian Serous Papillary Cystadenocarcinoma Stage IIIC in a 19-Year-Old S. LAFRAMBOISE, M.D., FRCS(C),
J. DUBUC-LISSOIR, M.D., FRCS(C)1
AND
Division of Gynecological Oncology, Department of Obstetrics and Gynecology, Hoˆpital Notre-Dame, Universite´ de Montre´al, 1560 East Sherbrooke Street, Montreal, Quebec, Canada H2L 4M1 Received May 23, 1996
CASE REPORT In mature women, the most common histological cell type of ovarian cancer is of epithelial origin. In children and adolescents, germ cell tumors are the most frequent. We report a case of a serous papillary cystadenocarcinoma FIGO stage IIIC in a 19year-old female. She presented with a 6-month history of vague lower abdominal pain. Preoperative CA-125 was elevated at 296 kU/liter. At laparotomy, she was found to have stage IIIC disease. A debulking procedure including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node sampling was performed. The immediate postoperative course was complicated by fulminant disseminated intravascular coagulopathy. She was subsequently treated with six courses of cyclophosphamide and carboplatin. Twenty-four months after surgery, the patient has no evidence of disease despite an increased CA-125 of 51 kU/liter. q 1997 Academic Press
INTRODUCTION
The most common histological cell type in malignant ovarian tumors is epithelial, and these represent 85% of all diagnoses [1]. In children and adolescents, most of the ovarian tumors are of germ cell origin (58–84%), and epithelial cell tumors, including benign, low-malignant, and malignant lesions, account for a minority (8–23%) of cases [2–4]. Since in this age group malignant ovarian tumors account for only 1% of all cancers, advanced-stage epithelial cancers are very rare [5]. An updated review of the literature reveals four cases of documented stage III malignant epithelial tumors in females less than 20 years of age [6–9]. We report a fifth case of a FIGO stage IIIC epithelial ovarian cancer complicated by disseminated intravascular coagulopathy (DIC).
1
To whom correspondence should be addressed. Fax: (514) 896-4703.
A 19-year-old Vietnamese nulligravida with a 6-month history of vague lower abdominal pain was seen. Patient denied any other gastrointestinal, gynecological, or urological symptoms. Past medical history was unremarkable. Family history was significant for tuberculosis. Patient reported normal menses, with her most recent period 10 days previously. She had been sexually active for a year, and had used condoms for contraception. Abdominal examination confirmed the presence of a lower abdominal mass; the upper abdomen was unremarkable and no ascites was noted. On pelvic examination, a small uterus and a large right adnexal mass were documented. An ultrasound showed a 10-cm complex mass in the pelvis, separate from the uterus, probably arising from the right ovary. Preoperative investigations were significant for a mild anemia (hemoglobin 10.4 g/dl) secondary to thalassemia minor, and an elevated CA-125 at 296 kU/liter (normal, õ45 kU/liter). The coagulation profile was normal. The patient was taken to the operating room on August 14, 1994. The examination under anesthesia confirmed preoperative findings but also revealed a left adnexal mass not previously palpated. At laparotomy, a moderate amount of ascites was noted. Large bilateral masses were found. The right ovary, 10 cm in size with a smooth surface, was fixed to the pelvic sidewall and to the uterus. The left ovary was 11 cm, had multiple implants on its surface, and was adherent to the cul-de-sac and sigmoid colon serosa. The uterus was studded with serosal implants. Tumor plaques of 2 to 3 cm were found on the vesicouterine fold. The omentum and diaphragmatic surfaces had implants of 1 cm in greatest diameter. Frozen-section analysis confirmed the diagnosis of adenocarcinoma, and therefore, a 4-hr maximal debulking procedure was performed with total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and paraaortic lymph node sampling, and excision of
279
AID
Gyn 4562
/
6d17$$$121
01-16-97 13:58:47
0090-8258/97 $25.00 Copyright q 1997 by Academic Press All rights of reproduction in any form reserved.
