- Email: [email protected]
Radiology–Pathology Conference
Journal of Clinical Imaging 27 (2003) 221 – 224
Radiology–Pathology Conference Juvenile granulosa cell tumor$ Adam M. Gittlemana, Anita P. Pricea, Charles Corenb, Mudnia Akhtarc, Virginia Donovanc, Douglas S. Katza,* a
Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY 11501, USA b Department of Pediatric Surgery, Winthrop-University Hospital, Mineola, NY, USA c Department of Pathology, Winthrop-University Hospital, Mineola, NY, USA Received 20 July 2002
Abstract Juvenile granulosa cell tumor (GCT) of the ovary is a rare neoplasm occurring in premenarchal girls and young women. Juvenile GCT that occurs in premenarchal girls usually produces sexual precocity as a consequence of estrogen secretion. Juvenile GCTs are more likely to grow to a relatively large size with a much smaller likelihood of peritoneal spread, unlike their counterpart, epithelial ovarian neoplasms. We report the radiology and pathology of a patient with juvenile GCT and review the literature of this rare tumor. D 2003 Elsevier Inc. All rights reserved. Keywords: Juvenile granulosa cell tumor; Ovary; Children; Computed tomography
Granulosa cell tumors (GCTs) are extremely uncommon, accounting for about 1 –2% of all ovarian malignancies. GCTs can occur at any age. Two types are distinguished histologically — adult GCT and juvenile GCT. The more common adult GCT occurs predominantly in perimenopausal and postmenopausal women, with a peak prevalence at 50 –55 years of age [1]. The rarer juvenile GCT represents only 5% of all GCTs, and is discovered in premenarchal girls and young women [1]. These tumors are of interest clinically because of their estrogenic hormonal effects, which include pseudoprecocious puberty, as well as endometrial bleeding, endometrial hyperplasia and carcinoma in older women [1]. Few reports have been published on the cross-sectional imaging appearance of juvenile GCT, although some series of adult GCTs have been reported in the literature. In this Radiology – Pathology Conference, the clinical presentation as well as the imaging and pathology findings of juvenile GCT are reviewed. $ From the monthly Radiology – Pathology Conferences at WinthropUniversity Hospital. * Corresponding author. Tel.: +1-516-663-3800; fax: +1-516-663-3800. E-mail address: [email protected] (D.S. Katz).
0899-7071/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0899-7071(02)00586-7
1. Case presentation A 9-year-old girl presented to our institution with acute abdominal pain and a large abdominal and pelvic mass. The patient had a 2-week history of flu-like symptoms, with nausea, vomiting, fatigue and abdominal pain. The pain had become much more severe 2 days prior to admission, and was associated with a protuberant abdomen. On examination, the patient had advanced sexual development for her age. She had started menstruating 6 months earlier, had experienced breast development for almost a year, and had axillary and pubic hair. In addition, her 11year-old sister was prepubertal at the time of admission. The patient was afebrile, and the abdomen was tender without any rigidity or rebound. A moderately sized abdominal and pelvic mass was palpable just below the umbilicus. A pelvic examination was not performed. Laboratory analysis revealed an elevated leukocyte count of 24,000, and decreased hemoglobin and hematocrit. A CT scan of the abdomen and pelvis was performed with oral and intravenous contrast, on the day of admission (Fig. 1A – B). This revealed a large, multicystic pelvic mass most likely of ovarian origin, with heterogenous enhance-
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A.M. Gittleman et al. / Journal of Clinical Imaging 27 (2003) 221–224
ment of the solid components. There was no ascites, but bilateral hydronephrosis was noted, presumably due to mass effect from the tumor. The patient then underwent an exploratory laparotomy. A large tumor was found involving the entire left ovary; the fallopian tube and the adjacent omentum were draped over the mass and the appendix was adherent to the mass. The tumor and the attached omentum and appendix were resected. The right adnexa and uterus were otherwise normal. No lymphadenopathy was identified. The pathology specimen consisted of a 1944-g, 19 15 10-cm, encapsulated, smooth, lobulated left ovarian mass, with a predominantly solid and partially cystic cut surface (Fig. 1C). The tumor on cut section (Fig. 1D) was variegated yellow to brown, with focal areas of hemorrhage. Histologically (Fig. 1E), the tumor was confined to the ovary (FIGO stage 1) and consisted of nodular aggregates of neoplastic granulosa cells with mucin-positive intrafollicular secretion. Theca cells were present between the nodules of granulose cells. The cytoplasm of the granulosa cells was heavily vacuolated, with hyperchromatic, round nuclei and a paucity of nuclear grooves. Mitotic figures were numerous, with 34 per high-powered field. These findings were diagnostic of a juvenile GCT. The patient’s postoperative course was uncomplicated. Her follow-up leukocyte count decreased to 10,000. She was started on oral iron supplements and was discharged home 6 days following surgery.
