# Understanding Mucinous Ovarian Cancer: A Rare Disease That Needs Its Own Treatment Plan

Mucinous ovarian carcinoma is a rare form of ovarian cancer. Mucinous ovarian carcinoma makes up only about 3% of epithelial ovarian cancers. Mucinous ovarian carcinoma behaves so differently from the common type (high-grade serous ovarian cancer) that it requires its own diagnosis and treatment plan. Researchers reviewed more than two decades of studies. Researchers found that 65% to 80% of mucinous tumors are caught early, when 5-year survival exceeds 90%. Survival drops sharply to 12-33 months once the cancer spreads. The 2014 World Health Organization split these tumors into two subtypes — expansile (low risk) and infiltrative (aggressive) — and that distinction now drives decisions about lymph node removal, fertility-sparing surgery, and chemotherapy. The authors emphasize that accurate pathological review is essential. This is because 50% to 70% of tumors once labeled "primary mucinous ovarian cancer" were actually spread from cancers of the colon, stomach, or other organs.

# Mucinous Ovarian Carcinoma

## Table of Contents

- Key Points
- Background: Why This Research Matters
- A Separate Disease: How Mucinous Ovarian Cancer Differs
- How Mucinous Ovarian Cancer Develops
- Risk Factors and Trends Over Time
- The Diagnostic Challenge: Ruling Out Spread From Other Cancers
- Two Subtypes: Expansile and Infiltrative
- Prognosis Depends on the Subtype
- Surgical Management of Early-Stage Disease
- Managing Stage III or IV Disease
- Chemotherapy and Medical Management
- The Molecular Landscape and Targeted Therapy
- Limitations of the Evidence
- What This Means for Patients
- Frequently Asked Questions
- Source Information

## Key Points

- Mucinous ovarian cancer is rare, making up about 3% of epithelial ovarian cancers, and is genetically distinct from the more common serous type.
- Between 65% and 80% of mucinous ovarian cancers are diagnosed at stage I, when 5-year survival exceeds 90%, but survival drops to 12-33 months once spread.
- The 2014 WHO classification divides mucinous ovarian cancer into expansile (low risk) and infiltrative (aggressive) subtypes, guiding lymph node removal and chemotherapy decisions.
- Accurate diagnosis is critical: 50% to 70% of tumors once called primary mucinous ovarian cancer were actually metastases from colon, stomach, or other cancers.
- Smoking is the only clinical risk factor linked to mucinous ovarian cancer; other risk factors for serous cancer, such as BRCA mutations, do not apply.

## Background: Why This Research Matters

Ovarian cancer is not one disease. Each year, doctors diagnose nearly **239,000 new cases of ovarian cancer** worldwide and record **152,000 deaths** from it. The highest rates occur in North America and in central and eastern Europe.

The most common type is **high-grade serous ovarian cancer**, which accounts for about **65%** of cases. Other types include low-grade serous, endometrioid, clear-cell, and mucinous ovarian cancers, plus a rare type called ovarian carcinosarcoma.

**Mucinous ovarian cancer** is uncommon. It probably accounts for about **3% of all epithelial ovarian cancers** (cancers that start in the surface layer of the ovary). Because it is rare, it has long puzzled oncologists.

For decades, doctors treated mucinous ovarian cancer using guidelines written for serous ovarian cancer. That approach has changed. Clinical experience and a better understanding of the tumor's biology have shown that mucinous ovarian cancer is a **unique disease that needs unique management**. This review highlights what sets it apart and provides an update on its molecular features, surgery, and medical treatment.

## A Separate Disease: How Mucinous Ovarian Cancer Differs

The first key point is that mucinous ovarian cancer is genetically distinct. Its **gene-expression profile** (the pattern of genes switched on and off in the tumor) does not match that of serous ovarian cancer.

Mucinous tumors are also usually found earlier. Between **65% and 80%** are diagnosed at an early stage — **FIGO stage I**, meaning the tumor is confined to a single ovary (FIGO is the International Federation of Gynecology and Obstetrics, the group that defines cancer staging).

By contrast, patients with serous ovarian cancer usually present at an advanced stage, with cancer spread inside the abdominal cavity in **more than 80%** of cases. Why the difference? Mucinous tumors are typically very large primary tumors — usually **more than 15 cm (about 6 inches) in diameter**. They cause symptoms while the disease is still limited to the ovary. As a result, the overall outlook is much better for women with mucinous ovarian cancer than for women with other epithelial subtypes.

