Gynandroblastoma of ovary with juvenile granulosa cell component and heterologous intestinal type glands

Sertoli-Leydig Cell Tumors of the Ovary With Follicular Differentiation Often Resembling Juvenile Granulosa Cell Tumor: A Report of 38 Cases Including Comments on Sex Cord-Stromal Tumors of Mixed Forms (So-called Gynandroblastoma)

Thirty-eight ovarian Sertoli-Leydig cell tumors that contained follicles are described; in 33 of them follicles imparted a microscopic appearance resembling that of the juvenile granulosa cell tumor. The average age of the patients (28 y), frequency of androgenic manifestations (40%), and dominant histopathologic features were all typical of Sertoli-Leydig cell tumor, mostly (80%) of intermediate differentiation. The remaining tumors were poorly differentiated; none were well differentiated. The follicles that mimicked juvenile granulosa cell tumor accounted for ∼5% to 40% of the tumor volume. They typically arose out of the characteristic lobules seen in Sertoli-Leydig cell tumors of intermediate differentiation. There appeared to be a gradual loosening of the stroma imparting a pale appearance to the lobules and on that background follicles emerged. The follicles were mostly relatively regular and round to oval with basophilic or eosinophilic secretion and when fully formed perfectly mimicked juvenile granulosa cell morphology. In 18 of these cases, and 5 others, follicles were present that had a nonspecific morphology and had a random, nonlobule-associated distribution. The presence of a juvenile granulosa-like appearance often raised consideration of the diagnosis of a sex cord-stromal tumor of mixed forms (so-called gynandroblastoma) but a multifocal origin within lobules of otherwise typical Sertoli-Leydig cell tumors, and overall tumor characteristics indicates aberrant differentiation within the latter tumor of a nature only sporadically noted in the prior literature. Such neoplasms should, in our opinion, not be placed in the grouping of a sex cord-stromal tumor of mixed forms but rather in the Sertoli-Leydig category.

Ovarian Gynandroblastoma with a Juvenile Granulosa Cell Tumor Component in a Postmenopausal Woman: A Case Report and Literature Review

Gynandroblastoma is an extremely rare sex cord-stromal tumor with both female (granulosa cell tumor) and male (Sertoli-Leydig cell tumor) elements. Juvenile granulosa cell tumors are also very rare and are so named because they usually occur in children and adolescents. A 71-year-old woman with right upper quadrant abdominal pain visited our hospital. Pelvic computed tomography showed a large multilocular cystic mass, suspected to be of ovarian origin. We performed a total abdominal hysterectomy (total abdominal hysterectomy was performed) with bilateral salpingo-oophorectomy. A 13-cm multilocular cystic mass with serous fluid was observed in her right ovary. Upon microscopic examination, the solid component of the mass showed both Sertoli-Leydig cell and juvenile granulosa cell differentiation, which we diagnosed as gynandroblastoma. Gynandroblastoma with a juvenile granulosa cell tumor component is extremely rare and, until now, only six cases have been reported in the English literature. We report the first gynandroblastoma with a juvenile granulosa cell tumor component diagnosed in an elderly patient, along with a literature review.

Sex Cord-stromal Tumors With Steroid Cell Tumor and Fibroma Components: Report of 2 Cases, Including One of Extraovarian Origin

We report 2 sex cord-stromal tumors with distinct components of fibroma and steroid cell tumor; one case was of ovarian and the other of extraovarian origin. In the ovarian tumor, there were discrete areas of fibroma and steroid cell tumor, not otherwise specified. The extraovarian case involved the pelvic soft tissues and comprised a cellular fibroma with subsequent recurrence 7 yr later as a steroid cell tumor, not otherwise specified. In both cases, aggregates of luteinized cells were present within the fibromatous component, raising the possibility that the steroid cell tumor arose from neoplastic transformation of these cells. While mixed ovarian sex cord-stromal tumors (gynandroblastomas) are well described, as far as we are aware there have been no prior reports of neoplasms containing a component of steroid cell tumor and fibroma.

