Difference between revisions of "Sertoli-Leydig cell tumour"

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==General==
==General==
*Sertoli and leydig cells are normal in the [[testis]].
*Sertoli and leydig cells are normal in the [[testis]].
*Poorly differentiated tumours have sarcomatous features.<ref name=Ref_PBoD1103>{{Ref PBoD|1103}}</ref>
**Tumor was called androblastoma or arrhenoblastoma in the past
*May present with masculinization (virilization).<ref name=pmid23173550>{{Cite journal  | last1 = Xiao | first1 = H. | last2 = Li | first2 = B. | last3 = Zuo | first3 = J. | last4 = Feng | first4 = X. | last5 = Li | first5 = X. | last6 = Zhang | first6 = R. | last7 = Wu | first7 = L. | title = Ovarian Sertoli-Leydig cell tumor: a report of seven cases and a review of the literature. | journal = Gynecol Endocrinol | volume = 29 | issue = 3 | pages = 192-5 | month = Mar | year = 2013 | doi = 10.3109/09513590.2012.738723 | PMID = 23173550 }}</ref>
*May present with masculinization (virilization).<ref name=pmid23173550>{{Cite journal  | last1 = Xiao | first1 = H. | last2 = Li | first2 = B. | last3 = Zuo | first3 = J. | last4 = Feng | first4 = X. | last5 = Li | first5 = X. | last6 = Zhang | first6 = R. | last7 = Wu | first7 = L. | title = Ovarian Sertoli-Leydig cell tumor: a report of seven cases and a review of the literature. | journal = Gynecol Endocrinol | volume = 29 | issue = 3 | pages = 192-5 | month = Mar | year = 2013 | doi = 10.3109/09513590.2012.738723 | PMID = 23173550 }}</ref>
*May present as abdominal swelling or pain.
*Generally a tumor of younger women and can present in children.<ref>{{Cite journal  | last1 = Young | first1 = RH. | last2 = Scully | first2 = RE. | title = Ovarian Sertoli-Leydig cell tumors. A clinicopathological analysis of 207 cases. | journal = Am J Surg Pathol | volume = 9 | issue = 8 | pages = 543-69 | month = Aug | year = 1985 | doi =  | PMID = 3911780 }}</ref>
**75% younger than 30 years of age
**10% over 50 years of age.
*[[DICER1 mutation]] common in moderately and poorly differentiated Sertoli-Leydig cell tumours.<ref name=pmid28654427>{{Cite journal  | last1 = de Kock | first1 = L. | last2 = Terzic | first2 = T. | last3 = McCluggage | first3 = WG. | last4 = Stewart | first4 = CJR. | last5 = Shaw | first5 = P. | last6 = Foulkes | first6 = WD. | last7 = Clarke | first7 = BA. | title = DICER1 Mutations Are Consistently Present in Moderately and Poorly Differentiated Sertoli-Leydig Cell Tumors. | journal = Am J Surg Pathol | volume = 41 | issue = 9 | pages = 1178-1187 | month = Sep | year = 2017 | doi = 10.1097/PAS.0000000000000895 | PMID = 28654427 }}</ref>