goa
AP: GYN
280
LAFRAMBOISE AND DUBUC-LISSOIR
pelvic and vesicouterine peritonei to residual disease of less than 1 cm. Soon after the beginning of surgery, an increased bleeding tendency was observed and prompted an immediate coagulation profile. The total blood loss was estimated at 2 liters. The patient received, in addition to 7 liters of crystalloids, 4 units of packed red blood cells (PRBC) and 3 units of Pentastarch. At the end of the surgical procedure, diffuse oozing was controlled with Surgicel, and the hemoglobin had been restored from 6.8 to 10.2 g/dl. The intraoperative partial thromboplastin time (PTT) was elevated to 68.9 sec and the international normalized ratio (INR) to 3.7. With pooled plasma, PTT corrected to 26.3 sec and the INR to 1.3. Laboratory evaluation 4 hr after surgery was significant for a hemoglobin of 3.9 g/dl, platelets of 157,000 mm3, PTT of 46 sec, INR of 2.6, and normal fibrinogen and D-dimer. Six hours after surgery, the patient was hemodynamically unstable and was reintubated due to respiratory distress, nausea, vomiting, decreased level of consciousness, and increasing abdominal girth. Despite 8 units of PRBC, 8 units of platelets, 7 units of fresh-frozen plasma, 30 units of cryoprecipitate, and crystalloid support, the hemoglobin remained at 6.6 g/dl, platelets fell to 36,000 mm3, PTT rose to 61 sec, fibrinogen decreased to 0.9 g/liter (normal, 1.9–5.3 g/liter), antithrombin III fell to 0.08 g/liter (normal, 0.21–0.39 g/ liter), and D-dimer increased to 0.4 to 0.8 mg/liter (normal, õ0.2 mg/liter). A hematological consultation was requested 7 hr after surgery due to bleeding from the nasogastric and endotracheal tubes, the puncture and intravenous access sites, and abdominal incision. A diagnosis of intraabdominal bleeding secondary to DIC was confirmed. For correction of coagulopathy, the patient was admitted to the intensive care unit (ICU). The patient had an expanding hematoma from the femoral area to the labia (site of arterial line puncture), oliguria, and ventilation difficulties. Once hemodynamically stabilized with ongoing transfusions, a second laparotomy was performed 9 hr after the initial procedure to drain 8 liters of blood and clots, at which time no active site of bleeding was found. The patient spent 5 days in the ICU and received a total of 16 units of PRBC, 24 units of plasma, 6 units of 25% albumin, 5 units of cryoprecipitate, 2 units of platelets, and 2 units of Pentastarch. Her hospital stay was complicated by reintubation on Postoperative Day 3 due to oxygen desaturation, atelectasis, and tracheobronchitis, secondary to aspiration. Furthermore, she had febrile episodes attributed to an anterior abdominal wall collection. This was drained under radiological guidance, with no bacteria isolated. Final pathology confirmed the diagnosis of FIGO (1989) stage IIIC ovarian serous papillary cystadenocarcinoma, grade 1, with two positive iliac and one positive paraaortic lymph node. She was treated with six cycles of carboplatin 300 mg/m2 and cyclophosphamide 600 mg/m2. At that time, the use of paclitaxel and cis-platinum was not yet standard
AID
Gyn 4562
/
6d17$$$122
01-16-97 13:58:47
first-line therapy in our institution. Hormonal replacement therapy was provided with Premarin 1.25 mg daily. Follow-up CA-125 were normal immediately after surgical treatment and remained normal until 11 months after surgery, when it increased to 59 kU/liter. Patient was asymptomatic and physical examination was normal. Pelvic and abdominal ultrasound examinations were normal. A CA-125 of 62 kU/liter at 14 months after primary treatment prompted repeat pelvic and abdominal ultrasound examinations, which were also normal. Patient remains well and asymptomatic 24 months after surgery with regular follow-ups and a CA125 of 51 kU/liter. DISCUSSION
