Utility of lmmunohistochemistry in Distinguishing Ovarian Sertoli-Stromal Cell Tumors From Carcinosarcomas MICHAEL J. COSTA, MD, ROBERT J. MORRIS, MD, REGINALD WILSON, MD, AND RANDY JUDD, MD Poorly

differentiated

Sertoli-stromal

cell tumors and carcinosar-

coma, stromal areas of Sertoli-stromal

cell tumor did not express

comas of the ovary both show biphasic epithelial and stromal pat-

S-100, even the one case containing heterologous

terns and may both show heterologous

we noted a lower disease-free

a difficult

differential

diagnosis.

stromal elements, presenting

We

studied

chemical profile of Sertoli cell differentiation

the immunohistoin human testes and

tumors, we studied too few poorly

ferentiated Sertoli-stromal

tumors to evaluate the clinical utility of

distinguishing

cell tumors, six carcinosarcomas

23:787-797.

fetal, one infant, and four adult) were studied using antibodies cytokeratinAElzAE3 (MSA),

vimentin, desmin, muscle-specific

(CEA-P),

(CEA-M),

and placental

carcinoembryonic

alkaline phosphatase

testes, immature gonadal

antigen polyclonal (PLAP).

In the fetal

stroma and sex cord areas stained with

(six

vimentin (six of six cases), AE1:3 (five of six cases), and CAM of six cases). Sertoli cells in immature gonadal cords, and seminiferous testes never showed CA 125, CEA-hi,

tubules of normal

immunoreactivity

CEA-P,

or PLAP.

stroma areas, sex

fetal, infant, or adult

for EMA,

S-100, CA

All Sertoli-stromal

19-9,

cell tumors

stained with AE1:3 and CAM in areas of Sertoli cell differentiation (11 of 11 cases) but did not stain with EMA, PLAP,

CEA-P,

CEA-

M, CA 19-9, CA 125, or S-100 (none of 11 cases). Carcinosarcomas expressed

AE1:3 and CAM

in all epithelial

areas (six of six cases)

and most stromal areas (five of six cases). Carcinomatous carcinosarcoma

also showed immunoreactivity

cases], CA 125 (two of six cases), PLAP (two of six cases), and CEA-M of carcinosarcoma

expressed

three of 11 Sertoli-stromal

areas of

for EMA (six of six

(two of six cases), CEA-P

(one of six cases), while stromal areas

(four of six cases). Heterologous

EMA

(four of six cases) and S-100

stromal elements were present in

cell tumors (two showed skeletal muscle

and one showed both skeletal muscle and cartilage differentiation) and in four of six carcinosarcomas

(one skeletal muscle, one car-

tilage, and two cartilage and skeletal muscle). All skeletal muscle heterologous

elements expressed desmin, vimentin, and MSA. The

heterologous

cartilage in carcinosarcoma

stained with S-100 (three

of three), while the one case of heterologous

cartilage

in Sertoli-

stromal cell tumor did not. These results suggest that ovarian Sertolistromal cell tumor can be distinguished the absence of staining for EMA, PLAP, in epithelial areas of Sertoli-stromal

from carcinosarcoma

from carcinosarcomas.

HLIM PATHOL

0 1992 by W.B. Saunders Company

Ovarian Sertoli-stromal cell tumors consist of six distinct entities,’ as outlined in Table 1. Sertoli-stromal cell tumors are sex cord-stromal tumors of the ovary that exhibit a testicular line of differentiation.‘-’ The large spectrum of histologic appearances of Sertolistroma cell tumor can pose diagnostic difficulties for the surgical pathologist, particularly the poorly differentiated or retiform Sertoli-Leydig cell tumors (Table 1).lm6Since these tumors are rare (only .2% of all ovarian neoplasms), they are rarely encountered in routine practice. The more frequent endometrioid adenocarcinema of the ovary often can mimic Sertoli-stromal cell (matumors quite closely. ‘9’ Ovarian carcinosarcomas lignant mixed miillerian [mesodermal] tumor)“-t4 also are mentioned often in the differential diagnosis of Sertoli-stromal cell tumors.2-5 Carcinosarcoma has a biphasic appearance, showing an epithelial carcinomatous component and a stromal sarcomatous component. The sarcomatous component may show heterologous differentiation to elements not normally present in the female genital tract, such as cartilage or skeletal muscle.‘0-14 Intermediately or poorly differentiated Sertoli-Leydig cell tumors may have a biphasic histologic pattern, and Sertoli-Leydig cell tumors may also show heterologous stroma elements (Table 1) that in certain cases can mimic carcinosarcoma quite closely.2e6 The distinction between these rare and histologically complicated tumors is of more than academic importance, as ovarian carcinosarcoma is a high-grade malignant tumor with a median survival rate of 6 to 12 months’O-l4 while Sertolistromal cell tumor is a low-grade malignant tumor with only approximately 7% to 18% of reported tumors behaving in a malignant fashion.‘-’ However, poorly differentiated Sertoli-stromal cell tumors, those tumors in which immunohistochemistry is diagnostically most useful, may have a worse prognosis approaching that of carcinosarcomas.2s6 We cannot add to the excellent discussions of the characteristic histologic and clinical differential features between carcinosarcoma and Sertoli-stromal cell tumor that have already been reported.2-5 However, these criteria can be difficult to apply in the individual case. Pre-

actin

S-100 protein (S-100), CA 19-9, CA 125, carcinoembryonic

antigen monoclonal

this subgroup Copyright

dif-

to

(AE1:3), cytokeratin CAM 5.2 (CAM), epithelial

membrane antigen (EMA),

com-

pared with Sertoli-stromal

applied these findings to the ovarian tumors. Eleven Sertoli-stromal of the ovary, and 11 testes (six

cartilage. While

survival rate in carcinosarcomas

by

CEA, CA 125, or CA 19-9

cell tumor. Unlike carcinosar-

From the Department of Pathology, University of California, San Francisco, CA; the Department of Pathology, Emory University, Atlanta, GA; the Department of Pathology, Beaumont Army Medical Center, El Paso. TX; and the Department of Pathology, Derrick and Associates, Orlando, FL. Accepted for publication September 16, 1991. Key words: ovarian Sertoli-stromal cell tumors, ovarian carcinosarcomas, ovarian malignant mixed miillerian (mesodermal) tumors, immunohistochemistry, Sertoli cells. Address correspondence and reprint requests to Michael J. Costa, MD, Department of Pathology. UC San Francisco, Campus Box 0506, San Francisco, CA 94143-0506. Copyright 0 1992 by W.B. Saunders Company 0046-8177/92/2307-0013$5.00/O

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HUMAN PATHOLOGY TABLE 1.