==Microscopic==
==Microscopic==
Features:
Features:
# Sertoli ''or'' Leydig cells.<ref name=Ref_PBoD1103>{{Ref PBoD|1103}}</ref>  
* Sertoli ''or'' Leydig cells.<ref name=Ref_PBoD1103>{{Ref PBoD|1103}}</ref>  
#* Leydig cells:
** Leydig cells:
#**Polygonal pink cells
***Polygonal pink cells
#** Abundant solid or somewhat granular eosinophilic cytoplasm.
*** Abundant solid or somewhat granular eosinophilic cytoplasm.
#** Round nuclei with fine chromatin and a small or indistinct [[nucleolus]].
*** Round nuclei with fine chromatin and a small or indistinct [[nucleolus]].
#** Often in small clusters ~ 5-25 cells/cluster.
*** Often in small clusters ~ 5-25 cells/cluster.
#* Sertoli cells:
** Sertoli cells:
#** Pale/clear vacuolated cytoplasm.
*** Pale/clear vacuolated cytoplasm.
#** Irregular nuclei with irregular/vacuolated-appearing chromatin.
*** Irregular nuclei with irregular/vacuolated-appearing chromatin.
#** Architecture: tubules, cords or sheets.
*** Architecture: tubules, cords or sheets.
# Stroma.  
****Classic Sertoli tubule shows an 'antipodal arrangement of nuclei'
# +/- Sarcomatous features (mucinous glands, bone, cartilage).
*****Nuclei sit near the basement membrane away from the tubule lumen.
*****A fair bit of cytoplasm sits above the nucleus.
*****Lumen is round.
***Mitotic activity may be much lower than expected for the degree of atypia (in comparison to adenocarcinoma).
**Stroma
***Varies from fibrous pink stroma in well differentiated tumors to cellular primative stroma in poorly differentiated tumors.
***+/-Stromal edema may be prominent
 
*Growth Patterns:
**Well-differentiated.
***Hollow or solid tubules of mature Sertoli cells with Leydig cells in the intervening stroma.
**Intermediate (most common).
***Jumbled admixture of dark blue Sertoli cells and Leydig cells.
***Lobules comprising sheets of Sertoli cells.
***Some areas of tubules.
**Poorly differentiated.
***Masses of malignant spindle cells – sheets of cells can be reminiscent of fibrosarcoma or granulosa cell tumour.
***Tubules may be a very minor element.
***Poorly differentiated tumours have sarcomatous features.<ref name=Ref_PBoD1103>{{Ref PBoD|1103}}</ref>
**Retiform.<ref>{{Cite journal  | last1 = Young | first1 = RH. | last2 = Scully | first2 = RE. | title = Ovarian Sertoli-Leydig cell tumors with a retiform pattern: a problem in histopathologic diagnosis. A report of 25 cases. | journal = Am J Surg Pathol | volume = 7 | issue = 8 | pages = 755-71 | month = Dec | year = 1983 | doi =  | PMID = 6660351 }}</ref>
***Tumour resembles rete testis/ovary with an irregular network of elongated slit-like tubules and cysts, which may contain papillae.
**With heterologous element.
***Mucinous intestinal-type epithelium, cartilage, skeletal muscle.
***Heterologous elements can occur in retiform or poorly differentiated tumours.
***+/-Sarcomatous features (mucinous glands, bone, cartilage).


*Well differentiated -
**Mature Sertoli cells line form tubules that grow in a fibrous stroma containing clusters of Leydig
cells
*Intermediate to poorly differentiated - 
**A more disorganized, more cellular tumor with less mature Sertoli cells growing in trabeculae and nests.  Some tubule formation, either round or retiform. Leydig cells, either singly or in clusters, are present in a cellular stroma.


