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Sex cord-stromal tumors of the ovary: Granulosa-stromal cell tumors

Author
David M Gershenson, MD
Section Editors
Barbara Goff, MD
Rochelle L Garcia, MD
Don S Dizon, MD, FACP
Deputy Editor
Sandy J Falk, MD, FACOG

INTRODUCTION

Ovarian sex cord-stromal tumors are a heterogeneous group of benign or malignant tumors that develop from the dividing cell population that would normally produce cells that support and surround the oocytes, including the cells that produce ovarian hormones (the non-germ cell and nonepithelial components of the gonads) (figure 1) [1]. Ovarian sex cord-stromal tumors are rare, comprising only 1.2 percent of all primary ovarian cancers [2].

In contrast with epithelial ovarian cancer, most patients with malignant sex cord-stromal tumors are diagnosed with early-stage disease; the tumors are generally considered to be low-grade malignancies.

Sex cord-stromal tumors include granulosa cell tumors (which differentiate toward female characteristics), fibroma-thecomas, and Sertoli-Leydig cell tumors (which differentiate toward male characteristics). Granulosa-stromal cell tumors include granulosa cell tumors, thecomas, and fibromas [3]. They account for 70 percent of ovarian sex cord-stromal tumors. Among granulosa-stromal cell tumors, fibromas are the most common histology. These tumors occur with equal frequency among pre- and postmenopausal women.

Granulosa cell, theca cell, and mixed tumors are usually hormonally active, in contrast to fibromas, which do not produce hormones. Granulosa cell tumors are more often malignant than thecomas or fibromas, which are most often benign.

Ovarian sex cord-stromal tumors of the granulosa-stromal cell type (granulosa cell tumors, fibromas, and thecomas) are reviewed here. An overview of sex cord-stromal tumors and other types of sex cord-stromal tumors of the ovary (Sertoli-stromal cell tumors and tumors with granulosa and Sertoli-Leydig elements), as well as epithelial ovarian cancer, are discussed separately. (See "Overview of sex cord-stromal tumors of the ovary" and "Sex cord-stromal tumors of the ovary: Sertoli-stromal cell tumors" and "Sex cord-stromal tumors of the ovary: Tumors with granulosa and Sertoli-Leydig elements" and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Histopathology" and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)

                  

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References
Top
  1. Young RH. Sex cord-stromal tumors of the ovary and testis: their similarities and differences with consideration of selected problems. Mod Pathol 2005; 18 Suppl 2:S81.
  2. Quirk JT, Natarajan N. Ovarian cancer incidence in the United States, 1992-1999. Gynecol Oncol 2005; 97:519.
  3. Segal R, DePetrillo AD, Thomas G. Clinical review of adult granulosa cell tumors of the ovary. Gynecol Oncol 1995; 56:338.
  4. Lack EE, Perez-Atayde AR, Murthy AS, et al. Granulosa theca cell tumors in premenarchal girls: a clinical and pathologic study of ten cases. Cancer 1981; 48:1846.
  5. Boyce EA, Costaggini I, Vitonis A, et al. The epidemiology of ovarian granulosa cell tumors: a case-control study. Gynecol Oncol 2009; 115:221.
  6. Young R, Clement PB, Scully RE. The ovary. In: Surgical Pathology, Sternberg SS (Ed), Raven Press, New York 1989. p.1687.
  7. McCluggage WG. Recent advances in immunohistochemistry in the diagnosis of ovarian neoplasms. J Clin Pathol 2000; 53:327.
  8. Movahedi-Lankarani S, Kurman RJ. Calretinin, a more sensitive but less specific marker than alpha-inhibin for ovarian sex cord-stromal neoplasms: an immunohistochemical study of 215 cases. Am J Surg Pathol 2002; 26:1477.
  9. Matias-Guiu X, Pons C, Prat J. Müllerian inhibiting substance, alpha-inhibin, and CD99 expression in sex cord-stromal tumors and endometrioid ovarian carcinomas resembling sex cord-stromal tumors. Hum Pathol 1998; 29:840.
  10. Hildebrandt RH, Rouse RV, Longacre TA. Value of inhibin in the identification of granulosa cell tumors of the ovary. Hum Pathol 1997; 28:1387.