Five-year overall survival for women with localized mucinous ovarian cancer **exceeds 90%**. Once the cancer has spread to the peritoneum (the membrane lining the abdominal cavity) or beyond — stage III or IV — the estimated median overall survival falls to **12 to 33 months**.

Age at diagnosis also differs. Mucinous tumors tend to appear in younger patients. In a recent analysis of the **SEER** (Surveillance, Epidemiology, and End Results) cancer registry, **26%** of mucinous ovarian cancers were diagnosed in women younger than 44 years. That makes mucinous ovarian cancer the most common histologic subtype among patients who are eligible for **fertility-sparing surgery** (surgery that preserves the ability to have children). In one series of 545 patients undergoing fertility-sparing surgery, **51% (280 patients)** had mucinous ovarian cancer.

Here is a side-by-side comparison of the two most relevant subtypes:

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**Median age at diagnosis:** 53 years for mucinous vs. 61 years for high-grade serous
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**Diagnosed before age 44:** 26% of mucinous patients vs. 7% of serous patients
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**Early-stage disease at diagnosis:** 65-80% of mucinous vs. 5% of serous
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**Tumor markers used:** CEA or CA 19-9 for mucinous; CA-125 for serous
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**Risk factors:** smoking for mucinous; nulliparity (never having given birth), early menarche (first period at a young age), late menopause, and inherited BRCA1 or BRCA2 mutations for serous
-
**Response rate to platinum-based chemotherapy:** 20-60% for mucinous vs. more than 70% for serous
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**5-year survival, stage I:** 92% for mucinous vs. 84% for serous
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**Median survival, advanced stage:** 12-33 months for mucinous vs. 35-60 months for serous

Notice the pattern: mucinous cancer is easier to cure when caught early, but harder to control once it spreads.

## How Mucinous Ovarian Cancer Develops

Most serous ovarian cancers begin in the fimbria — the finger-like end of the fallopian tube. Mucinous ovarian cancers appear to develop differently, in a **stepwise fashion**: normal benign epithelium first turns into a preinvasive lesion, which then becomes invasive cancer. This process resembles how colorectal cancer develops.

Mucinous ovarian cancer is often found mixed with areas of **mucinous cystadenoma** (a benign fluid-filled growth) or precancerous lesions. These can include borderline mucinous tumor, borderline tumor with intraepithelial carcinoma, microinvasive carcinoma, or a combination of these.

Genetic studies support this stepwise model. **KRAS mutations** are found in **40% to 65% of mucinous carcinomas**. Importantly, the same KRAS mutation appears in the cancerous areas and in the surrounding borderline and benign areas. That pattern suggests the mutation is an **early founder event** — one of the first steps toward cancer.

Other genetic changes behave differently. **HER2 amplification** (extra copies of the HER2 gene) and **TP53 mutation** are found almost exclusively in the cancerous part of the tumor, not the benign or borderline parts. Researchers interpret this as evidence that these are **later events** in malignant transformation.

A second hypothesis about the origin of these tumors suggests they may come from **transitional cells** — Walthard cell nests (clusters of cells) are seen in **59% of mucinous neoplasms** — or from metaplasia (a change in cell type) at the junction where the fallopian tube meets the peritoneum.

## Risk Factors and Trends Over Time

Risk factors are a clear point of separation between the two diseases. Nulliparity, early menarche, late menopause, and germline BRCA1 or BRCA2 mutations all raise the risk of serous ovarian cancer. **None of these are risk factors for mucinous ovarian cancer.**

The only clinical risk factor linked to mucinous ovarian cancer is **tobacco smoking**.

A **genomewide association study** (a study that scans the entire genetic code for disease-linked variations) of **1,644 mucinous ovarian cancers** identified susceptibility alleles (risk-related gene variants) at three locations: **2q13, 2q31.1, and 19q13.2**. The potential candidate gene for the 2q31.1 locus is **HOXD9**.

Rates of mucinous ovarian cancer in the United States **fell by 5% per year between 1995 and 2009** and have been stable since 2009. Researchers suggest two possible explanations: a decline in smoking, or improvements in how pathologists diagnose mucinous ovarian cancer in the late 1990s and early 2000s.

## The Diagnostic Challenge: Ruling Out Spread From Other Cancers

Getting the diagnosis right is the single most important step. Early reports probably overestimated how common mucinous ovarian cancer is, with some studies claiming it represented **10% to 15%** of epithelial ovarian cancers.