Volume 23, No. 7 (July 1992)

Sertoli-Stromal Cell Tumors (Androblastomas)

a 34-year-old

Sertoli cell tumors

Ovarian Tumor Selection Review

Sertoli-Leydig cell tumors Well differentiated Intermediately differentiated Poorly differentiated With heterologous elements Retiform type

with pros-

and Histologic

lmmunohistochemistry

AND METHODS

Selected blocks from testes and ovarian tumors were studied immunohistochemically using avidin-biotin complex methodology and the Code-On Immunology system.25 The primary antibodies and their dilutions are summarized in Table 2. Antibody binding was detected using the avidin-biotin complex LSAB kit (DAK0 Corporation, Carpinteria, CA). Primary antibodies were incubated for 30 minutes, and the biotinylated secondary antibody and streptavidin were incubated for 20 minutes each. All incubations were performed at 37°C. The chromogen was 3-amino, 9-ethylcarbazole. Each antibody stain included appropriate positive and negative controls. Positive controls included the large intestine with adenocarcinoma for cytokeratin (CK) AEl:AE3 (AEl:3), CK CAM 5.2 (CAM), EMA, vimentin, desmin, muscle-specific actin (MSA), and S-100 protein (s-100). Positive controls for carcinoembryonic antigen monoclonal (CEA-M), carcinoem-

Testes Selection The testes from all consecutive, nonmacerated male abortuses submitted to the Department of Pathology at Grady Memorial Hospital (Atlanta, GA) for a period of 2 months were routinely processed into paraffin and hematoxylin-eosinstained slides were prepared. The gestational age of the abortuses was estimated on the basis of crown rump dimension using standard charts. “J From this group we selected a series of five maturing testes ranging from 11 weeks’ to 21 weeks’ gestation. Testicular tissue also was obtained from routine surgical pathology material as follows: an intact, male, ectopic pregnancy specimen at approximately 8 weeks’ gestation; a normal adult testicular biopsy obtained during a hydrocele repair procedure; and four orchiectomy specimens obtained from the following patients: an infant with fibrous hamartoma,

TABLE 2.

and two patients

All cases coded as Sertoli-stromal cell tumor or carcinosarcoma of the ovary in the Emory University system, which includes Grady Memorial, Emory University, and Crawford Long Hospitals, in Atlanta, GA, were identified by tumor registry departments at the respective hospitals. Only cases with available paraffin-embedded material were used for the study. In addition, seven Sertoli-stromal cell tumors were obtained from outside the Emory University system for use in the study. One case came from Mt Zion Medical Center of the University of California, San Francisco, CA; three came from Beaumont Army Medical Center, El Paso, TX; and the final three came from Sioux Valley Hospital, Sioux Falls, SD, a University of South Dakota Medical School-affiliated hospital. In many instances the cases were sent to outside institutions with expertise in gynecologic pathology for another opinion. The expert opinions were used as the diagnosis in these instances. We used a standard histologic classification scheme’.’ for Sertoli-stromal cell tumor, as outlined in Table 1. The ovarian carcinosarcomas were classified into homologous and heterologous types based on established criteria for the identification of heterologous sarcomatous component.“-” The carcinomatous component was classified into the particular miillerian subtype of adenocarcinoma.24

vious studies have suggested that immunohistochemistry, particularly epithelial membrane antigen (EMA), may help distinguish ovarian Sertoli-stromal cell tumor (EMA negative) and carcinoma (EMA positive).g915 Most reported cases of carcinosarcoma of the uteri@-*‘’ and ovary20~21expressed EMA. The purpose of this study was to investigate the utility of immunohistochemistry in differentiating carcinosarcomas from Sertoli-stromal cell tumors. We characterized the immunophenotype of Sertoli cells both in developing and mature testes and in various Sertoli-stromal cell tumors. These results were then compared with those obtained from a series of ovarian carcinosarcoma to search for diagnostically useful differential staining. MATERIALS

with cryptorchidism,

tate carcinoma.

lmmunohistochemical Reaaents and Procedures Protein

Antibody

Source

Dilution

CA 125 monoclonal (CA1 25) CA 19-9 monoclonal (CA19) Carcinoembryonic antigen monoclonal (CEA-M) Carcinoembryonic antigen polyclonal (CEA-P) Cytokeratin AEl:AE3 monoclonal cocktail (AEl:3) Cytokeratin CAM 5.2 monoclonal cocktail (CAM) Desmin monoclonal (D) Epithelial membrane antigen monoclonal (EMA) Muscie-specific a&n monocionai (MSA) Placental alkaline phosphatase polyclonal (PLAP) S-l 00 protein monoclonal (Sl 00) Vimentin monoclonal (V)

Signet Laboratories (Dedham, MA) Signet Laboratories Biogenix Laboratories (San Ramon, CA) Biogenix Laboratories Boehringer Mannheim (Indianapolis, IN) Becton Dickinson (San Jose, CA) DAK0 Corporation (Santa Barbara, CA) DAK0 Corporation EN20 Diagnostics (New York, NY) DAK0 Corporation Chemicon (Temecula, CA) DAK0 Corporation

1:6 1:lO 1:lOO 1:lOO 1:300 1:1 1:200 I:10 I:400 1:lOO 1:500 1:lO

Digestion Protease, No No No Protease, Protease, No No No No Trypsin, Trypsin,

4 min

4 min 4 min

4 min 4 min

Note. Antibody abbreviations in parentheses are used in the text and tables. Digestion enzymes were purchased from Sigma Chemical Company (St Louis, MO).

788

IMMUNOSTAINING: SERTOLI-STROMAL CELL TUMORS (Costa et al)

TABLE 3.

Testes: lmmunohistochemical Findings Antibodies

Patient No.

