Malignant Germ Cell Tumors Research Articles

Relationship between Clinicopathologic Features and Recurrence in Ovarian Germ Cell Tumor

Background: We conducted the present study to analyze the clinicopathologic features of patients with malignant ovarian germ cell tumor (MOGCT) with recurrence after 2 and 5 years. Method: In this retrospective and analytical-descriptive study, the obtained data included: age, tumor size, histopathological type, tumor stage, lymph node involvement, laterality of tumor, tumor necrosis, and mitosis. We also evaluated the Cox Regression analysis between these variables with recurrence after 2 and 5 years. Results: According to our exclusion criteria, we eliminated 81 cases. These cases consisted of the subjects with dysgerminoma (48.1%), immature teratoma (22.2%), yolk sac (16%), mix germ cell (11.1%), non-gestational choriocarcinoma (1.2%), and embryonal carcinoma (1.2%). We did not observe pure polyembryoma or polyembryoma in combination with mixed germ cell. All the patients received the treatment. The patients’ mean age was 23.3±8.4 years. MOGCT reoccurred in 10 patients after 2 years and in 13 patients after 5 years (10 cases in the first 2 years, and 3 new cases in the next 3 years). Most of the cases (64.2%) were diagnosed to be at stage 1. The Cox regression analysis between positive lymph node and the recurrence of MOGCT after 2 years and between stage IV of disease and the recurrence after 2 years were significant. The Cox regression analysis between laterality, mitosis and necrosis in pathologic slides of the recurrence after 2 and 5 years was not significant. Conclusion: Stages and involvement of lymph nodes are two major factors concerning the recurrence of MOGCT. Most recurrences occur in the first 2 years. Pathologic features (mitosis and necrosis) of MOGCt in the time of diagnosis not correlated with the recurrence of the disease.

Nonepithelial ovarian cancers

Key content Nonepithelial ovarian cancers (NEOCs) are rare forms of ovarian cancer, including malignant ovarian germ cell tumours (MOGCTs), sex cord‐stromal tumours (SCSTs) and ovarian sarcoma. Tumour markers including alpha‐fetoprotein, human chorionic gonadotrophin, lactate dehydrogenase and inhibin can be useful in aiding preoperative diagnosis of malignant ovarian masses. NEOCs are staged using a similar classification to epithelial ovarian tumours; however, the staging system for male germ cell tumours is considered a more useful prognostic tool. These tumours can occur at any age; however, many present in the reproductive years, and fertility‐sparing treatments are often required. Advanced‐stage MOGCTs and SCSTs are managed with debulking surgery and platinum‐based adjuvant chemotherapy, with the regimen of bleomycin, etoposide and cisplatin being most widely used. Learning objectives To understand the classification and pathology of NEOCs. To describe the role of tumour markers in diagnostic criteria and to be aware of the FIGO staging classifications and their prognostic use. To understand management protocols and follow‐up regimens. Ethical issues Patients of reproductive age risk infertility if preoperative diagnosis is incorrect and more extensive surgery involving bilateral salpingo‐oophorectomy is performed.

Analysis of the genomic landscape of yolk sac tumors reveals mechanisms of evolution and chemoresistance

Yolk sac tumors (YSTs) are a major histological subtype of malignant ovarian germ cell tumors with a relatively poor prognosis. The molecular basis of this disease has not been thoroughly characterized at the genomic level. Here we perform whole-exome and RNA sequencing on 41 clinical tumor samples from 30 YST patients, with distinct responses to cisplatin-based chemotherapy. We show that microsatellite instability status and mutational signatures are informative of chemoresistance. We identify somatic driver candidates, including significantly mutated genes KRAS and KIT and copy-number alteration drivers, including deleted ARID1A and PARK2, and amplified ZNF217, CDKN1B, and KRAS. YSTs have very infrequent TP53 mutations, whereas the tumors from patients with abnormal gonadal development contain both KRAS and TP53 mutations. We further reveal a role of OVOL2 overexpression in YST resistance to cisplatin. This study lays a critical foundation for understanding key molecular aberrations in YSTs and developing related therapeutic strategies.

