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Karseladze AI, Asaturova AV, Kiseleva IA, Badlaeva AS, Tregubova AV, Zaretsky AR, Uvarova EV, Zanelli M, Palicelli A. Androgen Insensitivity Syndrome with Bilateral Gonadal Sertoli Cell Lesions, Sertoli-Leydig Cell Tumor, and Paratesticular Leiomyoma: A Case Report and First Systematic Literature Review. J Clin Med 2024; 13:929. [PMID: 38398243 PMCID: PMC10889606 DOI: 10.3390/jcm13040929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/28/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Androgen insensitivity syndrome (AIS) is a rare Mendelian disorder caused by mutations of the androgen receptor (AR) gene on the long arm of the X chromosome. As a result of the mutation, the receptor becomes resistant to androgens, and hence, karyotypically male patients (46,XY) carry a female phenotype. Their cryptorchid gonads are prone to the development of several types of tumors (germ cell, sex cord stromal, and others). Here, we report a 15-year-old female-looking patient with primary amenorrhea who underwent laparoscopic gonadectomy. Histologically, the patient's gonads showed Sertoli cell hamartomas (SCHs) and adenomas (SCAs) with areas of Sertoli-Leydig cell tumors (SLCTs) and a left-sided paratesticular leiomyoma. Rudimentary Fallopian tubes were also present. The patient's karyotype was 46,XY without any evidence of aberrations. Molecular genetic analysis of the left gonad revealed two likely germline mutations-a pathogenic frameshift deletion in the AR gene (c.77delT) and a likely pathogenic missense variant in the RAC1 gene (p.A94V). Strikingly, no somatic mutations, fusions, or copy number variations were found. We also performed the first systematic literature review (PRISMA guidelines; screened databases: PubMed, Scopus, Web of Science; ended on 7 December 2023) of the reported cases of patients with AIS showing benign or malignant Sertoli cell lesions/tumors in their gonads (n = 225; age: 4-84, mean 32 years), including Sertoli cell hyperplasia (1%), Sertoli cell nodules (6%), SCHs (31%), SCAs (36%), Sertoli cell tumors (SCTs) (16%), and SLCTs (4%). The few cases (n = 14, 6%; six SCAs, four SCTs, two SLCTs, and two SCHs) with available follow-up (2-49, mean 17 months) showed no evidence of disease (13/14, 93%) or died of other causes (1/14, 7%) despite the histological diagnosis. Smooth muscle lesions/proliferations were identified in 19 (8%) cases (including clearly reported rudimentary uterine remnants, 3 cases; leiomyomas, 4 cases). Rudimentary Fallopian tube(s) were described in nine (4%) cases. Conclusion: AIS may be associated with sex cord/stromal tumors and, rarely, mesenchymal tumors such as leiomyomas. True malignant sex cord tumors can arise in these patients. Larger series with longer follow-ups are needed to estimate the exact prognostic relevance of tumor histology in AIS.
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Affiliation(s)
- Apollon I. Karseladze
- Oncopathology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia, Bldg. 4, Oparina Street, Moscow 117513, Russia
| | - Aleksandra V. Asaturova
- 1st Pathology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia, Bldg. 4, Oparina Street, Moscow 117513, Russia
| | - Irina A. Kiseleva
- Pediatric Gynecology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia, Bldg. 4, Oparina Street, Moscow 117513, Russia
| | - Alina S. Badlaeva
- 1st Pathology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia, Bldg. 4, Oparina Street, Moscow 117513, Russia
| | - Anna V. Tregubova
- 1st Pathology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia, Bldg. 4, Oparina Street, Moscow 117513, Russia
| | - Andrew R. Zaretsky
- Department of Molecular Technologies, Research Institute of Translational Medicine, N. I. Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation, Bldg. 1, Ostrovityanova Street, Moscow 117997, Russia;
| | - Elena V. Uvarova
- Pediatric Gynecology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia, Bldg. 4, Oparina Street, Moscow 117513, Russia
| | - Magda Zanelli
- Pathology Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.Z.)
| | - Andrea Palicelli
- Pathology Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.Z.)
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Lee R, Lee WY, Park HJ. Diuron-induced fetal Leydig cell dysfunction in in vitro organ cultured fetal testes. Reprod Toxicol 2024; 123:108497. [PMID: 37949197 DOI: 10.1016/j.reprotox.2023.108497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
Diuron is a phenylurea herbicide widely used in the agricultural industry. In recent years, the risk of infertility and developmental defects has increased due to exposure to environmental pollutants. In this study, we investigated the toxicity of diuron in fetal mouse testes using three-dimensional organ cultures. Fetal testes derived from embryonic day (E) 14.5 were cultured with 200 µM diuron for 5 days. The results revealed that diuron did not impair fetal germ cell proliferation or the expression levels of germ cell markers such as Ddx4, Dazl, Oct 4, Nanog, Plzf, and TRA 98. Similarly, the gene or protein expression of the Sertoli cell markers Sox9 and Wt1 in diuron-exposed fetal testes did not change after 5 days of culture. In contrast, diuron increased fetal Leydig cell markers (FLC), Cyp11a1, Cyp17a1, Thbs2, and Pdgf α, and decreased adult Leydig cell (ALC) markers, Sult1e1, Hsd173, Ptgds, and Vcam1. However, 3-βHSD, an FLC and ALC marker, was consistently maintained upon exposure to diuron in fetal testes compared to non-treated groups. In conclusion, our study demonstrates that diuron negatively impacts Fetal Leydig cell development, although it does not affect germ and Sertoli cells.
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Affiliation(s)
- Ran Lee
- Department of Livestock, Korea National College of Agriculture and Fisheries, Jeonbuk 54874, Republic of Korea; Department of Animal Biotechnology, Sangji University, Wonju-si, Gangwon-do 26339, Republic of Korea
| | - Won-Young Lee
- Department of Livestock, Korea National College of Agriculture and Fisheries, Jeonbuk 54874, Republic of Korea
| | - Hyun-Jung Park
- Department of Animal Biotechnology, Sangji University, Wonju-si, Gangwon-do 26339, Republic of Korea.
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Delli Paoli E, Di Chiano S, Paoli D, Lenzi A, Lombardo F, Pallotti F. Androgen insensitivity syndrome: a review. J Endocrinol Invest 2023; 46:2237-2245. [PMID: 37300628 DOI: 10.1007/s40618-023-02127-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Androgen insensitivity syndrome (AIS) is a disorder characterized by peripheral androgen resistance due to androgen receptor mutations in subjects with 46 XY karyotype. The severity of hormone resistance (complete, partial or mild) determines the wide spectrum of phenotypes. METHODS We performed a literature review on Pubmed focusing on etiopathogenesis, molecular alterations, and diagnostic-therapeutic management. RESULTS AIS is determined by a large variety of X-linked mutations that account for the wide phenotypic spectrum of subjects; it represents one of the most frequent disorders of sexual development (DSD). Clinical suspicion can arise at birth in partial AIS, due to the presence of variable degrees of ambiguity of the external genitalia, and at pubertal age in complete AIS, due to the development of female secondary sex characteristics, primary amenorrhea, and absence of female primary sex characteristics (uterus and ovaries). Laboratory tests showing elevated LH and testosterone levels despite mild or absent virilization may be helpful, but diagnosis can be achieved only after genetic testing (karyotype examination and androgen receptor sequencing). The clinical phenotype and especially the decision on sex assignment of the patient, if the diagnosis is made at birth or in the neonatal period, will guide the following medical, surgical and psychological management. CONCLUSIONS For the management of AIS, a multidisciplinary team consisting of physicians, surgeons, and psychologists is highly recommended to support the patient and his/her family on gender identity choices and subsequent appropriate therapeutic decisions.
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Affiliation(s)
- E Delli Paoli
- Laboratory of Seminology‑Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - S Di Chiano
- Laboratory of Seminology‑Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - D Paoli
- Laboratory of Seminology‑Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - A Lenzi
- Laboratory of Seminology‑Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - F Lombardo
- Laboratory of Seminology‑Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - F Pallotti
- Laboratory of Seminology‑Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
- Faculty of Medicine and Surgery, University of Enna "Kore", Contrada Santa Panasia, 94100, Enna, Italy.
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Lee NY, Kim JH, Yoon JH, Hwang S, Kim GH, Yoo HW, Choi JH. Clinical outcomes and genotype-phenotype correlations in patients with complete and partial androgen insensitivity syndromes. Ann Pediatr Endocrinol Metab 2023; 28:184-192. [PMID: 36731508 PMCID: PMC10556439 DOI: 10.6065/apem.2244152.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Androgen insensitivity syndrome (AIS) is a rare X-linked recessive disorder caused by unresponsiveness to androgens because of mutations in the AR gene. Here, we investigated the clinical outcomes and molecular spectrum of AR variants in patients with AIS attending a single academic center. METHODS This study included 19 patients with AIS who were confirmed by molecular analysis of AR. Clinical features and endocrinological findings were retrospectively collected, including presenting features, external genitalia, sex of rearing, timing of gonadectomy, pubertal outcomes, and sex hormone levels. Molecular analysis of AR was performed using Sanger, targeted gene panel, or whole-exome sequencing. RESULTS Among all 19 patients, 14 (74%) were classified as having complete AIS (CAIS), whereas 5 (26%) had partial AIS (PAIS). All patients with CAIS, and 3 patients with PAIS were reared as female. One patient with CAIS manifested a mixed germ cell tumor at the age of 30 years. Molecular analysis of AR identified 19 sequence variants; 12 (63%) were previously reported, and the remaining 7 (37%) were novel. Missense mutations were the most common type (12 of 19, 63%), followed by small deletions, nonsense mutations, an insertion, and a splice site mutation. CONCLUSION Here, we describe the clinical outcomes and molecular characteristics of 19 Korean patients with AIS. Patients with PAIS manifested various degrees of masculinization of the external genitalia. Nonsense and frameshift mutations were frequent in patients with CAIS, whereas patients with PAIS harbored exclusively missense mutations.
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Affiliation(s)
- Nae-yun Lee
- Department of Pediatrics, Asan Medical Center Children, University of Ulsan College of Medicine, Seoul, Korea
| | - Ja Hye Kim
- Department of Pediatrics, Asan Medical Center Children, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji-Hee Yoon
- Department of Pediatrics, Asan Medical Center Children, University of Ulsan College of Medicine, Seoul, Korea
| | - Soojin Hwang
- Department of Pediatrics, Asan Medical Center Children, University of Ulsan College of Medicine, Seoul, Korea
| | - Gu-Hwan Kim
- Medical Genetics Center, Asan Medical Center Children, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center Children, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Pediatrics, Asan Medical Center Children, University of Ulsan College of Medicine, Seoul, Korea
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Johnson EK, Whitehead J, Cheng EY. Differences of Sex Development: Current Issues and Controversies. Urol Clin North Am 2023; 50:433-446. [PMID: 37385705 DOI: 10.1016/j.ucl.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Differences of sex development (DSD) encompass a broad range of conditions in which the development of chromosomal, gonadal, or anatomic sex is not typically male or female. Terms used to describe DSD are controversial, and continuously evolving. An individualized, multidisciplinary approach is key to both the diagnosis and management of DSD. Recent advances in DSD care include expanded genetic testing options, a more nuanced approach to gonadal management, and an emphasis on shared decision-making, particularly related to external genital surgical procedures. The timing of DSD surgery is currently being questioned and debated in both medical and advocacy/activism spheres.
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Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 2300, Chicago, IL, 60611, USA.
| | - Jax Whitehead
- Division of Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 54, Chicago, IL 60611, USA; Department of Pediatrics, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 86, Chicago, IL 60611, USA
| | - Earl Y Cheng
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 24, Chicago, IL 60611, USA; Department of Urology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 2300, Chicago, IL, 60611, USA
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Wong WY, Wong LM, Tam YH, Luk HM. A Baby With Complete Androgen Insensitivity Syndrome and the Fortuitous Discovery of 45,X/46,XY Mosaicism. Cureus 2023; 15:e43352. [PMID: 37700992 PMCID: PMC10493458 DOI: 10.7759/cureus.43352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Disorders of sex development (DSD) are caused by defects in the complex sexual differentiation cascade, resulting in discordance among an individual's genetic, gonadal, and genital sexes. It affects one in 4,500 live births. A wide spectrum of genital phenotypes can be found depending on the underlying pathogenic mechanism and the developmental stage that is affected. We herein report a newborn with female external genitalia but palpable gonads at labia majora with normal testicular function and structure, which is typical of complete androgen insensitivity syndrome (CAIS). The genetic study revealed 45,X/46,XY mosaicism and c.2081A>C missense androgen receptor gene mutation, indicating the likelihood of co-existing CAIS. This case demonstrated the importance of correlating genital phenotype and the underlying pathogenic mechanism, to provide appropriate management of DSD. Important considerations on managing the gonads about the risks of gonadal malignancies are also discussed.