  11. Zhao C, Vinh TN, McManus K, et al. Identification of the most sensitive and robust immunohistochemical markers in different categories of ovarian sex cord-stromal tumors. Am J Surg Pathol 2009; 33:354.
  12. Shah SP, Köbel M, Senz J, et al. Mutation of FOXL2 in granulosa-cell tumors of the ovary. N Engl J Med 2009; 360:2719.
  13. Köbel M, Gilks CB, Huntsman DG. Adult-type granulosa cell tumors and FOXL2 mutation. Cancer Res 2009; 69:9160.
  14. Evans AT 3rd, Gaffey TA, Malkasian GD Jr, Annegers JF. Clinicopathologic review of 118 granulosa and 82 theca cell tumors. Obstet Gynecol 1980; 55:231.
  15. Adamian RT. [Hyperplastic processes and endometrial cancer in patients with hormone-producing ovarian tumors]. Vopr Onkol 1991; 37:48.
  16. Berek JS, Hacker NF. Nonepithelial ovarian and fallopian tube cancers. In: Practical Gynecologic Oncology, 3rd, Berek JS, Hacker NF (Eds), Lippincott Williams & Wilkins, Philadelphia 2000. p.539.
  17. Schumer ST, Cannistra SA. Granulosa cell tumor of the ovary. J Clin Oncol 2003; 21:1180.
  18. Zanagnolo V, Pasinetti B, Sartori E. Clinical review of 63 cases of sex cord stromal tumors. Eur J Gynaecol Oncol 2004; 25:431.
  19. Nakashima N, Young RH, Scully RE. Androgenic granulosa cell tumors of the ovary. A clinicopathologic analysis of 17 cases and review of the literature. Arch Pathol Lab Med 1984; 108:786.
  20. Norris HJ, Taylor HB. Virilization associated with cystic granulosa tumors. Obstet Gynecol 1969; 34:629.
  21. Castro CY, Malpica A, Hearne RH, Silva EG. Androgenic adult granulosa cell tumor in a 13-year-old prepubertal patient: a case report and review of the literature. Int J Gynecol Pathol 2000; 19:266.
  22. Lappöhn RE, Burger HG, Bouma J, et al. Inhibin as a marker for granulosa-cell tumors. N Engl J Med 1989; 321:790.
  23. Jobling T, Mamers P, Healy DL, et al. A prospective study of inhibin in granulosa cell tumors of the ovary. Gynecol Oncol 1994; 55:285.
  24. Boggess JF, Soules MR, Goff BA, et al. Serum inhibin and disease status in women with ovarian granulosa cell tumors. Gynecol Oncol 1997; 64:64.
  25. Healy DL, Burger HG, Mamers P, et al. Elevated serum inhibin concentrations in postmenopausal women with ovarian tumors. N Engl J Med 1993; 329:1539.
  26. Gustafson ML, Lee MM, Scully RE, et al. Müllerian inhibiting substance as a marker for ovarian sex-cord tumor. N Engl J Med 1992; 326:466.
  27. Robertson DM, Stephenson T, Pruysers E, et al. Characterization of inhibin forms and their measurement by an inhibin alpha-subunit ELISA in serum from postmenopausal women with ovarian cancer. J Clin Endocrinol Metab 2002; 87:816.
  28. Mom CH, Engelen MJ, Willemse PH, et al. Granulosa cell tumors of the ovary: the clinical value of serum inhibin A and B levels in a large single center cohort. Gynecol Oncol 2007; 105:365.
  29. Robertson DM, Stephenson T, Pruysers E, et al. Inhibins/activins as diagnostic markers for ovarian cancer. Mol Cell Endocrinol 2002; 191:97.
  30. Rey RA, Lhommé C, Marcillac I, et al. Antimüllerian hormone as a serum marker of granulosa cell tumorsof the ovary: comparative study with serum alpha-inhibin and estradiol. Am J Obstet Gynecol 1996; 174:958.
  31. Lane AH, Lee MM, Fuller AF Jr, et al. Diagnostic utility of Müllerian inhibiting substance determination in patients with primary and recurrent granulosa cell tumors. Gynecol Oncol 1999; 73:51.