English

Primary malignant extra gonadal germ cell tumours (GCT) of mediastinum are very rare tumours, comprising 1 - 4 % of all mediastinal tumours.1 Even though they are rare tumours of mediastinum, they should always be considered in the differential diagnosis of mediastinal tumours in young adults. Primary malignant GCT can be divided into 2 groups: Seminomatous and non-seminomatous tumours. Mature teratomas (non-seminomatous) are the most common primary malignant germ cell tumours of mediastinum.2 Non-seminomatous tumours tend to be more aggressive than seminomatous tumours present as heterogeneous masses with areas of necrosis and show local invasion. Seminomas usually present as lobulated homogeneous masses and rarely show signs of local invasion. These tumours usually present with asymptomatic lesions or with symptoms due to compression of adjacent structures and usually have a better prognosis than non-seminomatous tumours. Here, we present a case of primary malignant extra gonadal seminoma with sternal involvement.

Imaging in gynecological disease (22): clinical and ultrasound characteristics of ovarian embryonal carcinomas, non-gestational choriocarcinomas and malignant mixed germ cell tumors.

To describe the clinical and ultrasound characteristics of three types of rare malignant ovarian germ cell tumor: embryonal carcinoma, non-gestational choriocarcinoma and malignant mixed germ cell tumor. This was a retrospective multicenter study. From the International Ovarian Tumor Analysis (IOTA) database, we identified patients with a histological diagnosis of ovarian embryonal carcinoma, non-gestational choriocarcinoma or malignant mixed germ cell tumor, who had undergone preoperative ultrasound examination by an experienced ultrasound examiner between 2000 and 2020. Additional patients with the same histology were identified from the databases of the departments of gynecological oncology in the participating centers. All tumors were described using IOTA terminology. Three examiners reviewed all available ultrasound images and described them using pattern recognition. One patient with embryonal carcinoma, five patients with non-gestational ovarian choriocarcinoma and seven patients with ovarian malignant mixed germ cell tumor (six primary tumors and one recurrence) were identified. Seven patients were included in the IOTA studies and six patients were examined outside of the IOTA studies. The median age at diagnosis was 26 (range, 14-77) years. Beta-human chorionic gonadotropin levels were highest in non-gestational choriocarcinomas and alpha-fetoprotein levels were highest in malignant mixed germ cell tumors. Most tumors were International Federation of Gynecology and Obstetrics (FIGO) Stage I (9/12 (75.0%)). All tumors were unilateral, and the median largest diameter was 129 (range, 38-216) mm. Of the tumors, 11/13 (84.6%) were solid and 2/13 (15.4%) were multilocular-solid; 9/13 (69.2%) manifested abundant vascularization on color Doppler examination. Using pattern recognition, the typical ultrasound appearance was a large solid tumor with inhomogeneous echogenicity of the solid tissue and often dispersed cysts which, in most cases, were small and irregular. Some tumors had smooth contours while others had irregular contours. A unilateral, large solid tumor with inhomogeneous echogenicity of the solid tissue and with dispersed small cystic areas in a young woman should raise the suspicion of a rare malignant germ cell tumor. This suspicion can guide the clinician to test tumor markers specific for malignant germ cell tumors. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

A Case of a Rare Malignant Mixed Ovarian Germ Cell Tumor Masquerading as an Ectopic Pregnancy

Malignant ovarian germ cell tumors (MOGCTs) are rare but disproportionately affect young women and adolescent girls. Although clinical presentation varies, these tumors can present with an adnexal mass and raised serum beta-human chorionic gonadotrophin (beta-hCG), mimicking an ectopic pregnancy. We present the case of a 20-year-old nulliparous woman, who was initially treated both medically and surgically as an ectopic pregnancy, and was eventually diagnosed with a malignant mixed germ cell tumor (MMGCT) following laparoscopy. We highlight the diagnostic challenges of ectopic pregnancies versus MOGCTs, and the importance of adopting a fertility-sparing approach in young nulliparous women. J Clin Gynecol Obstet. 2021;10(2):55-58 doi: https://doi.org/10.14740/jcgo743

Laparoscopic and imaging findings of growing teratoma syndrome

Growing teratoma syndrome (GTS) occurs during post-treatment observation of ovarian malignant germ cell tumors. The characteristic features of this syndrome are normal tumor marker levels and evident tumoral mass or implants on imaging studies. We report a case of GTS in a 22-year-old woman with a malignant germ cell tumor. After staging surgery and chemotherapy, computed tomography showed peritoneal implants. Laparoscopy was planned to exclude malignant recurrence. During laparoscopy, smooth and pink-colored lesions were seen at the lateral pelvic wall. Histopathologic evaluation reported mature teratoma tissue with extensive mature glial components. GTS is not a malignant condition and the benefit of radical surgical intervention in cases without mass-related complication is not proven. GTS should be kept in mind after primary treatment of ovarian immature teratoma.