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Affiliation(s)
- Wai Yu Wong
- Paediatrics and Adolescent Medicine, Tuen Mun Hospital, Hong Kong, HKG
| | - Lap Ming Wong
- Paediatrics and Adolescent Medicine, Tuen Mun Hospital, Hong Kong, HKG
| | - Yuk Him Tam
- Paediatric Surgery, Hong Kong Children's Hospital, Hong Kong, HKG
| | - Ho Ming Luk
- Clinical Genetics Service Unit, Hong Kong Children's Hospital, Hong Kong, HKG
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Dutt AS, Bakhshi G, Sabale C, Landge R, Baligar S, V. R, Jha M, Joshi S, Teja CR. Bilateral Breast Phyllodes Tumor in Androgen Insensitivity Syndrome. Surg J (N Y) 2023; 9:e23-e27. [PMID: 36742156 PMCID: PMC9897893 DOI: 10.1055/s-0042-1758668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/14/2022] [Indexed: 02/05/2023] Open
Abstract
Phyllodes is a rare tumor found exclusively in females. It can be classified into benign, intermediate, or malignant variety based on the aggressive nature of the disease. With adequate preoperative clinical assessment combined with histopathology and radiological investigations the adequate treatment strategy can be formulated to avoid future recurrences. Complete androgen insensitivity syndrome (CAIS) is associated with a genotypic male, which can be confirmed by karyotyping, with phenotypic female characteristics. The present case is the first case of bilateral breast phyllodes tumor in a patient with CAIS. Preoperative assessment was suggestive of bilateral phyllodes tumor with bilateral gonads in the inguinal region which was confirmed to be testis postoperatively on histopathological analysis. A brief case report with review of literature is presented.
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Affiliation(s)
- Aishwarya Sunil Dutt
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India,Address for correspondence Aishwarya Sunil Dutt, MBBS Department of General Surgery, Grant Medical CollegeMumbai 400008, MaharashtraIndia
| | - Girish Bakhshi
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
| | - Chandrakant Sabale
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
| | - Ravi Landge
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
| | - Sushrut Baligar
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
| | - Rajalakshmi V.
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
| | - Madhu Jha
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
| | - Sampada Joshi
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
| | - Chettubattina Ravi Teja
- Department of General Surgery, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India
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Al-Sharkawi M, Calonga-Solís V, Dressler FF, Busch H, Hiort O, Werner R. Persistence of foetal testicular features in patients with defective androgen signalling. Eur J Endocrinol 2023; 188:7017644. [PMID: 36721956 DOI: 10.1093/ejendo/lvad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/09/2023] [Accepted: 01/26/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Congenital defects of androgen synthesis or action in 46,XY individuals can result in impaired virilisation, despite the apparent testicular development. In a recent case, report of a young adult with complete androgen insensitivity syndrome (CAIS), tumourous gonadal tissue was shown to express HSD17B3 in Sertoli cells (SCs) and not in Leydig cells (LCs). This expression pattern differs from the typical adult human testis and resembles a foetal mouse testis, suggesting an underlying testicular development and function defect. Here, we investigate the effect of altered androgen signalling in gonads from five 46,XY individuals with defects in androgen synthesis or action. METHODS Gonadal tissue sections from four patients with CAIS, one with CYP17A1 deficiency, and one control were immunostained for LC developmental and steroidogenic markers. The expression of some of these markers during development was investigated by reanalysing previously published single-cell RNA sequencing (scRNA-seq) data from normal human testicular tissues. RESULTS All gonadal tissues from the patients show an exclusive expression of HSD17B3 in SCs and an expression of the foetal/immature LC marker DLK1 in a subset of LCs, suggesting an androgen-dependent differentiation defect of adult SCs and LCs. Furthermore, reanalysis of scRNA-seq data reveals an expression of HSD17B3 in foetal and neonatal SCs that is downregulated in adult SCs. CONCLUSIONS Androgen signalling may affect the differentiation of adults, but possibly not foetal SCs or LCs, and may induce a shift of testosterone production from the tubular compartment in the foetal phase to the interstitial compartment in the adult phase.
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Affiliation(s)
- Mostafa Al-Sharkawi
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, University of Lübeck, 23562 Lübeck, Germany
- Biochemical Genetics Department, Human Genetics and Genome Research Institute, 12622 Dokki, Cairo, Egypt
| | - Verónica Calonga-Solís
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, University of Lübeck, 23562 Lübeck, Germany
- Medical Systems Biology Division, Lübeck Institute of Experimental Dermatology and Institute for Cardiogenetics, University of Lübeck, 23562 Lübeck, Germany
| | - Franz F Dressler
- Institute of Pathology, University Hospital Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Institute of Pathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117, Berlin, Germany
| | - Hauke Busch
- Medical Systems Biology Division, Lübeck Institute of Experimental Dermatology and Institute for Cardiogenetics, University of Lübeck, 23562 Lübeck, Germany
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, University of Lübeck, 23562 Lübeck, Germany
| | - Ralf Werner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, University of Lübeck, 23562 Lübeck, Germany
- Institute of Molecular Medicine, University of Lübeck, 23562 Lübeck, Germany
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Identification of the Rare Ala871Glu Mutation in the Androgen Receptor Gene Leading to Complete Androgen Insensitivity Syndrome in an Adolescent Girl with Primary Amenorrhea. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121900. [PMID: 36553343 PMCID: PMC9777019 DOI: 10.3390/children9121900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Complete Androgen Insensitivity Syndrome (CAIS) is a rare genetic condition by mutations in the androgen receptor (AR) gene resulting in target issue resistance to androgens and a female phenotype in genetically male individuals. A 16-year-old phenotypically female individual presented to our clinic with primary amenorrhea. Her clinical evaluation showed normal female external genitalia, Tanner III breast development and sparse pubic and axillary hair (Tanner stage II). Hormonal assessment revealed increased concentrations of Luteinizing Hormone (LH), Testosterone and Antimüllerian Hormone (AMH). Image studies detected no uterus or gonads, but a blind vagina and the karyotype was 46, XY. These findings suggested the diagnosis of CAIS, and genetic testing of the AR gene revealed a rare pathogenic mutation of cytosine to adenine (c.2612C>A) replacing alanine with glutamic acid at position 871 (p.Ala871Glu) in the AR, previously described once in two adult sisters. The patient underwent gonadectomy and received hormonal replacement therapy. This study expands the AR mutation database and shows the complexity and the importance of prompt diagnosis, proper management, and follow-up for CAIS patients, underlining the need for standardized protocols.
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Segura SE, Young RH, Oliva E, Ulbright TM. Malignant Gonadal Germ Cell Tumors (Other Than Pure Germinoma) in Patients With Disorders of Sex Development: A Report of 21 Cases Based Largely on the Collection of Dr Robert E. Scully, Illustrating a High Frequency of Yolk Sac Tumor With Prominent Hepatoid and Glandular Features. Am J Surg Pathol 2022; 46:664-676. [PMID: 34560684 DOI: 10.1097/pas.0000000000001815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We describe 21 nonpure germinomatous gonadal germ cell tumors (9 with a germinoma component), all but 1 associated with gonadoblastoma, in patients with disorders of sex development who ranged from 7 to 36 years old (average, 20 y). Twenty patients were clinically described as phenotypic females with ambiguous genitalia/virilization and primary amenorrhea. The most common documented peripheral karyotype was 46,XY (10/12; 83%). Fifteen of 16 tumors with available clinicopathologic data were unilateral. They ranged from 7 to 30 cm (mean, 15.5 cm) and were solid and cystic with frequent necrosis and hemorrhage. Gonadoblastoma, in its classic (70%), dissecting (5%), or combined (25%) forms, was identified in all but 1. The malignant germ cell tumors were typically mixed except for 5 pure yolk sac tumors and 1 expansile gonadoblastoma with syncytiotrophoblast cells. When admixed, the most common component was yolk sac tumor (n=10), followed by germinoma (n=9), embryonal carcinoma (n=5), choriocarcinoma (n=4), immature teratoma (n=3), and teratoma (n=2). Typical morphologic patterns of yolk sac neoplasia, including reticular/microcystic, solid (including blastema-like), and endodermal sinus (Schiller-Duval bodies), were seen, as well as glandular (n=10) and hepatoid (n=6) differentiation, with cystically dilated glands and diffuse hepatoid morphology in 3 and 2 tumors, respectively. Two yolk sac tumors showed a sarcomatoid pattern. Somatic-type malignancies (alveolar rhabdomyosarcoma and low-grade spindle cell sarcoma, not otherwise specified) were identified in 1 case each. This is the first large series of germ cell tumors other than typical pure germinoma associated with gonadoblastoma. The high frequency of yolk sac tumor with glandular (especially cystic glandular) and hepatoid morphologies is noteworthy, and their presence should prompt further evaluation for an associated gonadoblastoma and possible disorder of sex development.
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Affiliation(s)
- Sheila E Segura
- Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Robert H Young
- James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Esther Oliva
- James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thomas M Ulbright
- Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN
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Wang JM, Li ZF, Yang WX. What Does Androgen Receptor Signaling Pathway in Sertoli Cells During Normal Spermatogenesis Tell Us? Front Endocrinol (Lausanne) 2022; 13:838858. [PMID: 35282467 PMCID: PMC8908322 DOI: 10.3389/fendo.2022.838858] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/01/2022] [Indexed: 01/18/2023] Open
Abstract
Androgen receptor signaling pathway is necessary to complete spermatogenesis in testes. Difference between androgen binding location in Sertoli cell classifies androgen receptor signaling pathway into classical signaling pathway and non-classical signaling pathway. As the only somatic cell type in seminiferous tubule, Sertoli cells are under androgen receptor signaling pathway regulation via androgen receptor located in cytoplasm and plasma membrane. Androgen receptor signaling pathway is able to regulate biological processes in Sertoli cells as well as germ cells surrounded between Sertoli cells. Our review will summarize the major discoveries of androgen receptor signaling pathway in Sertoli cells and the paracrine action on germ cells. Androgen receptor signaling pathway regulates Sertoli cell proliferation and maturation, as well as maintain the integrity of blood-testis barrier formed between Sertoli cells. Also, Spermatogonia stem cells achieve a balance between self-renewal and differentiation under androgen receptor signaling regulation. Meiotic and post-meiotic processes including Sertoli cell - Spermatid attachment and Spermatid development are guaranteed by androgen receptor signaling until the final sperm release. This review also includes one disease related to androgen receptor signaling dysfunction named as androgen insensitivity syndrome. As a step further ahead, this review may be conducive to develop therapies which can cure impaired androgen receptor signaling in Sertoli cells.
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Karmazyn B, Salama A, Jennings SG, Kaefer M. Ultrasound of retained gonads in children and young women with androgen insensitivity syndrome. J Pediatr Urol 2021; 17:797-802. [PMID: 34556411 DOI: 10.1016/j.jpurol.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/02/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Gonadal management in androgen insensitivity syndrome (AIS) patients has been controversial due to low risk of testicular cancer. Our study evaluated the role of ultrasound (US) in screening for malignancy in retained gonads in AIS patients. METHODS This was a retrospective study (2001-2020) of gonadal US in patients with AIS. Demographics and clinical information were retrieved from the medical records. US studies were reviewed for nodule presence, size, echotexture, and change on follow-up studies. When available, pathology correlation was performed. Two-tailed t-test was used to compare age and development of nodules clinically or on US examination. RESULTS 13 patients were included with a median age was 9.9 years (range 3.8-18.4 years). In 11 patients, gonads were in the inguinal canals on either initial or follow-up US. No nodules were palpable on physical examination, but nodules were detected in ten testicles by US in five of 13 patients (41.7%). Presence of nodules was significantly (p = 0.0038) associated with older age. The largest nodule size varied from 0.4 to 2.2 cm (average 0.9 ± 0.5 cm) and most (7/10, 70%) were hypoechoic. Finding testicular nodules on US led to change in management in three patients; bilateral gonadectomies, unilateral gonadectomy, and gonadal excisional biopsies (Figure). Pathology demonstrated Sertoli hamartoma in these patients, and in an additional two patients who underwent post-puberty gonadectomy. No malignancy was found in any specimen. DISCUSSION Preservation of the gonads in children with AIS is associated with low risk for malignant transformation. The role of US surveillance of the gonads is unknown. In our series on 13 patients, most of the visualized 24 gonads (22/24, 91.7%) were localized in the groins in either the first or follow-up US studies. Nodules were detected in ten gonads in five of 13 patients (41.7%). Most of these gonads (8/10) had numerous nodules, most (7/10) were hypoechoic with average diameter of the largest nodule of 0.9 ± 0.5 cm. Pathology in 5 patients demonstrated Sertoli hamartomas in all of the gonads. No malignancy was found. In our series, gonadal nodules led to either gonadectomies or excisional biopsies in three patients. Our study has several limitations, related to the retrospective nature of the study and the small size of our series. CONCLUSION Multiple testicular nodules were commonly detected by US in AIS patients and were not associated with malignancy. Therefore, we are concerned that US screening can lead to unnecessary excisional biopsies and orchiectomies.
