Surgical removal of a mammary adenocarcinoma and a granulosa cell tumor in an African pygmy hedgehog

A 3-year-old, female African pygmy hedgehog (Atelerix albiventris) was referred with a history of hematuria. Hyperglycemia and glucosuria were found at presentation. Mammary adenocarcinoma and a granulosa cell tumor were found and removed surgically. Glucosuria and hematuria resolved, and the hedgehog has done well for 10 mo postoperatively.

[Peripheral precocious puberty caused by a juvenile granulosa cell ovarian tumor, with iso and heterosexual manifestations in a six years old girl]

A six years old girl consulted due to mammary development. On physical examination, clitoris enlargement and a tumor localized in the abdominal-pelvic region were observed. Hormonal study disclosed elevated testosterone and estradiol levels. On exploratory laparotomy, a right ovarian tumor was observed and a right salpingooophorectomy was performed. The contemporary biopsy informed a disgerminoma, leading to a surgical staging of the tumor. The definitive pathological diagnosis was a juvenile granular cell tumor, limited to the ovary. In the postoperative period, estradiol and testosterone levels returned to normal values and the pseudopuberty reverted. The patient did not receive adjuvant treatment and after three years of follow up, there is no evidence of tumor recidivism.

[Association of ovarian juvenile granulosa cell tumor with Maffucci's syndrome]

The authors report a rare case of the ovarian juvenile granulosa cell tumor associated with Maffucci's syndrome (enchondromathosis + hemangiomas), no heriditary mesodermal dysplasia. Sarcomatous changes of chondromas are encountered most frequently; however other various typed neoplasma have been reported: ovarian juvenile granulosa cell tumor may occur not infrequently in female patients with Maffucci's syndrome in the first or second decades. Sarcomatous changes of choromas established prognosis of the Maffucci's syndrome.

Precocious puberty in a female with Proteus Syndrome

Proteus syndrome is a complex disorder comprising malformations and overgrowth of multiple tissues and characterized by its polymorphism and mosaicism. The syndrome is rare and sporadic. Oliveira M da C et al reported the first case of Proteus syndrome associated with precocious puberty in a boy. We are reporting a case of a 7-month old girl with Proteus syndrome who developed a juvenile granulosa cell tumor in one ovary causing precocious puberty. At our knowledge this is the first case of Proteus syndrome with precocious puberty in a female.

Life-threatening haemoptysis presenting as a late complication of an ovarian tumour

Massive haemoptysis may arise as a result of lung malignancy. This case represents the first report of an ovarian granulosa cell tumour metastasising many years after initial tumour resection to the lung causing life-threatening haemoptysis. The management and subsequent clinical course of the patient are discussed as well as the natural history of granulosa-theca cell tumours.

Hyperprolactinemia complicating juvenile granulosa cell tumor of the ovary

BACKGROUND

Granulosa cell tumors are known to be hormonally active. They usually produce estrogen and inhibin, and the serum inhibin level is often considered a useful tumor marker during the follow-up of this illness.

CASE

We present a case of malignant juvenile granulosa cell tumor associated with hyperprolactinemia. In our patient, the serum prolactin concentration closely reflected the behavior of the disease.

CONCLUSION

Our findings are consistent with the assumption that prolactin was a tumor marker in this patient.

Androgenic adult granulosa cell tumor in a 13-year-old prepubertal patient: a case report and review of the literature

We report the clinicopathologic findings of an unusual case of adult granulosa cell tumor with androgenic manifestation in a 13-year-old prepubertal girl. The patient had never had a menstrual period and presented with a 1 year history of hirsutism. Physical examination was only remarkable for an increase in facial and abdominal hair, both with a male pattern of distribution. A pelvic ultrasound demonstrated a 6.0 cm right adnexal cyst. Plasma testosterone and 17-hydroxyprogesterone levels were elevated. The patient initially was treated with monophasic oral contraceptive pills for 3 months and owing to lack of response, she underwent an exploratory laparotomy in which a left ovarian tumor, 7.0 cm in greatest dimension, and a 6.5 cm right paratubal cyst were found. A wedge biopsy of the left ovary and subsequent left oophorectomy with right salpingectomy were performed. No gross evidence of disease outside the ovary was noted. Microscopic examination of the left ovarian tumor revealed the typical features of an adult granulosa cell tumor. No tumor was seen outside the ovary. Six days after surgery, plasma testosterone and 17-hydroxyprogesterone levels were in the normal range. Nine months postoperatively, the patient shows no evidence of disease. To our knowledge, this represents the first case of a prepubertal patient with an adult granulosa cell tumor with androgenic manifestations reported in the English literature.