DDx:
DDx:
*[[Endometrioid carcinoma of the ovary]].
*[[Endometrioid carcinoma of the ovary]] (sertoliform variant)
*Luteinized [[adult granulosa cell tumour]] - super rare, 50% of cell with eosinophilic cytoplasm, other findings of granulosa cell tumour, e.g. Call-Exner bodies.<ref name=pmid21804396>{{Cite journal  | last1 = Ganesan | first1 = R. | last2 = Hirschowitz | first2 = L. | last3 = Baltrušaitytė | first3 = I. | last4 = McCluggage | first4 = WG. | title = Luteinized adult granulosa cell tumor--a series of 9 cases: revisiting a rare variant of adult granulosa cell tumor. | journal = Int J Gynecol Pathol | volume = 30 | issue = 5 | pages = 452-9 | month = Sep | year = 2011 | doi = 10.1097/PGP.0b013e318214b17f | PMID = 21804396 }}</ref>
**Should be positive for EMA, CK7 and negative for inhibin and calretinin.<ref>{{Cite journal  | last1 = McCluggage | first1 = WG. | last2 = Young | first2 = RH. | title = Ovarian sertoli-leydig cell tumors with pseudoendometrioid tubules (pseudoendometrioid sertoli-leydig cell tumors). | journal = Am J Surg Pathol | volume = 31 | issue = 4 | pages = 592-7 | month = Apr | year = 2007 | doi = 10.1097/01.pas.0000213365.56498.72 | PMID = 17414107 }}</ref>
**Should have some characteristic areas of endometriod carcinoma and may have some typical features
***Cilia, squamous metaplasia, mucin production
*Luteinized [[adult granulosa cell tumour]] - super rare, 50% of cell with eosinophilic cytoplasm, other findings of granulosa cell tumour, e.g. Call-Exner bodies. More likely to be keratin negative than a Sertoli-Leydig cell tumor. <ref name=pmid21804396>{{Cite journal  | last1 = Ganesan | first1 = R. | last2 = Hirschowitz | first2 = L. | last3 = Baltrušaitytė | first3 = I. | last4 = McCluggage | first4 = WG. | title = Luteinized adult granulosa cell tumor--a series of 9 cases: revisiting a rare variant of adult granulosa cell tumor. | journal = Int J Gynecol Pathol | volume = 30 | issue = 5 | pages = 452-9 | month = Sep | year = 2011 | doi = 10.1097/PGP.0b013e318214b17f | PMID = 21804396 }}</ref>
*Ovarian carcinosarcoma - especially considering poorly differentiated versions with heterologous areas.


Retiform variant
*Ovarian serous carcinoma - generally carcinoma patients are older.
*Ovarian yolk sac tumor
===Images===
===Images===
<gallery>
<gallery>
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Image:Sertoli-Leydig_cell_tumour_-_high_mag.jpg | Sertoli-Leydig cell tumour - high mag. (WC)
Image:Sertoli-Leydig_cell_tumour_-_high_mag.jpg | Sertoli-Leydig cell tumour - high mag. (WC)
Image:Sertoli-Leydig_cell_tumour_-_very_high_mag.jpg | Sertoli-Leydig cell tumour - very high mag. (WC)
Image:Sertoli-Leydig_cell_tumour_-_very_high_mag.jpg | Sertoli-Leydig cell tumour - very high mag. (WC)
Image:Ovary SertoliLeydigCellTumor 4 PA.jpg|Ovarian Sertoli Leydig Cell Tumor - Well differentiated - low power (SKB)
Image:Ovary SertoliLeydigCellTumor 5 PA.jpg|Ovarian Sertoli Leydig Cell Tumor - Well differentiated - low power (SKB)
Image:Ovary SertoliLeydigCellTumor 7 PA.jpg|Ovarian Sertoli Leydig Cell Tumor - Well differentiated - medium power (SKB)
Image:Ovary SertoliLeydigCellTumor 6 PA.jpg|Ovarian Sertoli Leydig Cell Tumor - Well differentiated (SKB)
Image:Ovary SertoliLeydigCellTumor.jpg|Ovarian Sertoli Leydig Cell Tumor - Well differentiated (SKB)
Image:Ovary SertoliLeydigCellTumor 3 PA.jpg|Ovarian Sertoli Leydig Cell Tumor - Well differentiated - see how much cytoplasm is between the nucleus and the lumen?  See the crisp outline of the lumen by the apical membrane of the cells - this is a typical Leydig tubule. (SKB)
Image:Ovary SertoliLeydigCellTumor PA.jpg|Ovarian Sertoli Leydig Cell Tumor - Well differentiated (SKB)
Image:Ovary SertoliLeydigCellTumor MP2 CTR.jpg|Ovarian Sertoli Leydig Cell Tumor - medium power - This example is somewhat between the previous well differentiated and following intermediate differentiated examples (SKB)
Image:Ovary SertoliLeydigCellTumor MP3 CTR.jpg|Ovarian Sertoli Leydig Cell Tumor - medium power (SKB)
Image:Ovary SertoliLeydigCellTumor MP CTR.jpg|Ovarian Sertoli Leydig Cell Tumor - medium power (SKB)
Image:Ovary SertoliLeydig Intermediate MP CTR.jpg|Ovarian Sertoli-Leydig Cell Tumor - Intermediate differentiation - Medium power (SKB)
Image:Ovary SertoliLeydig Intermediate HP CTR.jpg|Ovarian Sertoli-Leydig Cell Tumor - Intermediate differentiation - High power (SKB)
Image:Ovary SertoliLeydig Intermediate HP2 CTR.jpg|Ovarian Sertoli-Leydig Cell Tumor - Intermediate differentiation - High power (SKB)
</gallery>
</gallery>
www:
www:
*[http://path.upmc.edu/cases/case270/micro.html Sex cord stromal tumour with Sertoli-Leydig component - several images (upmc.edu)].
*[http://path.upmc.edu/cases/case270/micro.html Sex cord stromal tumour with Sertoli-Leydig component - several images (upmc.edu)].
==Prognosis==
*Dependant on degree of differentiation and stage at presentation.<ref>{{Cite journal  | last1 = Young | first1 = RH. | last2 = Scully | first2 = RE. | title = Ovarian Sertoli-Leydig cell tumors. A clinicopathological analysis of 207 cases. | journal = Am J Surg Pathol | volume = 9 | issue = 8 | pages = 543-69 | month = Aug | year = 1985 | doi =  | PMID = 3911780 }}</ref>
*Heterologous mesenchymal elements may portend a worse outcome.<ref>{{Cite journal  | last1 = Zaloudek | first1 = C. | last2 = Norris | first2 = HJ. | title = Sertoli-Leydig tumors of the ovary. A clinicopathologic study of 64 intermediate and poorly differentiated neoplasms. | journal = Am J Surg Pathol | volume = 8 | issue = 6 | pages = 405-18 | month = Jun | year = 1984 | doi =  | PMID = 6731664 }}</ref>