Surveillance alone in stage I malignant ovarian germ cell tumors: a MITO (Multicenter Italian Trials in Ovarian cancer) prospective observational study

ObjectiveThe aim of this study was to analyze the oncological outcome of stage I malignant ovarian germ cell tumors patients included in the MITO-9 study to identify those who might...

Malignant Germ Cell Tumors and Their Precursor Gonadal Lesions in Patients with XY-DSD: A Case Series and Review of the Literature

The risk of gonadal germ cell tumors is increased over the lifetime of patients with XY-disorders of sex development (XY-DSD). The aim of this study was to evaluate clinical features and histopathological outcome after gonadectomy in patients with XY-DSD to assess the risk of malignant transformation to gonadal germ cell tumors. Thirty-five women treated for XY-DSD at our hospital between 2003 and 2020 were enrolled in this study. Twenty-seven (77%) underwent prophylactic gonadectomy, 10 (29%) at our department and 17 (48%) at external hospitals. Eight (23%) patients didn’t receive gonadectomy. Of the patients who underwent a surgical procedure at our hospital, two patients were diagnosed with a unilateral seminoma, one patient with a bilateral and one patient with a unilateral Sertoli cell adenoma. According to these findings, preventive gonadectomy in patients with XY-DSD should be taken into consideration. Guidelines concerning the necessity of gonadectomy to avoid malignant transformation are still lacking. The risk of malignant germ cell tumors from rudimentary gonads has not been investigated sufficiently to date, as it is mostly based on case series due to the rarity of the condition. In our study we retrospectively analyzed patients who partly underwent bilateral gonadectomy, aiming to fill this gap. Concerning the ideal point of time for gonadectomy, further studies with a higher number of patients are needed.

Ovarian yolk sac tumor

Ovarian germ cell tumors derive from ovarian germ cells and account for approximately 20% of all ovarian neoplasms. Only 1–2% of ovarian germ cell tumors are called malignant ovarian germ...

Targeting Cancer Stem Cells with Differentiation Agents as an Alternative to Genotoxic Chemotherapy for the Treatment of Malignant Testicular Germ Cell Tumors.

Simple SummaryTesticular germ cell tumors (TGCTs) are the most common solid malignancy in young men. Fortunately, these tumors are highly curable with conventional genotoxic chemotherapy. However, because these chemotherapeutics have significant short- and long-term side effects, less toxic treatment options are desired. We report that thioridazine, an FDA-approved antipsychotic, differentiates embryonal carcinoma (EC) cells, the cancer stem cells of many malignant TGCTs, and suppresses their tumor propagating activity. Additionally, thioridazine treatment of mice with EC-containing neoplasms extends survival relative to untreated control mice. These findings identify thioridazine as a promising alternative or adjuvant to chemotherapy for the treatment of TGCTs.Testicular germ cell tumors (TGCTs) are exceptionally sensitive to genotoxic chemotherapy, resulting in a high cure rate for the young men presenting with these malignancies. However, this treatment is associated with significant toxicity, and a subset of malignant TGCTs demonstrate chemoresistance. Mixed nonseminomas often contain pluripotent embryonal carcinoma (EC) cells, the cancer stem cells (CSCs) of these tumors. We hypothesized that differentiation therapy, a treatment strategy which aims to induce differentiation of tumor-propagating CSCs to slow tumor growth, could effectively treat mixed nonseminomas without significant toxicity. The FDA-approved antipsychotic thioridazine and the agricultural antibiotic salinomycin are two drugs previously found to selectively target CSCs, and here we report that these agents differentiate EC cells in vitro and greatly reduce their tumorigenic potential in vivo. Using a novel transformed induced pluripotent stem cell allograft model and a human xenograft model, we show that thioridazine extends the survival of tumor-bearing mice and can reduce the number of pluripotent EC cells within tumors. These results suggest that thioridazine could be repurposed as an alternative TGCT treatment that avoids the toxicity of conventional chemotherapeutics.