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Affiliation(s)
- Boaz Karmazyn
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Room 1053, Indianapolis, IN, 46202, USA.
| | - Amr Salama
- Division of Pediatric Urology, Urology Department at Alexandria School of Medicine, Alexandria University, Egypt
| | - S Gregory Jennings
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 950 W. Walnut Street, Room E124, Indianapolis, IN, 46202, USA
| | - Martin Kaefer
- Department of Urology, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Room 4230, Indianapolis, IN, 46202, USA
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Kudryavtseva E, Kovalev V, Geets A, Patsyuk O. Late diagnosis of complete androgen insensitivity syndrome: Case report. SEXOLOGIES 2021. [DOI: 10.1016/j.sexol.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Hosseinirad H, Yadegari P, Mohanazadeh Falahieh F, Nouraei S, Paktinat S, Afsharzadeh N, Sadeghi Y. Disorders of sex development and female reproductive capacity: A literature review. Syst Biol Reprod Med 2021; 67:323-336. [PMID: 34196232 DOI: 10.1080/19396368.2021.1937376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Disorders of sex development (DSD) are a wide-ranging group of complex conditions that influence chromosomal, gonadal, and phenotypic sex. The prevalence of DSD is very low, but affected patients deserve individualized management to improve psychological, sexual, and reproductive outcomes. This review aims to clarify the fertility potential of DSD patients who can be reared as females and their chance of becoming pregnant, especially using assisted reproductive techniques (ART). Due to the effects of DSD on internal and external genital organs, these conditions result in varying degrees of fertility potential. Fertility rate depends on the phenotype and is inversely related to the severity of the disorder. Reproductive endocrinologists and infertility specialists must be considered active partners of the interdisciplinary treatment team. With current advances in ART, pregnancy is more achievable in patients who were considered infertile at first glance. Due to the complexity of the medical management in DSD patients, more studies should be conducted to conclusively suggest the best choice for improving their fertility potential.Abbreviations: AIS: Androgen Insensitivity Syndrome; AMH: Anti-Müllerian Hormone; ART: Assisted Reproductive Technology; ASRM: American Society for Reproductive Medicine; CAH: Congenital Adrenal Hyperplasia; CAIS: Complete Androgen Insensitivity Syndrome; DHT: Dihydrotestosterone; DSD: Disorders of Sexual Development; FSH: Follicle Stimulating Hormone; GD: Gonadal Dysgenesis; ICSI: Intracytoplasmic Sperm Injection; IUGR: Intrauterine Growth Restriction; IVF: In Vitro Fertilization; IVF-ET: IVF and Embryo Transfer; LH: Luteinizing Hormone; MGD: Mixed Gonadal Dysgenesis; MRI: Magnetic Resonance Imaging; MRKH: Mayer-Rokitansky-Kuster-Hauser; US: Ultrasonography; HSG: Hysterosalpingography; PAIS: Partial Androgen Insensitivity Syndrome; PGD: Preimplantation Genetic Diagnosis; POR: P450 Oxidoreductase; PROM: Premature Rupture of Membranes; TS: Turner Syndrome; 17β-HSD III: 17β-Hydroxysteroid Dehydrogenase III; 21-OHD: 21-hydroxylase deficiency; 5α-RD-2: 5α-reductase-2.
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Affiliation(s)
- Hossein Hosseinirad
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pouya Yadegari
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Soheila Nouraei
- Department of Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahrokh Paktinat
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Yousef Sadeghi
- Department of Anatomy and Physiology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria, Australia
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15
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Marino L, Messina A, S Acierno J, Phan-Hug F, J Niederländer N, Santoni F, La Rosa S, Pitteloud N. Testosterone-induced increase in libido in a patient with a loss-of-function mutation in the AR gene. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM21-0031. [PMID: 34152287 PMCID: PMC8240814 DOI: 10.1530/edm-21-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/13/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Complete androgen-insensitivity syndrome (CAIS), a disorder of sex development (46,XY DSD), is caused primarily by mutations in the androgen receptor (AR). Gonadectomy is recommended due to the increased risk of gonadoblastoma, however, surgical intervention is often followed by loss of libido. We present a 26-year-old patient with CAIS who underwent gonadectomy followed by a significant decrease in libido, which was improved with testosterone treatment but not with estradiol. Genetic testing was performed and followed by molecular characterization. We found that this patient carried a previously unidentified start loss mutation in the androgen receptor. This variant resulted in an N-terminal truncated protein with an intact DNA binding domain and was confirmed to be loss-of-function in vitro. This unique CAIS case and detailed functional studies raise intriguing questions regarding the relative roles of testosterone and estrogen in libido, and in particular, the potential non-genomic actions of androgens. LEARNING POINTS N-terminal truncation of androgen receptor can cause androgen-insensitivity syndrome. Surgical removal of testosterone-producing gonads can result in loss of libido. Libido may be improved with testosterone treatment but not with estradiol in some forms of CAIS. A previously unreported AR mutation - p.Glu2_Met190del (c.2T>C) - is found in a CAIS patient and results in blunted AR transcriptional activity under testosterone treatment.
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Affiliation(s)
- Laura Marino
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Andrea Messina
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - James S Acierno
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Franziska Phan-Hug
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Nicolas J Niederländer
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Federico Santoni
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Stefano La Rosa
- Department of Laboratory Medicine and Pathology, Centre Hospitalier Universitaire Vaudois, Lausanne, Vaud, Switzerland
| | - Nelly Pitteloud
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
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Steinmacher S, Brucker SY, Kölle A, Krämer B, Schöller D, Rall K. Malignant Germ Cell Tumors and Their Precursor Gonadal Lesions in Patients with XY-DSD: A Case Series and Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115648. [PMID: 34070473 PMCID: PMC8197511 DOI: 10.3390/ijerph18115648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/11/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022]
Abstract
The risk of gonadal germ cell tumors is increased over the lifetime of patients with XY-disorders of sex development (XY-DSD). The aim of this study was to evaluate clinical features and histopathological outcome after gonadectomy in patients with XY-DSD to assess the risk of malignant transformation to gonadal germ cell tumors. Thirty-five women treated for XY-DSD at our hospital between 2003 and 2020 were enrolled in this study. Twenty-seven (77%) underwent prophylactic gonadectomy, 10 (29%) at our department and 17 (48%) at external hospitals. Eight (23%) patients didn’t receive gonadectomy. Of the patients who underwent a surgical procedure at our hospital, two patients were diagnosed with a unilateral seminoma, one patient with a bilateral and one patient with a unilateral Sertoli cell adenoma. According to these findings, preventive gonadectomy in patients with XY-DSD should be taken into consideration. Guidelines concerning the necessity of gonadectomy to avoid malignant transformation are still lacking. The risk of malignant germ cell tumors from rudimentary gonads has not been investigated sufficiently to date, as it is mostly based on case series due to the rarity of the condition. In our study we retrospectively analyzed patients who partly underwent bilateral gonadectomy, aiming to fill this gap. Concerning the ideal point of time for gonadectomy, further studies with a higher number of patients are needed.
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17
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Slayden T, Bauer EM, Shakir MK, Hoang TD. Dilemmas in management of osteoporosis in patients with complete androgen insensitivity syndrome. BMJ Case Rep 2021; 14:14/5/e241968. [PMID: 33980561 PMCID: PMC8118069 DOI: 10.1136/bcr-2021-241968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Complete androgen insensitivity syndrome (CAIS)-resulting in 46,XY karyotype, but female phenotype-is a disorder of sex development and primary amenorrhea, but its effect on bone mineral density (BMD) is singular and difficult to manage. Androgens are an important modulator of bone remodeling and health, and the androgen receptor (AR) is pivotal for signaling within the bone cells. CAIS results in a severely disrupted AR throughout the body, causing an elevated risk of early osteoporosis. Timing of gonadectomy and hormone replacement therapy protocols are not established, creating a wide variety of treatment plans and BMD profiles. Our objective is to report a patient with CAIS status post prepubertal orchiectomy that developed early osteoporosis and to describe the lack of optimal strategies and consensus available to improve bone health in this population. Additionally, our case illustrates the fact there are no guidelines advocating the use of newer drugs for osteoporosis in this population.
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Affiliation(s)
- Tanner Slayden
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Elizabeth M Bauer
- Department of Endocrinology, Diabetes & Metabolism, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Mohamed Km Shakir
- Department of Endocrinology, Diabetes & Metabolism, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.,Department of Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
| | - Thanh Duc Hoang
- Department of Endocrinology, Diabetes & Metabolism, Walter Reed National Military Medical Center, Bethesda, Maryland, USA .,Department of Medicine, Uniformed Services University of the Health Sciences F Edward Hebert School of Medicine, Bethesda, Maryland, USA
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18
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Izawa M, Hisamatsu E, Yoshino K, Yoshida M, Sato T, Narumi S, Hasegawa T, Hamajima T. Complete androgen insensitivity syndrome with accelerated onset of puberty due to a Sertoli cell tumor. Clin Pediatr Endocrinol 2021; 30:99-104. [PMID: 33867670 PMCID: PMC8022032 DOI: 10.1297/cpe.30.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/27/2020] [Indexed: 11/12/2022] Open
Abstract
Complete androgen insensitivity syndrome (CAIS) is caused by mutations in the androgen
receptor gene. Patients with this syndrome have a 46,XY karyotype, male gonads, and normal
female external genitalia. While the pre-pubertal risk of developing gonadal tumors is low
in these patients, it increases with age. Most gonadal tumors arise from germ cells;
stromal cell tumors are uncommon. Herein, we report a CAIS patient with a feminizing
Sertoli cell tumor. The patient presented at 8 yr of age with breast enlargement and
growth acceleration, concomitant with elevated serum estradiol levels and suppressed serum
gonadotropin levels; these findings were inconsistent with CAIS. The patient underwent
gonadectomy at 10 yr of age, and histology demonstrated presence of a non-malignant
Sertoli cell tumor in the right gonad. We conclude that this is the first reported case of
CAIS with accelerated onset of puberty resulting from a Sertoli cell tumor.
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Affiliation(s)
- Masako Izawa
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Eiji Hisamatsu
- Department of Urology, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Kaoru Yoshino
- Department of Urology, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Makiko Yoshida
- Department of Pathology, Kobe Children's Hospital, Hyogo, Japan
| | - Takeshi Sato
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Narumi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Hamajima
- Department of Endocrinology and Metabolism, Aichi Children's Health and Medical Center, Aichi, Japan
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Barros BA, de Oliveira LR, Surur CRC, Barros-Filho ADA, Maciel-Guerra AT, Guerra-Junior G. Complete androgen insensitivity syndrome and risk of gonadal malignancy: systematic review. Ann Pediatr Endocrinol Metab 2021; 26:19-23. [PMID: 33819955 PMCID: PMC8026333 DOI: 10.6065/apem.2040170.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/13/2020] [Indexed: 12/02/2022] Open
Abstract
Complete androgen insensitivity syndrome (CAIS) is a rare condition characterized by 46,XY karyotype, female external genitalia, absence of uterus, and testes located intra-abdominally, in the inguinal ring or in the labia majora. In the present study, the frequency of testicular malignancy in prepubertal and pubertal patients with CAIS who underwent gonadectomy or gonadal biopsy were evaluated. Systematic review was performed using electronic databases according to the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. The samples included 15 articles published between 1998 and 2019. From a total of 456 patients who underwent gonadectomy or gonadal biopsy, 6.14% had a premalignant lesion and most were postpubertal (82.14%). A malignant lesion was found in 1.3% and all were postpubertal. Because the risk of malignancy is very low in prepubertal patients with CAIS, gonadectomy may be delayed until puberty is complete, allowing it to progress naturally; however, close follow-up of the patient is required.