Study Area

AE1:3

CAM

EMA

V

D

MSA

SlOO

Tubal pregnancy 8-wk gestation CR: 2.5 cm

SC SS MD LC

DS A DS A

DS A DS A

N

DS A DS A

FW A N A

DW A N A

N

A DS A

A N A

2

Abortion 1 I-wk gestation CR: 4.5 cm

SC ss MD LC

N A DS N

DS A DS N

N A DS N

DW A DS N

N A N N

FW A N FW

N A N N

3

Abortion 15-wk gestation CR: 9 cm

SC ss ED LC

DS N DS N

DS FS DS N

N N DS N

FW DS N DW

FW N N N

FW N N N

N N N N

4

Abortion 16-wk gestation CR: 11 cm

SC ss ED LC

DS N DS N

DS FW DS N

N N DS N

DW FW N FW

N N N N

FW N N N

N N N N

5

Abortion 17-wk gestation CR: 12 cm

SC ss ED LC

DS N DS N

DS FS DS N

N N DS N

DW DW N N

N N N N

FW N N N

N N N N

6

Abortion 23-wk gestation CR: 21 cm

SC ss ED LC

DS N DS N

DS DW DS N

N N DS N

FW FW N FW

N N N N

FW N N N

N N N N

7

Cryptorchid 32-yr Prophylactic

ss ED LC SA

N DS N N

FS DS N FW

N DS N N

DS N FW DS

N N N N

N N N N

N N N N

ss ED LC

N A A

FW A A

N A A

DS A A

N A A

N A A

N A A

ss ED

LC

N A N

N A N

N A N

DS A FS

* * *

* * *

* * *

1

8

9

IO

11

Testes Description

orchiectomy

Normal infant 8-mos, Orchiectomy harmatoma

for

Normal teenager 15-yr, Biopsy during repair

hydrocele

Normal adult 62-yr, Orchiectomy carcinoma

for prostate

ss ED LC

N DS N

N DS N

N DS DS

DS N FS

* * *

* * *

* * *

Normal adult 74-yr, Orchiectomy carcinoma

for prostate

ss ED LC

N A N

N A N

N A N

DS A FS

* * *

* * *

* * *

Abbreviations: SC, Sertoli cells not in seminiferous tubules; SS, Sertoli cells in seminiferous tubules; MD, mesonephric ducts; ED, epididymus or other efferent duct structures; LC, Leydig cells; SA, incidental Sertoli adenoma; CR, crown rump length. Antibodies: AEl:AE3, cytokeratin AEl:AE3; CAM, cytokeratin CAM 5.2; EMA, epithelial membrane antigen; V, vimentin; D, desmin; MSA, muscle-specific actin; SlOO, SlOO protein. Staining pattern: DS, diffuse strong; FS, focal strong; DW, diffuse weak; FW, focal weak; N, negative; A, structure not present for evaluation. * Stain not performed.

bryonic antigen polyclonal (CEA-P), CA 125, and CA 19-9 were adenocarcinomas known to express these antigens. Normal placenta was the positive control for placental alkaline phosphatase (PLAP). To ensure proper fixation internal controls for vimentin, such as endothelium, were checked in all cases. Negative controls replaced primary antibodies with mouse serum (for monoclonal antibodies) and rabbit serum (for polyclonal antibodies) (DAK0 Corporation). The intensity of immunohistochemical staining was recorded as weak (detectable at X 100 or greater magnification) or strong (detectable at X40 or lower magnification). Diffuse staining was defined as positivity in more than 50% of cells;

789

focal staining decorated a smaller proportion of cells. The staining reactions of different cellular elements of testes, Sertoli-stromal cell tumors, and carcinosarcomas were recorded separately.

RESULTS Testes Table 3 outlines the histologic and most of the immunohistochemical findings in the testes. CA 19, CA 125, CEA-M, CEA-P, and PLAP immunostains were

HUMAN PATHOLOGY

Volume 23, No. 7 (July 1992)

toli-stromal cell tumors included 10 Sertoli-Leydig cell tumors (including four cases with heterologous elements and two retiform subtypes) and one Sertoli cell tumor (Table 4). The Sertoli-stromal cell tumors ranged from 4 to 29 cm (mean, 16 cm; median, 15 cm) and 10 of 11 tumors were partially cystic; five were ruptured at presentation. Four of the Sertofi-stromal cell tumor cases had endometrium available for review; three showed atrophy and the other case showed proliferative phase. The Sertoli-stromal cell tumor patients’ ages ranged from 7 to 78 years (mean, 28 years; median, 20 years). Only one patient (case no. 10) presented with tumor outside the ovary, microscopic spread to the omentum. Recurrences developed in three patients from 4 years to 18 years after operation; one died of disease and the other two are alive with disease. Four patients were disease free with 1 year or greater follow-up. The carcinosarcoma included four heterologous and two homologous subtypes (Table 5). The tumors ranged from 5 to 30 cm (mean, 14 cm; median, 11 cm); all were partially cystic and ruptured at surgical presentation. Three cases had endometrium available for evaluation; two showed atrophy and the other was in the proliferative phase. The carcinosarcoma patients’ ages ranged from 47 to 74 years (mean, 65 years; median, 66 years). All but one patient presented with tumor outside the ovary. All five patients with 1 year or greater follow-up had disease; four were dead from disease.

negative in all areas of testes,‘-* so these data were not included in Table 3. As previously reported,26 we observed a progressive maturation in our series of fetal testes ranging from (1) primitive gonadal stroma with poorly formed sex cords and no Leydig cells at 8 weeks; (2) well-defined sex cords separated by Leydig cells, with no seminiferous tubules at 11 weeks (Fig 1); and (3) seminiferous tubules, defined by tubular arrangements of Sertoli cells surrounded by myoid cells, and a hilar region with developing rete testes, residual sex cords, and gonadal stroma at 15 weeks and beyond. The immunohistochemical reactions (Table 3) are recorded for Sertoli cells either arranged in seminiferous tubules (labeled “SS” in Table 3) or in other more primitive arrangements (labeled “SC” in Table 3), such as primitive gonadal stroma, sex cords, or differentiating early rete testes in the hilar region. Those immature Sertoli cells not arranged in seminiferous tubules stained with CAM in all cases and with AE1:3 in five of six cases (Fig 1). As Sertoli cells formed seminiferous tubules they continued to stain with CAM, but in a weaker, more focal fashion, and stopped staining with AE1:3. Sertoli cells in infant and cryptorchid testes stained weakly with CAM and did not stain with AE1:3. The Sertob cells in normal mature testes undergoing spermatogenesis did not stain with CAM or AE1:3, but did express vimentin quite strongly. Sertoli cells in fetal, infant, or cryptorchid testes never showed immunoreactivity for EMA, S-100, CA 19, CA 125, CEA-M, CEA-P, or PLAP. In contrast to Sertoli cells, the epithelium of mesonephric tubules, efferent ductules, and epididymis stained positively for AEl:3, CAM, and EMA in all testes in which these structures were available for study. The Leydig cells showed weak or focal staining for vimentin in seven of nine testes. No Leydig cells were present in the infant or S-week fetal testes. Leydig cells never stained with CAM, AE1:3, EMA, S-100, CA 19, CA 125, CEA-M, CEA-P, or PLAP.