2. Discussion In addition to surface epithelial cells and germ cells, the ovary contains granulosa cells, theca cells, interstitial (hilus) cells and stromal fibroblasts, and each can result in neoplasia. All such lesions are grouped together as sex cordstromal tumors, and represent approximately 10% of all ovarian neoplasms in children and adolescents [1,2]. Many of these sex cord-stromal tumors, which include GCTs, thecomas and fibromas, are hormonally active, because the cells they are derived from are a source of ovarian hormones [3]. Granulosa cells normally surround each oocyte and form the lining of the developing follicle [4]. GCTs of the ovary were first described by Rokitansky in 1855. GCTs are extremely uncommon, accounting for only 1 – 2% of all ovarian tumors [1]. GCTs are classified histologically into two categories: adult and juvenile. Both
223
tumors share similar gross appearances and therefore similar radiographic features. These tumors are usually unilateral and estrogen secreting. However, the two types of GCT demonstrate disparity in malignant potential, the average age of affected individuals and the effects of hormone secretion [3]. Adult GCTs are far more common than the juvenile form. The adult type accounts for over 95% of all GCTs [4]. Adult GCTs are generally encountered in perimenopausal and postmenopausal women, with peak prevalence around 50– 55 years of age [1]. GCTs present with irregular bleeding in postmenopausal patients, due to the production of estrogen by these tumors. The high levels of estrogen production may lead to endometrial hyperplasia, polyps or carcinoma; the risk of endometrial carcinoma with the adult form of GCT is 10 – 15% or higher [3]. Juvenile GCTs represent only five percent of all granulosa cell neoplasms, and generally occur in premenarchal girls and young women under the age of 30. Juvenile GCTs occurring in premenarchal girls usually produce sexual precocity, including vaginal bleeding, clitoral enlargement and growth of pubic and axillary hair, as a result of estrogen secretion [1]. Juvenile GCTs, although rare, account for up to 10% of cases of precocious puberty in girls. Technically, the precocity is actually pseudoprecocity, as ovulation does not occur [4]. Acute abdominal presentations, as in our patient, have been reported secondary to intratumoral hemorrhage or tumoral rupture [1,4]; rupture has been reported in up to 10% of cases, but the presence of rupture does not necessarily affect the prognosis [5]. Juvenile GCT has also been associated with enchondromatosis or Ollier’s disease, as well as with Mafucci’s syndrome, the latter consisting of enchondromatosis and concurrent soft-tissue hemangiomas [4]; the authors have also encountered a case of juvenile GCT in a young teenage girl with McCune Albright syndrome. GCTs vary in size at the time of presentation, but are much more likely to grow to a relatively large size with a much smaller likelihood of associated peritoneal spread, compared with the more common epithelial ovarian tumors [4]. Grossly, they are partly solid and partly cystic, and a characteristic feature is the presence of multiple blood-filled cysts. The tumor may show a variegated appearance on cut section, with gray, yellow, orange or brown nodules separated by fibrous bands. Occasionally, necrosis may be encountered. GCT is usually confined to the ovary [6].