Gynandroblastoma with a Juvenile Granulosa Cell Component in an Adolescent: Case Report and Literature Review

BACKGROUND

Gynandroblastoma is an extremely rare ovarian sex cord tumor with malignant potential.

CASE

An 18-year-old adolescent experienced intermittent vaginal bleeding. A year later, a right adnexal mass with a heterogeneous imaging appearance was identified. Laparoendoscopic single-site ovarian tumorectomy was performed. A histopathological examination showed gynandroblastoma composed of juvenile granulosa and Sertoli-Leydig cells. Because the tumor was upstaged to stage Ic because of cyst rupture during surgery, three cycles of adjuvant chemotherapy with carboplatin and paclitaxel were added. Three years after surgery, no signs of recurrence have been noted.

SUMMARY AND CONCLUSION

The present findings can help clinicians make an accurate preoperative imaging diagnosis of gynandroblastoma with a juvenile granulosa cell component and plan an adequate treatment strategy for this rare, potentially malignant neoplasm.

Gynandroblastoma With Juvenile Granulosa Cell Tumor and Concurrent Renal Cell Carcinoma

Gynandroblastoma is an extremely rare primary tumor of the ovary showing morphological evidence of both female (granulosa cell tumor) and male (Sertoli or Sertoli–Leydig tumor) differentiation. We report an unusual case of a 32-year-old female who presented with hyperandrogenism and was found on imaging to have concurrent ovarian and renal masses. Following surgical excision, the ovarian mass was diagnosed as gynandroblastoma, which consisted of 45% juvenile granulosa cell tumor and 55% intermediately differentiated Sertoli–Leydig tumor. The renal mass was diagnosed as a conventional renal clear cell carcinoma. Gynandroblastoma, especially with juvenile granulosa cell tumor, is an extremely rare ovarian tumor. Concurrent gynandroblastoma with another malignant neoplasm has not been reported in the literature.

[Gynandroblastoma: a rare ovarian tumour. Case report]

Gynandroblastoma is an extremely rare sex cord-stromal ovarian tumor. Only thirty cases have been published in the literature up to now. Clinical investigations include virilism associated with menstrual irregularity, or amenorrhea. The surgical treatment is salpingo-oophorectomy and lymphadenectomy if malignant spread is suspected.

Recent Advances in the Pathology and Classification of Ovarian Sex Cord-Stromal Tumors

In recent years, our knowledge of ovarian sex cord-stromal tumors has increased, and their classification has evolved. In this review, recent advances in the classification and pathology of ovarian sex cord-stromal tumors are discussed, and the controversy regarding the classification of sex cord tumor with annular tubules is addressed. The current classification is built on those of the past, and future classifications should improve on what is now in place incorporating new knowledge from more sophisticated clinicopathologic studies and advanced molecular techniques. This review emphasizes articles written in the 21st century as well as those that have significantly advanced our knowledge of sex cord-stromal tumors in past decades. The tumors in this group occur over a wide age range and are often unilateral. In difficult cases, immunocytochemistry provides improved diagnostic accuracy. The most useful immunohistochemical marker for their identification is alpha-inhibin, which is positive in most neoplasms in the sex cord-stromal group. The article concludes with a section discussing the pathogenesis of sex cord-stromal tumors.

Composite mucinous and granulosa cell tumor of the ovary

A composite mucinous and granulosa cell tumor of the ovary in a 76-year-old woman is herein reported. At laparotomy this tumor proved to be a solid and cystic mass measuring 10 cm in greatest diameter. Many of the cysts were lined with a benign mucinous epithelium of the endocervical type, and solid areas contained a proliferation of granulosa cells. These two disparate components were intimately mixed. A theca cell component was also present in areas adjacent to the mucinous epithelium. The coexistence of mucinous and granulosa cell tumor is extremely rare and only four such cases have previously been reported in the literature, and the histogenesis of this tumor has not yet been elucidated. In the present case it is suggested that the granulosa cell element commenced as a reactive stromal hyperplasia in the wall of the pre-existing mucinous neoplasm and thereafter progressed to the point of producing a tumor-like mass or neoplastic changes.