Virilizing tumors of the ovary: imaging features

AIM

Virilizing tumors of the ovary are an uncommon cause of a common clinical problem. The reported imaging features of these tumors are based on case reports. The purpose of this study was to determine the spectrum of imaging characteristics of these tumors based on a larger referral population.

PATIENTS AND METHODS

Case records from the Armed Forces Institute of Pathology were searched for clinical evidence of virilization as a presentation of an excised sex cord-stromal and steroid cell ovarian tumor. Records and imaging studies on 14 patients with virilizing tumors were found. All available imaging studies (ultrasound studies of the pelvis (11 patients), CT scans of the pelvis (five patients), MRI examinations of the pelvis (two patients), and plain films of the pelvis (four patients) were reviewed by three radiologists independently for ascites, calcification, percent solid portion, echogenicity and attenuation.

RESULTS

On CT and/or ultrasound most (69%) of the tumors appeared to be solid or mostly solid. The amount of solid tissue varied with the tumor type, granulosa cell tumors were predominantly cystic. The masses were isoechoic (82%) or hypoechoic (18%). Ascites was an infrequent (23%) finding. Only a minority of these tumors (14%) were calcified on imaging studies. Six tumors were 5.0 cm or less in mean size, and two less than 3.0 cm in size. All cases were stage I tumors at presentation.

CONCLUSION

The majority of virilizing tumors of the ovary are typically solid, noncalcified, confined to the ovary at presentation, and not associated with ascites. Variability in appearance depends in part on tumor type. Many are small and may be difficult to recognize as a mass morphologically.

[Early isosexual precocious pseudopuberty revealing a juvenile granulosa cell tumor in a 3-year-old Congolese girl]

We describe a juvenile granulosa cell tumor expressed by an early pseudopuberty occurring in a 3-year-old black child. Clinically, an endocrine syndrome was associated with a pelvic mass and ascites. Hyperoestrogenia and serum alphafetoprotein level were biologically detected. Histological examination showed typical microscopic features of a granulosa cell tumor. The patient is well four years after surgery. Growth and mental development are normal.

Reproductive features in women developing ovarian granulosa cell tumour at a fertile age

Ovarian granulosa cell tumour (GCT) is a rare malignancy, which has been linked to both infertility and infertility treatment with ovulation inducers. The reproductive features were analysed of 146 women with GCT diagnosed between 1956 and 1996. During the study period no changes were found in the mean age (53 years), menopausal status (59% postmenopausal), parity (32% nulliparous) or tumour size or stage at diagnosis. The clinical features in women with GCT at fertile age were compared with GCT diagnosed later in life and to population-based data. Nulliparity (50%) and history of infertility (22%) were more frequent if the tumour occurred at fertile age (n = 50). Of the 12 infertile cases, seven had anovulatory infertility (58%); 11 occurred during the era of ovulation inducers, but only five had used these drugs (clomiphene citrate in five patients, gonadotrophins in two, and tamoxifen in one patient) and no patient had undergone in-vitro fertilization. Endometrial hyperplasia was associated with GCT at all ages, while endometrial cancer was found solely after the age of 45 years. In conclusion, GCT at fertile age is associated with nulliparity and with a clinical presentation of anovulatory infertility, while GCT later in life is associated with a more normal average fertility pattern and with occurrence of endometrial cancer.

An earlier menopause as clinical manifestation of granulosa-cell tumor: a case report

We present a case of a granulosa-cell tumor, which can cause menopause at an earlier than normal age. The hormonal profiles were characterized by undetectable FSH levels associated with an estradiol level compatible with the level seen in perimenopausal women and by a significant increase in the inhibin level.

Hemoperitoneum is an initial presentation of recurrent granulosa cell tumors of the ovary

Ovarian sex cord-stromal tumors account for less than 5% of all ovarian carcinoma, of which granulosa cell tumors account for 70%. These tumors have a propensity for indolent growth and late recurrence; they may even occur 25 years after initial treatment. We report a 44-year-old woman with hemoperitoneum (acute abdomen) after initial treatment 10 years earlier for granulosa cell tumor of the ovary. This case re-emphasizes the need for long-term follow-up in patients with stromal cell tumors of the ovary and considers the possibility of recurrence when presented with acute abdomen after conservative treatment.