A poor prognostic metastatic nongestational choriocarcinoma of the ovary: a case report and the literature review

BackgroundPure ovarian choriocarcinoma can be gestational or nongestational in origin. Nongestational pure ovarian choriocarcinoma is extremely rare and the prognosis is thought to be worse than that of the gestational type in patients with metastatic disease. We present a case of metastatic pure ovarian choriocarcinoma with poor prognosis in which the origin was identified as nongestational by DNA short tandem repeat (STR) analysis.Case presentationA nulliparous woman in her thirties with metastatic choriocarcinoma was referred to our hospital after initial treatment proved unsuccessful. Two months earlier, she had undergone brain tumor resection and histological examination confirmed choriocarcinoma. Serum human chorionic gonadotropin (hCG) concentration at initial diagnosis was 5030 IU/L. Two cycles of a combination chemotherapy regimen of methotrexate, etoposide, and actinomycin-D (MEA therapy), which is commonly used for gestational choriocarcinoma, was administered. However, the disease could not be controlled. Imaging modalities at presentation revealed tumor present in the left ovary and left lung, but not in the uterus, which led us think that the choriocarcinoma was nongestational. Bleomycin, etoposide, and cisplatin (BEP therapy) which is commonly used for nongestational choriocarcinoma (malignant germ cell tumor) and surgical resection of the uterus, bilateral ovaries, and an affected part of the left lung led to the nadir level of hCG, but the tumor relapsed and levels of hCG again increased. To investigate the origin of choriocarcinoma, we performed DNA STR analysis of tumor cells and oral mucosal cells. Analysis revealed the origin of the choriocarcinoma as nongestational, as the genotype of tumor cells entirely corresponded with that of oral mucosal cells. BEP therapy and chemotherapy regimens administered for nongestational choriocarcinoma and gestational choriocarcinoma proved ineffective, and the patient died 21 months after diagnosis of metastatic choriocarcinoma.ConclusionMetastaic nongestational pure choriocarcinoma of ovary is an extremely rare and an aggressive disease, frequently resulting in poor outcome.

Disgerminoma Simulando Abdome Agudo: Relato de Caso

O disgerminoma é um o tumor de células germinativas maligno mais frequente no ovário, representa 1% de todos os tumores do ovário. Ocorrem na segunda e terceira década de vida. Em pacientes pré menarca apresenta-se com massa pélvica, comprimindo estruturas e órgãos, podendo se manifestar com um quadro de abdome agudo. Neste artigo, relata-se um caso de paciente com disgerminoma.
 
 
 

Could MicroRNAs Be Useful Tools to Improve the Diagnosis and Treatment of Rare Gynecological Cancers? A Brief Overview.

Gynecological cancers pose an important public health issue, with a high incidence among women of all ages. Gynecological cancers such as malignant germ-cell tumors, sex-cord-stromal tumors, uterine sarcomas and carcinosarcomas, gestational trophoblastic neoplasia, vulvar carcinoma and melanoma of the female genital tract, are defined as rare with an annual incidence of <6 per 100,000 women. Rare gynecological cancers (RGCs) are associated with poor prognosis, and given the low incidence of each entity, there is the risk of delayed diagnosis due to clinical inexperience and limited therapeutic options. There has been a growing interest in the field of microRNAs (miRNAs), a class of small non-coding RNAs of ∼22 nucleotides in length, because of their potential to regulate diverse biological processes. miRNAs usually induce mRNA degradation and translational repression by interacting with the 3′ untranslated region (3′-UTR) of target mRNAs, as well as other regions and gene promoters, as well as activating translation or regulating transcription under certain conditions. Recent research has revealed the enormous promise of miRNAs for improving the diagnosis, therapy and prognosis of all major gynecological cancers. However, to date, only a few studies have been performed on RGCs. In this review, we summarize the data currently available regarding RGCs.