  32. Chang HL, Pahlavan N, Halpern EF, MacLaughlin DT. Serum Müllerian Inhibiting Substance/anti-Müllerian hormone levels in patients with adult granulosa cell tumors directly correlate with aggregate tumor mass as determined by pathology or radiology. Gynecol Oncol 2009; 114:57.
  33. Miller BE, Barron BA, Wan JY, et al. Prognostic factors in adult granulosa cell tumor of the ovary. Cancer 1997; 79:1951.
  34. Brown J, Sood AK, Deavers MT, et al. Patterns of metastasis in sex cord-stromal tumors of the ovary: can routine staging lymphadenectomy be omitted? Gynecol Oncol 2009; 113:86.
  35. Abu-Rustum NR, Restivo A, Ivy J, et al. Retroperitoneal nodal metastasis in primary and recurrent granulosa cell tumors of the ovary. Gynecol Oncol 2006; 103:31.
  36. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
  37. Gershenson DM. Management of early ovarian cancer: germ cell and sex cord-stromal tumors. Gynecol Oncol 1994; 55:S62.
  38. Zhang M, Cheung MK, Shin JY, et al. Prognostic factors responsible for survival in sex cord stromal tumors of the ovary--an analysis of 376 women. Gynecol Oncol 2007; 104:396.
  39. Schneider DT, Calaminus G, Wessalowski R, et al. Ovarian sex cord-stromal tumors in children and adolescents. J Clin Oncol 2003; 21:2357.
  40. Young RH, Scully RE. Ovarian Sertoli-Leydig cell tumors. A clinicopathological analysis of 207 cases. Am J Surg Pathol 1985; 9:543.
  41. 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.
  42. Calaminus G, Wessalowski R, Harms D, Göbel 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.
  43. Schneider DT, Calaminus G, Wessalowski R, et al. Therapy of advanced ovarian juvenile granulosa cell tumors. Klin Padiatr 2002; 214:173.
  44. Schneider DT, Jänig U, Calaminus G, et al. Ovarian sex cord-stromal tumors--a clinicopathological study of 72 cases from the Kiel Pediatric Tumor Registry. Virchows Arch 2003; 443:549.
  45. Plantaz D, Flamant F, Vassal G, et al. [Granulosa cell tumors of the ovary in children and adolescents. Multicenter retrospective study in 40 patients aged 7 months to 22 years]. Arch Fr Pediatr 1992; 49:793.
  46. Uygun K, Aydiner A, Saip P, et al. Clinical parameters and treatment results in recurrent granulosa cell tumor of the ovary. Gynecol Oncol 2003; 88:400.
  47. Al-Badawi IA, Brasher PM, Ghatage P, et al. Postoperative chemotherapy in advanced ovarian granulosa cell tumors. Int J Gynecol Cancer 2002; 12:119.
  48. Chan JK, Zhang M, Kaleb V, et al. Prognostic factors responsible for survival in sex cord stromal tumors of the ovary--a multivariate analysis. Gynecol Oncol 2005; 96:204.
  49. Lauszus FF, Petersen AC, Greisen J, Jakobsen A. Granulosa cell tumor of the ovary: a population-based study of 37 women with stage I disease. Gynecol Oncol 2001; 81:456.
  50. Homesley HD, Bundy BN, Hurteau JA, Roth LM. Bleomycin, etoposide, and cisplatin combination therapy of ovarian granulosa cell tumors and other stromal malignancies: A Gynecologic Oncology Group study. Gynecol Oncol 1999; 72:131.
  51. Savage P, Constenla D, Fisher C, et al. Granulosa cell tumours of the ovary: demographics, survival and the management of advanced disease. Clin Oncol (R Coll Radiol) 1998; 10:242.
  52. Colombo N, Sessa C, Landoni F, et al. Cisplatin, vinblastine, and bleomycin combination chemotherapy in metastatic granulosa cell tumor of the ovary. Obstet Gynecol 1986; 67:265.
  53. Zambetti M, Escobedo A, Pilotti S, De Palo G. cis-platinum/vinblastine/bleomycin combination chemotherapy in advanced or recurrent granulosa cell tumors of the ovary. Gynecol Oncol 1990; 36:317.