Advanced epithelial ovarian cancers (stages III and IV) are rarely diagnosed in children and adolescents, with the experience limited to case reports [10]. To our knowledge, four such cases have been well documented in the literature. Hong et al. reported the case of a stage III ovarian cystadenocarcinoma in a 4-year-old girl [6]. This was felt to be the first case ever reported prior to puberty. The patient was initially treated with unilateral salpingo-oophorectomy and oral cyclophosphamide, but required Platinol-based combination therapy and definitive surgery for recurrent disease; resected disease was benign on final pathology [6]. Raney et al. [7] and Moen et al. [8] reported on two 15-yearolds with stage III serous cystadenocarcinoma treated with bilateral salpingo-oophorectomy and combination chemotherapy regimens of cyclophosphamide, doxorubicin, Adriamycin, and cisplatin. Raney and co-workers’ patient showed no evidence of disease at 29 months of follow-up, whereas Moen and co-workers’ patient had a negative second-look laparotomy (time unspecified) [7, 8]. Kelley et al. [9] reported a case of a stage IIIC serous ovarian psammocarcinoma in a 18-year-old treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and paraaortic lymph node dissection, appendectomy, and sigmoid colectomy with primary repair. She subsequently received nine courses of carboplatin and cyclophosphamide chemotherapy. The patient was free of disease at 42 months of follow-up [9]. Because of the ongoing concerns of maintaining future childbearing capacities with today’s modern technology, one might consider not removing the uterus in this group of patients. Due to extension pelvic and uterine serosal disease, this option was not considered for our patient. In the present case, the increased bleeding tendency was noted soon after the initiation of surgery, before any significant attempt at dissection or debulking was made. Because of this, a coagulation profile was obtained intraoperatively, the results of which were abnormal. We believe that these coagulation abnormalities could have been triggered by the surgical manipulation of the tumor with subsequent libera-
goa
AP: GYN
281
CASE REPORT
tion of tissue factors. These acute phenomena in cancers have been described, most often in association with adenocarcinomas and acute promyelocytic leukemia [11]. The large amount of crystalloids given intraoperatively probably contributed to the dilution of the coagulation factors and worsened the bleeding and the consumptive coagulopathy. The latter was also exacerbated by the intraabdominal clot formation. Nonetheless, the acute drop in the platelet count and antithrombin III and fibrinogen values substantiates the diagnosis of DIC, though the D-dimer was only weakly abnormal. In summary, we describe what we feel is the fifth case in the literature of documented stage III epithelial ovarian cancer in a female patient less than 20 years of age. The primary treatment remains surgical followed by multiagent chemotherapy. Even though this diagnosis is very rare in adolescents, gynecologists must be aware of its occurrence when caring for this population of patients. Fortunately, fulminant DIC is a rare complication of malignancies and/or associated surgeries. REFERENCES 1. Morrow CP, Curtin JP, Townsend DE: Synopsis of Gynecologic Oncology, New York, Churchill Livingstone, 1993
AID
Gyn 4562
/
6d17$$$122
01-16-97 13:58:47
2. Norris HJ, Jensen RD: Relative frequency of ovarian neoplasms in children and adolescents. Cancer 30:713–719, 1972 3. La Vecchia C, Morris HB, Draper GJ: Malignant ovarian tumors in childhood in Britain, 1962–78. Br J Cancer 48:363–374, 1983 4. Anteby SO, Mor-Josef S, Schenker JG: Ovarian cancer in the young. Eur J Gynaecol Oncol 6:41–44, 1985 5. Young JL, Miller RW: Incidence of malignant tumors in US children. J Pediatr 86:254–258, 1975 6. Hong SJ, Lurain JR, Tsukada Y, Piver MS, Humbert JR, Freeman AI: Cystadenocarcinoma of the ovary in a 4-year-old: Benign transformation during therapy. Cancer 45:2227–2230, 1980 7. Raney RB, Sinclair L, Uri A, Schnaufer L, Cooper A, Littman P: Malignant ovarian tumors in children and adolescents. Cancer 59:1214– 1220, 1987 8. Moen MD, Cliby WA, Wilson TO: Stage III papillary serous cystadenocarcinoma of the ovary in a 15-year-old female. Gynecol Oncol 53:274– 276, 1994 9. Kelley JL, Capelle SC, Kanbour-Shakir A: Serous psammocarcinoma of the ovary in an adolescent female. Gynecol Oncol 59:309–311, 1995 10. Deprest J, Moerman P, Corneillie P, Ide P: Ovarian borderline mucinous tumor in a premenarchal girl: A review on ovarian epithelial cancer in young girls. Gynecol Oncol 45:219–224, 1992 11. Braunwalk E, Isselbacher KJ, Petersdorf RG, Wilson JD, Martin JB, Fauci AS: Harrison’s Principles of Internal Medicine, New York, McGraw-Hill, 1987, pp 1478–1479