Fig. 1. A 9-year-old girl with a large abdominal mass and accelerated sexual development. (A – B) Contrast-enhanced CT images of the lower abdomen and pelvis show a large multicystic mass with solid components and areas of peripheral enhancement. No ascites is present. Sagittal reconstruction reveals right hydronephrosis due to mass effect by the tumor (arrow, B). (C – D) Gross pathology specimen consisted of a 1944-g, 19 15 10-cm, encapsulated, smooth, lobulated polycystic left ovarian mass. On cut section (D), the tumor is hemorrhagic and friable, and contains multiple small cysts and a 6 6-cm central necrotic and hemorrhagic cyst. (E) Histological examination of a representative portion of the ovarian tumor shows nodular aggregates of neoplastic granulosa cells with mucin positive intrafollicular secretion. Theca cells are present between the nodules of granulose cells. The cytoplasm of the granulose cells is heavily vacuolated with hyperchromatic, round nuclei and a paucity of nuclear grooves. Mitotic figures are numerous, 34 per high-power field (hematocylin and eosin 10; inset 40).
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Typical histologic features include a diffuse or macrofollicular pattern of growth, and large tumor cells with abundant eosinophilic or heavily vacuolated cytoplasm that are luteinized with mucin-positive intrafollicular secretion [6]. Theca cells are often present between the nodules of granulose cells; occasionally, both cell types are present in a disorderly fashion and are difficult to distinguish. CallExner bodies and nuclear grooves, which are a typical feature of adult GCT, are rare or absent in juvenile GCT. Mitotic figures, which may be atypical, are often numerous in juvenile GCTs, whereas adult GCTs usually have low mitotic activity. In 10 –15% of cases of juvenile GCT, there is marked nuclear atypia [6]. Although there are few reports of the cross-sectional imaging findings in juvenile GCT, due to the rarity of the tumor, both adult and juvenile GCTs display similar appearances on cross-sectional imaging studies [4,7]. On CT and sonography, they most typically appear as large, multilocular masses, with either thin septations or thick, irregular septations, as well as solid components [4,7]. The adult form of GCT may have a variable amount and appearance of the cystic components, however. The typical multilocular cystic findings were discovered in only 6 of a series of 13 adult patients with GCT who were imaged with CT; 3 patients had a thick- or thin-walled unilocular cystic lesion and 4 had homogeneously or heterogeneously solid lesions without an identifiable cystic component [8]. In contrast to surface epithelial neoplasms, calcifications and peritoneal metastases are rare, and intracystic papillary projections are not found [4]. On T1-weighted MR images, the tumors have foci of high signal intensity due to the characteristic finding of hemorrhage within the tumoral cysts [4]. On T2-weighted images, GCTs demonstrate a sponge-like appearance with areas of solid, intermediate-signal intensity alternating with many cystic spaces. Endometrial thickening has been identified in older women presenting with adult GCTs [9]. Although, to our knowledge, only a small number of cases of juvenile GCTs, which have been identified on cross-sectional imaging, have been reported, in girls presenting with (pseudo)precocious puberty the identification of these fairly characteristic features on cross-sectional imaging studies may permit the correct preoperative diagnosis [7].
The prognosis for patients presenting with either the adult or juvenile type of GCT is excellent. Over 90% are FIGO stage I at initial diagnosis — i.e., confined to the ovary — which is very dissimilar to the much more common epithelial ovarian neoplasms [10]. Juvenile GCT is even less likely to recur after surgical resection than the adult type [4]. However, those rare cases of juvenile GCT demonstrating malignant behavior have a rapid course rather than prolonged growth, with early intraabdominal spread, early relapse following surgery and a poor prognosis [4]. There may be a role for multidrug chemotherapy, including cisplatin-based regimens, for the small percent of patients who present with more advanced FIGO stages, or who have recurrent tumor [1].