Hemoperitoneum in a postmenopausal woman

As the number of postmenopausal women increases, physicians will have more opportunities to treat elderly women with gynecological complications. This case report describes a 76-year-old, obese, multiparous woman, known to have gallstones who presented with acute abdomen complaints and was admitted for observation. Treatment was delayed until significant blood loss was recognized. At laparotomy, a ruptured ovarian granulosa cell tumor was found.

Endometriosis and uterine leiomyomata with ovarian granulosa cell tumour

We report the first known case of right endometrial cyst and multiple uterine leiomyomata complicated by an ovarian granulosa cell tumour of adult type. A 42 year old woman had an adult type left granulosa cell tumour. Laparoscopy 13 years earlier had revealed a small endometrial implant on the peritoneum, without uterine leiomyomata or bilateral ovarian tumours. Findings in this case suggest that the aetiology of endometriosis and uterine leiomyomata are related to the presence of an oestrogen-secreting neoplasm and that the presence of a state of hyperoestrogenaemia due to granulosa cell tumour over several years might have stimulated the development of endometriosis and leiomyomata.

Granulosa and theca cell tumors in children: a report of 17 cases and literature review

The files of the Emil Novak Ovarian Tumor Registry (ENOTR) were searched for granulosa and theca cell tumors in children aged 12 years and less. In addition, an extensive literature search was done for English publications on children with these tumors aged 10 years or less. Of the 17 children from the ENOTR, 5 had adult-type granulosa cell tumors, 6 had juvenile granulosa cell tumors, and 1 had a luteinized granulosa cell tumor. In addition, there were three cases with gonadal stomal tumors, one theca cell tumor, and one granulosa-theca cell tumor. Precocious pseudopuberty was present in 70 percent of the children, abdominal pain in 24 percent, and ascites in 18 percent. The literature review revealed a tumor-related mortality rate of 9 percent (based on 163 cases with granulosa cell tumors, including the juvenile type). Some of these tumors are large with acute pain, but nevertheless, the prognosis is good, particularly in cases with precocious puberty. Treatment can be conservative.

Juvenile granulosa cell tumor of the ovary in infants: a clinicopathologic study of three cases and review of the literature

The clinical and pathological features of three cases of juvenile granulosa cell tumors occurring in infants were studied. Precocious pseudopuberty developed in two patients and acute abdominal symptoms related to the rupture of the tumor developed in one. Surgery was the only treatment in each case and no adjuvant therapy was delivered. No patient experienced relapse. Histological examination showed a predominantly diffuse pattern with prominent luteinization. Call-Exner bodies were absent. Two tumors had multilocular thin walled cysts containing large amounts of estradiol, the third one contained rudimentary microfollicles. The prognosis of juvenile granulosa cell tumors in infancy appears more favorable than those occurring in older patients. No case of tumor recurrence has been reported in infancy so far. Surgery appears to be the state-of-the-art treatment of these tumors and additional therapy (chemotherapy or radiotherapy) must be discussed with caution, even in advanced stages.

A mare with colic caused by an ovarian tumour

An 11-year-old Arabian mare had sudden signs of colic 10 days post partum. Rectal examination revealed a large mass in the abdomen. The mare was successfully operated on for a granulosa cell tumour of 31.5 kg. The large abdominal wound healed by primary intention.

Bennhold's analbuminemia: a follow-up study of the first two cases (1953-1992)

A pair of siblings with analbuminemia were followed for 38 years. The female patient received replacement therapy with human serum albumin. Extreme lipodystrophy developed in this patient by the fourth decade of life. She had juvenile osteoporosis, which normalized under albumin replacement. She died from a granulosa cell cancer at age 69. Her brother never received albumin, even though his serum contained only 60 micrograms/ml of an albumin-like protein. He suffered from severe osteoporosis with gibbus formation, and he died from a colon carcinoma at age 59. Despite high cholesterol values and high levels of several blood clotting factors, neither of the patients had severe atherosclerosis or thrombotic events. Laboratory findings before and after infusion of large amounts of albumin into the sister point to a mechanism whereby albumin-bound substances can be passively transported from the bloodstream into the extravascular space and vice versa.