goa
AP: GYN
64, 279–281 (1997)
GO964562
CASE REPORT Ovarian Serous Papillary Cystadenocarcinoma Stage IIIC in a 19-Year-Old S. LAFRAMBOISE, M.D., FRCS(C),
J. DUBUC-LISSOIR, M.D., FRCS(C)1
AND
Division of Gynecological Oncology, Department of Obstetrics and Gynecology, Hoˆpital Notre-Dame, Universite´ de Montre´al, 1560 East Sherbrooke Street, Montreal, Quebec, Canada H2L 4M1 Received May 23, 1996
CASE REPORT In mature women, the most common histological cell type of ovarian cancer is of epithelial origin. In children and adolescents, germ cell tumors are the most frequent. We report a case of a serous papillary cystadenocarcinoma FIGO stage IIIC in a 19year-old female. She presented with a 6-month history of vague lower abdominal pain. Preoperative CA-125 was elevated at 296 kU/liter. At laparotomy, she was found to have stage IIIC disease. A debulking procedure including total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node sampling was performed. The immediate postoperative course was complicated by fulminant disseminated intravascular coagulopathy. She was subsequently treated with six courses of cyclophosphamide and carboplatin. Twenty-four months after surgery, the patient has no evidence of disease despite an increased CA-125 of 51 kU/liter. q 1997 Academic Press
INTRODUCTION
The most common histological cell type in malignant ovarian tumors is epithelial, and these represent 85% of all diagnoses [1]. In children and adolescents, most of the ovarian tumors are of germ cell origin (58–84%), and epithelial cell tumors, including benign, low-malignant, and malignant lesions, account for a minority (8–23%) of cases [2–4]. Since in this age group malignant ovarian tumors account for only 1% of all cancers, advanced-stage epithelial cancers are very rare [5]. An updated review of the literature reveals four cases of documented stage III malignant epithelial tumors in females less than 20 years of age [6–9]. We report a fifth case of a FIGO stage IIIC epithelial ovarian cancer complicated by disseminated intravascular coagulopathy (DIC).
1
To whom correspondence should be addressed. Fax: (514) 896-4703.
A 19-year-old Vietnamese nulligravida with a 6-month history of vague lower abdominal pain was seen. Patient denied any other gastrointestinal, gynecological, or urological symptoms. Past medical history was unremarkable. Family history was significant for tuberculosis. Patient reported normal menses, with her most recent period 10 days previously. She had been sexually active for a year, and had used condoms for contraception. Abdominal examination confirmed the presence of a lower abdominal mass; the upper abdomen was unremarkable and no ascites was noted. On pelvic examination, a small uterus and a large right adnexal mass were documented. An ultrasound showed a 10-cm complex mass in the pelvis, separate from the uterus, probably arising from the right ovary. Preoperative investigations were significant for a mild anemia (hemoglobin 10.4 g/dl) secondary to thalassemia minor, and an elevated CA-125 at 296 kU/liter (normal, õ45 kU/liter). The coagulation profile was normal. The patient was taken to the operating room on August 14, 1994. The examination under anesthesia confirmed preoperative findings but also revealed a left adnexal mass not previously palpated. At laparotomy, a moderate amount of ascites was noted. Large bilateral masses were found. The right ovary, 10 cm in size with a smooth surface, was fixed to the pelvic sidewall and to the uterus. The left ovary was 11 cm, had multiple implants on its surface, and was adherent to the cul-de-sac and sigmoid colon serosa. The uterus was studded with serosal implants. Tumor plaques of 2 to 3 cm were found on the vesicouterine fold. The omentum and diaphragmatic surfaces had implants of 1 cm in greatest diameter. Frozen-section analysis confirmed the diagnosis of adenocarcinoma, and therefore, a 4-hr maximal debulking procedure was performed with total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and paraaortic lymph node sampling, and excision of
279
AID
Gyn 4562
/
6d17$$$121
01-16-97 13:58:47
0090-8258/97 $25.00 Copyright q 1997 by Academic Press All rights of reproduction in any form reserved.