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Affiliation(s)
- Beatriz Amstalden Barros
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil,Department of Pediatrics, State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil,Address for correspondence: Beatriz Amstalden Barros Rua Tessalia Vieira de Camargo, 126 Cidade Universitaria, Campinas (SP) 13083-887, Brazil
| | | | | | | | - Andrea Trevas Maciel-Guerra
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil,Department of Medical Genetics, State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil
| | - Gil Guerra-Junior
- Interdisciplinary Group for the Study of Sex Determination and Differentiation (GIEDDS), State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil,Department of Pediatrics, State University of Campinas (UNICAMP), Campinas/São Paulo, Brazil
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20
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Erkekoglu P, Özyurt A, Yirün A, Çakır D. Testicular dysgenesis syndrome and phthalate exposure: A review of literature. ARHIV ZA FARMACIJU 2021. [DOI: 10.5937/arhfarm71-34438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Endocrine disruptors are chemicals that interfere with the body's endocrine system and cause adverse effects in biological systems. Phthalates are a group of man-made chemicals which are mainly used as plasticizers and classified as endocrine disruptors. They are also used in cosmetic and personal care products as color or smell fixators. Moreover, phthalates are present in inks, adhesives, sealants, automobile parts, tools, toys, carpets, medical tubing and blood storage bags, and food packages. Pathological condition known as "testicular dysgenesis syndrome" (TDS) or "phthalate syndrome" is usually linked to phthalate exposure and is coined to describe the rise in alterations in reproductive health in men, such as reduced semen quality (decrease in sperm counts, sperm motility and increase in abnormal sperms), hypospadias, cryptorchidism, reduced anogenital distance and early-life testicular cancer. Phthalates are suggested to cause direct effect on gonadal and non-gonadal tissues, impair the differentiation and morphogenesis of seminiferous tubules and accessory sex organs and testicular cells (both Sertoli and Leydig cells), alter estradiol and/or testosterone levels, decrease insulin-like 3 (INSL3) peptide production, impair spermatogenesis and lead to epigenetic alterations, all of which may lead to TDS. This review will mainly focus on phthalates as causes of TDS and their mechanisms of action.
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21
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Nagahama Y, Chakraborty T, Paul-Prasanth B, Ohta K, Nakamura M. Sex determination, gonadal sex differentiation, and plasticity in vertebrate species. Physiol Rev 2020; 101:1237-1308. [PMID: 33180655 DOI: 10.1152/physrev.00044.2019] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A diverse array of sex determination (SD) mechanisms, encompassing environmental to genetic, have been found to exist among vertebrates, covering a spectrum from fixed SD mechanisms (mammals) to functional sex change in fishes (sequential hermaphroditic fishes). A major landmark in vertebrate SD was the discovery of the SRY gene in 1990. Since that time, many attempts to clone an SRY ortholog from nonmammalian vertebrates remained unsuccessful, until 2002, when DMY/dmrt1by was discovered as the SD gene of a small fish, medaka. Surprisingly, however, DMY/dmrt1by was found in only 2 species among more than 20 species of medaka, suggesting a large diversity of SD genes among vertebrates. Considerable progress has been made over the last 3 decades, such that it is now possible to formulate reasonable paradigms of how SD and gonadal sex differentiation may work in some model vertebrate species. This review outlines our current understanding of vertebrate SD and gonadal sex differentiation, with a focus on the molecular and cellular mechanisms involved. An impressive number of genes and factors have been discovered that play important roles in testicular and ovarian differentiation. An antagonism between the male and female pathway genes exists in gonads during both sex differentiation and, surprisingly, even as adults, suggesting that, in addition to sex-changing fishes, gonochoristic vertebrates including mice maintain some degree of gonadal sexual plasticity into adulthood. Importantly, a review of various SD mechanisms among vertebrates suggests that this is the ideal biological event that can make us understand the evolutionary conundrums underlying speciation and species diversity.
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Affiliation(s)
- Yoshitaka Nagahama
- Laboratory of Reproductive Biology, National Institute for Basic Biology, Okazaki, Japan.,South Ehime Fisheries Research Center, Ehime University, Ainan, Japan.,Faculty of Biological Science and Technology, Kanazawa University, Ishikawa, Japan
| | - Tapas Chakraborty
- Laboratory of Reproductive Biology, National Institute for Basic Biology, Okazaki, Japan.,South Ehime Fisheries Research Center, Ehime University, Ainan, Japan.,Laboratory of Marine Biology, Faculty of Agriculture, Kyushu University, Fukouka, Japan.,Karatsu Satellite of Aqua-Bioresource Innovation Center, Kyushu University, Karatsu, Japan
| | - Bindhu Paul-Prasanth
- Laboratory of Reproductive Biology, National Institute for Basic Biology, Okazaki, Japan.,Centre for Nanosciences and Molecular Medicine, Amrita Vishwa Vidapeetham, Kochi, Kerala, India
| | - Kohei Ohta
- Laboratory of Marine Biology, Faculty of Agriculture, Kyushu University, Fukouka, Japan
| | - Masaru Nakamura
- Sesoko Station, Tropical Biosphere Research Center, University of the Ryukyus, Okinawa, Japan.,Research Center, Okinawa Churashima Foundation, Okinawa, Japan
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22
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Slowikowska-Hilczer J, Szarras-Czapnik M, Duranteau L, Rapp M, Walczak-Jedrzejowska R, Marchlewska K, Oszukowska E, Nordenstrom A. Risk of gonadal neoplasia in patients with disorders/differences of sex development. Cancer Epidemiol 2020; 69:101800. [PMID: 32905884 DOI: 10.1016/j.canep.2020.101800] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with disorders/differences of sex development (DSD), especially those possessing the Y chromosome, have a higher risk of gonadal germ-cell tumours (GCTs). We aimed to examine the incidence of different types of gonadal neoplasia and associated risk factors. METHODS A total of 1040 DSD patients aged ≥16 years participated in a cross-sectional multicentre European study (dsd-LIFE). Data on medical history were gathered from the patients' archival medical documents. A web-based questionnaire was filled out individually by the participants. A physical examination was performed in all, while ultrasonography of gonads was carried out in 214 and semen analysis was performed for 53 patients. RESULTS Germ-cell neoplasia was present in 12 % of patients with DSD and in 14 % of those with XY DSD. The highest risk (36 %) was observed in 46,XY patients with gonadal dysgenesis (GD): complete GD (33 %) and partial GD (23 %), but also in mixed GD (8 %) and complete androgen insensitivity syndrome (AIS) (6%). It was not reported in partial AIS, XX male, 46,XX DSD and congenital adrenal hyperplasia, Turner and Klinefelter syndromes, or in androgen biosynthesis defects. Benign sex cord-stromal tumours (Sertoli- and Leydig-cell tumours) were noted only in patients with complete AIS (3.1 %) and Klinefelter syndrome (14.3 %). A relationship between risk factors for GCT and gonadal neoplasia appearance, other than the Y chromosome, was not found. CONCLUSION Adult patients with GD and the Y chromosome have the highest risk of GCT and should be kept under thorough medical control and receive special medical follow-up to prevent the development of gonadal tumours.
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Affiliation(s)
- Jolanta Slowikowska-Hilczer
- Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland.
| | - Maria Szarras-Czapnik
- Department of Endocrinology and Diabetology, Children's Memorial Health Institute, Aleja Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Lise Duranteau
- Adolescent and Young Adult Gynaecology Unit and DSD Reference Centre, Bicêtre Hospital, AP.HP Université Paris Saclay, France
| | - Marion Rapp
- Clinic for Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23538 Lubeck, Germany
| | - Renata Walczak-Jedrzejowska
- Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Katarzyna Marchlewska
- Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Elzbieta Oszukowska
- II Clinic of Urology, Medical University of Lodz, Pabianicka 62, 93-513 Lodz, Poland
| | - Anna Nordenstrom
- Department of Paediatric Endocrinology, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
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Inguinal hernia in girls: A retrospective analysis of over 1000 patients. J Pediatr Surg 2020; 55:1908-1913. [PMID: 32317102 DOI: 10.1016/j.jpedsurg.2020.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 02/21/2020] [Accepted: 03/08/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND In girls with inguinal hernia, timing of surgical repair to prevent ovarian strangulation and screening for Androgen Insensitivity Syndrome (AIS) remain controversial. This study assesses the incidence of ovarian strangulation and AIS, and its associated risk factors. METHODS Electronic patient records were used to study girls aged 0-15 years who underwent inguinal hernia repair between 2000 and 2017. Patients with incomplete data were excluded. Risk factors were identified using logistic regression. RESULTS This study includes 1084 girls (median (IQR) age: 133.5 (14-281) weeks) who underwent 1132 hernia repairs (1015 unilateral, 117 bilateral) within a median (IQR) time interval of 12 (6-23) days following diagnosis. Hernia sac intraoperatively contained ovary in 235 (21.7%) patients, ovary was strangulated in 14 (6%). Risk factors for ovarian strangulation were younger gestational age (OR 0.49), higher birthweight (OR 32.18), and first presentation at the emergency department (OR 13.07). However data were partly missing. Ectopic testis was found in seven (0.6%) patients. Metachronous contralateral inguinal hernia and ipsilateral recurrence developed in 6.1% and 0.3%, respectively. CONCLUSIONS Ovarian hernia was diagnosed in 21.7%, and ovary was strangulated in 6%. No definite conclusions can be drawn regarding risk factors for strangulation and timing of surgery in girls with irreducible ovarian hernia. LEVEL OF EVIDENCE Level III.
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Vogt PH, Besikoglu B, Bettendorf M, Frank-Herrmann P, Zimmer J, Bender U, Knauer-Fischer S, Choukair D, Sinn P, Lau YFC, Heidemann PH, Strowitzki T. Gonadoblastoma Y locus genes expressed in germ cells of individuals with dysgenetic gonads and a Y chromosome in their karyotypes include DDX3Y and TSPY. Hum Reprod 2020; 34:770-779. [PMID: 30753444 DOI: 10.1093/humrep/dez004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/17/2018] [Accepted: 01/10/2019] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Which Y genes mapped to the 'Gonadoblastoma Y (GBY)' locus on human Y chromosome are expressed in germ cells of individuals with some Differences of Sexual Development (DSD) and a Y chromosome in their karyotype (DSD-XY groups)? SUMMARY ANSWER The GBY candidate genes DDX3Y and TSPY are expressed in the germ cells of DSD-XY patients from distinct etiologies: patients with mixed gonadal dysgenesis (MGD) and sex chromosome mosaics (45,X0/46,XY; 46,XX/46,XY); patients with complete androgen insensitivity (CAIS), patients with complete gonadal dysgenesis (CGD; e.g. Swyer syndrome). WHAT IS KNOWN ALREADY A GBY locus was proposed to be present on the human Y chromosome because only DSD patients with a Y chromosome in their karyotype have a high-although variable-risk (up to 55%) for germ cell tumour development. GBY was mapped to the proximal part of the short and long Y arm. TSPY located in the proximal part of the short Y arm (Yp11.1) was found to be a strong GBY candidate gene. It is expressed in the germ cells of DSD-XY patients with distinct etiologies but also in foetal and pre-meiotic male spermatogonia. However, the GBY region extends to proximal Yq11 and therefore includes probably more than one candidate gene. STUDY DESIGN, SIZE, DURATION Protein expression of the putative GBY candidate gene in proximal Yq11, DDX3Y, is compared with that of TSPY in serial gonadal tissue sections of 40 DSD-XY individuals from the three DSD patient groups (MGD, Complete Androgen Insensitivity Syndrome [CAIS], CGD) with and without displaying malignancy. Expression of OCT3/4 in the same tissue samples marks the rate of pluripotent germ cells. PARTICIPANTS/MATERIALS, SETTING, METHOD A total of 145 DSD individuals were analysed for the Y chromosome to select the DSD-XY subgroup. PCR multiplex assays with Y gene specific marker set score for putative microdeletions in GBY Locus. Immunohistochemical experiments with specific antisera mark expression of the GBY candidate proteins, DDX3Y, TSPY, in serial sections of the gonadal tissue samples; OCT3/4 expression analyses in parallel reveal the pluripotent germ cell fraction. MAIN RESULTS AND THE ROLE OF CHANCE Similar DDX3Y and TSPY protein expression patterns were found in the germ cells of DSD-XY patients from each subgroup, independent of age. In CAIS patients OCT3/4 expression was often found only in a fraction of these germ cells. This suggest that GBY candidate proteins are also expressed in the non-malignant germ cells of DSD-XY individuals like in male spermatogonia. LIMITATIONS, REASONS FOR CAUTION Variation of the expression profiles of GBY candidate genes in the germ cells of some DSD-XY individuals suggests distinct transcriptional and translational control mechanisms which are functioning during expression of these Y genes in the DSD-XY germ cells. Their proposed GBY tumour susceptibility function to transform these germ cells to pre-malignant GB/Germ Cell Neoplasia in Situ (GB/GCNIS) cells seems therefore to be limited and depending on their state of pluripotency. WIDER IMPLICATIONS OF THE FINDINGS These experimental findings are of general importance for each individual identified in the clinic with DSD and a Y chromosome in the karyotype. To judge their risk of germ cell tumour development, OCT3/4 expression analyses on their gonadal tissue section is mandatory to reveal the fraction of germ cells still being pluripotent. Comparative expression analysis of the GBY candidate genes can be helpful to reveal the fraction of germ cells with genetically still activated Y chromosomes contributing to further development of malignancy if at high expression level. STUDY FUNDING/COMPETING INTEREST(S) This research project was supported by a grant (01GM0627) from the BMBF (Bundesministerium für Bildung und Forschung), Germany to P.H.V. and B.B. The authors have no competing interests.