  54. Schwartz PE, Smith JP. Treatment of ovarian stromal tumors. Am J Obstet Gynecol 1976; 125:402.
  55. Ohel G, Kaneti H, Schenker JG. Granulosa cell tumors in Israel: a study of 172 cases. Gynecol Oncol 1983; 15:278.
  56. Pankratz E, Boyes DA, White GW, et al. Granulosa cell tumors. A clinical review of 61 cases. Obstet Gynecol 1978; 52:718.
  57. Björkholm E, Silfverswärd C. Prognostic factors in granulosa-cell tumors. Gynecol Oncol 1981; 11:261.
  58. Stenwig JT, Hazekamp JT, Beecham JB. Granulosa cell tumors of the ovary. A clinicopathological study of 118 cases with long-term follow-up. Gynecol Oncol 1979; 7:136.
  59. Fox H, Agrawal K, Langley FA. A clinicopathologic study of 92 cases of granulosa cell tumor of the ovary with special reference to the factors influencing prognosis. Cancer 1975; 35:231.
  60. Sehouli J, Drescher FS, Mustea A, et al. Granulosa cell tumor of the ovary: 10 years follow-up data of 65 patients. Anticancer Res 2004; 24:1223.
  61. Malmström H, Högberg T, Risberg B, Simonsen E. Granulosa cell tumors of the ovary: prognostic factors and outcome. Gynecol Oncol 1994; 52:50.
  62. Gershenson DM, Hartmann LC, Young RH. Ovarian sex cord-stromal tumors. In: Principles and Practice of Gynecologic Oncology, WJ, Young RC, Markman M, Perez CA, Barakat R, Randall M (Eds), Lippincott Williams & Wilkins, Philadelphia 2005. p.1011.
  63. Wolf JK, Mullen J, Eifel PJ, et al. Radiation treatment of advanced or recurrent granulosa cell tumor of the ovary. Gynecol Oncol 1999; 73:35.
  64. Gershenson DM, Morris M, Burke TW, et al. Treatment of poor-prognosis sex cord-stromal tumors of the ovary with the combination of bleomycin, etoposide, and cisplatin. Obstet Gynecol 1996; 87:527.
  65. Disaia P, Saltz A, Kagan AR, Rich W. A temporary response of recurrent granulosa cell tumor to adriamycin. Obstet Gynecol 1978; 52:355.
  66. Powell JL, Otis CN. Management of advanced juvenile granulosa cell tumor of the ovary. Gynecol Oncol 1997; 64:282.
  67. Muntz HG, Goff BA, Fuller AF Jr. Recurrent ovarian granulosa cell tumor: role of combination chemotherapy with report of a long-term response to a cyclophosphamide, doxorubicin and cisplatin regimen. Eur J Gynaecol Oncol 1990; 11:263.
  68. Gershenson DM, Copeland LJ, Kavanagh JJ, et al. Treatment of metastatic stromal tumors of the ovary with cisplatin, doxorubicin, and cyclophosphamide. Obstet Gynecol 1987; 70:765.
  69. Pectasides D, Alevizakos N, Athanassiou AE. Cisplatin-containing regimen in advanced or recurrent granulosa cell tumours of the ovary. Ann Oncol 1992; 3:316.
  70. Tresukosol D, Kudelka AP, Edwards CL, et al. Recurrent ovarian granulosa cell tumor: a case report of a dramatic response to Taxol. Int J Gynecol Cancer 1995; 5:156.
  71. Brown J, Shvartsman HS, Deavers MT, et al. The activity of taxanes in the treatment of sex cord-stromal ovarian tumors. J Clin Oncol 2004; 22:3517.
  72. Brown J, Shvartsman HS, Deavers MT, et al. The activity of taxanes compared with bleomycin, etoposide, and cisplatin in the treatment of sex cord-stromal ovarian tumors. Gynecol Oncol 2005; 97:489.
  73. Powell JL, Connor GP, Henderson GS. Management of recurrent juvenile granulosa cell tumor of the ovary. Gynecol Oncol 2001; 81:113.
  74. Emons G, Schally AV. The use of luteinizing hormone releasing hormone agonists and antagonists in gynaecological cancers. Hum Reprod 1994; 9:1364.