goa
AP: GYN
280
LAFRAMBOISE AND DUBUC-LISSOIR
pelvic and vesicouterine peritonei to residual disease of less than 1 cm. Soon after the beginning of surgery, an increased bleeding tendency was observed and prompted an immediate coagulation profile. The total blood loss was estimated at 2 liters. The patient received, in addition to 7 liters of crystalloids, 4 units of packed red blood cells (PRBC) and 3 units of Pentastarch. At the end of the surgical procedure, diffuse oozing was controlled with Surgicel, and the hemoglobin had been restored from 6.8 to 10.2 g/dl. The intraoperative partial thromboplastin time (PTT) was elevated to 68.9 sec and the international normalized ratio (INR) to 3.7. With pooled plasma, PTT corrected to 26.3 sec and the INR to 1.3. Laboratory evaluation 4 hr after surgery was significant for a hemoglobin of 3.9 g/dl, platelets of 157,000 mm3, PTT of 46 sec, INR of 2.6, and normal fibrinogen and D-dimer. Six hours after surgery, the patient was hemodynamically unstable and was reintubated due to respiratory distress, nausea, vomiting, decreased level of consciousness, and increasing abdominal girth. Despite 8 units of PRBC, 8 units of platelets, 7 units of fresh-frozen plasma, 30 units of cryoprecipitate, and crystalloid support, the hemoglobin remained at 6.6 g/dl, platelets fell to 36,000 mm3, PTT rose to 61 sec, fibrinogen decreased to 0.9 g/liter (normal, 1.9–5.3 g/liter), antithrombin III fell to 0.08 g/liter (normal, 0.21–0.39 g/ liter), and D-dimer increased to 0.4 to 0.8 mg/liter (normal, õ0.2 mg/liter). A hematological consultation was requested 7 hr after surgery due to bleeding from the nasogastric and endotracheal tubes, the puncture and intravenous access sites, and abdominal incision. A diagnosis of intraabdominal bleeding secondary to DIC was confirmed. For correction of coagulopathy, the patient was admitted to the intensive care unit (ICU). The patient had an expanding hematoma from the femoral area to the labia (site of arterial line puncture), oliguria, and ventilation difficulties. Once hemodynamically stabilized with ongoing transfusions, a second laparotomy was performed 9 hr after the initial procedure to drain 8 liters of blood and clots, at which time no active site of bleeding was found. The patient spent 5 days in the ICU and received a total of 16 units of PRBC, 24 units of plasma, 6 units of 25% albumin, 5 units of cryoprecipitate, 2 units of platelets, and 2 units of Pentastarch. Her hospital stay was complicated by reintubation on Postoperative Day 3 due to oxygen desaturation, atelectasis, and tracheobronchitis, secondary to aspiration. Furthermore, she had febrile episodes attributed to an anterior abdominal wall collection. This was drained under radiological guidance, with no bacteria isolated. Final pathology confirmed the diagnosis of FIGO (1989) stage IIIC ovarian serous papillary cystadenocarcinoma, grade 1, with two positive iliac and one positive paraaortic lymph node. She was treated with six cycles of carboplatin 300 mg/m2 and cyclophosphamide 600 mg/m2. At that time, the use of paclitaxel and cis-platinum was not yet standard
AID
Gyn 4562
/
6d17$$$122
01-16-97 13:58:47
first-line therapy in our institution. Hormonal replacement therapy was provided with Premarin 1.25 mg daily. Follow-up CA-125 were normal immediately after surgical treatment and remained normal until 11 months after surgery, when it increased to 59 kU/liter. Patient was asymptomatic and physical examination was normal. Pelvic and abdominal ultrasound examinations were normal. A CA-125 of 62 kU/liter at 14 months after primary treatment prompted repeat pelvic and abdominal ultrasound examinations, which were also normal. Patient remains well and asymptomatic 24 months after surgery with regular follow-ups and a CA125 of 51 kU/liter. DISCUSSION