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Affiliation(s)
- P H Vogt
- Division of Reproduction Genetics, Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
| | - B Besikoglu
- Division of Reproduction Genetics, Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany.,Novum, Center for Reproductive Medicine, Akazienallee 8, Essen, Germany
| | - M Bettendorf
- Division of Paediatric Endocrinology and Diabetes, Children Hospital, University of Heidelberg, Heidelberg, Germany
| | - P Frank-Herrmann
- Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
| | - J Zimmer
- Division of Reproduction Genetics, Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
| | - U Bender
- Division of Reproduction Genetics, Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
| | - S Knauer-Fischer
- Division of Paediatric Endocrinology and Diabetes, Children Hospital, University of Heidelberg, Heidelberg, Germany
| | - D Choukair
- Division of Paediatric Endocrinology and Diabetes, Children Hospital, University of Heidelberg, Heidelberg, Germany
| | - P Sinn
- Division of Gynaecopathology, Department of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, Heidelberg, Germany
| | - Y-F C Lau
- Division of Cell & Developmental Genetics, Department of Medicine, VAMC 111C5, San Francisco, CA, USA
| | - P H Heidemann
- Children Hospital Augsburg I, Academic Hospital of University of Munich, Stenglinstraβe 2, Augsburg, Germany
| | - T Strowitzki
- Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
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Disorders of Sex Development-Novel Regulators, Impacts on Fertility, and Options for Fertility Preservation. Int J Mol Sci 2020; 21:ijms21072282. [PMID: 32224856 PMCID: PMC7178030 DOI: 10.3390/ijms21072282] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/09/2020] [Accepted: 03/24/2020] [Indexed: 12/13/2022] Open
Abstract
Disorders (or differences) of sex development (DSD) are a heterogeneous group of congenital conditions with variations in chromosomal, gonadal, or anatomical sex. Impaired gonadal development is central to the pathogenesis of the majority of DSDs and therefore a clear understanding of gonadal development is essential to comprehend the impacts of these disorders on the individual, including impacts on future fertility. Gonadal development was traditionally considered to involve a primary 'male' pathway leading to testicular development as a result of expression of a small number of key testis-determining genes. However, it is increasingly recognized that there are several gene networks involved in the development of the bipotential gonad towards either a testicular or ovarian fate. This includes genes that act antagonistically to regulate gonadal development. This review will highlight some of the novel regulators of gonadal development and how the identification of these has enhanced understanding of gonadal development and the pathogenesis of DSD. We will also describe the impact of DSDs on fertility and options for fertility preservation in this context.
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Comparative Transcriptomics Analysis of Testicular miRNA from Cryptorchid and Normal Horses. Animals (Basel) 2020; 10:ani10020338. [PMID: 32098036 PMCID: PMC7070967 DOI: 10.3390/ani10020338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/10/2020] [Accepted: 02/17/2020] [Indexed: 12/11/2022] Open
Abstract
Simple Summary The testis is an important organ for mammals, and testicular microRNA expression is associated with male fertility to a certain extent. Cryptorchidism is the failure of one or both testes to descend into the scrotal sac. It is a common congenital malformation in horses. The major clinical consequence of this abnormality is impaired fertility. The expression of testicular microRNAs is influenced by many factors, including high temperature and disease, in cryptorchid horses. Here, we investigated the microRNA expression levels of normal and retained testes. Their expression patterns showed significant differences. In addition, we obtained comprehensive expression data for equine testicular microRNA, which is fundamental information for further analysis. Abstract In the biological process of testicular spermatogenesis, the expression and interaction of many genes are regulated by microRNAs (miRNAs). However, comparisons of miRNA expression between descended testes (DTs) and undescended testes (UDTs) are rarely done in horses. In this study, we selected two UDTs (CKY2b and GU4b) from Chakouyi (CKY) and Guanzhong (GU) horses and eight DTs (GU1–3, CKY1, CKY3, CKY2a, GU4a, and GU5). Three groups were compared to evaluate expression patterns of testicular miRNA in stallion testes. Group 1 compared normal CKY horses and GU horses (CKY1 and CKY3 vs. GU1–3). Group 2 (CKY2a and GU4a (DTs) vs. CKY2b and GU4b (UDTs)) and group 3 (GU1–3, CKY1, CKY3 (DTs) vs. CKY2b and GU4b (UDTs)) compared the expression levels in unilateral retained testes to normal testes. The results show that 42 miRNAs (7 upregulated and 35 downregulated) had significantly different expression levels in both comparisons. The expression levels of eca-miR-545, eca-miR-9084, eca-miR-449a, eca-miR-9024, eca-miR-9121, eca-miR-8908e, eca-miR-136, eca-miR-329b, eca-miR-370, and eca-miR-181b were further confirmed by quantitative real-time PCR assay. The target genes of differentially expressed miRNAs in three comparisons were predicted, and the functions were annotated. The putative target genes of the 42 co-differentially expressed miRNAs were annotated to 15 functional terms, including metal ion binding, GTPase activator activity, zinc ion binding, intracellular, cytoplasm, and cancer pathways, and osteoclast differentiation. Our data indicate that the differentially expressed miRNAs in undescended testis suggests a potential role in male fertility and a relationship with cryptorchidism in horses. The discovery of miRNAs in stallion testes might contribute to a new direction in the search for biomarkers of stallion fertility.
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A Management Protocol for Gonad Preservation in Patients with Androgen Insensitivity Syndrome. J Pediatr Adolesc Gynecol 2019; 32:605-611. [PMID: 31233832 PMCID: PMC6917890 DOI: 10.1016/j.jpag.2019.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022]
Abstract
Historically, individuals with androgen insensitivity syndrome (AIS) were managed with removal of gonadal tissue at various ages to avert the risk of gonadal malignancy. Recently, clinical practice changed, with gonadectomy being postponed until late adolescence. Adolescents and adults with complete AIS have questioned this approach. Additionally, testicular germ cell tumors are increasingly believed to be quite rare with rates as low as 0% in molecularly confirmed individuals with AIS. Gonadectomy deprives patients of the benefits of their endogenous hormones and potential fertility. Furthermore, human rights organizations advocate for deferring irreversible surgery in conditions known as differences of sex development, which includes AIS, to allow patient autonomy in decision-making. Recent literature supports an approach that uses risk stratification to manage gonads in AIS. Herein we review what is known about malignancy risk in the different subtypes of AIS and propose a management protocol for gonad retention.
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Jarzabek K, Koda M, Chrusciel M, Kanczuga-Koda L, Sobczynska-Tomaszewska A, Rahman NA, Wolczynski S. Features of the fetal gonad in androgen synthesis in the postpubertal testis are preserved in complete androgen insensitivity syndrome due to a novel genetic splice site donor variant in androgen receptor gene intron 1. J Steroid Biochem Mol Biol 2019; 193:105420. [PMID: 31283987 DOI: 10.1016/j.jsbmb.2019.105420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/19/2019] [Accepted: 06/26/2019] [Indexed: 12/14/2022]
Abstract
Mutations in the X-linked androgen receptor (AR) gene cause complete androgen insensitivity syndrome (CAIS). CAIS may cause congenital sexual development disorder, which frequently develops into testicular tumors. Here, we describe a novel splice-site intron 1 mutation in AR leading to improper splicing and AR protein absence in CAIS gonads. We characterized a patient's postpubertal gonadal steroidogenic enzyme expression profile. Localization of both CYP11A1 and CYP17A1 enzymes was restricted to both Leydig tumor cells and adjacent to tumor gonadal tissues. Sertoli cells of the CAIS gonad showed abundant HSD17B3 protein, which is an adult Leydig cell marker that enables the conversion of androstenedione to testosterone. Such HSD17B3 expression is typical for fetal-type Sertoli cells in rodents. The postpubertal CAIS gonad of our patient was completely devoid of androgen signaling pathway activity. Plausibly, the postpubertal Leydig cells consisted of two distinct cell populations: postpubertal fetal-type Leydig cells that persisted as androgen-independent cells and immature adult Leydig cells that failed to differentiate. Taken together, in this CAIS postpubertal testis, both Leydig and fetal-type Sertoli cells participated in testosterone production. Our results indicate the importance of molecular analysis as well as the characterization of steroidogenic enzyme profiling in the CAIS patient's gonad.
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Affiliation(s)
- Katarzyna Jarzabek
- Department of Reproduction and Gynaecological Endocrinology, Medical University of Bialystok, Poland.
| | - Mariusz Koda
- Department of General Pathomorphology, Medical University of Bialystok, Poland
| | | | - Luiza Kanczuga-Koda
- Department of Pathology, Maria Curie-Sklodowska Bialystok Oncology Center, Bialystok, Poland
| | | | - Nafis A Rahman
- Department of Reproduction and Gynaecological Endocrinology, Medical University of Bialystok, Poland; Institute of Biomedicine, University of Turku, Turku, Finland
| | - Slawomir Wolczynski
- Department of Reproduction and Gynaecological Endocrinology, Medical University of Bialystok, Poland
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Oakes JA, Li N, Wistow BRC, Griffin A, Barnard L, Storbeck KH, Cunliffe VT, Krone NP. Ferredoxin 1b Deficiency Leads to Testis Disorganization, Impaired Spermatogenesis, and Feminization in Zebrafish. Endocrinology 2019; 160:2401-2416. [PMID: 31322700 DOI: 10.1210/en.2019-00068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/13/2019] [Indexed: 01/08/2023]
Abstract
The roles of steroids in zebrafish sex differentiation, gonadal development, and function of the adult gonad are poorly understood. Herein, we used ferredoxin 1b (fdx1b) mutant zebrafish to explore such processes. Fdx1b is an essential electron-providing cofactor to mitochondrial steroidogenic enzymes, which are crucial for glucocorticoid and androgen production in vertebrates. Fdx1b-/- zebrafish mutants develop into viable adults in which concentrations of androgens and cortisol are significantly reduced. Adult fdx1b-/- mutant zebrafish display predominantly female secondary sex characteristics but may possess either ovaries or testes, confirming that androgen signaling is dispensable for testicular differentiation in this species, as previously demonstrated in androgen receptor mutant zebrafish. Adult male fdx1b-/- mutant zebrafish exhibit reduced characteristic breeding behaviors and impaired sperm production, resulting in infertility in standard breeding scenarios. However, eggs collected from wild-type females can be fertilized by the sperm of fdx1b-/- mutant males by in vitro fertilization. The testes of fdx1b-/- mutant males are disorganized and lack defined seminiferous tubule structure. Expression of several promale and spermatogenic genes is decreased in the testes of fdx1b-/- mutant males, including promale transcription factor sox9a and spermatogenic genes igf3 and insl3. This study establishes an androgen- and cortisol-deficient fdx1b zebrafish mutant as a model for understanding the effects of steroid deficiency on sex development and reproductive function. This model will be particularly useful for further investigation of the roles of steroids in spermatogenesis, gonadal development, and regulation of reproductive behavior, thus enabling further elucidation of the physiological consequences of endocrine disruption in vertebrates.