Pediatric sex cord-stromal tumor with composite morphology: a case report

A 12-year-old female with developmental delay/mental retardation and a family history of gynecologic cancers presented with nonspecific abdominal complaints and was found to have a 4.5-kg, 25- x 23- x 15-cm pelvic mass with solid and cystic components and associated retroperitoneal and mesenteric lymphadenopathy. Laboratory studies revealed increased serum levels of CA-125 and inhibin B. Histologically, the tumor exhibited several different morphologic appearances including adult granulosa cell tumor, juvenile granulosa cell tumor (with areas of marked atypia), and Sertoli cell tumor. Immunohistochemically, the tumor was positive for calretinin, MIC-2 (CD99), S100 protein, PGP 9.5, and neuron-specific enolase. Electron microscopy of the Sertoli cell tumor-like areas showed Charcot-Bottcher filaments, a distinguishing feature of Sertoli cells. Together, these findings supported a diagnosis of mixed sex cord-stromal tumor including granulosa cell tumor of adult and juvenile types and intermediate- to high-grade Sertoli cell tumor, with large areas of markedly atypical sex cord-stromal tumor.

Combined Adult Granulosa Cell Tumor and Mucinous Cystadenoma of the Ovary: Granulosa Cell Tumor with Heterologous Mucinous Elements

We describe an unusual ovarian neoplasm in a 57-year-old woman composed of an admixture of mucinous cystadenoma and adult granulosa cell tumor (AGCT). In areas the two components were separate but elsewhere there was intermingling of the two elements. The combination of mucinous cystadenoma and AGCT has only rarely been reported. Theories of histogenesis include a collision tumor and heterologous mucinous differentiation within an AGCT. We favor the latter theory in this case, because in many areas there was an intimate admixture of the two components. Because heterologous mucinous elements are well described in other ovarian sex-cord-stromal neoplasms, especially but not exclusively Sertoli Leydig cell tumors, it is not unexpected that a similar phenomenon could occur in an AGCT. We review the previously reported cases of combined mucinous cystadenoma and granulosa cell tumor of the ovary.

Comparative Immunohistochemical Analysis of Granulosa and Sertoli Components in Ovarian Sex Cord-Stromal Tumors with Mixed Differentiation: Potential Implications for Derivation of Sertoli Differentiation in Ovarian Tumors

Granulosa cell tumors of the ovary occasionally show admixed Sertoli components, just as tumors that are predominantly Sertoli or Sertoli-Leydig cell tumors can contain minor granulosa elements. Although the immunoprofiles of pure granulosa cell tumors and pure Sertoli cell tumors have been characterized, little is known regarding what immunophenotypic relationships exist between the granulosa and Sertoli components in ovarian sex cord-stromal tumors that contain both elements. Furthermore, it is not completely understood why sex cord-stromal tumors of the ovary with female-type (granulosa) differentiation can produce male-type (Sertoli) differentiation. To better understand why simultaneous differentiation into female-type and male-type components occurs, eight tumors with mixed differentiation were stained with a panel of antibodies to androgen receptor (AR), calretinin, CD10, CD99, estrogen receptor, inhibin, Ki-67, low molecular weight cytokeratin, pancytokeratin, progesterone receptor, p53, and vimentin. Immunohistochemical composite scores were determined separately for the matched pairs of granulosa and Sertoli components in each case. Differences between both components were statistically analyzed using the Wilcoxon signed rank test. AR and vimentin expression showed a difference at the 10% statistical significance level (p < 0.1), demonstrating higher levels of expression in the granulosa components. The differences between the granulosa and Sertoli components in expression of CD99, inhibin, or pancytokeratin were not statistically significant (p > 0.1, each). Statistical calculations could not be made for calretinin, CD10, estrogen receptor, Ki-67, low molecular weight cytokeratin, progesterone receptor, or p53, although the overall mean levels of expression of CD10 and low molecular weight cytokeratin were substantially higher in the Sertoli components. Not surprisingly, the granulosa and Sertoli components of ovarian sex cord-stromal tumors with mixed differentiation show overlapping immunophenotypic profiles consistent with derivation from a common lineage rather than reflecting a composite tumor. However, because components of a sex cord-stromal tumor simultaneously differentiate along granulosa or Sertoli lines, they seem to show preferential expression of certain antigens. CD10 and low molecular weight cytokeratin are more often associated with Sertoli cell differentiation, whereas AR and vimentin expression seem to reflect granulosa differentiation.