==IHC==
==IHC==
Features:<ref name=pmid19033865>{{Cite journal  | last1 = Zhao | first1 = C. | last2 = Vinh | first2 = TN. | last3 = McManus | first3 = K. | last4 = Dabbs | first4 = D. | last5 = Barner | first5 = R. | last6 = Vang | first6 = R. | title = Identification of the most sensitive and robust immunohistochemical markers in different categories of ovarian sex cord-stromal tumors. | journal = Am J Surg Pathol | volume = 33 | issue = 3 | pages = 354-66 | month = Mar | year = 2009 | doi = 10.1097/PAS.0b013e318188373d | PMID = 19033865 }}</ref>
Features:<ref name=pmid19033865>{{Cite journal  | last1 = Zhao | first1 = C. | last2 = Vinh | first2 = TN. | last3 = McManus | first3 = K. | last4 = Dabbs | first4 = D. | last5 = Barner | first5 = R. | last6 = Vang | first6 = R. | title = Identification of the most sensitive and robust immunohistochemical markers in different categories of ovarian sex cord-stromal tumors. | journal = Am J Surg Pathol | volume = 33 | issue = 3 | pages = 354-66 | month = Mar | year = 2009 | doi = 10.1097/PAS.0b013e318188373d | PMID = 19033865 }}</ref>
*AE1/AE3 +ve
 