Then came a critical finding. When pathologists centrally reviewed ovarian tumors originally classified as primary mucinous ovarian carcinoma, they discovered that **50% to 70% were actually metastases** — cancers that had spread to the ovary from somewhere else. According to different reports, the true proportion of ovarian epithelial cancers that are mucinous ovarian cancers is closer to **1% to 3%**.

Because of this, doctors recommend a full workup to rule out an occult (hidden) gastrointestinal primary cancer. That workup includes:

1.
**Colonoscopy** to examine the colon
1.
**Esophagogastroduodenoscopy (EGD)** and **endoscopic ultrasonography** to examine the upper digestive tract
1. Evaluation for cervical, breast, or uterine cancer

These investigations are especially recommended when clinical or radiologic findings point toward a nonovarian primary cancer. Warning signs include a tumor smaller than **10 cm** in diameter, tumors in both ovaries, peritoneal spread, or other evidence of advanced-stage disease.

The features that support a diagnosis of a true primary mucinous ovarian tumor are:

- Negative results on gastrointestinal investigations (especially important in advanced-stage or bilateral tumors)
- A large tumor (greater than 10 cm)
- A tumor in one ovary only
- No mucin in the abdominal cavity and a normal appendix
- No implants on the capsule or serosa (outer surfaces) of the ovary
- On immunohistochemical testing (lab tests that identify proteins in tissue): no extracellular mucin, strongly positive CK7, positive CK20, and positive CDX2

To confirm the diagnosis, a central review by an expert pathologist is needed, along with extensive tumor sampling — **1 to 2 tumor blocks per centimeter** of tumor. The precise diagnosis requires evidence of malignant proliferation covering an area of **more than 10 mm²** on cross section. Staging then involves a CT scan of the chest, abdomen, and pelvis, and optionally a PET scan.

For decades, mucinous ovarian cancer was graded 1, 2, or 3 based on nuclear atypia (abnormal-looking cell nuclei) and how much of the tumor was solid. That system has now been replaced.

## Two Subtypes: Expansile and Infiltrative

In 2014, the **World Health Organization (WHO)** introduced a new classification based on the tumor's growth pattern. This is now the most important distinction in early-stage disease.

The **expansile (confluent) subtype** is defined by a confluent glandular growth pattern, with little intervening normal ovarian stroma — in other words, minimal or no stromal invasion. Think of it as a tumor that grows by pushing tissue aside rather than destroying it.

The **infiltrative subtype** shows obvious destructive stromal invasion by malignant glands, cell nests, or individual cells. It is often accompanied by a desmoplastic stromal reaction (scar-like tissue forming around the invading cancer). This tumor actively destroys the tissue it enters.

## Prognosis Depends on the Subtype

This distinction matters enormously. Multiple studies have confirmed that the risk of relapse for women with **stage I expansile mucinous ovarian cancer is extremely low**. In one analysis, only **3 recurrences occurred among 75 cases**, and 2 of those 3 were successfully treated with secondary surgery.

More than **95% of women with expansile mucinous ovarian cancer** present with stage I disease. Peritoneal spread in the expansile subtype is extraordinarily rare — only **3 cases** have ever been reported.

Infiltrative mucinous ovarian cancer behaves very differently. It is far more aggressive:

- At least **26%** of women present with advanced, nonlocalized disease at diagnosis
-
**17% to 30%** of women who appear to have stage I disease actually have lymph-node metastases (compared with no cases among women with expansile tumors)
- Even when diagnosed early, **15% to 30% of patients with stage I disease** experience fatal relapses

Across the published series, women with expansile tumors rarely relapsed. Women with infiltrative tumors had recurrences and deaths in substantial numbers. This included some patients initially thought to have stage I disease. This is why the expansile-versus-infiltrative distinction is crucial: it changes whether doctors recommend lymph-node removal or adjuvant chemotherapy (treatment given after surgery to reduce the risk of recurrence).

## Surgical Management of Early-Stage Disease

For young patients who wish to preserve fertility, doctors usually propose a **unilateral salpingo-oophorectomy** (removal of one ovary and its fallopian tube), along with peritoneal staging procedures: cytology (fluid sampling), peritoneal biopsies, and omentectomy (removal of the omentum, a fatty apron inside the abdomen). In older patients, **bilateral salpingo-oophorectomy** (removal of both ovaries and tubes) is preferred.

The surgical team's priority is choosing the approach — open surgery (laparotomy) or minimally invasive laparoscopy — that best avoids **perioperative tumor rupture**. A rupture would change the FIGO stage and alter both surgical and medical management.