Inhibin immunohistochemical staining: a practical approach for the surgical pathologist in the diagnoses of ovarian sex cord-stromal tumors

Through a brief introduction of inhibin history, characteristics of the antibody against inhibin, and normal tissue distribution of alpha-inhibin expression, this comprehensive review focuses on a practical approach to using alpha-inhibin in the differential diagnosis of ovarian sex cord-stromal tumors (SCSTs). Alpha-inhibin has become a most useful immunohistochemical marker of gonadal SCST, regardless if the tumors are primary, recurrent, or metastatic. However, pathologic diagnosis of individual SCST is still based largely on morphologic criteria. Alpha-inhibin immunohistochemical (IHC) staining should be used only when a difficult morphologic diagnosis is encountered. In this perspective, alpha-inhibin and other properly selected markers should be ordered at the same time. This is simply because alpha-inhibin is not specific for SCSTs. Caution should be exercised in the interpretation of alpha-inhibin-positive cells, because a wide variety of primary and metastatic ovarian tumors may contain significant numbers of alpha-inhibin-positive stromal cells. As with other immunohistochemical stains, a panel of stains and comparison with the corresponding hematoxylin and eosin (H&E) slides is necessary, especially when staining patterns and cellular localization are in question. The antibody will not help to differentiate tumors within the category of SCST. The pattern or the intensity of staining in SCSTs does not predict tumor behavior, although there is a tendency of loss of alpha-inhibin expression in poorly differentiated Sertoli or Sertoli-Leydig cell tumors. In cases where metastatic granulosa or Sertoli-Leydig cell tumors are a concern, positive alpha-inhibin staining is diagnostic, but a negative result does not rule out metastatic disease. Calretinin has been recently recognized as a more sensitive, but less specific marker for SCSTs and it may be used to recognize an inhibin-negative SCST. In this review, we have listed nine of the most commonly encountered clinical scenarios where alpha-inhibin and other markers could be used in diagnostic surgical pathology of ovarian tumors.

Recent advances in immunohistochemistry in the diagnosis of ovarian neoplasms

This leader reviews recent advances in immunohistochemistry that are useful in the diagnosis of ovarian neoplasms. These include the value of different anticytokeratin antibodies in the distinction between a primary ovarian adenocarcinoma and a metastatic adenocarcinoma, especially of colorectal origin. These antibodies have also helped to clarify the origin of the peritoneal disease in most cases of pseudomyxoma peritonei. The value of antibodies against so called tumour specific antigens, such as CA125 and HAM56, in determining the ovarian origin of an adenocarcinoma is also reviewed. In recent years, several studies have investigated the value of a variety of monoclonal antibodies in the diagnosis of ovarian sex cord stromal tumours and in the distinction between these neoplasms and their histological mimics. These antibodies include those directed against inhibin, CD99, Mullerian inhibiting substance, relaxin like factor, melan A, and calretinin. Of these, anti-alpha inhibin appears to be of most diagnostic value. It is stressed that these antibodies should always be used as part of a larger panel and not in isolation.