*Inhibin +ve
*'''Inhibin''' +ve
*'''Calretinin''' +ve.
*WT-1 +ve.  
*WT-1 +ve.  
*Melan A (MART-1) +ve - marks the Leydig component.
*Melan A (MART-1) +ve - marks the Leydig component.
*Vimentin +ve.<ref name=pmid20349790>{{Cite journal  | last1 = Kondi-Pafiti | first1 = A. | last2 = Grapsa | first2 = D. | last3 = Kairi-Vassilatou | first3 = E. | last4 = Carvounis | first4 = E. | last5 = Hasiakos | first5 = D. | last6 = Kontogianni | first6 = K. | last7 = Fotiou | first7 = S. | title = Granulosa cell tumors of the ovary: a clinicopathologic and immunohistochemical study of 21 cases. | journal = Eur J Gynaecol Oncol | volume = 31 | issue = 1 | pages = 94-8 | month =  | year = 2010 | doi =  | PMID = 20349790 }}</ref>
*Vimentin +ve.<ref name=pmid20349790>{{Cite journal  | last1 = Kondi-Pafiti | first1 = A. | last2 = Grapsa | first2 = D. | last3 = Kairi-Vassilatou | first3 = E. | last4 = Carvounis | first4 = E. | last5 = Hasiakos | first5 = D. | last6 = Kontogianni | first6 = K. | last7 = Fotiou | first7 = S. | title = Granulosa cell tumors of the ovary: a clinicopathologic and immunohistochemical study of 21 cases. | journal = Eur J Gynaecol Oncol | volume = 31 | issue = 1 | pages = 94-8 | month =  | year = 2010 | doi =  | PMID = 20349790 }}</ref>
*Calretinin +ve.
*CD99 +ve.
*CD99 +ve.
*[[AE1/AE3]] and [[pankeratin]] +ve


Others:<ref name=pmid20349790/>
Others:<ref name=pmid20349790/>
*CD34 -ve.
*CD34 -ve.
*EMA -ve.
*'''[[EMA]]''' -ve.
*[[CK7]] -ve.
 
Keep in mind that this is a biphasic tumor - Leydig cells will not be Pan-keratin positive - Sertoli cells do not express calretinin - Both components express inhibin - etcetera - interpreting this immunopanal requires correlation with the histomorphology.  Immunoreactivity may be focal.


Pan-keratins and AE1/AE3 may mark granulosa cell tumors and Sertoli cell tumors causing confusion with adenocarcinoma. EMA is a better marker to exclude an epithelial tumor as EMA is negative in sex cord-stromal tumors.  Adding complexity, endometrioid adenocarcinomas may occasionally weakly express inhibin, calretinin or WT-1.
Pan-keratins and AE1/AE3 may mark granulosa cell tumors and Sertoli cell tumors causing confusion with adenocarcinoma. EMA is a better marker to exclude an epithelial tumor as EMA is negative in sex cord-stromal tumors.  Highlighting why a panel of stains is needed, endometrioid adenocarcinomas may occasionally weakly express inhibin, calretinin or WT-1.


==See also==
==See also==

Latest revision as of 09:43, 11 September 2018

Sertoli-Leydig cell tumour, also Sertoli-Leydig tumour, is a rare tumour of the gonad in the sex cord-stromal group of tumours.

General

  • Sertoli and leydig cells are normal in the testis.
    • Tumor was called androblastoma or arrhenoblastoma in the past
  • May present with masculinization (virilization).[1]
  • May present as abdominal swelling or pain.
  • Generally a tumor of younger women and can present in children.[2]
    • 75% younger than 30 years of age
    • 10% over 50 years of age.
  • DICER1 mutation common in moderately and poorly differentiated Sertoli-Leydig cell tumours.[3]

Microscopic

Features:

  • Sertoli or Leydig cells.[4]
    • Leydig cells:
      • Polygonal pink cells
      • Abundant solid or somewhat granular eosinophilic cytoplasm.
      • Round nuclei with fine chromatin and a small or indistinct nucleolus.
      • Often in small clusters ~ 5-25 cells/cluster.
    • Sertoli cells:
      • Pale/clear vacuolated cytoplasm.
      • Irregular nuclei with irregular/vacuolated-appearing chromatin.
      • Architecture: tubules, cords or sheets.
        • Classic Sertoli tubule shows an 'antipodal arrangement of nuclei'
          • Nuclei sit near the basement membrane away from the tubule lumen.
          • A fair bit of cytoplasm sits above the nucleus.
          • Lumen is round.
      • Mitotic activity may be much lower than expected for the degree of atypia (in comparison to adenocarcinoma).
    • Stroma
      • Varies from fibrous pink stroma in well differentiated tumors to cellular primative stroma in poorly differentiated tumors.
      • +/-Stromal edema may be prominent
  • Growth Patterns:
    • Well-differentiated.
      • Hollow or solid tubules of mature Sertoli cells with Leydig cells in the intervening stroma.
    • Intermediate (most common).
      • Jumbled admixture of dark blue Sertoli cells and Leydig cells.
      • Lobules comprising sheets of Sertoli cells.
      • Some areas of tubules.
    • Poorly differentiated.
      • Masses of malignant spindle cells – sheets of cells can be reminiscent of fibrosarcoma or granulosa cell tumour.
      • Tubules may be a very minor element.
      • Poorly differentiated tumours have sarcomatous features.[4]
    • Retiform.[5]
      • Tumour resembles rete testis/ovary with an irregular network of elongated slit-like tubules and cysts, which may contain papillae.
    • With heterologous element.
      • Mucinous intestinal-type epithelium, cartilage, skeletal muscle.
      • Heterologous elements can occur in retiform or poorly differentiated tumours.
      • +/-Sarcomatous features (mucinous glands, bone, cartilage).


DDx:

  • Endometrioid carcinoma of the ovary (sertoliform variant)
    • Should be positive for EMA, CK7 and negative for inhibin and calretinin.[6]
    • Should have some characteristic areas of endometriod carcinoma and may have some typical features
      • Cilia, squamous metaplasia, mucin production
  • Luteinized adult granulosa cell tumour - super rare, 50% of cell with eosinophilic cytoplasm, other findings of granulosa cell tumour, e.g. Call-Exner bodies. More likely to be keratin negative than a Sertoli-Leydig cell tumor. [7]
  • Ovarian carcinosarcoma - especially considering poorly differentiated versions with heterologous areas.

Retiform variant

  • Ovarian serous carcinoma - generally carcinoma patients are older.
  • Ovarian yolk sac tumor

Images

  • Sertoli-Leydig cell tumour - intermed. mag. (WC)

  • Sertoli-Leydig cell tumour - high mag. (WC)

  • Sertoli-Leydig cell tumour - very high mag. (WC)

  • Ovarian Sertoli Leydig Cell Tumor - Well differentiated - low power (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - Well differentiated - low power (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - Well differentiated - medium power (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - Well differentiated (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - Well differentiated (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - Well differentiated - see how much cytoplasm is between the nucleus and the lumen? See the crisp outline of the lumen by the apical membrane of the cells - this is a typical Leydig tubule. (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - Well differentiated (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - medium power - This example is somewhat between the previous well differentiated and following intermediate differentiated examples (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - medium power (SKB)

  • Ovarian Sertoli Leydig Cell Tumor - medium power (SKB)

  • Ovarian Sertoli-Leydig Cell Tumor - Intermediate differentiation - Medium power (SKB)

  • Ovarian Sertoli-Leydig Cell Tumor - Intermediate differentiation - High power (SKB)

  • Ovarian Sertoli-Leydig Cell Tumor - Intermediate differentiation - High power (SKB)

www:

Prognosis

  • Dependant on degree of differentiation and stage at presentation.[8]
  • Heterologous mesenchymal elements may portend a worse outcome.[9]

IHC

Features:[10]

  • Inhibin +ve
  • Calretinin +ve.
  • WT-1 +ve.
  • Melan A (MART-1) +ve - marks the Leydig component.
  • Vimentin +ve.[11]
  • CD99 +ve.
  • AE1/AE3 and pankeratin +ve

Others:[11]

Keep in mind that this is a biphasic tumor - Leydig cells will not be Pan-keratin positive - Sertoli cells do not express calretinin - Both components express inhibin - etcetera - interpreting this immunopanal requires correlation with the histomorphology. Immunoreactivity may be focal.