Central precocious puberty following feminizing right ovarian granulosa cell tumor

A 7-month-old girl presented with ascites and breast enlargement due to right ovarian granulosa cell tumor. After tumor removal, the clinical signs of incomplete precocious puberty regressed. Four years later, the patient reappeared with signs of precocious puberty. Our investigations proved that this was not due to tumor recurrence, but it was a true central precocious puberty. She responded well to therapy with a luteinizing hormone releasing hormone agonist, and 3 years after onset of this therapy, she is growing at a normal prepubertal rate.

Testicular juvenile granulosa cell tumor in an infant with X/XY mosaicism clinically diagnosed as true hermaphroditism

We report a testicular juvenile granulosa cell tumor (T-JGCT) with characteristic clinical and histopathological features. The tumor was present in the left abdominal testis of a 7-month-old infant with a 45,X/46,XY karyotype and ambiguous genitalia. Preoperatively, the infant was diagnosed as having functional testicular and ovarian elements based on elevated levels of serum testosterone and estradiol following human chorionic gonadotropin and human menopausal gonadotropin administration, respectively. Histologically, the left gonad contained a tumorous lesion composed of an admixture of cellular areas and multiple cystic follicles that had some continuity with the adjacent testicular tubules. Some tumor cells showed immunoreactivity for estradiol. The right gonad was a streak gonad containing small irregular nests of sex cord-type cells. No maturing ovarian follicle was present in either gonad. To our knowledge, this is the fifth reported case of T-JGCT with abnormal sex chromosomes, and the first case of T-JGCT confirmed to have not only the morphological but also the functional characteristics of granulosa cells.

Congenital bilateral juvenile granulosa cell tumor of the ovary in leprechaunism: a case report

We report on a case of leprechaunism. In addition to the typical clinical and biochemical features, a bilateral juvenile granulosa cell tumor of the ovaries and cytomegalovirus hepatitis were found. The granulosa cell tumor may result from the mitogenic effect of insulin at high concentration, which acts via a mechanism mediated by insulin-like growth factor I receptors.

Androgenic granulosa cell tumor of the ovary: in vivo hormonal studies

Androgenic granulosa cell tumors of the ovary are rare and have not been well studied hormonally. A 20-year-old woman complaining of secondary amenorrhea with high plasma testosterone (295 ng/dl) and a right ovarian tumor was studied. Plasma testosterone levels decreased after two days of dexamethasone (36 ng/dl), increased after hCG administration (538 ng/dl) and a unilateral right ovarian gradient of testosterone was noted at the selective catheterization of ovarian veins. After removal of the granulosa cell tumor, testosterone concentration returned to normal (68 ng/dl) and the patient had resumption of normal menses.

[Secondary amenorrhea and LH hypersecretion. An unusual report of a granulosa cell ovarian tumor]

Granulosa cell ovarian tumors are infrequent. Since they originate from the gonadal stroma, they retain a high secretory potential and some of their clinical manifestations may be secondary to the production of sexual steroids. A 36 year old woman with an ovarian tumor presenting as a secondary amenorrhea is reported. This patient had a positive progesterone test and her hormonal profile showed a maintained LH hypersecretion (> 75 mUl/ml) which, joined to the presence of a hypophyseal microadenoma lead to suspect the presence of a gonadotrophin secreting tumor. The absence of LH response to TRH and its adequate suppression using oral contraceptives discarded this diagnosis. The histopathology of the excised ovarian tumor demonstrated that it is was a granulosa cell tumor. The physiopathological explanation of the case is based on the maintained levels of estrogens produced by the tumor that, through a positive feed-back mechanism similar to that of the polycystic ovary syndrome, produced a tonic LH elevation and GnRH hyper response. After the tumor excision, ovulatory cycles resumed and the patient became pregnant, facts that confirm the postulated hypothesis.

Primary cutaneous endometriosis of thoracic skin with ovarian granulosa cell tumor

A case of non-cicatricial endometriosis of the thoracic skin is described in a patient affected by an ovarian granulosa cell tumor, adult type. To the best of our knowledge, this is the first case of this type of association reported in the literature although some cases in which endometriosis was related to high estrogen levels are well documented. We suggest that in presence of an estrogen secreting neoplasm, foci of endometriosis might not be such a rare condition if clinicians and pathologists carefully looked for it.