Immunoexpression of inhibin alpha subunit, inhibin/activin betaA subunit and CD99 in ovarian tumors

OBJECTIVE

Anti-inhibin alpha and inhibin/activin betaA subunit and anti-CD99 monoclonal antibodies (mAbs) have recently been demonstrated to be able to label ovarian granulosa cells; thus, they may be of value in the diagnosis of granulosa cell tumors. The present study aimed to determine what combination of these mAbs may be useful for the differential diagnosis of sex cord-stromal tumors of ovary.

DESIGN

Immunohistochemical analyses with anti-inhibin alpha and inhibin/activin betaA subunit antibody and anti-CD99 mAb were performed on 42 ovarian tumors, including sex cord-stromal tumors (29), ovarian epithelial cancers (10), and Krukenberg tumors (3).

RESULTS

All sex cord-stromal tumors were positive for inhibin alpha subunit, and 17 cases (58.6%) of sex cord-stromal tumors were immunoreactive for inhibin/activin betaA subunit. Epithelial tumors and Krukenberg tumors were all negative for inhibin/activin betaA subunit except mucinous carcinoma, which showed strong cytoplasmic immunoreactivity. All sex cord-stromal tumors except one granulosa cell tumor showed membranous staining for CD99. A case of serous carcinoma and a case of mucinous carcinoma were positive for CD99, and the remaining epithelial tumors and Krukenberg tumor were all negative for CD99.

CONCLUSIONS

The results of immunohistochemical analysis, together with literature review, suggest that inhibin alpha subunit may be a useful diagnostic marker for sex cord-stromal tumor of the ovary. In addition, anti-CD99 antibody may be useful for the differential diagnosis between ovarian tumors. Inhibin/activin betaA subunit has a limited usefulness in the differential diagnosis of ovarian tumor because of its wider immunoreactivity for both sex cord-stromal tumors and mucinous carcinomas. The differential diagnosis of sex cord-stromal tumors of the ovary would be better made with a combined use of both anti-inhibin alpha subunit and anti-CD99 mAbs.

Hormonally Functional Ovarian Neoplasms

Hormonally functional ovarian neoplasms are those tumors that secrete one or more hormones that are clinically manifested in the patient. The hormone production may have implications for the diagnosis, management or treatment of the patient. Hormonally functional ovarian neoplasms include tumors that belong to various histologic categories and produce a variety of hormonal effects. Functional ovarian tumors most commonly produce steroid hormones, and such tumors frequently belong in the sex cord-stromal and steroid cell categories. In addition, a wide variety of peptide hormones may be produced by ovarian tumors. Although in most instances the neoplastic cells themselves produce the hormones, a wide variety of tumors may induce their stroma to produce steroid hormones. The stroma of ovarian tumors is derived from the ovarian stroma and may, on occasion, resemble specialized ovarian stroma and its derivatives. Cells resembling luteinized stromal cells or luteinized theca cells may be present and appear to be responsible for the resultant hormone secretion.

Immunohistochemical staining of ovarian granulosa cell tumors with monoclonal antibody against inhibin

Inhibin is a peptide hormone produced by ovarian granulosa cells and by granulosa cell tumors. Serum inhibin measurements have been used as a biochemical marker of the presence or progression of ovarian granulosa cell tumors and their metastases. In the current study, an antibody against the alpha-subunit of human inhibin was used to stain 16 cases of ovarian adult granulosa cell tumors, 15 cases of other ovarian sex cord-stromal tumors, and 51 cases of a range of ovarian and extraovarian neoplasms, many of which may mimic granulosa cell tumor. There was diffuse strong cytoplasmic staining of all cases of adult granulosa cell tumor. Diffuse positive staining also was observed in all Leydig cell tumors, and there was focal staining in a proportion of fibrothecomas. There was focal weak staining of one case of ovarian clear cell carcinoma but no staining of other ovarian and extraovarian neoplasms. Immunohistochemical staining with antibodies against inhibin is of value in the diagnosis of granulosa cell tumor and in the distinction of this neoplasm from others that may mimic it. The antibody also may be useful for the confirmation of late metastasis of granulosa cell tumor, especially when the previous history is not known.