For women with stage I disease who want to preserve fertility, unilateral salpingo-oophorectomy is a reasonable option. The recurrence risk is lower than that reported for women with stage I serous cancers: **6% versus 20%**, a statistically significant difference (P<0.001). Only one study has evaluated fertility-sparing surgery in both the expansile and infiltrative subtypes, and its results suggest it can be used safely for both.

A small number of patients with normal-looking findings at surgery still have microscopic spread. Specifically:

- Positive cytology in **5.7%** of cases
- Microscopic involvement of the omentum or a peritoneal biopsy specimen in **1.7%** of cases
- Appendiceal spread (cancer in the appendix) in **1.1%** of cases

These events remain rare compared with other epithelial subtypes. Lymph-node spread is also very low in apparent stage I mucinous ovarian cancer — **less than 2%**. However, the much higher rate in stage I infiltrative disease (17% to 30%) leads to a clear recommendation: **pelvic and para-aortic lymphadenectomy** (removal of lymph nodes) should be offered to all patients with infiltrative disease, regardless of stage. It can safely be omitted in patients with stage I expansile disease.

## Managing Stage III or IV Disease

The outlook for women with stage III or IV mucinous ovarian cancer is worse than for women with other, more common subtypes — particularly serous or endometrioid ovarian cancer. Part of the reason may be a poorer response to chemotherapy.

Some authors have argued that the poor prognosis reflects inherently aggressive tumor biology. Some authors have also argued about the questionable feasibility of complete surgical removal. This raises doubts about whether aggressive debulking is worthwhile in these patients.

Other evidence points the other way. In a series of **50 patients** with stage III or IV mucinous ovarian cancer, overall survival was increased by a factor of **3.8** among patients who underwent optimal debulking surgery. In an analysis of three randomized trials involving **3,126 patients** (147 of whom had mucinous ovarian cancer), the size of the residual disease significantly affected both overall and event-free survival in a multivariate analysis. The authors' conclusion: **debulking surgery aiming for complete macroscopic resection remains a cornerstone** of managing advanced mucinous ovarian cancer.

## Chemotherapy and Medical Management

Outcomes in mucinous ovarian cancer depend heavily on stage. In a comparison of histologic subtypes, overall survival was higher for the majority of patients presenting with stage I disease than for those with nonmucinous subtypes — hazard ratio **0.52** (95% CI, 0.30 to 0.92).

A **hazard ratio** compares the risk of an event between two groups; 0.52 means roughly half the risk. The **95% confidence interval (CI)** of 0.30 to 0.92 means the true value is very likely in that range, and because the range does not cross 1.0, the finding is statistically significant.

The trend reverses for advanced disease. Women with stage III or IV mucinous ovarian cancer have significantly **lower** overall survival than women with nonmucinous subtypes — hazard ratio **2.81** (95% CI, 2.47 to 3.21).

Retrospective series (studies looking back at existing records) confirm lower response rates to first-line platinum-based chemotherapy, mainly carboplatin and paclitaxel:

-
**Mucinous ovarian cancer:** response rates of 13% to 60% (or 20% to 60% in another compilation)
-
**Serous ovarian cancer:** response rates of 64% to 87% (more than 70%)

Mucinous ovarian cancer looks similar under the microscope to gastrointestinal carcinomas. Oxaliplatin and fluorouracil work synergistically in laboratory models of the disease. Because of this, researchers tested chemotherapy regimens traditionally used for gastrointestinal cancers. The **Gynecologic Oncology Group trial 0241** (with European, Australian, Korean, and North American groups) studied a colorectal cancer regimen in women with newly diagnosed metastatic mucinous ovarian cancer.

This phase 3 trial randomly assigned women to receive either paclitaxel plus carboplatin (control group) or capecitabine plus oxaliplatin. A secondary randomization assigned women to receive bevacizumab or placebo to test antiangiogenesis therapy (treatment that blocks the growth of new blood vessels feeding the tumor).

Accrual was slow and the trial closed prematurely. Preliminary results from the small group of **50 patients** who were randomized showed **no significant difference in progression-free survival** among the treatment groups. The trial confirmed a **low objective response rate**: 10 of the 50 women, or **20%**, responded regardless of the regimen.

Neoadjuvant treatment (chemotherapy given before surgery) for advanced ovarian cancer has been tested in the European Organisation for Research and Treatment of Cancer **EORTC 55971** and **CHORUS** trials, both of which compared initial surgery with a strategy of neoadjuvant chemotherapy.

