Overwhelmed by Heterologous Elements: The Hidden Identity of an Ovarian Sertoli–Leydig Cell Tumor with Extensive Heterologous Elements

Background: Sertoli–Leydig cell tumors (SLCTs) are rare ovarian sex cord–stromal tumors, often presenting diagnostic challenges due to their varied morphology and association with heterologous elements. Case Presentation: We report a case of 21-year-old female presenting with pelvic pain, secondary amenorrhea, and virilization. Radiology revealed a left ovarian mass. Patient underwent fertility sparing left partial oophorectomy. Histopathological examination demonstrated extensive calcification and ossification with scanty tumor cells, posing significant diagnostic difficulty. Based on morphology differential included were mesenchymal tumors of ovary, mature teratoma and sex cord stromal tumors. Immunohistochemistry played a crucial role in establishing the diagnosis of Sertoli–Leydig cell tumor with extensive heterologous elements.Conclusion: This case highlights the importance of correlating morphology, immunohistochemistry, and clinical features to arrive at an accurate diagnosis, especially in tumors with dominant heterologous components.