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Affiliation(s)
- James A Oakes
- Department of Oncology & Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
- The Bateson Centre, Department of Biomedical Science, University of Sheffield, Western Bank, Sheffield, United Kingdom
| | - Nan Li
- Department of Oncology & Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
- The Bateson Centre, Department of Biomedical Science, University of Sheffield, Western Bank, Sheffield, United Kingdom
| | - Belinda R C Wistow
- Department of Oncology & Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
- The Bateson Centre, Department of Biomedical Science, University of Sheffield, Western Bank, Sheffield, United Kingdom
| | - Aliesha Griffin
- Epilepsy Research Laboratory and Weill Institute for Neuroscience, Department of Neurologic Surgery, University of California, San Francisco, California
| | - Lise Barnard
- Department of Biochemistry, Stellenbosch University, Stellenbosch, Matieland, South Africa
| | - Karl-Heinz Storbeck
- Department of Biochemistry, Stellenbosch University, Stellenbosch, Matieland, South Africa
| | - Vincent T Cunliffe
- The Bateson Centre, Department of Biomedical Science, University of Sheffield, Western Bank, Sheffield, United Kingdom
| | - Nils P Krone
- Department of Oncology & Metabolism, School of Medicine, University of Sheffield, Sheffield, United Kingdom
- The Bateson Centre, Department of Biomedical Science, University of Sheffield, Western Bank, Sheffield, United Kingdom
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Williams JA, Bruce G, Patel N, Nesiama JA. Case 4: Two Children with Presumed Inguinal Hernias. Pediatr Rev 2019; 40:491-493. [PMID: 31477593 DOI: 10.1542/pir.2017-0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Gordon Bruce
- Department of Pediatric Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nishit Patel
- Department of Pediatric Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jo-Ann Nesiama
- Department of Pediatric Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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31
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Islam R, Lane S, Williams SA, Becker CM, Conway GS, Creighton SM. Establishing reproductive potential and advances in fertility preservation techniques for XY individuals with differences in sex development. Clin Endocrinol (Oxf) 2019; 91:237-244. [PMID: 31004515 DOI: 10.1111/cen.13994] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/07/2019] [Accepted: 04/15/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Discordance between gonadal type and gender identity has often led to an assumption of infertility in patients with differences in sex development (DSD). However, there is now greater recognition of fertility being an important issue for this group of patients. Currently, gonadal tissue that may have fertility potential is not being stored for individuals with DSD and, where gonadectomy forms part of management, is often discarded. The area of fertility preservation has been predominantly driven by oncofertility which is a field dedicated to preserving the fertility of patients undergoing gonadotoxic cancer treatment. The use of fertility preservation techniques could be expanded to include individuals with DSD where functioning gonads are present. METHODS This is a systematic literature review evaluating original research articles and relevant reviews between 1974 and 2018 addressing DSD and fertility, in vitro maturation of sperm, and histological/ultrastructural assessment of gonadal tissue in complete and partial androgen insensitivity syndrome, 17β-hydroxysteroid dehydrogenase type 3 and 5α-reductase deficiency. CONCLUSION Successful clinical outcomes of ovarian tissue cryopreservation are paving the way for similar research being conducted using testicular tissue and sperm. There have been promising results from both animal and human studies leading to cryopreservation of testicular tissue now being offered to boys prior to cancer treatment. Although data are limited, there is evidence to suggest the presence of reproductive potential in the gonads of some individuals with DSD. Larger, more detailed studies are required, but if these continue to be encouraging, individuals with DSD should be given the same information, opportunities and access to fertility preservation as other patient groups.
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Affiliation(s)
- Rumana Islam
- Department of Reproductive Medicine, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Sheila Lane
- Department of Paediatric Oncology and Haematology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Suzannah A Williams
- Nuffield Department of Women's and Reproductive Health, Women's Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Christian M Becker
- Nuffield Department of Women's and Reproductive Health, Oxford Endometriosis CaRe Centre, Women's Centre, John Radcliffe Hospital University of Oxford, Oxford, UK
| | - Gerard S Conway
- Department of Endocrinology, University College London Hospitals, London, UK
| | - Sarah M Creighton
- Elizabeth Garrett Anderson UCL Institute of Women's Health, University College London Hospitals, London, UK
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CHEN G, WANG X, TANG D. [Progress on evaluation, diagnosis and management of disorders of sex development]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2019; 48:358-366. [PMID: 31901037 PMCID: PMC8800683 DOI: 10.3785/j.issn.1008-9292.2019.08.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/30/2019] [Indexed: 06/10/2023]
Abstract
Disorders of sex development (DSD) refer to a group of diseases characterized by abnormal congenital development of chromosomes, gonad or genitals with different pathophysiological changes and clinical manifestations. DSD is more common in neonates and adolescents, and neonates often show genital abnormalities while adolescents show abnormal sexual development during puberty. It is the international consensus that the scope of DSD should include basic clinical evaluation (internal and external genitalia and endocrine hormones), diagnostic confirmation (chromosome, genetic diagnosis), psychological assessment for children and family, treatment (sex assignment, hormone replacement and surgical intervention), potential fertility protection and long-term follow-up, which require the expertise of pediatric endocrinology, pediatric urology, clinical psychology, genetic disciplines, medical images and other related disciplines; that is, individualized management of children with DSD requires an experienced multidisciplinary team (MDT). This article reviews the recent progress on the evaluation, diagnosis and management of disorders of sex development.
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Affiliation(s)
| | | | - Daxing TANG
- 唐达星(1961—), 男, 博士, 硕士生导师, 主任医师, 主要从事小儿泌尿外科学研究; E-mail:
;
https://orcid.org/0000-0003-2103-4931
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Abstract
Disorders of sex development (DSD) are a group of complex conditions that can affect chromosomal, gonadal, and/or phenotypical sex with a highly variable fertility potential amongst affected individuals. In this review we discuss fertility issues facing patients affected by DSD and Turner syndrome and summarise the literature on fertility and reproductive outcomes. We will also discuss fertility preservation prior to gonadotoxic treatment in adolescent and prepubertal girls. Future directions in fertility preservation and ethical issues will also be addressed. Fertility preserving options that are established include ovarian tissue and oocyte cryopreservation. However, in many of the DSDs fertility is not possible and the discussion may need to move toward alternative methods of creating a family such as gamete donation or surrogacy.
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Affiliation(s)
- Rashi Kalra
- Reproductive Services Unit, The Royal Women's Hospital, Parkville VIC 3052, Australia.
| | - Melissa Cameron
- Department of Obstetrics and Gynaecology, University of Melbourne, The Royal Women's Hospital, Parkville, VIC 3052, Australia
| | - Catharyn Stern
- Department of Obstetrics and Gynaecology, University of Melbourne, The Royal Women's Hospital, Parkville, VIC 3052, Australia
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Abstract
The term primary gonadal failure encompasses not only testicular insufficiency in 46,XY males and ovarian insufficiency in 46,XX females, but also those disorders of sex development (DSD) which result in gender assignment that is at variance with the genotype and gonadal type. In boys, causes of gonadal failure include Klinefelter and other aneuploidy syndromes, bilateral cryptorchidism, testicular torsion, and forms of 46,XY DSD such as partial androgen insensitivity. Causes in girls include Turner syndrome and other aneuploidies, galactosemia, and autoimmune ovarian failure. Iatrogenic causes in both boys and girls include the late effects of childhood cancer treatment, total body irradiation prior to bone marrow transplantation, and iron overload in transfusion-dependent thalassaemia. In this paper, a brief description of the physiology of testicular and ovarian development is followed by a section on the causes and practical management of gonadal impairment in boys and girls. Protocols for pubertal induction and post-pubertal hormone replacement - intramuscular, oral and transdermal testosterone in boys; oral and transdermal oestrogen in girls - are then given. Finally, current and future strategies for assisted conception and fertility preservation are discussed.
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Affiliation(s)
- Asmahane Ladjouze
- Faculté de Médecine d'Alger, Service de Pédiatrie, Centre Hospitalo-Universitaire Bad El Oued, 1 Boulevard Said Touati, Algiers, Algeria.
| | - Malcolm Donaldson
- Section of Child Health, School of Medicine, Queen Elizabeth University Hospital, Govan Road, Glasgow, G51 4TF, United Kingdom.
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35
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Lanciotti L, Cofini M, Leonardi A, Bertozzi M, Penta L, Esposito S. Different Clinical Presentations and Management in Complete Androgen Insensitivity Syndrome (CAIS). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16071268. [PMID: 30970592 PMCID: PMC6480640 DOI: 10.3390/ijerph16071268] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 01/08/2023]
Abstract
Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive genetic disorder resulting from maternally inherited or de novo mutations involving the androgen receptor gene, situated in the Xq11-q12 region. The diagnosis is based on the presence of female external genitalia in a 46, XY human individual, with normally developed but undescended testes and complete unresponsiveness of target tissues to androgens. Subsequently, pelvic ultrasound or magnetic resonance imaging (MRI) could be helpful in confirming the absence of Mullerian structures, revealing the presence of a blind-ending vagina and identifying testes. CAIS management still represents a unique challenge throughout childhood and adolescence, particularly regarding timing of gonadectomy, type of hormonal therapy, and psychological concerns. Indeed this condition is associated with an increased risk of testicular germ cell tumour (TGCT), although TGCT results less frequently than in other disorders of sex development (DSD). Furthermore, the majority of detected tumoral lesions are non-invasive and with a low probability of progression into aggressive forms. Therefore, histological, epidemiological, and prognostic features of testicular cancer in CAIS allow postponing of the gonadectomy until after pubertal age in order to guarantee the initial spontaneous pubertal development and avoid the necessity of hormonal replacement therapy (HRT) induction. However, HRT is necessary after gonadectomy in order to prevent symptoms of hypoestrogenism and to maintain secondary sexual features. This article presents differential clinical presentations and management in patients with CAIS to emphasize the continued importance of standardizing the clinical and surgical approach to this disorder.
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Affiliation(s)
- Lucia Lanciotti
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Marta Cofini
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Alberto Leonardi
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Mirko Bertozzi
- Pediatric Surgery, Azienda Ospedaliera Santa Maria della Misericordia, 20122 Perugia, Italy.
| | - Laura Penta
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
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Liu S, Wang Z, Jiang J, OuYang H, Wei S, Liang J, Chen N, Zeng W, Chen L, Xie X. Severe forms of complete androgen insensitivity syndrome caused by a p.Q65X novel mutation in androgen receptor: Clinical manifestations, imaging findings and molecular genetics. Steroids 2019; 144:47-51. [PMID: 30742848 DOI: 10.1016/j.steroids.2019.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/24/2019] [Accepted: 02/04/2019] [Indexed: 11/24/2022]
Abstract
Androgen insensitivity syndrome (AIS), a rare X-linked recessive genetic disorder with a normal 46, XY karyotype, is caused by defect of androgen receptor gene (AR) leading to resistance of the target tissues to androgenic hormones. There is a wide spectrum of clinical presentations of AIS, ranging from male infertility, hypospadias to completely normal female external genitalia. Here, we describe a 15-year old, phenotypically female individual, who visited our clinic for primary amenorrhea. The physical examination revealed normal female external genitalia, normal breast development, as well as sparse pubic hair and absence of axillary hair. A short blind vagina pouch was noticed in gynecological examination apart from the absence of cervix and uterus. Serum testosterone measured a considerable high level, and the karyotype was indicative of a normal male (46, XY). Transabdominal ultrasound (US) and magnetic resonance imaging (MRI) confirmed the absence of uterus, ovaries and fallopian tubes, only with a small blind-ending vagina observed. The clinical, laboratory, imaging, and genetic findings strongly suggest the diagnosis of complete androgen insensitivity syndrome (CAIS). Mutational analysis of the AR gene revealed a novel small insertion mutation c.192_193insTAGCAG(Q65X) in exon 1, which gives rise to a truncated nonfunctional protein, resulting in the loss of the remaining 856 C-terminus amino acid residues. This study indicates that US and MRI are two useful and noninvasive imaging methods for the diagnosis and evaluation of CAIS, and identification of this novel mutation expands the database of AR gene mutations. Furthermore, with the availability of the identification technology for this mutation, prenatal diagnosis could be offered for future pregnancies.