Pan-keratins and AE1/AE3 may mark granulosa cell tumors and Sertoli cell tumors causing confusion with adenocarcinoma. EMA is a better marker to exclude an epithelial tumor as EMA is negative in sex cord-stromal tumors. Highlighting why a panel of stains is needed, endometrioid adenocarcinomas may occasionally weakly express inhibin, calretinin or WT-1.

See also

References

  1. ↑ Xiao, H.; Li, B.; Zuo, J.; Feng, X.; Li, X.; Zhang, R.; Wu, L. (Mar 2013). "Ovarian Sertoli-Leydig cell tumor: a report of seven cases and a review of the literature.". Gynecol Endocrinol 29 (3): 192-5. doi:10.3109/09513590.2012.738723. PMID 23173550.
  2. ↑ Young, RH.; Scully, RE. (Aug 1985). "Ovarian Sertoli-Leydig cell tumors. A clinicopathological analysis of 207 cases.". Am J Surg Pathol 9 (8): 543-69. PMID 3911780.
  3. ↑ de Kock, L.; Terzic, T.; McCluggage, WG.; Stewart, CJR.; Shaw, P.; Foulkes, WD.; Clarke, BA. (Sep 2017). "DICER1 Mutations Are Consistently Present in Moderately and Poorly Differentiated Sertoli-Leydig Cell Tumors.". Am J Surg Pathol 41 (9): 1178-1187. doi:10.1097/PAS.0000000000000895. PMID 28654427.
  4. ↑ 4.0 4.1 Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1103. ISBN 0-7216-0187-1.
  5. ↑ Young, RH.; Scully, RE. (Dec 1983). "Ovarian Sertoli-Leydig cell tumors with a retiform pattern: a problem in histopathologic diagnosis. A report of 25 cases.". Am J Surg Pathol 7 (8): 755-71. PMID 6660351.
  6. ↑ McCluggage, WG.; Young, RH. (Apr 2007). "Ovarian sertoli-leydig cell tumors with pseudoendometrioid tubules (pseudoendometrioid sertoli-leydig cell tumors).". Am J Surg Pathol 31 (4): 592-7. doi:10.1097/01.pas.0000213365.56498.72. PMID 17414107.
  7. ↑ Ganesan, R.; Hirschowitz, L.; Baltrušaitytė, I.; McCluggage, WG. (Sep 2011). "Luteinized adult granulosa cell tumor--a series of 9 cases: revisiting a rare variant of adult granulosa cell tumor.". Int J Gynecol Pathol 30 (5): 452-9. doi:10.1097/PGP.0b013e318214b17f. PMID 21804396.
  8. ↑ Young, RH.; Scully, RE. (Aug 1985). "Ovarian Sertoli-Leydig cell tumors. A clinicopathological analysis of 207 cases.". Am J Surg Pathol 9 (8): 543-69. PMID 3911780.
  9. ↑ Zaloudek, C.; Norris, HJ. (Jun 1984). "Sertoli-Leydig tumors of the ovary. A clinicopathologic study of 64 intermediate and poorly differentiated neoplasms.". Am J Surg Pathol 8 (6): 405-18. PMID 6731664.
  10. ↑ Zhao, C.; Vinh, TN.; McManus, K.; Dabbs, D.; Barner, R.; Vang, R. (Mar 2009). "Identification of the most sensitive and robust immunohistochemical markers in different categories of ovarian sex cord-stromal tumors.". Am J Surg Pathol 33 (3): 354-66. doi:10.1097/PAS.0b013e318188373d. PMID 19033865.
  11. ↑ 11.0 11.1 Kondi-Pafiti, A.; Grapsa, D.; Kairi-Vassilatou, E.; Carvounis, E.; Hasiakos, D.; Kontogianni, K.; Fotiou, S. (2010). "Granulosa cell tumors of the ovary: a clinicopathologic and immunohistochemical study of 21 cases.". Eur J Gynaecol Oncol 31 (1): 94-8. PMID 20349790.
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