Ovarian Tumors: lmmunohistochemical Findings The immunohistochemical findings of the 17 ovarian tumors appear in Tables 6 and 7. Well-differentiated (Fig 2), poorly differentiated (Fig 3), or retiform (Fig 4) areas of Sertoli-stromal cell tumors stained with AEl:3 and CAM, but not with EMA, S-100, desmin, CA 19, CA 125, CEA-M, CEA-P, or PLAP (Table 6). Expression of vimentin and MSA by Sertoli cells was sporadic, at times only present in more poorly differentiated areas (Table 6). Leydig cells, when present, expressed vimentin in eight of nine Sertoli-Leydig cell tumors. Leydig cells

Ovarian Tumors: Clinical and Pathologic Features The clinical and pathologic features of the 17 ovarian tumors are summarized in Tables 4 and 5. The Ser-

FIGURE 1. (Left) Fetal testis, 11 weeks (case no. 2, Table 3). Sertoli cells arranged in primitive sex cords (arrow) separated by sheets of Leydig cells (L). (Hematoxylin-eosin stain; magnification x200.) (Right) Fetal testis, 11 weeks (case no. 2, Table 3). Cytokeratin CAM shows diffuse strong immunoreactivity in Sertoli cells arranged in primitive sex cords (arrow) and in primitive gonadal stroma areas (arrowhead). Leydig cells are negative (L). (CAM; magnification x200.)

790

IMMUNOSTAINING:

TABLE 4. Case No.

SERTOLI-STROMAL

CELL TUMORS

Pathologic and Clinical Features: Ovarian Sertoli-Stromal Size

Diagnosis/Consultant

(cm)

G

Side

Age (yr)

Presentation

(Costa et al) Tumor (Androblastoma)

HP

SG 1 1 1

0 0 0

Cases

Follow-Up

RX

1 2 3

Sertoli-Leydig Sertoh-Leydig Sertoli-Leydig

WD, none ID, AFIP ID, MGH

4 8 17

S-I SC-I SC-R

L L RT

23 19 78

I

v

M 1

v N

4 5

Sertoli-Leydig ID, Mayo Sertoli-Leydig PD, GWU/GT Sertoli-Leydig PD, HET mutinous, MGH Sertoli-Leydig PD. HET RB, none Sertoh-Leydig PD, HET RB-CH, MGH Sertoli-Leydig ID, retiform, AFIP Sertoli-Leydig PD. retiform HET RB, MGH Sertoli, AFIP

6 28

SC-R SC-R

RT L

24 11

I M

v

N

1 1

0 OC

24

SC-R

L

19

AA

N

1

OC

12

SC-I

RT

20

M. I

v

1

0

29

SC-R

L

46

M

N

1

HO

9

SC-I

RT

M, P

N

1

0

26

SC-I

u

15

AA

N

2

0

Recent case; no follow-up since surgery

15

SC-I

RT

42

M

N

1

HO

Alive, peritoneal recurrence after surgery

6 7 8 9 10

11

7

M

Alive, NED 5 mo Alive, NED 29 mo Alive, peritoneal recurrence diagnosis Alive, NED 4 mo Alive. NED 12 mo

4 yr after

DOD, 66 mo; peritoneal recurrence at 55 mo; treated unsuccessfully with C Alive, NED 13 yr Patient lost to follow-up, last contact at surgery Alive, NED 26 mo

18 yr

Abbreviations: WD, well; ID, intermediate; PD. poorly differentiated; HET, with heterologous elements; mutinous, mutinous epithelium; RB, skeletal muscle; CH, cartilage; G, gross appearance; S, solid; SC, solid and cystic; I, intact; R, ruptured; RT, right; L, left; U, unknown; M, mass or swelling; P, pain; I, ammenorhea/infertility; AA, acute abdomen; HP, hormonal production; V, virilizing; N, none; SG, stage at presentation; RX, treatment; 0, oophorectomy; H, hysterectomy; C, chemotherapy; NED, no evidence of disease; DOD, dead of disease; MGH, Massachusetts General Hospital; AFIP, Armed Forces Institute of Pathology; Mayo, Mayo Clinic; GWU, George Washington University; GT, Georgetown University.

did not stain for AE1:3, CAM, EMA, or any other immunohistochemical marker in our panel. Mutinous heterologous elements (case no. 6) did express EMA, CA 19, and PLAP (Table 6). Stromal skeletal muscle heterologous elements expressed desmin and MSA, but did not express CAM or AE1:3. Stromal cartilage heterologous elements stained weakly with CAM and AEl:3, but did not stain with S-100. The epithelial carcinomatous component of carcinosarcomas showed immunoreactivity with AEl:3, CAM, and EMA (Fig 5) in all six cases (Table 7). The epithelial carcinomatous component of carcinosarcomas also stained with CA 125 (Fig 6, bottom) in two cases, CEA-P in two cases, PLAP in two cases, and CEA-M in

TABLE 5.

one case (Table 7). Focal vimentin expression was present in the epithelial carcinomatous component in three cases. The stromal sarcomatous component of carcinosarcomas stained with AEl:3 and CAM in five of six cases and with EMA in four of six cases. S-100 protein was expressed in all three areas of heterologous cartilage and in sarcomatous component not showing cartilage differentiation in two cases (Fig 6, Table 7). Musclespecific actin was expressed in the sarcomatous component of five of six cases, often present in areas not showing heterologous skeletal muscle differentiation. Heterologous cartilage stained with AEl:3 and CAM in both cases in which this area was available for study, and EMA was also present in one of these two areas.

Pathologic and Clinical Features: Ovarian CarcinOSarcOma CaSeS

Case No.

Diagnosis CaC/SaC

Size (cm)

G

Side

Age (yr)

HP

SG

RX

Follow-up

1

CS HOM E/HOM SaC CS HOM E/HOM SaC CS HET S-E/CH CS HET S/RB CS HET E/CH-RB CS HET SKH-RB

16

SC-R

L

59

M

N

1

HOC

5

SC-R

RT

73

M

N

3

HO

Alive, NED 3 mo after surgery DOD, 8 mo after surgery

15

SC-R

RT

74

M

N

3

0

DOD, 19 mo after surgery

30

SC-R

RT

47

M

N

3

HO

DOD, 2 mo after surgery

11

SC-R

RT

72

M

N

3

HOC

Alive, with disease 10 mo

6

SC-R

RT

66

M

N

3

HO

DOD, 12 mo after surgery

2 3 4 5 6

Presentation

Abbreviations: CS, carcinosarcoma; HOM, homologous; HET, heterologous; Sac, sarcomatous components; CH, chondrosarcoma; RB, rhabdomyosarcoma; CaC, carcinomatous component; E, endometrioid; S, serous adenocarcinoma; G. gross appearance; S, solid; SC, solid and cystic; R, ruptured; RT, right; L, left; M, mass or swelling; HP, hormonal production; N, none; SG, stage at presentation; RX, treatment; 0, oophorectomy; H, hysterectomy; C, chemotherapy; NED, no evidence of disease; DOD, dead of disease.

791

HUMAN PATHOLOGY

TABLE 6.