References [1] Calaminus G, Wessalowski R, Harms D, Gobel U. Juvenile granulosa cell tumors of the ovary in children and adolescents: results from 33 patients registered in a prospective cooperative study. Gynecol Oncol 1997;65:447 – 52. [2] Perlman EJ, Fritsch MK. The female reproductive system. In: Stocker JT, Dehner LP, editors. Pediatric pathology. Philadelphia: Lippincott Williams and Wilkins, 2001. pp. 927 – 8. [3] Sutton CL, McKinney CD, Jones JE, Gay SB. Ovarian masses revisited: radiologic and pathologic correlation. Radiographics 1992;12: 853 – 77. [4] Outwater EK, Wagner BJ, Mannion C, McLarney JK, Kim B. Sex cord-stromal and steroid cell tumors of the ovary. Radiographics 1998; 18:1523 – 46. [5] Young RH, Dickersin GR, Scully RE. Juvenile granulosa cell tumor of the ovary: a clinicopathological analysis of 125 cases. Am J Surg Pathol 1984;8:575 – 96. [6] Rosai J. Female reproductive system. In: Rosai J, editor. Ackerman’s surgical pathology. St. Louis: Mosby, 1996. pp. 1505 – 8. [7] Fink D, Kubik-Huch RA, Wildermuth S. Juvenile granulosa cell tumor. Abdom Imaging 2001;26:550 – 2. [8] Ko SF, Wan YL, Ng SH, Lee T, Lin IW, Chen WJ, Kung FT, Tsai CC. Adult ovarian granulosa cell tumors: spectrum of sonographic and CT findings with pathologic correlation. AJR 1999;172:1227 – 33. [9] Morikawa K, Hatabu H, Togashi K, Kataoka ML, Mori T, Konishi J. Granulosa cell tumor of the ovary: MR findings. JCAT 1997;21: 1001 – 4. [10] Young RH, Clement PB, Scully RE. The ovary. In: Sternberg SS, Antonioli DA, Carter D, Mills SE, Oberman HA, editors. Diagnostic surgical pathology. Philadelphia: Lippincott Williams and Wilkins, 1999. pp. 2345 – 6.
Radiology–Pathology Conference Juvenile granulosa cell tumor$ Adam M. Gittlemana, Anita P. Pricea, Charles Corenb, Mudnia Akhtarc, Virginia Donovanc, Douglas S. Katza,* a
Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY 11501, USA b Department of Pediatric Surgery, Winthrop-University Hospital, Mineola, NY, USA c Department of Pathology, Winthrop-University Hospital, Mineola, NY, USA Received 20 July 2002
Abstract Juvenile granulosa cell tumor (GCT) of the ovary is a rare neoplasm occurring in premenarchal girls and young women. Juvenile GCT that occurs in premenarchal girls usually produces sexual precocity as a consequence of estrogen secretion. Juvenile GCTs are more likely to grow to a relatively large size with a much smaller likelihood of peritoneal spread, unlike their counterpart, epithelial ovarian neoplasms. We report the radiology and pathology of a patient with juvenile GCT and review the literature of this rare tumor. D 2003 Elsevier Inc. All rights reserved. Keywords: Juvenile granulosa cell tumor; Ovary; Children; Computed tomography
Granulosa cell tumors (GCTs) are extremely uncommon, accounting for about 1 –2% of all ovarian malignancies. GCTs can occur at any age. Two types are distinguished histologically — adult GCT and juvenile GCT. The more common adult GCT occurs predominantly in perimenopausal and postmenopausal women, with a peak prevalence at 50 –55 years of age [1]. The rarer juvenile GCT represents only 5% of all GCTs, and is discovered in premenarchal girls and young women [1]. These tumors are of interest clinically because of their estrogenic hormonal effects, which include pseudoprecocious puberty, as well as endometrial bleeding, endometrial hyperplasia and carcinoma in older women [1]. Few reports have been published on the cross-sectional imaging appearance of juvenile GCT, although some series of adult GCTs have been reported in the literature. In this Radiology – Pathology Conference, the clinical presentation as well as the imaging and pathology findings of juvenile GCT are reviewed. $ From the monthly Radiology – Pathology Conferences at WinthropUniversity Hospital. * Corresponding author. Tel.: +1-516-663-3800; fax: +1-516-663-3800. E-mail address: [email protected] (D.S. Katz).