  75. Martikainen H, Penttinen J, Huhtaniemi I, Kauppila A. Gonadotropin-releasing hormone agonist analog therapy effective in ovarian granulosa cell malignancy. Gynecol Oncol 1989; 35:406.
  76. Fishman A, Kudelka AP, Tresukosol D, et al. Leuprolide acetate for treating refractory or persistent ovarian granulosa cell tumor. J Reprod Med 1996; 41:393.
  77. Briasoulis E, Karavasilis V, Pavlidis N. Megestrol activity in recurrent adult type granulosa cell tumour of the ovary. Ann Oncol 1997; 8:811.
  78. Hardy RD, Bell JG, Nicely CJ, Reid GC. Hormonal treatment of a recurrent granulosa cell tumor of the ovary: case report and review of the literature. Gynecol Oncol 2005; 96:865.
  79. Maxwell GL, Soisson AP, Miles P. Failure of gonadotropin releasing hormone therapy in patients with metastatic ovarian sex cord stromal tumors. Oncology 1994; 51:356.
  80. Tao X, Sood AK, Deavers MT, et al. Anti-angiogenesis therapy with bevacizumab for patients with ovarian granulosa cell tumors. Gynecol Oncol 2009; 114:431.
  81. Cronjé HS, Niemand I, Bam RH, Woodruff JD. Review of the granulosa-theca cell tumors from the emil Novak ovarian tumor registry. Am J Obstet Gynecol 1999; 180:323.
  82. Uygun K, Aydiner A, Saip P, et al. Granulosa cell tumor of the ovary: retrospective analysis of 45 cases. Am J Clin Oncol 2003; 26:517.
  83. Lee YK, Park NH, Kim JW, et al. Characteristics of recurrence in adult-type granulosa cell tumor. Int J Gynecol Cancer 2008; 18:642.
  84. Auranen A, Sundström J, Ijäs J, Grénman S. Prognostic factors of ovarian granulosa cell tumor: a study of 35 patients and review of the literature. Int J Gynecol Cancer 2007; 17:1011.
  85. Ala-Fossi SL, Mäenpää J, Aine R, et al. Prognostic significance of p53 expression in ovarian granulosa cell tumors. Gynecol Oncol 1997; 66:475.
  86. Roush GR, el-Naggar AK, Abdul-Karim FW. Granulosa cell tumor of ovary: a clinicopathologic and flow cytometric DNA analysis. Gynecol Oncol 1995; 56:430.
  87. Crew KD, Cohen MH, Smith DH, et al. Long natural history of recurrent granulosa cell tumor of the ovary 23 years after initial diagnosis: a case report and review of the literature. Gynecol Oncol 2005; 96:235.
  88. Ishiko O, Yoshida H, Sumi T, et al. Vascular endothelial growth factor levels in pleural and peritoneal fluid in Meigs' syndrome. Eur J Obstet Gynecol Reprod Biol 2001; 98:129.
  89. Stuart GC, Dawson LM. Update on granulosa cell tumours of the ovary. Curr Opin Obstet Gynecol 2003; 15:33.
  90. Chechia A, Attia L, Temime RB, et al. Incidence, clinical analysis, and management of ovarian fibromas and fibrothecomas. Am J Obstet Gynecol 2008; 199:473.e1.
  91. Brun JL. Demons syndrome revisited: a review of the literature. Gynecol Oncol 2007; 105:796.
  92. MEIGS JV. Fibroma of the ovary with ascites and hydrothorax; Meigs' syndrome. Am J Obstet Gynecol 1954; 67:962.
  93. Timmerman D, Moerman P, Vergote I. Meigs' syndrome with elevated serum CA 125 levels: two case reports and review of the literature. Gynecol Oncol 1995; 59:405.
  94. Peparini N, Chirletti P. Ovarian malignancies with cytologically negative pleural and peritoneal effusions: demons' or meigs' pseudo-syndromes? Int J Surg Pathol 2009; 17:396.
  95. Tsuji T, Catasus L, Prat J. Is loss of heterozygosity at 9q22.3 (PTCH gene) and 19p13.3 (STK11 gene) involved in the pathogenesis of ovarian stromal tumors? Hum Pathol 2005; 36:792.
  96. DiSaia PJ, Creasman WT. Germ cell, stromal and other ovarian tumors. In: Clinical Gynecologic Oncology, 7th, Mosby-Elsevier, 2007. p.387.