### What the Guidelines Say

Current recommendations are pragmatic. The National Comprehensive Cancer Network (**NCCN**) guidelines recommend:

-
**Stage IA or IB:** surgery alone
-
**Stage II or more advanced:** adjuvant platinum-based chemotherapy (carboplatin and paclitaxel, or oxaliplatin with fluorouracil or capecitabine)
-
**Stage IC:** either observation or adjuvant chemotherapy

Some European guidelines go further, refining stage I recommendations according to the expansile versus infiltrative subtype:

1.
**Stage IA or IB expansile disease** (considered low risk): observation alone
1.
**Stage IC expansile disease:** adjuvant chemotherapy is discussed
1.
**Stage I infiltrative disease:** adjuvant chemotherapy proposed for most cases

This underscores the essential role of high-quality pathological review in managing these rare tumors.

## The Molecular Landscape and Targeted Therapy

Serous ovarian cancers are the opposite of mucinous tumors at the molecular level. Serous cancers lack genomic alterations in typically actionable driver oncogenes (genes that, when mutated, drive cancer growth and can be targeted by drugs) such as **HER2, EGFR, ALK, and BRAF**. Instead, they are characterized by defects in homologous recombination DNA-repair genes, such as **BRCA1 or BRCA2**.

That DNA-repair deficiency has been successfully exploited with **poly(adenosine diphosphate–ribose) polymerase (PARP) inhibitors** — a drug class that blocks a backup DNA repair pathway, causing cancer cells with faulty repair to die. This drug class represents the first targeted therapy with a proven role in that setting. Ongoing research is exploring how these and other targeted approaches might apply to mucinous ovarian cancer.

## Limitations of the Evidence

Patients and families should understand several important caveats in this evidence base.

-
**Mucinous ovarian cancer is rare**, making up only 1% to 3% of epithelial ovarian cancers. That limits how many patients can be studied.
-
**Much of the evidence is retrospective** — based on looking back at existing records rather than on randomized trials. The prognostic data on expansile versus infiltrative subtypes come largely from these smaller series.
-
**The key randomized trial closed early.** GOG 0241 randomized only 50 patients, which is far too few to reliably compare chemotherapy regimens.
-
**Guideline recommendations are not uniformly based on clear evidence of benefit.** The authors note that some recommendations reflect expert consensus rather than definitive proof.
-
**Historical misdiagnosis** complicates older research: because 50% to 70% of tumors once called primary mucinous ovarian cancer were actually metastases, older studies may have described a different disease entirely.
-
**Only one study** has examined fertility-sparing surgery separately in the expansile and infiltrative subtypes, and peritoneal spread in the expansile subtype rests on just 3 reported cases.

## What This Means for Patients

If you or someone you love has been diagnosed with mucinous ovarian cancer, several practical points follow from this review.

1.
**Ask whether the diagnosis has been confirmed by an expert pathologist.** Because up to 70% of tumors initially labeled as primary mucinous ovarian cancer turn out to be spread from elsewhere, confirming the diagnosis is critical. Extensive tumor sampling (1 to 2 blocks per centimeter) is part of that process.
1.
**Make sure the workup ruled out other primary cancers.** Colonoscopy and upper gastrointestinal endoscopy, including endoscopic ultrasonography, may be needed — especially if the tumor is smaller than 10 cm, involves both ovaries, or shows peritoneal spread.
1.
**Find out whether the tumor is expansile or infiltrative.** This single distinction drives decisions about lymph-node removal and chemotherapy. Stage I expansile tumors are low risk; stage I infiltrative tumors are not.
1.
**Discuss the surgical goal clearly.** For early disease, the priority is avoiding tumor rupture. For stage III or IV disease, complete macroscopic resection is associated with a 3.8-fold improvement in overall survival.
1.
**If you are young and hope to have children, ask about fertility-sparing surgery.** Mucinous ovarian cancer is the most common subtype in patients eligible for this approach, and recurrence risk after fertility-sparing surgery (6%) is lower than for stage I serous cancer (20%).
1.
**Set realistic expectations about chemotherapy.** Response rates to platinum-based regimens are 13% to 60% — lower than the 64% to 87% seen in serous ovarian cancer. Clinical trials comparing regimens are limited.
1.
**Ask about clinical trials and genetic testing.** KRAS mutations appear in 40% to 65% of these tumors, and HER2 amplification and TP53 mutations occur in the cancerous component. Research into targeted therapies continues.
1.
**Do not smoke.** Smoking is the only clinical risk factor identified for mucinous ovarian cancer.