Ovarian Sertoli-Stromal

Volume 23, No. 7 (July 1992)

Tumors (Androblastomas):

lmmunohistochemical

Findings

Antibodies Case No. 1

EMA

v

ST LC

DS N

DS N

N N

N DS

N

ST ss LC

DS FS N

DS FS N

N N N

N FW N

N

N N

N

N N

ST ss LC

DS FS N

DS FS N

N N N

N DS FW

N N N

N FS N

ST ss LC

DS FW N

DS FS N

N N N

N FW FW

N N N

Sertoli-Leydig PD, no LC

ST ss

DS FS

DS FS

N N

DW DW

Sertoli-Leydig PD, HET mutinous

ST ss HET LC

DS FS DS N

DS FS DS N

N N DS N

Sertoli-Leydig PD. HET RB

ST ss HET LC

DS FS N N

DS FS N N

N N *

Sertoli-Leydig PD, HET RBCH

ST ss HET LC

DS DS FW-CH N

DS FS FW-CH N

N N N N

ST-R ss LC

DS FS N

DS FS N

ST-R ss HET LC

DS FW N N

ST ss

DS FS

Diagnosis Sertoli-Leydig WD Sertoli-Leydig

Sertoli-Leydig

Sertoli-Leydig

7

8

9

10

11

Studv Are;

Sertoli-Leydig retiform

ID

ID

ID

ID

Sertoli-Leydig ID retiform, HET RB

Sertoli. no LC recurrence

AEl :AE3

CAM

D

MSA

SlOO

CA19

CA1?5

GA-M

CEA-I’

PLAP

N

N N

N

N N N

N N

N

N N N

N N N

N N N

N N

IN N

N

N

N DS N

N N

N N N

N N N

N

N N

N FS

N N

N N

N N

N N

DW DW N DS

N N N N

N N N N

N N FS N

N N N N

N N

N N

N

FW N

FS DS N FW

N N DS N

N N DS N

N N *

N

N

N *

N *

N N *

N

N

N

N

FS DS DS FW

N N DS-RB N

N FS DS-RB N

N N N N

N N

N

N N N N

N N N

N FW DS

N N N

N N N

N N N

N N N

DS FS N N

N N *

N N DS N

N N DS N

N N *

N N *

N

N *

N N *

N

N FS DW DS

N

N

N

N

DS DS

N N

DS DS

N N

N N

N N

N N

N N

N N

N

N

N

N

s

N

N N

N

N

N

N

N

N

N N N N

N N

N

N N

N N N

Abbreviations: ST, Sertoli cells in tubules; SS, Sertoli cells in nontubular pattern (ie, sex cord or sarcomatoid), ST-R, Sertoli cells in tubular and retiform pattern; LC, Leydig cell; WD, well differentiated; ID, intermediately differentiated; PD, poorly differentiated; HET, heterologous elements; RB, skeletal muscle; CH, cartilage; mutinous, mutinous epithelium. Antibodies: AEl:AE3, cytokeratin AEl:AES; CAM, cytokeratin CAM 5.2; EMA, epithelial membrane antigen; V, vimentin; D, desmin; MSA, muscle-specific actin; SlOO, SlOO protein; CA1 9, CA 19-9, CA1 25, CA1 25; CEA-M and CEA-P: monoclonal and polyclonal carcinoembryonic antigen, respectively; PLAP, placental alkaline phosphatase. Staining pattern: DS, diffuse strong; FS, focal strong; DW, diffuse weak; FW, focal weak; N, negative. * Stain not performed on this area.

tion’” in the hilar areas of our fetal testes showed the most intense CK expression (Table 3). This observation is in keeping with the intense CK expression of the rete testis in hyperplastic conditions.‘* We never observed immunoreactivity for EMA, S-100, CA 19, CA 125, CEA-M, CEA-P, or PLAP in Sertoli cells at any stage of differentiation in our testes. Efferent ductules, epididymis, and other mesonephric structures did express EMA strongly, which served as an internal control in many cases. In our series of fetal testes, immature Sertoli cells showed CK intermediate filament expression in the absence of EMA expression. This unusual pattern of immunoreactivity has been reported in embryonal carcinomas,‘” in Sertoli-Leydig cell tumors,g”5 and in a ma-

Heterologous skeletal muscle expressed MSA and desmin in both cases, and stained with AE1:3 and CAM in one of the two cases. DISCUSSION Sertoli cells in our series of testes showed a progressive loss of CK expression with maturation, while vimentin continued to be expressed. These results parallel observations in rat testes in which progressive loss of CK intermediate filaments was confirmed using both immunocytochemical and immunoblotting techniques.*’ The gonadal stroma undergoing rete testis differentia792

IMMUNOSTAINING:

TABLE 7.

SERTOLI-STROMAL

CELL TUMORS

(Costa et al)

Ovarian Carcinosarcomas: lmmunohistochemical Findings Antibodies

Case No.

Diagnosis CaC/SaC

Study Area

AEl:AES

CAM

EMA

V

MSA

SlOO

CA19

CA125

CEA-M

CEA-P

PLAP

CS HOM E/HOM SaC

CaC SaC

DS FS

DS FS

DS FS

FW FS

N N

D

N N

N DS

N N

DS FS

N N

N N

N N

CS HOM E/HOM SaC

CaC SaC

DS FS

DS FS

DS N

N DS

N N

N FW

N N

N N

N N

FW N

FW N

N N

CS HET S-E/CH

CaC SaC HET-CH

DS FS FS

DS FS FS

DS N FS

FS DS DS

N N N

N FS N

N N DS

N N N

DS N N

N N N

FS N N

DW N N

CS HET S/RB

CaC SaC HET-RB

DS N N

DS N N

DS N N

N DS FS

N N DS

N DS DS

N N N

N N N

N N N

N N N

N N N

DW N N

CS HET E/CH-RB

CaC SaC HET-CH HET-RB

DS FS FW FW

DS FS FW FW

DS FS N N

N FS DS FW

N N N DS

N FS N DS

N FS DS N

N N N N

N N N N

N N N N

N N N N

N N N N

CS HET E/CH-RB

CaC SaC HET-CH HET-RB

DS FS *

DS FS *

DS FW *

FS DS *

N FW *

N DS *

FS

*

N

DS

DS

DS

N N DS N

N N N N

N N N N

N N N N

N N N N

N N N N

Abbreviations: CS, carcinosarcoma; HOM, homologous; HET, heterologous; CaC, carcinomatous component; S, serous; E, endometrioid adenocarcinoma; Sac, sarcomatous component; RB, rhabdomyosarcoma; CH, chondrosarcoma. Antibodies: AEl:AE3. cytokeratin AEl:AE3; CAM, cytokeratin CAM 5.2; EMA, epithelial membrane antigen; V, vimentin; D, desmin; MSA, muscle-specific actin; Sl 00, SlOO protein; CA19, CA19-9; CA125, CA1 25; CEA-M and GA-P, monoclonal and polyclonal carcinoembtyonic antigen, respectively; PLAP, placental alkaline phosphatase. Staining pattern: DS, diffuse strong; FS, focal strong; DW, diffuse weak; FW, focal weak; N, negative. * Stain not performed on this area.