Granulosa cell tumor of the ovary with diffuse true hepatic differentiation simulating stromal luteinization

A case of granulosa cell tumor of the ovary associated with hepatocytic differentiation is reported in a 45-year-old patient with a torsioned ovarian tumor. Serum alpha-fetoprotein (AFP) levels were normal 6 days postoperatively. Histopathologically, the granulosa cell tumor was typically trabecular. Its cells had nuclear grooves and were positive only for vimentin. Scattered diffusely throughout the tumor were small groups of regular polygonal cells, the cytoplasm of which secreted bile and was strongly positive for keratin, carcinoembryonic antigen (CEA), alpha-1-antitrypsin (A1AT), and ferritin and moderately positive for fibrinogen and ceruloplasmin. These results unequivocally identified them as hepatic cells. The AFP negativity of the hepatic cells was interpreted as a sign of terminal hepatocytic differentiation. The scattered arrangement of the hepatocytes simulated stromal luteinization. As neither a primary liver tumor nor any associated germ cell tumor was found, the histogenesis of the hepatic cells was thought to be metaplastic.

Hypertrophic osteopathy in three horses and a pony

Hypertrophic osteopathy was diagnosed in 3 horses and in a pony, ranging in age from 8 to 21 years. There were 2 females, 1 sexually intact male, and 1 gelding. In 3 animals, hypertrophic osteopathy was associated with pulmonary abscesses, bronchogenic squamous cell carcinoma, and ovarian granulosa-cell tumor, respectively, and resulted in death or euthanasia. Duration of the condition ranged from 1 to 4 months. In 1 horse, hypertrophic osteopathy was believed to be secondary to pregnancy, and resolved following uncomplicated delivery of a live foal.

Cystic adult granulosa cell tumor causing precocious pseudopuberty in a six-year-old girl

A very rare occurrence of adult granulosa cell tumor of the ovary (not of the juvenile type) causing precocious pseudopuberty in a six-year-old girl is described. An additional feature of interest was that the tumor appeared entirely cystic. To our knowledge, this condition in such a young premenarchal patient has not been reported previously.

[Juvenile granulosa cell tumor with subsequent occurrence of gastrointestinal polyposis, subcutaneous lipomatosis and nodular goiter]

A juvenile tumour from granulosa cells (M-8622/1), 13 x 8 x 6 cm, in the right ovary in a three-month-old girl produced some symptoms of pseudopubertas praecox isosexualis which disappeared after operation. Microscopic examination of the tumour revealed in addition to typical structures a less common differentiation to Sertoli cells. Despite actinotherapy and chemotherapy one and a half years after the onset of the disease X-ray examination revealed metastases in the lungs which were successfully cured by further doses of the above two types of treatment. Between the age of 6 and 15 years the girl developed successively polyposis of the stomach, small and large intestine (M-7564/0), subcutaneous lipomatosis of the trunk and left lower extremity (M-8881/0) and nodular goitre (M-7164/0), predominantly quiescent. In the literature a connection between gonadal stromal ovarian tumours and mesenchymal tumours, intestinal polyposis and disorders of the thyroid gland is described, but in different patients. The authors' observation is unique by the successive incidence of these changes in a single patient surviving 15 years after operation; and thus genetically conditioned associations could be involved.

Juvenile granulosa cell tumor in a 2-year-old infant: report of a case complicated with ascites and acute respiratory distress

A two-year-old girl with a juvenile granulosa cell tumor (JGCT) and with acutely progressive hydrothorax and ascites is presented. She had precocious pseudopuberty and an elevated level of serum estradiol. Sudden onset of respiratory distress, due to a pleural effusion and severe abdominal distention, led to an emergency laparatomy. Unilateral salpingo-oophorectomy induced a rapidly favorable course. Histological examination showed no evidence of invasion or peritoneal metastasis. This is the first case of JGCT associated with an acute respiratory emergency as a main clinical feature.