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Affiliation(s)
- Shu Liu
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China.
| | - Zhiqing Wang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, No. 1838 North Guangzhou Avenue, Baiyun District, Guangzhou, Guangdong 510515, PR China
| | - Jianhui Jiang
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China.
| | - Haimei OuYang
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China
| | - Sisi Wei
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China
| | - Jinqun Liang
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China
| | - Nuan Chen
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China
| | - Weihong Zeng
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China
| | - Liying Chen
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China
| | - Xunjie Xie
- Children Inherited Metabolism and Endocrine Department, Guangdong Women and Children Hospital, No. 521 XingNan Road, Panyu District, Guangzhou, Guangdong 511400, PR China
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Jariwala S. Complete androgen insensitivity syndrome: A case report. JOURNAL OF DR. NTR UNIVERSITY OF HEALTH SCIENCES 2019. [DOI: 10.4103/jdrntruhs.jdrntruhs_101_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Tack LJW, Maris E, Looijenga LHJ, Hannema SE, Audi L, Köhler B, Holterhus PM, Riedl S, Wisniewski A, Flück CE, Davies JH, T'Sjoen G, Lucas-Herald AK, Evliyaoglu O, Krone N, Iotova V, Marginean O, Balsamo A, Verkauskas G, Weintrob N, Ellaithi M, Nordenström A, Verrijn Stuart A, Kluivers KB, Wolffenbuttel KP, Ahmed SF, Cools M. Management of Gonads in Adults with Androgen Insensitivity: An International Survey. Horm Res Paediatr 2018; 90:236-246. [PMID: 30336477 DOI: 10.1159/000493645] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Complete and partial androgen insensitivity syndrome (CAIS, PAIS) are associated with an increased risk of gonadal germ cell cancer (GGCC). Recent guidelines recommend gonadectomy in women with CAIS in late adolescence. Nevertheless, many adult women prefer to retain their gonads. AIMS This study aims to explore attitudes towards gonadectomy in AIS in centres around the world, estimate the proportion of adults with retained gonads and/or who developed GGCC, and explore reasons for declining gonadectomy. METHODS A survey was performed among health care professionals who use the International DSD Registry (I-DSD). RESULTS Data were provided from 22 centres in 16 countries on 166 women (CAIS) and 26 men (PAIS). In CAIS, gonadectomy was recommended in early adulthood in 67% of centres; 19/166 (11.4%) women refused gonadectomy. Among 142 women who had gonadectomy, evidence of germ cell neoplasm in situ (GCNIS), the precursor of GGCC, was reported in 2 (1.4%) out of 8 from whom pathology results were formally provided. Nine out of 26 men with PAIS (34.6%) had retained gonads; 11% of centres recommended routine gonadectomy in PAIS. CONCLUSION Although development of GGCC seems rare, gonadectomy after puberty is broadly recommended in CAIS; in PAIS this is more variable. Overall, our data reflect the need for evidence-based guidelines regarding prophylactic gonadectomy in AIS.
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Affiliation(s)
- Lloyd J W Tack
- Division of Paediatric Endocrinology, Department of Paediatrics, Ghent University Hospital, Department of Internal Medicine and Paediatrics, Ghent University, Ghent,
| | - Ellen Maris
- Division of Paediatric Endocrinology, Department of Paediatrics, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Leendert H J Looijenga
- Laboratory for Experimental Patho-Oncology, Department of Pathology, Josephine Nefkens Building, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Laura Audi
- Growth and Development Research Unit, Vall d'Hebron Research Institute (VHIR), Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Birgit Köhler
- Klinik für Pädiatrische Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Paul-Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel, Kiel, Germany
| | - Stefan Riedl
- Department of Pediatric Pulmology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
- Department of Pediatrics, St. Anna Children´s Hospital, Medical University of Vienna, Vienna, Austria
| | - Amy Wisniewski
- Department of Urology, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Christa E Flück
- Paediatric Endocrinology, Diabetology and Metabolism, Department of Paediatrics and Department of BioMedical Research, Bern University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Justin H Davies
- Department of Endocrinology, University Hospital Southampton, Southampton, United Kingdom
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Angela K Lucas-Herald
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, United Kingdom
| | - Olcay Evliyaoglu
- Department of Paediatric Endocrinology, Faculty of Medicine, İstanbul University Cerrahpaşa, İstanbul, Turkey
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Violeta Iotova
- Department of Paediatrics, Medical University Varna, Varna, Bulgaria
| | - Otilia Marginean
- First Paediatric Clinic, University of Medicine and Pharmacy Victor Babes, Timisoara, Romania
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Paediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Gilvydas Verkauskas
- Centre of Paediatric Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Naomi Weintrob
- Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Department of Paediatrics, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mona Ellaithi
- Faculty of Medical Laboratory Sciences, Al-Neelain University, Khartoum, Sudan
| | - Anna Nordenström
- Department of Women's and Children's Health, Paediatric Endocrinology Q2: 04, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Annemarie Verrijn Stuart
- Department of Paediatrics, Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Kirsten B Kluivers
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Katja P Wolffenbuttel
- Department of Urology and Paediatric Urology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
| | - Martine Cools
- Division of Paediatric Endocrinology, Department of Paediatrics, Ghent University Hospital, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
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Cools M, Wolffenbuttel KP, Hersmus R, Mendonca BB, Kaprová J, Drop SLS, Stoop H, Gillis AJM, Oosterhuis JW, Costa EMF, Domenice S, Nishi MY, Wunsch L, Quigley CA, T'Sjoen G, Looijenga LHJ. Malignant testicular germ cell tumors in postpubertal individuals with androgen insensitivity: prevalence, pathology and relevance of single nucleotide polymorphism-based susceptibility profiling. Hum Reprod 2018; 32:2561-2573. [PMID: 29121256 DOI: 10.1093/humrep/dex300] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 09/14/2017] [Indexed: 01/29/2023] Open
Abstract
STUDY QUESTION What is the prevalence of malignant testicular germ cell tumors (TGCT) and its precursors, (pre-) germ cell neoplasia in situ (GCNIS), in late teenagers and adults who have androgen insensitivity syndrome (AIS) and the impact of an individual's genetic susceptibility to development of TGCT? SUMMARY ANSWER No GCNIS or TGCT was diagnosed, but pre-GCNIS was identified in 14 and 10% of complete and partial AIS patients, respectively, and was associated with a higher genetic susceptibility score (GSS), with special attention for KITLG (rs995030) and ATFZIP (rs2900333). WHAT IS KNOWN ALREADY Many adult women with AIS decline prophylactic gonadectomy, while data regarding the incidence, pathophysiology and outcomes of TGCT in postpubertal individuals with AIS are lacking. The relevance of genetic factors, such as single nucleotide polymorphisms (SNPs), in predisposing AIS individuals to TGCT is unknown. STUDY DESIGN, SIZE, DURATION This multicenter collaborative study on prophylactically removed gonadal tissue was conducted in a pathology lab specialized in germ cell tumor biology. PARTICIPANTS/MATERIALS, SETTING, METHODS Material from 52 postpubertal individuals with molecularly confirmed AIS (97 gonadal samples) was included; the median age at surgery was 17.5 (14-54) years. Immunohistochemical studies and high-throughput profiling of 14 TGCT-associated SNPs were performed. The main outcome measures were the prevalence of pre-GCNIS, GCNIS and TGCT, and its correlation with a GSS, developed based on the results of recent genome-wide association studies. MAIN RESULTS AND ROLE OF CHANCE The earliest recognizable change preceding GCNIS, referred to as pre-GCNIS, was present in 14% of individuals with complete and 10% of those with partial AIS at a median age of 16 years. No GCNIS or invasive TGCT were found. The median GSS was significantly greater for those with, compared to those without, pre-GCNIS (P = 0.01), with an overlap between groups. Our data suggest important roles for risk alleles G at KITLG (rs995030) and C at ATFZIP (rs2900333), among the 14 studied TGCT-associated SNPs. LARGE SCALE DATA N/A. LIMITATIONS REASONS FOR CAUTION A limited number of cases were included. WIDER IMPLICATIONS OF THE FINDINGS Our data suggest that the prevalence of pre-GCNIS in individuals with AIS beyond puberty is around 15%. Genetic susceptibility likely contributes to pre-GCNIS development in AIS but factors related to malignant progression remain unclear. Although data in older patients remain scarce, malignant progression appears to be a rare event, although the natural history of the premalignant lesion remains unknown. Therefore, the practice of routine prophylactic gonadectomy in adults with AIS appears questionable and the patient's preference, after having been fully informed, should be decisive in this matter. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by research grants from the Research Foundation Flanders (FWO) (to M.C.), the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq G0D6713N) (to B.B.M. and M.C.) and the European Society for Pediatric Endocrinology (ESPE), granted by Novo Nordisk AB (to J.K.). There are no competing interests.
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Affiliation(s)
- M Cools
- Pediatrics and Genetics, Ghent University and Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - K P Wolffenbuttel
- Department of Pediatric Urology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - R Hersmus
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - B B Mendonca
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - J Kaprová
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Pediatrics, Charles University, 2nd Faculty of Medicine and University Hospital Motol, Prague, Czech Republic
| | - S L S Drop
- Department of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - H Stoop
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - A J M Gillis
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - J W Oosterhuis
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - E M F Costa
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - S Domenice
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - M Y Nishi
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - L Wunsch
- Department of Pediatric Urology, Universitätsklinikum Schleswig-Holstein and Universität zu Lübeck, Lübeck, Germany
| | - C A Quigley
- Pediatric Endocrinology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - G T'Sjoen
- Internal Medicine, Ghent University and Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - L H J Looijenga
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
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Coutifaris C, Kilcoyne A, Feldman AS, Sabatini ME, Oliva E. Case 29-2018: A 31-Year-Old Woman with Infertility. N Engl J Med 2018; 379:1162-1172. [PMID: 30231229 DOI: 10.1056/nejmcpc1807497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Christos Coutifaris
- From the Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, and the Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (C.C.); and the Departments of Radiology (A.K.), Urology (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Radiology (A.K.), Surgery (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Harvard Medical School - both in Boston
| | - Aoife Kilcoyne
- From the Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, and the Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (C.C.); and the Departments of Radiology (A.K.), Urology (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Radiology (A.K.), Surgery (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Harvard Medical School - both in Boston
| | - Adam S Feldman
- From the Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, and the Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (C.C.); and the Departments of Radiology (A.K.), Urology (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Radiology (A.K.), Surgery (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Harvard Medical School - both in Boston
| | - Mary E Sabatini
- From the Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, and the Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (C.C.); and the Departments of Radiology (A.K.), Urology (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Radiology (A.K.), Surgery (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Harvard Medical School - both in Boston
| | - Esther Oliva
- From the Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, and the Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (C.C.); and the Departments of Radiology (A.K.), Urology (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Massachusetts General Hospital, and the Departments of Radiology (A.K.), Surgery (A.S.F.), Obstetrics and Gynecology (M.E.S.), and Pathology (E.O.), Harvard Medical School - both in Boston
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Perera N, Szarek M, Vannitamby A, Vikraman J, Huan G, Durston A, Hutson J, Li R. An immunohistochemical analysis of the effects of androgen receptor knock out on gubernacular differentiation in the mouse. J Pediatr Surg 2018; 53:1776-1780. [PMID: 29395149 DOI: 10.1016/j.jpedsurg.2017.11.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 11/09/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
Abstract
AIM Cryptorchidism affects 2%-4% of newborn boys and causes infertility and cancer. While normal androgen function is required for successful inguinoscrotal descent, its exact role on gubernacular morphology remains unidentified. We aimed to decipher the effect of androgen blockade on the gubernaculum and surrounding structures. METHODS Genetically modified mice with androgen receptor knock out (ARKO) were sectioned at ages E17, D0, and D2 for immunohistochemical analysis and D4 for morphological analysis (with ethical approval; A644). Mutants and control littermates were labeled with Ki67, Desmin, and Pax7 to identify the degree of gubernaculuar eversion and the composition of the growth center in the gubernaculum, using light or confocal microscopy. RESULTS Androgen blockade prevented gubernacular eversion in all animals aged between E17 and D2 when compared to wild types. Furthermore, a growth center was visible, as indicated by a 'swirl' of immature fibroblasts, in D2 animals but was absent in ARKO mice. Moreover, the gubernacular cord was seen to increase in ARKO mice when compared to wild types and increased in size with age. There were no labeling differences in the antibodies tested for gubernacular differentiation. CONCLUSION Gubernacular eversion in rodents prior to inguinoscrotal migration was androgen dependent, as well as maintenance of gubernacular cord length. This study shows that androgen blockade causes cryptorchidism in mice by preventing gubernacular eversion and possibly by preventing shortening of the gubernacular cord. Altering the morphology of the gubernaculum in response to androgen clearly contributes to the clinical problem of cryptorchidism.