0899-7071/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0899-7071(02)00586-7
1. Case presentation A 9-year-old girl presented to our institution with acute abdominal pain and a large abdominal and pelvic mass. The patient had a 2-week history of flu-like symptoms, with nausea, vomiting, fatigue and abdominal pain. The pain had become much more severe 2 days prior to admission, and was associated with a protuberant abdomen. On examination, the patient had advanced sexual development for her age. She had started menstruating 6 months earlier, had experienced breast development for almost a year, and had axillary and pubic hair. In addition, her 11year-old sister was prepubertal at the time of admission. The patient was afebrile, and the abdomen was tender without any rigidity or rebound. A moderately sized abdominal and pelvic mass was palpable just below the umbilicus. A pelvic examination was not performed. Laboratory analysis revealed an elevated leukocyte count of 24,000, and decreased hemoglobin and hematocrit. A CT scan of the abdomen and pelvis was performed with oral and intravenous contrast, on the day of admission (Fig. 1A – B). This revealed a large, multicystic pelvic mass most likely of ovarian origin, with heterogenous enhance-
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A.M. Gittleman et al. / Journal of Clinical Imaging 27 (2003) 221–224
A.M. Gittleman et al. / Journal of Clinical Imaging 27 (2003) 221–224
ment of the solid components. There was no ascites, but bilateral hydronephrosis was noted, presumably due to mass effect from the tumor. The patient then underwent an exploratory laparotomy. A large tumor was found involving the entire left ovary; the fallopian tube and the adjacent omentum were draped over the mass and the appendix was adherent to the mass. The tumor and the attached omentum and appendix were resected. The right adnexa and uterus were otherwise normal. No lymphadenopathy was identified. The pathology specimen consisted of a 1944-g, 19 15 10-cm, encapsulated, smooth, lobulated left ovarian mass, with a predominantly solid and partially cystic cut surface (Fig. 1C). The tumor on cut section (Fig. 1D) was variegated yellow to brown, with focal areas of hemorrhage. Histologically (Fig. 1E), the tumor was confined to the ovary (FIGO stage 1) and consisted of nodular aggregates of neoplastic granulosa cells with mucin-positive intrafollicular secretion. Theca cells were present between the nodules of granulose cells. The cytoplasm of the granulosa cells was heavily vacuolated, with hyperchromatic, round nuclei and a paucity of nuclear grooves. Mitotic figures were numerous, with 34 per high-powered field. These findings were diagnostic of a juvenile GCT. The patient’s postoperative course was uncomplicated. Her follow-up leukocyte count decreased to 10,000. She was started on oral iron supplements and was discharged home 6 days following surgery.