  97. Clement PB, Young RH, Hanna W, Scully RE. Sclerosing peritonitis associated with luteinized thecomas of the ovary. A clinicopathological analysis of six cases. Am J Surg Pathol 1994; 18:1.
  98. Staats PN, McCluggage WG, Clement PB, Young RH. Luteinized thecomas (thecomatosis) of the type typically associated with sclerosing peritonitis: a clinical, histopathologic, and immunohistochemical analysis of 27 cases. Am J Surg Pathol 2008; 32:1273.
  99. Bahar B, Hu Z, Szpaderska A, et al. Fatal case of luteinized thecoma with sclerosing peritonitis in a 40-year-old woman. Int J Gynecol Pathol 2014; 33:30.
  100. Nauen DW, Martin A, Katz A, et al. A case of luteinizing thecoma with sclerosing peritonitis: revisiting a link with anti-epileptic drugs. Pediatr Blood Cancer 2010; 54:470.
  101. Lo WK, Chan KT, Leung AC, et al. Sclerosing peritonitis complicating prolonged use of chlorhexidine in alcohol in the connection procedure for continuous ambulatory peritoneal dialysis. Perit Dial Int 1991; 11:166.
  102. Marshall AJ, Baddeley H, Barritt DW, et al. Practolol peritonitis. A study of 16 cases and a survey of small bowel function in patients taking beta adrenergic blockers. Q J Med 1977; 46:135.
  103. Bianco R, de Rosa G, Staibano S, et al. Ovarian luteinized thecoma with sclerosing peritonitis in an adult woman treated with leuprolide and toremifene in complete remission at 5 years. Gynecol Oncol 2005; 96:846.
  104. Schonman R, Klein Z, Edelstein E, et al. Luteinized thecoma associated with sclerosing peritonitis--conservative surgical approach followed by corticosteroid and GnRH agonist treatment--a case report. Gynecol Oncol 2008; 111:540.
  105. Noyes N, Perretta RC, Fino ME, et al. Use of hormone suppression then oocyte freezing to preserve reproductive capability in an adolescent girl with ovarian luteinized thecoma associated with sclerosing peritonitis. Fertil Steril 2009; 92:393.e11.
  106. Mellembakken JR, Engh V, Tanbo T, et al. Mitotically active cellular luteinized thecoma of the ovary and luteinized thecomatosis associated with sclerosing peritonitis: case studies, comparison, and review of the literature. Pathol Res Pract 2010; 206:744.
  107. Roth LM, Czernobilsky B. Perspectives on pure ovarian stromal neoplasms and tumor-like proliferations of the ovarian stroma. Am J Surg Pathol 2011; 35:e15.
  108. Nowak M, Podciechowski L, Krawczyk T, Wilczynski J. Meigs' syndrome and virilizing ovarian fibrothecoma complicating pregnancy. A case report and review of the literature. Neuro Endocrinol Lett 2009; 30:192.
  109. Elghorori MR, Al-Taher H, Redwood NF. Ovarian fibrothecoma: a benign neoplasm with potential adverse consequences. J Obstet Gynaecol 2003; 23:677.
  110. Liu H, Hao SH, Li WM. Giant malignant ovarian fibrothecoma involved with retroperitoneal structures mimicking a retroperitoneal sarcoma. Arch Gynecol Obstet 2009; 279:763.
  111. Troiano RN, Lazzarini KM, Scoutt LM, et al. Fibroma and fibrothecoma of the ovary: MR imaging findings. Radiology 1997; 204:795.
  112. Jung SE, Rha SE, Lee JM, et al. CT and MRI findings of sex cord-stromal tumor of the ovary. AJR Am J Roentgenol 2005; 185:207.
  113. Tanaka YO, Saida TS, Minami R, et al. MR findings of ovarian tumors with hormonal activity, with emphasis on tumors other than sex cord-stromal tumors. Eur J Radiol 2007; 62:317.
  114. Okajima Y, Matsuo Y, Tamura A, et al. Intracellular lipid in ovarian thecomas detected by dual-echo chemical shift magnetic resonance imaging: report of 2 cases. J Comput Assist Tomogr 2010; 34:223.