potential for a distinctive marker of Sertoli cell differentiation in ovarian tumors. The immunohistochemical staining pattern of our group of 11 Sertoli-stromal cell tumors (Table 6, Figs 2 through 4) paralleled our findings in fetal testes. Cytokeratin was expressed in Sertoli cells in all cases of Sertoli-stromal cell tumor, and was often co-expressed with vimentin in the more poorly differentiated areas. Epithelial membrane antigen, S-100, CA 19, CA 125, CEA-M, CEA-P, and PLAP were not present in the Ser-

lignant Sertoli cell tumor of the testis3’ In addition, immature Sertoli cells did not express any of the carcinoma-associated carbohydrates (such as carcinoembryonic antigen, CA 19-9, or CA 1 25),31 which are seen commonly in ovarian carcinomas,2’ or PLAP, which is expressed by germ cells and ovarian carcinomas.2’ The unique pattern of immunoreactivity demonstrated by immature Sertoli cells differs from the usual staining pattern of carcinomas21,31 of the ovary or carcinosarcomas of the female genital tract.‘6-2’ This creates the

FIGURE 2. Well-differentiated Sertoli-Leydig cell tumor (case no. 1, Tables 4 and 6). (Left) Sertoli cells arranged in tubules, with Leydig cells present (arrow). (Hematoxylin-eosin stain; magnification x200.) (Right) Cytokeratin CAM shows diffuse strong reactivity in Sertoli cells. Leydig cells (arrow) are negative. (CAM; magnification x1.000.)

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FIGURE 3. Poorly differentiated Sertoli-Leydig cell tumor (case no. 7, Tables 4 and 6). (Left) Spindled primitive mesenchymal component of the tumor arranged in a sarcomatoid pattern alternating with Sertoli cells in primitive sex cords. (Hematoxylin-eosin stain; magnification X1.000.) (Right) Cytokeratin CAM shows diffuse strong immunoreactivity highlighting well-differentiated Sertoli cell areas. Focal strong staining is present in adjacent, poorly differentiated Sertoli cells (arrow). (CAM; magnification x400.)

ular tumors showing Sertoli cell differentiation should be similar to the findings in Sertoli-stromal cell tumors. Unfortunately, these tumors are rare and immunohistochemical studies are limited to single case reports. A malignant Sertoli cell tumor expressed CK and vimentin but did not express EMA, CEA, or PLAP,30 a benign Sertoli cell tumor expressed vimentin but did not etgress human chorionic gonadotropin or a-l-antitrypsin; and another benign Sertoli cell tumor did not express CEA or a-fetoprotein.” All six cases of carcinosarcoma showed immunoreactivity for EMA, AE1:3, and CAM (Table 7) in the carcinomatous component. The sarcomatous component also focally stained with AE1:3 (five of six cases), CAM (five of six cases), and EMA (four of six cases). A few of the carcinosarcomas showed immunoreactivity for adenocarcinoma markers2’.31 in the carcinomatous component: CA 125 (two of six cases), PLAP (two of six cases), CEA-P (two of six cases), and CEA-M (one of

toli cell areas. The heterologous mutinous epithelium in case no. 6 did express EMA, CA 19, and PLAP. This is not surprising considering the potential for gastrointestinal-ty e epithelium in mutinous heterologous eler Posmve .’ ments .52,3. staining of mutinous heterologous elements should not be falsely interpreted as positive staining of Sertoli cells, which were negative for these markers in this case. Previous immunohistochemical studies of Sertoli-stromal cell tumors reported positivity for CK (nine of 10 cases) and vimentin (10 of 10 cases)34; CAM (four of four cases) and vimentin (four of four cases)35; AE1:3 (13 of 14 cases), CAM (12 of 14 cases), and vimentin (10 of 14 cases)“; and AE1:3 (five of five cases), CAM (four of five cases), and vimentin (two of five cases).15 Only rare cases stained for EMA (one of 14 cases and one of five cases) and S-100 (two of 14 cases and none of five cases).‘.i5 None of these earlier studies included CA 19, CA 125, CEA-P, CEA-M, or PLAP.“,‘5.Y”,35 Immunohistochemical staining of testic-

FIGURE 4. Retiform Sertoli-Leydig cell tumor (case no. 9, Tables 4 and 6). (Left) Irregular glandular area characteristic of retiform Sertoli cell differentiation. (Hematoxylin-eosin stain; mogniftcation X100.) (Right) Cytokerotin CAM shows diffuse strong immunoreactivity in retiform areas. (CAM; magnification X 100.)

794

IMMUNOSTAINING:

SERTOLI-STROMAL

CELL TUMORS

(Costa et al)

FIGURE 5. Carcinosarcoma (case no. 5, Tables 5 and 7). (Left) Biphasic tumor showing epithelial carcinomatous component (C) and stromal sarcomatous component (S). (Hematoxylin-eosin stain; magnification X100.) (Right) Epithelial membrane antigen shows diffuse strong immunoreactivity with more intense luminal staining (arrow) in carcinomatous component of carcinosarcoma. (EMA: magnification x400.)

six cases) (Table 5). The sarcomatous component of the carcinosarcomas expressed S-l 00 in four of six cases (Table 7), including areas of heterologous cartilage (three of three cases) and areas lacking heterologous cartilage (two of six cases). Most carcinosarcomas of the

female genital tract express EMA and CK in the carcinomatous component, as well as focally in the sarcomatous component. ‘6-2’ Various investigators have reported positivity for other markers, including CEA-P staining of the carcinomatous component of many cases

FIGURE 6. Carcinosarcoma (case no. I, Tables 5 and 7). (Top left) Carcinosarcoma showing well-differentiated glandular carcinomatous component and sarcomatous component showing myxoid change (M). (Hematoxylin-eosin stain; magnification x40.) (Top right) CA 125 shows a diffuse strong luminal pattern of immunoreactivity in the carcinomatous component. (CA 125; magnification x200.) (Bottom) S-100 protein shows diffuse strong immunoreactivity in the myxoid stromal areas (arrow). The carcinomatous component (C) is negative. (S-100: magnification X200.)