## Frequently Asked Questions

### How is mucinous ovarian cancer different from other ovarian cancers?

Mucinous ovarian cancer is genetically distinct from serous ovarian cancer and usually found earlier. Between 65% and 80% are diagnosed at stage I, when the tumor is confined to one ovary. It tends to appear in younger patients and is the most common subtype among those eligible for fertility-sparing surgery. It also responds less to platinum chemotherapy than serous cancer.

### What does it mean if my tumor is expansile or infiltrative?

The 2014 World Health Organization split mucinous ovarian cancer into two subtypes based on growth pattern. Expansile tumors push tissue aside and are low risk; infiltrative tumors destroy tissue and are aggressive. This distinction drives decisions about lymph node removal and chemotherapy. Stage I expansile tumors rarely relapse, while infiltrative tumors often do, even when caught early.

### Why do I need tests like colonoscopy if I have an ovarian tumor?

When pathologists reviewed tumors labeled primary mucinous ovarian cancer, they found 50% to 70% were actually spread from cancers of the colon, stomach, or other organs. So doctors recommend colonoscopy and upper gastrointestinal endoscopy to rule out a hidden gastrointestinal primary. This is especially important if the tumor is smaller than 10 cm, involves both ovaries, or shows peritoneal spread.

### What is the survival rate for early-stage mucinous ovarian cancer?

For women with localized mucinous ovarian cancer, five-year overall survival exceeds 90%. In a comparison, five-year survival for stage I mucinous cancer was 92% versus 84% for serous cancer. However, once the cancer has spread to the peritoneum or beyond (stage III or IV), median overall survival falls to 12 to 33 months.

### Can I have fertility-sparing surgery if I have mucinous ovarian cancer?

Mucinous ovarian cancer is the most common subtype among patients eligible for fertility-sparing surgery. In one series of 545 patients undergoing this surgery, 51% had mucinous ovarian cancer. For stage I disease, unilateral salpingo-oophorectomy is a reasonable option. Recurrence risk after fertility-sparing surgery was 6% versus 20% for stage I serous cancer, a significant difference.

### How effective is chemotherapy for mucinous ovarian cancer?

Response rates to first-line platinum-based chemotherapy are lower than for serous ovarian cancer: 13% to 60% for mucinous versus 64% to 87% for serous. A trial comparing a colorectal regimen (capecitabine plus oxaliplatin) with standard paclitaxel plus carboplatin closed early after randomizing only 50 patients and showed no significant difference in progression-free survival. Guidelines recommend adjuvant platinum-based chemotherapy for stage II or more advanced disease.

### What should I ask my doctor about my diagnosis and treatment?

Ask whether an expert pathologist confirmed the diagnosis, since up to 70% of tumors initially labeled primary mucinous ovarian cancer are actually spread from elsewhere. Find out if the tumor is expansile or infiltrative, as this drives decisions about lymph node removal and chemotherapy. Discuss the surgical goal: avoiding tumor rupture in early disease, or complete macroscopic resection in advanced disease. Also ask about clinical trials and genetic testing.

### When should a patient with newly diagnosed mucinous ovarian cancer seek a second opinion?

A second opinion is warranted at diagnosis, because 50% to 70% of tumors once labeled primary mucinous ovarian cancer were actually spread from the colon, stomach, or other organs. Expert pathological review with extensive sampling (1 to 2 blocks per centimeter) confirms the diagnosis, and the expansile versus infiltrative subtype then drives decisions about lymph-node removal and chemotherapy. A review also helps ensure gastrointestinal investigations such as colonoscopy and upper endoscopy were done. Diagnostic Detectives Network provides independent expert second opinions.

## Source Information

**Original article title:** Mucinous Ovarian Carcinoma

**Authors:** Philippe Morice, M.D., Ph.D.; Sebastien Gouy, M.D., Ph.D.; and Alexandra Leary, M.D., Ph.D. — from the Departments of Gynecological Surgery and Medical Oncology, INSERM Unit 981, and INSERM Unit 10-30, Gustave Roussy Cancer Campus, Villejuif, and University Paris-Sud (Paris XI), Le Kremlin-Bicêtre, France.

**Series editor:** Dan L. Longo, M.D.

**Publication details:** *New England Journal of Medicine*, 2019; volume 380, pages 1256-1266. DOI: 10.1056/NEJMra1813254. Copyright © 2019 Massachusetts Medical Society.

*This patient-friendly article is based on peer-reviewed research.*


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