УЗ-признаки герминогенных опухолей яичников у беременных перед хирургическим лечением или химиотерапией

The problem of ovarian tumor differential diagnosis is solved using comprehensive ultrasound examination at different levels of efficiency. However, ultrasound imaging is an operator-dependent technique due to subjective interpretation of results. The study was aimed to assess the ultrasound signs of benign and malignant ovarian germ cell tumors (OGCTs) in pregnant women in order to determine the feasibility of surgical treatment and chemotherapy. The study was carried out using the logistic regression models. A group of 199 pregnant women with benign and malignant OGCTs were enrolled. Of them, 183 patients had benign, and nine patients had malignant tumors. In order to assess menstrual function and fertility, seven pregnant women were enrolled, who had previously received treatment for malignant OGCTs. Pre-operative assessment results were compared with morphological assessment data. Organ-preserving surgical treatment was performed (unilateral adnexectomy); if necessary, the patients received cisplatin-based chemotherapy. Perinatal outcomes were assessed. The median observation time between the malignant OGCT detection and the end of the study was 66 months (12–240 months). It was found that comprehensive ultrasound examination and logistic regression models (sensitivity 100%, specificity 92.3%, overall accuracy 92.8%) enabled differential diagnosis of benign and malignant OGCTs. The number of unnecessary surgical procedures in patients with benign OGCTs was been limited, the pregnancy and childbirth outcomes were improved. Nine pregnant women received organ-preserving surgical treatment for malignant OGCTs, and three patients received chemotherapy after surgery, which allowed the patients to realize their reproductive potential.

Clinicopathologic Characteristics and Survival of Patients with Rare Malignant Ovarian Yolk Sac Tumors: A Population-based Analysis

Yolk sac tumors (YSTs) are rare malignant germ cell tumors that usually affect young females. To date, there have been few studies on YSTs. We evaluated the relationship between clinicopathologic characteristics of patients with ovarian YSTs and disease outcome based on Surveillance, Epidemiology, and End Results data. The Kaplan-Meier method and log-rank test were used to evaluate differences in survival rates. Data for 269 patients were analyzed. The incidence of YSTs among ovarian germ cell tumors (OGCTs) cases was 0.4%; median patient age was 22.0 years, and most tumors were unilateral. Patients presented with distant metastasis (37.5%), localized disease (49.1%), and regional spread (8.9%). American Joint Committee on Cancer stage was available for 13 patients (stage IA, n=2; stage IC, n=1; stage IIIA, n=1; stage IIIB, n=3; stage IIIC, n=2; and stage IV, n=4). Survival rates at 1, 3, and 5 years were 91.0%, 84.0%, and 83.2%, respectively, for overall survival (OS) and 92.0%, 85.4%, and 84.5%, respectively, for disease-specific survival (DSS). The 5-year OS and DSS of patients with ovary tumors were 91.5% and 92.9%, respectively, compared to 74.8% and 77.2%, respectively, for those with extra-ovarian spread (P<.001 for both OS and DSS). Age >50 years was associated with shorter OS and DSS (both P<0.001), whereas no associatios of OS and DSS were observed with pathologic grade (P=0.49 for OS and 0.52 for DSS). In summary, YSTs are typically unilateral, of a high grade, and localized to the ovary; extra-ovarian spread has a poor outcome, and postmenopausal women have worse prognosis than premenopausal women.

Lung autotransplantation for bronchial necrosis after radiotherapy: a case report

BackgroundBronchial necrosis is a rare but fatal complication after radiation therapy. Because of the anatomical complexity and rarity of this condition, determining the most appropriate management for individual patients is extremely challenging. Lung autotransplantation is a surgical technique that has been applied to hilar neoplastic lesions to preserve pulmonary function and avoid pneumonectomy. We herein report a case of bronchial necrosis secondary to radiotherapy that was treated with lung autotransplantation.Case presentationA 46-year-old man developed broad necrosis and infection of the right bronchus secondary to previous stereotactic body-radiation therapy. This treatment was supplied close to a right hilar metastatic pulmonary tumor derived from a mediastinal malignant germ cell tumor that had been surgically resected with the left phrenic nerve. The bronchial necrosis accompanied by infection with Aspergillus fumigatus was progressive despite antibiotics and repetitive bronchoscopic debridement. Because of the patient’s critical condition and limited pulmonary function, right lung autotransplantation with preservation of the right basal segment was selected. An omental flap was placed around the bronchial anastomosis to prevent later complications. The postoperative course involved multiple complications including contralateral pneumonia and delayed wound healing at the bronchial anastomosis with resultant stenosis, the latter of which was overcome by placement of a silicone stent. The patient was discharged 5 months postoperatively. Three months after discharge, however, the patient developed hemoptysis and died of bronchopulmonary arterial fistula formation.ConclusionsWe experienced an extremely challenging case of bronchial necrosis secondary to radiotherapy. The condition was managed with lung autotransplantation and omental wrapping; however, the treatment success was temporary and the patient eventually died of bronchopulmonary arterial fistula formation. This technique seems to be a feasible option for locally advanced refractory bronchial necrosis, although later complications can still be fatal.