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of uterine carcinosarcoma”; S-100 staining of uterine and ovarian carcinosarcomas, including areas of heterologous cartilage’7~1g*20;and staining for CA 125 (two of three cases), PLAP (one of three cases), and CEA-P (one of three cases) in carcinosarcoma of the ovary.21 The immunohistochemical results we found in our series of ovarian carcinosarcomas agree with these previously reported observations. Since both carcinosarcoma and Sertoli-stromal cell tumor may have a biphasic epithelial and stromal pattern and heterologous stromal elements, such as skeletal muscle and cartilage, carcinosarcoma is always considered in the differential diagnosis of poorly differentiated Sertoli-stromal cell tumor. 2-5 The distinction between ovarian carcinosarcoma and Sertoli-stromal cell tumor has important prognostic implications since carcinosarcoma is an aggressive neoplasm with a median survival rate of 6 to 12 months,‘0-14 while only 7% to 18% of Sertoli stromal cell tumors behave in a malignant fashion. ‘-’ This was certainly true in our group of patients as carcinosarcomas showed no disease-free survivors at 1 year (five cases) compared with Sertoli-stromal cell tumors that showed three patients with late recurrences at 4 to 18 years and four disease-free survivors at 1 year (Tables 4 and 5). However, only poorly differentiated Sertoli-stromal cell tumors really present a difficult diagnostic challenge in which carcinosarcoma enters into the differential diagnosis. Unfortunately, our study included too few examples of poorly differentiated Sertolistromal cell tumors to allow direct comparison of the clinical outcome of this subgroup to carcinosarcomas. Other investigators report a much worse prognosis for poorly differentiated Sertoli-stromal cell tumors2.6 compared with the better-differentiated tumors. For this reason, there may be little clinical importance in distinguishing between carcinosarcoma and poorly differentiated Sertoli-stromal cell tumor. The distinction between carcinosarcoma and Sertoli-stromal cell tumor is facilitated by a careful evaluation of clinical and histologic features. Young patient age favored Sertoli-stromal cell tumor.294*5This also was noted in our study, in which patients with Sertoli-stromal cell tumors had a median age of 20 years (mean, 28 years) while patients with carcinosarcomas had a median age of 66 years (mean, 65 years) (Tables 4 and 5). However, there were exceptions, since one patient with Sertoli-stromal cell tumor was 78 years old (case no. 3) and another was in her fourth decade of life; two carcinosarcoma patients were also in their fifth decade of life. Andropnic manifestations favored Sertoli-stromal cell tumor and were present in four of our 11 cases of Sertoli-stromal cell tumor. However, if androgenic manifestations were not present, we cannot exclude Sertoli-stromal cell tumor, since six of our 11 cases did not show androgenic effects. In addition, tumors other than Sertoli-stromal cell tumor can produce virilization.‘p6 For difficult or poorly differentiated tumors the demonstration of foci of typical Sertoli-stromal cell tumor can be helpful in establishing the correct diagnosis.2-5 However, some histologic patterns of carcinosarcomas may mimic characteristic Sertoli-stromal cell tu796

mor quite closely and make this criterion difficult to apply in an individual case. A high grade of the epithelial component, usually a high-grade miillerian carcinomatous component, favored the diagnosis of carcinosarcoma, since well-differentiated tubular structures tend to predominate in Sertoli-stromal cell tumor.2’4 This criterion was the most easily applied and usually helpful, except for poorly differentiated Sertoli-Leydig cell tumors with mutinous heterologous elements. The mucinous heterologous elements in these cases can appear atypical” and resemble the carcinomatous component of carcinosarcoma, and the poorly differentiated SertoliLeydig cell tumor areas can mimic the homologous sarcomatous component of carcinosarcoma. The final potentially helpful histologic feature’ was the blander appearance of the stromal heterologous elements in Sertoli-stromal cell tumor compared with carcinosarcoma. The heterologous skeletal muscle in our carcinosarcomas was clearly more pleomorphic than the welldifferentiated heterologous skeletal muscle in Sertolistromal cell tumors. The heterologous cartilage elements were very pleomorphic in two of three carcinosarcoma, but appeared quite bland in the one Sertoli-stromal cell tumor in which they were present. This study demonstrates that immunohistochemistry can provide additional data that can clearly aid in distinguishing carcinosarcoma from Sertoli-stromal cell tumor.2-5 Staining for CK and EMA strongly favors carcinosarcoma, since Sertoli cells in maturing testes and Sertoli-stromal cell tumor express CK but not EMA. The presence of AE1:3 and CAM immunoreactivity in the absence of EMA expression is rarely encountered in ovarian neoplasms, embryonal carcinomas*’ being one exception. Our data suggest that this pattern is also characteristic of Sertoli cell differentiation in testes and Sertoli-stromal cell tumors. Other investigators have reported similar immunohistochemical findings in ovarian Sertoli-stromal cell tumorsg**5 and a malignant testicular Sertoli cell tumor. 3o Staining for carcinoma-associated markers, such as CA 125, CEA-M, CEA-P, or PLAP,21V31 on the other hand, favors carcinosarcoma. None of the Sertoli cells in our Sertoli-stromal cell tumors and testes reacted with any of the carcinoma-associated markers included in this study. Finally, staining of the stromal component by S-l 00 should also favor carcinosarcoma, since Sertoli cells never expressed S-100 in any of our Sertoli-stromal cell tumors or maturing testes. Acknowledgment. The authors thank Razia Khan, Maribeth Gagnon, Linda Leslie, and Eugene Semple for their technical assistance. We also thank the tumor registries at Grady Memorial Hospital, Emory University Hospital, and Crawford Long Hospitals in Atlanta, GA and Sioux Valley Hospital in Sioux Falls, SD for their assistance in obtaining clinical followup data. The following pathologists generously submitted material for this study: Susan S. Cafferty, MD, University of South Dakota School of Medicine, Sioux Falls, SD; John F. Nickerson, MD, Crawford Long Hospital of Emory University, Atlanta, GA; Harvey Z. Klein, MD, Mount Zion Medical Center of University of California at San Francisco, San Francisco, CA; T. Stewart, MD, Northeast Georgia Hospital, Gainsville, GA; and Ernest0 Lopez, MD, Memorial Hospital, Waycross, GA. We also acknowledge Charles Shirmer, MD, for his careful

IMMUNOSTAINING:

SERTOLI-STROMAL

gross description and submission of histologic sections from a tubal ectopic pregnancy.