2. Discussion In addition to surface epithelial cells and germ cells, the ovary contains granulosa cells, theca cells, interstitial (hilus) cells and stromal fibroblasts, and each can result in neoplasia. All such lesions are grouped together as sex cordstromal tumors, and represent approximately 10% of all ovarian neoplasms in children and adolescents [1,2]. Many of these sex cord-stromal tumors, which include GCTs, thecomas and fibromas, are hormonally active, because the cells they are derived from are a source of ovarian hormones [3]. Granulosa cells normally surround each oocyte and form the lining of the developing follicle [4]. GCTs of the ovary were first described by Rokitansky in 1855. GCTs are extremely uncommon, accounting for only 1 – 2% of all ovarian tumors [1]. GCTs are classified histologically into two categories: adult and juvenile. Both
223
tumors share similar gross appearances and therefore similar radiographic features. These tumors are usually unilateral and estrogen secreting. However, the two types of GCT demonstrate disparity in malignant potential, the average age of affected individuals and the effects of hormone secretion [3]. Adult GCTs are far more common than the juvenile form. The adult type accounts for over 95% of all GCTs [4]. Adult GCTs are generally encountered in perimenopausal and postmenopausal women, with peak prevalence around 50– 55 years of age [1]. GCTs present with irregular bleeding in postmenopausal patients, due to the production of estrogen by these tumors. The high levels of estrogen production may lead to endometrial hyperplasia, polyps or carcinoma; the risk of endometrial carcinoma with the adult form of GCT is 10 – 15% or higher [3]. Juvenile GCTs represent only five percent of all granulosa cell neoplasms, and generally occur in premenarchal girls and young women under the age of 30. Juvenile GCTs occurring in premenarchal girls usually produce sexual precocity, including vaginal bleeding, clitoral enlargement and growth of pubic and axillary hair, as a result of estrogen secretion [1]. Juvenile GCTs, although rare, account for up to 10% of cases of precocious puberty in girls. Technically, the precocity is actually pseudoprecocity, as ovulation does not occur [4]. Acute abdominal presentations, as in our patient, have been reported secondary to intratumoral hemorrhage or tumoral rupture [1,4]; rupture has been reported in up to 10% of cases, but the presence of rupture does not necessarily affect the prognosis [5]. Juvenile GCT has also been associated with enchondromatosis or Ollier’s disease, as well as with Mafucci’s syndrome, the latter consisting of enchondromatosis and concurrent soft-tissue hemangiomas [4]; the authors have also encountered a case of juvenile GCT in a young teenage girl with McCune Albright syndrome. GCTs vary in size at the time of presentation, but are much more likely to grow to a relatively large size with a much smaller likelihood of associated peritoneal spread, compared with the more common epithelial ovarian tumors [4]. Grossly, they are partly solid and partly cystic, and a characteristic feature is the presence of multiple blood-filled cysts. The tumor may show a variegated appearance on cut section, with gray, yellow, orange or brown nodules separated by fibrous bands. Occasionally, necrosis may be encountered. GCT is usually confined to the ovary [6].
Fig. 1. A 9-year-old girl with a large abdominal mass and accelerated sexual development. (A – B) Contrast-enhanced CT images of the lower abdomen and pelvis show a large multicystic mass with solid components and areas of peripheral enhancement. No ascites is present. Sagittal reconstruction reveals right hydronephrosis due to mass effect by the tumor (arrow, B). (C – D) Gross pathology specimen consisted of a 1944-g, 19 15 10-cm, encapsulated, smooth, lobulated polycystic left ovarian mass. On cut section (D), the tumor is hemorrhagic and friable, and contains multiple small cysts and a 6 6-cm central necrotic and hemorrhagic cyst. (E) Histological examination of a representative portion of the ovarian tumor shows nodular aggregates of neoplastic granulosa cells with mucin positive intrafollicular secretion. Theca cells are present between the nodules of granulose cells. The cytoplasm of the granulose cells is heavily vacuolated with hyperchromatic, round nuclei and a paucity of nuclear grooves. Mitotic figures are numerous, 34 per high-power field (hematocylin and eosin 10; inset 40).