Advanced epithelial ovarian cancers (stages III and IV) are rarely diagnosed in children and adolescents, with the experience limited to case reports [10]. To our knowledge, four such cases have been well documented in the literature. Hong et al. reported the case of a stage III ovarian cystadenocarcinoma in a 4-year-old girl [6]. This was felt to be the first case ever reported prior to puberty. The patient was initially treated with unilateral salpingo-oophorectomy and oral cyclophosphamide, but required Platinol-based combination therapy and definitive surgery for recurrent disease; resected disease was benign on final pathology [6]. Raney et al. [7] and Moen et al. [8] reported on two 15-yearolds with stage III serous cystadenocarcinoma treated with bilateral salpingo-oophorectomy and combination chemotherapy regimens of cyclophosphamide, doxorubicin, Adriamycin, and cisplatin. Raney and co-workers’ patient showed no evidence of disease at 29 months of follow-up, whereas Moen and co-workers’ patient had a negative second-look laparotomy (time unspecified) [7, 8]. Kelley et al. [9] reported a case of a stage IIIC serous ovarian psammocarcinoma in a 18-year-old treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and paraaortic lymph node dissection, appendectomy, and sigmoid colectomy with primary repair. She subsequently received nine courses of carboplatin and cyclophosphamide chemotherapy. The patient was free of disease at 42 months of follow-up [9]. Because of the ongoing concerns of maintaining future childbearing capacities with today’s modern technology, one might consider not removing the uterus in this group of patients. Due to extension pelvic and uterine serosal disease, this option was not considered for our patient. In the present case, the increased bleeding tendency was noted soon after the initiation of surgery, before any significant attempt at dissection or debulking was made. Because of this, a coagulation profile was obtained intraoperatively, the results of which were abnormal. We believe that these coagulation abnormalities could have been triggered by the surgical manipulation of the tumor with subsequent libera-
goa
AP: GYN
281
CASE REPORT
tion of tissue factors. These acute phenomena in cancers have been described, most often in association with adenocarcinomas and acute promyelocytic leukemia [11]. The large amount of crystalloids given intraoperatively probably contributed to the dilution of the coagulation factors and worsened the bleeding and the consumptive coagulopathy. The latter was also exacerbated by the intraabdominal clot formation. Nonetheless, the acute drop in the platelet count and antithrombin III and fibrinogen values substantiates the diagnosis of DIC, though the D-dimer was only weakly abnormal. In summary, we describe what we feel is the fifth case in the literature of documented stage III epithelial ovarian cancer in a female patient less than 20 years of age. The primary treatment remains surgical followed by multiagent chemotherapy. Even though this diagnosis is very rare in adolescents, gynecologists must be aware of its occurrence when caring for this population of patients. Fortunately, fulminant DIC is a rare complication of malignancies and/or associated surgeries. REFERENCES 1. Morrow CP, Curtin JP, Townsend DE: Synopsis of Gynecologic Oncology, New York, Churchill Livingstone, 1993
AID
Gyn 4562
/
6d17$$$122
01-16-97 13:58:47
2. Norris HJ, Jensen RD: Relative frequency of ovarian neoplasms in children and adolescents. Cancer 30:713–719, 1972 3. La Vecchia C, Morris HB, Draper GJ: Malignant ovarian tumors in childhood in Britain, 1962–78. Br J Cancer 48:363–374, 1983 4. Anteby SO, Mor-Josef S, Schenker JG: Ovarian cancer in the young. Eur J Gynaecol Oncol 6:41–44, 1985 5. Young JL, Miller RW: Incidence of malignant tumors in US children. J Pediatr 86:254–258, 1975 6. Hong SJ, Lurain JR, Tsukada Y, Piver MS, Humbert JR, Freeman AI: Cystadenocarcinoma of the ovary in a 4-year-old: Benign transformation during therapy. Cancer 45:2227–2230, 1980 7. Raney RB, Sinclair L, Uri A, Schnaufer L, Cooper A, Littman P: Malignant ovarian tumors in children and adolescents. Cancer 59:1214– 1220, 1987 8. Moen MD, Cliby WA, Wilson TO: Stage III papillary serous cystadenocarcinoma of the ovary in a 15-year-old female. Gynecol Oncol 53:274– 276, 1994 9. Kelley JL, Capelle SC, Kanbour-Shakir A: Serous psammocarcinoma of the ovary in an adolescent female. Gynecol Oncol 59:309–311, 1995 10. Deprest J, Moerman P, Corneillie P, Ide P: Ovarian borderline mucinous tumor in a premenarchal girl: A review on ovarian epithelial cancer in young girls. Gynecol Oncol 45:219–224, 1992 11. Braunwalk E, Isselbacher KJ, Petersdorf RG, Wilson JD, Martin JB, Fauci AS: Harrison’s Principles of Internal Medicine, New York, McGraw-Hill, 1987, pp 1478–1479
goa
AP: GYN