(Costa et al)

19. Auerbach HE, Livolsi VA, Merino MJ: Malignant mixed miillerian tumors of the uterus. An immunohistochemical study. Int J Gynecol Path01 7:123-130, 1988 20. George E, Manivel C, Dehner LP, et al: Malignant mixed miillerian tumors: An immunohistochemical study of 47 cases with histogenetic considerations and clinical correlation. HUM PATHOL 22: 215-223, 1991 21. Nouwen EJ, Hendrix PG, Dauwe S, et al: Tumor markers in the human ovary and its neoplasms. A comparative immunohistochemical study. Am J Path01 126:230-242, 1987 22. Singer DB, Sung CJ, Wigglesworth JS: Fetal growth and maturation: With standards for body and organ development, in Wigglesworth JS, Singer DB (eds): Textbook of Fetal and Perinatal Pathology. Boston, MA, Blackwell Scientific Publications, 1991, pp 3035 23. Appendix II: Specimen evaluation and collection, in Kalousek DK, Fitch N, Paradice BA (eds): Pathology of the Human Embryo and Previable Fetus. New York, NY, Springer Verlag, 1990, pp 226228 24. Lauchlan SC: Metaplasias and neoplasias of the miillerian epithelium. Histopathology 8:543-557, 1984 25. Brigati DJ, Budgeon LR, Unger ER, et al: Immunocytochemistry is automated: Development of a robotic workstation based upon the capillary action principle. J Histotechnol 11: 165-183, 1988 26. Maizels M: Normal development of the urinary tract, in Walsh PC, Gittes RF, Perlmutter AD, et al (eds): Campbell’s Urology. Philadelphia, PA, Saunders, 1986, pp 1161-l 163 27. Paranko J, Kallajoki M, Pelliniemi LJ, et al: Transient coexpression of cytokeratin and vimentin in differentiating rat Sertoli cells. Dev Biol 117:35-44, 1989 28. Ulbright TM, Gersell DJ: Rete testes hyperplasia with hyaline globule formation. A lesion simulating yolk sac tumor. Am J Surg Pathol 15:66-74, 1991 29. Thomas P, Battifora H: Keratins versus epithelial membrane antigen in tumor diagnosis: An immunohistochemical comparison of five monoclonal antibodies. HUM PATHOL 18:728-734, 1987 30. Nielsen K, Jacobsen GK: Malignant Sertoli cell tumor of the testes. An immunohistochemical study and a review of the literature. APMIS 96:755-760, 1988 3 1. Sell S: Cancer-associated carbohydrates identified by monoclonal antibodies. HUM PATHOL 21:1003-1019, 1991 32. Aguirre P, Scully RE, DeLellis RA: Ovarian heterologous Sertoli-Leydig cell tumors with gastrointestinal-type epithelium. Arch Pathol Lab Med 110:528-533, 1986 33. Sweeney EC, Barry-Walsh C, Robinson A: Sertoli-Leydigcell tumor of the ovary with heterologous elements and carcinoid: An immunohistochemical and ultrastructural study. Ultrastruct Patho15: 185-194, 1983 34. Miettinen M, Talerman A, Wahstrom T, et al: Cellular differentiation in ovarian sex-cord-stromal and germ-cell tumors studied with antibodies to intermediate-filament proteins. Am J Surg Pathol 9:640-651, 1985 35. Benjamin E, Law S, Bobrow L: Intermediate filaments cytokeratin and vimentin in ovarian sex cord-stromal tumours with correlative studies inadult and fetal ovaries. J Path01 152:253-263, 1987 36. Ventura T, Discepoli S, Coletti G, et al: Light microscopic, immunocytochemical and ultrastructural study of a case of Sertoli cell tumor of the testis. Tumori 73:649-653, 1987 37. Okoye MI, Mueller WF, Chang CY, et al: Testicular gonadal stromal (Sertoli cell) tumor. Urology 25:184-186, 1985

REFERENCES Scully RE: Ovarian sex cord-stromal tumors. diagnosis. Path01 Annu 23:237-296, 1988 2. Young RH, Scully RE: Ovarian Sertoli-Leydig cell tumors. A clinicopathologic analysis of 207 cases. Am J Surg Pathol 9:543-569, 1985 3. Roth LM, Anderson MC, Govan ADT, et al: Sertoli-Leydig cell tumors: A clinicopathologic study of 34 cases. Cancer 48:187197, 1981 4. Young RH, Scully RE: Ovarian Sertoli-Leydig cell tumors with a retiform pattern: A problem in histopathologic diagnosis. Am J Surg Path01 7:755-771, 1983 5. Talerman A: Ovarian Sertoli-Leydig cell tumor (androblastoma) with retiform pattern. Cancer 60:3056-3064, 1987 6. Zaloudek C, Norris HJ: Sertoli-Leydig tumors of the ovary. A clinicopathologic study of 64 intermediate and poorly differentiated neoplasms. Am J Surg Path01 8:405-418, 1984 7. Tavassoli FA, Norris HJ: Sertoli tumors of the ovary. A clinicopathologic study of 28 cases with ultrastructural observations. Cancer 46:2281-2297, 1980 8. Roth LM, Liban E, Czernobilsky B: Ovarian endometrioid tumors mimicking Sertoli and Sertoli-Leydig cell tumors. Sertoliform variant of endometrioid carcinoma. Cancer 50:1322-1331, 1982 9. Aguirre P, Thor AD, Scully RE: Ovarian endometrioid carcinomas resembling sex cord-stromal tumors. An immunohistochemical study. Int J Gynecol Path01 8 364-373, 1989 10. Dehner LP, Norris HJ, Taylor HB: Carcinosarcomas and mixed mesodermal tumors of the ovary. Cancer 27:207-216, 1971 11. Barwick KW, Livolsi VA: Malignant mixed mesodermal tumors of the ovary: A clinicopathologic assessment of 12 cases. Am J Surg Path01 4:37-42, 1980 12. Deligdisch L, Plaxe S, Cohen CJ: Extrauterine pelvic malignant mixed mesodermal tumors. A study of 10 cases with immunochemistry. Int J Gynecol Path01 7:361-372, 1988 13. Terada KY, Johnson TL, Hopkins M, et al: Clinicopathologic features of ovarian mixed mesodermal tumors and carcinosarcomas. Gynecol Oncol 32:228-232, 1989 14. Calame JJ, Schaberg A: Solid teratomas and mixed miillerian tumors of the ovary: A clinical, histological and immunocytochemical comparative study. Gynecol Oncol 33:2 12-22 1, 1989 15. Aguirre P, Thor AD, Scully RE: Ovarian small cell carcinoma. Histogenetic considerations based on immunohistochemical and other findings. Am J Clin Path01 92:140-149, 1989 16. Ramadan M, Goudie RB: Epithelial antigens in malignant mixed miillerian tumors of endometrium. J Path01 148: 13-l 8, 1986 17. Chung MT, Mukai K, Teshima S, et al: Expression of various antigens by different components of uterine mixed miillerian tumors. An immunohistochemical study. Acta Path01 Jpn 38:35-45, 1988 18. Bitterman P, Chun B, Kurman RJ: The significance of epithelial differentiation in mixed mesodermal tumors of the uterus. A clinicopathologic and immunohistochemical study. Am J Surg Pathol 14:317-328, 1990 1. Young

CELL TUMORS

RH,

Problems in differential

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