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Typical histologic features include a diffuse or macrofollicular pattern of growth, and large tumor cells with abundant eosinophilic or heavily vacuolated cytoplasm that are luteinized with mucin-positive intrafollicular secretion [6]. Theca cells are often present between the nodules of granulose cells; occasionally, both cell types are present in a disorderly fashion and are difficult to distinguish. CallExner bodies and nuclear grooves, which are a typical feature of adult GCT, are rare or absent in juvenile GCT. Mitotic figures, which may be atypical, are often numerous in juvenile GCTs, whereas adult GCTs usually have low mitotic activity. In 10 –15% of cases of juvenile GCT, there is marked nuclear atypia [6]. Although there are few reports of the cross-sectional imaging findings in juvenile GCT, due to the rarity of the tumor, both adult and juvenile GCTs display similar appearances on cross-sectional imaging studies [4,7]. On CT and sonography, they most typically appear as large, multilocular masses, with either thin septations or thick, irregular septations, as well as solid components [4,7]. The adult form of GCT may have a variable amount and appearance of the cystic components, however. The typical multilocular cystic findings were discovered in only 6 of a series of 13 adult patients with GCT who were imaged with CT; 3 patients had a thick- or thin-walled unilocular cystic lesion and 4 had homogeneously or heterogeneously solid lesions without an identifiable cystic component [8]. In contrast to surface epithelial neoplasms, calcifications and peritoneal metastases are rare, and intracystic papillary projections are not found [4]. On T1-weighted MR images, the tumors have foci of high signal intensity due to the characteristic finding of hemorrhage within the tumoral cysts [4]. On T2-weighted images, GCTs demonstrate a sponge-like appearance with areas of solid, intermediate-signal intensity alternating with many cystic spaces. Endometrial thickening has been identified in older women presenting with adult GCTs [9]. Although, to our knowledge, only a small number of cases of juvenile GCTs, which have been identified on cross-sectional imaging, have been reported, in girls presenting with (pseudo)precocious puberty the identification of these fairly characteristic features on cross-sectional imaging studies may permit the correct preoperative diagnosis [7].
The prognosis for patients presenting with either the adult or juvenile type of GCT is excellent. Over 90% are FIGO stage I at initial diagnosis — i.e., confined to the ovary — which is very dissimilar to the much more common epithelial ovarian neoplasms [10]. Juvenile GCT is even less likely to recur after surgical resection than the adult type [4]. However, those rare cases of juvenile GCT demonstrating malignant behavior have a rapid course rather than prolonged growth, with early intraabdominal spread, early relapse following surgery and a poor prognosis [4]. There may be a role for multidrug chemotherapy, including cisplatin-based regimens, for the small percent of patients who present with more advanced FIGO stages, or who have recurrent tumor [1].
References [1] Calaminus G, Wessalowski R, Harms D, Gobel U. Juvenile granulosa cell tumors of the ovary in children and adolescents: results from 33 patients registered in a prospective cooperative study. Gynecol Oncol 1997;65:447 – 52. [2] Perlman EJ, Fritsch MK. The female reproductive system. In: Stocker JT, Dehner LP, editors. Pediatric pathology. Philadelphia: Lippincott Williams and Wilkins, 2001. pp. 927 – 8. [3] Sutton CL, McKinney CD, Jones JE, Gay SB. Ovarian masses revisited: radiologic and pathologic correlation. Radiographics 1992;12: 853 – 77. [4] Outwater EK, Wagner BJ, Mannion C, McLarney JK, Kim B. Sex cord-stromal and steroid cell tumors of the ovary. Radiographics 1998; 18:1523 – 46. [5] Young RH, Dickersin GR, Scully RE. Juvenile granulosa cell tumor of the ovary: a clinicopathological analysis of 125 cases. Am J Surg Pathol 1984;8:575 – 96. [6] Rosai J. Female reproductive system. In: Rosai J, editor. Ackerman’s surgical pathology. St. Louis: Mosby, 1996. pp. 1505 – 8. [7] Fink D, Kubik-Huch RA, Wildermuth S. Juvenile granulosa cell tumor. Abdom Imaging 2001;26:550 – 2. [8] Ko SF, Wan YL, Ng SH, Lee T, Lin IW, Chen WJ, Kung FT, Tsai CC. Adult ovarian granulosa cell tumors: spectrum of sonographic and CT findings with pathologic correlation. AJR 1999;172:1227 – 33. [9] Morikawa K, Hatabu H, Togashi K, Kataoka ML, Mori T, Konishi J. Granulosa cell tumor of the ovary: MR findings. JCAT 1997;21: 1001 – 4. [10] Young RH, Clement PB, Scully RE. The ovary. In: Sternberg SS, Antonioli DA, Carter D, Mills SE, Oberman HA, editors. Diagnostic surgical pathology. Philadelphia: Lippincott Williams and Wilkins, 1999. pp. 2345 – 6.