Metastatic granulosa cell tumor in a mare

A 5-year-old Quarter Horse mare was referred for evaluation of an acute non-weightbearing lameness of the left hind limb in which musculoskeletal abnormalities had not been detected. After admission, the mare had signs of colic. Exploratory laparotomy revealed the left ovary to be large, masses in the left sublumbar space, and diffuse infiltration of the mesentery, omentum, liver, and spleen with variably-sized masses. The mare was euthanatized, and granulosa cell tumor was identified on histologic examination of the left ovary, left sublumbar and cranial thoracic lymph nodes, omentum, mesentery, liver, spleen, and lung.

Ovarian juvenile granulosa cell tumor associated with Maffucci's syndrome

A 15-year-old girl developed a juvenile granulosa cell tumor associated with Maffucci's syndrome (enchondromatosis + hemangiomas). Clinical manifestations of the disease included an abdominal mass and progressive anemia. She underwent the removal of a Stage Ic juvenile granulosa cell tumor and subsequent adjuvant chemotherapy. On follow-up examination 4 years later, no recurrence of the ovarian tumor was noted. A review of the literature showed 10 previous cases of juvenile granulosa cell tumor associated with enchondromatosis, two associated with Maffucci's syndrome, and the rest with Ollier's disease (enchondromatosis). Ovarian juvenile granulosa cell tumor may occur not infrequently in female patients with enchondromatosis in the first or second decades, in contrast to the widely recognized sarcomatous changes of enchondromas that usually occur after the second decade. Data provided from these cases also emphasize the concept of a generalized mesodermal dysplasia.

Malignant granulosa cell tumor of the testis associated with gynecomastia and long survival

A case is reported of classic granulosa cell tumor of the testis with metastases to the retroperitoneal lymph nodes occurring in a 26-year-old man. The patient had left-sided testicular enlargement and bilateral gynecomastia. He was treated by radical orchiectomy, retroperitoneal lymph node dissection, and radiation therapy and is well without evidence of disease 14 years after diagnosis. This is the first documented case of granulosa cell tumor of the testis with metastases and long remission after successful therapy to the authors' knowledge.

Juvenile granulosa cell tumor of an intraabdominal testis

Juvenile granulosa cell tumor of the testis is a distinct form of sex cord-stromal tumor of neonates and infants [1]. This tumor comprises a significant percentage of testicular tumors in baby boys. We present a patient who had preoperative imaging studies.

Ollier's disease with secondary chondrosarcoma associated with ovarian tumour. A case report

The association of an ovarian tumour with Ollier's disease or the Maffucci Syndrome is rare. We report what we believe to be the first patient with Ollier's disease associated with an ovarian tumour who later developed a secondary chondrosarcoma.

Pseudo-precocious puberty in a Kenyan African child: a case report

A female Kenyan child with pseudoprecocious puberty due to juvenile granulosa cell tumour is presented. Clinical features in this patient included a mass in the lower abdomen, a growth spurt and appearance of pubic hairs as well as enlargements of the breasts. No similar case has been reported in a Kenyan child. The management and review of literature are discussed.

[Ollier's disease and juvenile ovarian granulosa tumor]

The authors report one case of Ollier's disease in a 12 year-old girl in whom the occurrence of an ascites revealed a secretant juvenile granulosa cell tumor some years later. The tumor was right-sided, homolateral to the hemicorporal side involved by enchondromatosis. Five other cases of this association were previously reported. Attention is drawn not only to the risk of chondrosarcomatous change but also to the possible recurrence of ovarian tumor in the year following ovariectomy.

[Juvenile granulosa-cell tumor of the ovary. Immunohistochemical and ultrastructural study]

In 1977 Scully first described the juvenile granulosa cell tumor of the ovary (JGCT) as a special variation of the granulosa cells tumor, which occurs in the two first decades of life, and 97% of the cases show characteristic microscopic and histological features. Five previous cases have been reported concerning the ultramicroscopic characteristics of this ovarian neoplasia. The purpose of this paper is to report the immunohistochemical and ultrastructural characteristics in a case of OJCGT which occurred in a four year old girl with isosexual precocious pseudopuberty. The presence of vimentin and absence of keratin was proven immunohistochemically in this ovarian neoplasia. Intermediate filaments were found ultrastructurally. The combined use of immunohistochemical and ultrastructural techniques has proven to be of extraordinary usefulness for the differential diagnosis between epithelial and non epithelial ovarian tumors and adds a new and highly specific method to characterize and differentiate the cells of embryonic carcinoma, choriocarcinomas and endodermal sinus tumors which are keratin positive.