Extragonadal Yolk Sac Tumor with Spinal Cord Compression in a Little Boy, with Complete Response to the Bleomycin, Etoposide, and Carboplatin: A Case Report and Review of the Literature

Introduction: Germ cell tumors account for 3.5 % of pediatric tumors and yolk sac tumors are the most common pure malignant germ cell tumors in children. Testis and ovary are the most common sites of involvement in children older than 2 years. Case Presentation: A 20-month-old boy with a complaint of limping was described in this case report. Abdominal ultrasonography showed a 52 × 50 mm solid abdominal mass. Abdominal and pelvic computed tomography scans showed a left paraspinal heterogeneous mass. The tumor was extended into the spinal column with spinal cord compression. Four months later, at the end of chemotherapy, the tumor was completely resolved. Conclusions: Spinal cord compression is a rare presentation of yolk sac tumor (YST) and although this tumor is an uncommon malignancy, it can be cured completely.

Chance diagnosis of mixed gonadal dysgenesis in an adult case of malignant gonadal germ cell tumor: a case report

BackgroundMixed gonadal dysgenesis (MGD) is a subtype of the disorders of sex development (DSD) associated with sex chromosome abnormalities characterized by abnormal external genitalia, short stature, and primary amenorrhea. This disease is generally diagnosed from the neonatal stage to early childhood, and by puberty at the latest. Cases that are phenotypically female or those with ambiguous genitalia experience a high risk of gonadal tumor formation. As tumor risk is known to increase with age, prophylactic bilateral gonadectomy is recommended following early diagnosis.Case presentationHere we report a case of an adult Japanese woman diagnosed with MGD during treatment for a giant pelvic tumor. The patient initially visited a gynecology clinic during puberty for primary amenorrhea, at which time an abnormality was found with the external genitalia. However, a diagnosis of MGD was not made at this time, resulting in the development of a malignant gonadal germ cell tumor in adulthood.ConclusionsFor early diagnosis of MGD and the prevention of gonadal tumor formation, it is essential that gynecologists fully understand MGD and other DSD.

Whole-exome sequencing reveals potential germline and somatic mutations in 60 malignant ovarian germ cell tumors

Malignant ovarian germ cell tumors (MOGCTs) are rare and heterogeneous ovary tumors. We aimed to identify potential germline mutations and somatic mutations in MOGCTs by whole-exome sequencing. The peripheral blood and tumor samples from these patients were used to identify germline mutations and somatic mutations, respectively. For those genes with copy number alterations (deletion and duplication region), functional annotation was performed. Immunohistochemistry was performed to evaluate the expression of mutated genes corresponding to CNA deletion region and duplication region. In peripheral blood, copy number loss and gain were mostly found in yolk sac tumors (YSTs). Moreover, POU5F1 was the most significant mutated gene with mutation frequency>10% in both CNA deletion and duplication region. In addition, strong cytoplasm staining of POU5F1 (corresponding to CNA deletion region and duplication region) was found in two YST and nuclear staining in two dysgerminomas tumor samples. Genes corresponding to CNA deletion region were significantly enriched in the signaling pathway of regulating pluripotency of stem cells. In addition, genes corresponding to CNA duplication region were significantly enriched in the signaling pathways of RIG-I (DExD/H-box helicase 58)-like receptor, Toll-like receptor and nuclear factor (NF)-kappa. Keratin 4 (KRT4), ribosomal protein L14 (RPL14), proprotein convertase subtilisin/kexin type 6 (PCSK6), poly(A)-binding protein cytoplasmic 3 (PABPC3), and sterile alpha and TIR motif containing 1 (SARM1) mutations were detected in both peripheral blood and tumor samples. Identification of potential germline mutations and somatic mutations in MOGCTs may provide a new field in understanding the genetic feature of the rare biological tumor type in the ovary.