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Affiliation(s)
- Nayomi Perera
- Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Maciej Szarek
- Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Amanda Vannitamby
- Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Jaya Vikraman
- Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia
| | - Georgina Huan
- Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Abigale Durston
- Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia
| | - John Hutson
- Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia; Urology Department, Royal Children's Hospital, Melbourne, Australia.
| | - Ruili Li
- Douglas Stephens Surgical Research Laboratory, Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia
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Paris F, Boulahtouf A, Kalfa N, Guibal MP, Gaspari L, Servant N, Bourguet W, Sultan C, Balaguer P. Functional and Structural Study of the Amino Acid Substitution in a Novel Familial Androgen Receptor Mutation (W752G) Responsible for Complete Androgen Insensitivity Syndrome. Sex Dev 2018; 12:218-224. [PMID: 30064134 DOI: 10.1159/000491114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2018] [Indexed: 11/19/2022] Open
Abstract
Mutations of the androgen receptor (AR) gene are the most frequent cause of 46,XY disorders of sex development. They are associated with a variety of phenotypes, ranging from phenotypic women (complete androgen insensitivity syndrome, CAIS) to milder degrees of undervirilization (partial forms) or men with only infertility (mild form). We identified a new W752G AR mutation responsible for a familial case of CAIS and performed an in vitro study and structural analysis of this mutation and the only other reported substitution affecting the same amino acid (W752R). Although sex assignment is not discussed in cases of CAIS, we show how the phenotype-genotype correlation can be refined by in vitro and structural studies according to the nature of the amino acid substitution, which in turn may have interesting impacts on the follow-up of these patients.
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Aliberti P, Perez Garrido N, Marino R, Ramirez P, Solari AJ, Sciurano R, Costanzo M, Guercio G, Warman DM, Bailez M, Baquedano MS, Rivarola MA, Belgorosky A, Berensztein E. Androgen Insensitivity Syndrome at Prepuberty: Marked Loss of Spermatogonial Cells at Early Childhood and Presence of Gonocytes up to Puberty. Sex Dev 2018; 11:225-237. [PMID: 29393262 DOI: 10.1159/000486089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 01/01/2023] Open
Abstract
Androgen insensitivity syndrome (AIS) is a hereditary condition in patients with a 46,XY karyotype in which loss-of-function mutations of the androgen receptor (AR) gene are responsible for defects in virilization. The aim of this study was to investigate the consequences of the lack of AR activity on germ cell survival and the degree of testicular development reached by these patients by analyzing gonadal tissue from patients with AIS prior to Sertoli cell maturation at puberty. Twenty-three gonads from 13 patients with AIS were assessed and compared to 18 testes from 17 subjects without endocrine disorders. The study of the gonadal structure using conventional microscopy and the ultrastructural characteristics of remnant germ cells using electron microscopy, combined with the immunohistochemical analysis of specific germ cell markers (MAGE-A4 for premeiotic germ cells and of OCT3/4 for gonocytes), enabled us to carry out a thorough investigation of germ cell life in an androgen-insensitive microenvironment throughout prepuberty until young adulthood. Here, we show that germ cell degeneration starts very early, with a marked decrease in number after only 2 years of life, and we demonstrate the permanence of gonocytes in AIS testis samples until puberty, describing 2 different populations. Additionally, our results provide further evidence for the importance of AR signaling in peritubular myoid cells during prepuberty to maintain Sertoli and spermatogonial cell health and survival.
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Affiliation(s)
- Paula Aliberti
- Servicio de Endocrinología, Hospital de Pediatría 'Prof. Dr. Juan Pedro Garrahan', Buenos Aires, Argentina
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Abdel-Maksoud FM, Knight R, Waler K, Yaghoubi-Yeganeh N, Olukunle JO, Thompson H, Panizzi JR, Akingbemi BT. Exposures of male rats to environmental chemicals [bisphenol A and di (2-ethylhexyl) phthalate] affected expression of several proteins in the developing epididymis. Andrology 2017; 6:214-222. [DOI: 10.1111/andr.12451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/31/2017] [Accepted: 11/08/2017] [Indexed: 11/30/2022]
Affiliation(s)
- F. M. Abdel-Maksoud
- Department of Anatomy, Physiology, and Pharmacology; College of Veterinary Medicine; Auburn University; Auburn AL USA
| | - R. Knight
- Department of Anatomy, Physiology, and Pharmacology; College of Veterinary Medicine; Auburn University; Auburn AL USA
| | - K. Waler
- Department of Anatomy, Physiology, and Pharmacology; College of Veterinary Medicine; Auburn University; Auburn AL USA
| | - N. Yaghoubi-Yeganeh
- Department of Anatomy, Physiology, and Pharmacology; College of Veterinary Medicine; Auburn University; Auburn AL USA
| | | | - H. Thompson
- Department of Anatomy, Physiology, and Pharmacology; College of Veterinary Medicine; Auburn University; Auburn AL USA
| | - J. R. Panizzi
- Department of Anatomy, Physiology, and Pharmacology; College of Veterinary Medicine; Auburn University; Auburn AL USA
| | - B. T. Akingbemi
- Department of Anatomy, Physiology, and Pharmacology; College of Veterinary Medicine; Auburn University; Auburn AL USA
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Chaudhry S, Tadokoro-Cuccaro R, Hannema SE, Acerini CL, Hughes IA. Frequency of gonadal tumours in complete androgen insensitivity syndrome (CAIS): A retrospective case-series analysis. J Pediatr Urol 2017; 13:498.e1-498.e6. [PMID: 28351649 DOI: 10.1016/j.jpurol.2017.02.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive disorder of sex development (DSD) where affected individuals are phenotypically female, but have an XY karyotype and testes. The risk of gonadal tumour development in CAIS may increase with age; incidence rates have been reported to be 0.8-22% in patients who have retained their gonads into adulthood. Consequently, gonadectomy has been recommended either during childhood or after puberty is complete, although there is no consensus on the optimal timing for this procedure. OBJECTIVE AND HYPOTHESES To establish the frequency of histological abnormalities in CAIS in relation to the age at gonadectomy. METHOD Data were collected from the Cambridge DSD database on patients with CAIS (n = 225; age range 3-88 years) who had undergone gonadectomy, and their age of gonadectomy, gonadal histology and immunohistochemistry. RESULTS Evaluable data were obtained from 133 patients. Median age at gonadectomy was 14.0 years (range: 18 days-68 years). Pubertal status was: prepuberty, n = 62; postpuberty, n = 68. Thirteen cases were aged >20 years at gonadectomy. The pattern of histology is summarised in the Summary table. DISCUSSION In this large case series of CAIS patients who had undergone gonadectomy, while the combined malignant and premalignant gonadal histology prevalence was 6.0%, the findings confirm the low occurrence of gonadal malignancy in CAIS, with a frequency of 1.5%. The two cases of malignancy were postpubertal. Germ cell neoplasia in situ (GCNIS) was observed in six cases, of which one occurred prepuberty and five postpuberty. The study highlighted difficulties in diagnosis of GCNIS and the need for histological analysis in expert centres. CONCLUSION The results support the current recommendation that gonads in CAIS can be retained until early adulthood. The small number of individuals with gonadectomy after age 20 years do not allow firm conclusion regarding later adulthood. Therefore, it is recommended that the option of gonadectomy be discussed in adulthood. Some form of regular surveillance of the gonads is then recommended, although none of the available options are ideal.
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Affiliation(s)
- S Chaudhry
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - R Tadokoro-Cuccaro
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
| | - S E Hannema
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands; Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C L Acerini
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - I A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Abstract
PURPOSE OF REVIEW To describe pubertal testicular growth in humans, changes in testicular cell populations that result in testicular growth, and the role of testosterone and gonadotrophins follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in testicular growth. When human data were not available, studies in nonhuman primates and/or rodents were used as surrogates. RECENT FINDINGS Testicular growth in puberty follows a sigmoidal growth curve, with a large variation in timing of testicular growth and adult testicular volume. Testicular growth early in puberty is due to increase in Sertoli cell number and length of seminiferous tubules, whereas the largest and fastest growth results from the increase in the diameter of the seminiferous tubules first due to spermatogonial proliferation and then due to the expansion of meiotic and haploid germ cells. FSH stimulates Sertoli cell and spermatogonial proliferation, whereas LH/testosterone is mandatory to complete spermatogenesis. However, FSH and LH/testosterone work in synergy and are both needed for normal spermatogenesis. SUMMARY Testicular growth during puberty is rapid, and mostly due to germ cell expansion and growth in seminiferous tubule diameter triggered by androgens. Pre-treatment with FSH before the induction of puberty may improve the treatment of hypogonadotropic hypogonadism, but remains to be proven.
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Affiliation(s)
- Jaakko J Koskenniemi
- Institute of Biomedicine, Department of Physiology, University of Turku, and Department of Paediatrics, Turku University Hospital, Turku, Finland
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Abstract
Disorders of sex development (DSD) represent a spectrum of conditions in which chromosomal, gonadal, or anatomic sex are atypical and affect 1 in 4,500-5,000 live births. The diagnosis of DSD raises concerns of tumor risk and treatment as well as future fertility preservation. We review the current understanding of the types of gonadal tumors that arise in DSD patients as well as possible markers and treatment. The goal is to inform the members of the DSD team (urologist, endocrinologist, geneticist, psychologist) of the latest findings regarding malignancy in DSD. PubMed® and Google ScholarTM literature searches were performed of current and past peer-reviewed literature on DSD (intersex) regarding gonadal development and tumor formation/treatment. Relevant reviews and original research articles were examined, including cited references, and a synopsis of the data was generated. DSD patients are at increased risk for the development of testicular carcinoma in-situ (CIS) and germ cell tumors (GCT), including seminoma, non-seminoma, juvenile granulosa cell, gonadoblastoma, and dysgerminoma. Cancer risk factors include Y-chromosomal material and gonadal position, especially for streak gonads. The 46 XX DSD patients [congenital adrenal hyperplasia (CAH)] with no genetic Y-chromosomal material are not at higher risk of cancer. Post-pubertal complete androgen insensitivity syndrome (AIS) patients remain prone to tumor development if the testes remain in the abdomen. Estimates of the risk of GCT in partial AIS for untreated undescended testes may be as high as 50%. The cancer risk of scrotal testes in partial AIS is unknown. CIS occurs almost exclusively in patients with hypovirilization, most notably in AIS. Persistent Mullerian Duct Syndrome (PMDS) confers the usual cancer risk associated with cryptorchidism, but also a possible tumor risk of the Mullerian remnant. Several markers are under investigation for tumor evaluation in the DSD population beyond hCG and AFP (Oct3/4, TSPY, WT-1). The management of patients with DSD is complex and evaluation of tumor risk is aided by advances in genotyping for Y-chromosomal material not evident in traditional karyotyping. More complete genetic screening for DSD patients should increasingly become the standard of care. Developments in pathologic diagnosis will further challenge our traditional understanding of the oncologic management and surveillance of these patients. Future studies utilizing more advanced histologic examination of gonads will improve our understanding of the true incidences of malignancy in this diverse population.
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Affiliation(s)
- Martin Kathrins
- Department of Urology (Surgery), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas F Kolon
- Department of Urology (Surgery), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; ; Department of Urology (Surgery), Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Calvo A, Escolino M, Settimi A, Roberti A, Caprio MG, Esposito C. Laparoscopic approach for gonadectomy in pediatric patients with intersex disorders. Transl Pediatr 2016; 5:295-304. [PMID: 27867855 PMCID: PMC5107383 DOI: 10.21037/tp.2016.09.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The birth of a child with a disorder of sex development (DSD) prompts a long-term management strategy that involves a myriad of professionals working with the family. There has been progress in diagnosis, surgical techniques and in understanding psychosocial issues related to this condition. However, since these kinds of disorders are rare and have many anatomical variations, individual care is necessary, especially regarding surgical management. Gonadectomy is indicated in a number of intersex disorders with a Y chromosome to reduce the associated risk of cancer. Recently, laparoscopy has gained wide acceptance in pediatric urology. Laparoscopy is also reported to be a useful tool for diagnosing and treating DSD because of its minimal invasiveness and favorable cosmetic outcome. However, reports of evaluation and management using laparoscopy for large numbers of DSD patients are limited and debate is still open about indications and timing of gonadectomy. In this study, we reviewed the literature of the last 10 years about the role of laparoscopic gonadectomy in patients with DSD. In the analyzed papers, all the procedures were accomplished successfully using laparoscopy. No conversions to open surgery neither intra-operative complications were reported in all series. Post-operative complications were reported only in one series and included 1 umbilical port infection [2% (1/50)] and 1 pelvic abscess [2% (1/50)], both treated with antibiotic therapy (grade I Clavien-Dindo). Of the analyzed series, 7/10 reported postoperative diagnosis of gonadal tumors. The histopathologic examinations revealed 15 cases of gonadoblastoma, 7 cases of dysgerminoma and 2 cases of seminoma. Analyzing the single series, the incidence of these tumors varied between 10% and 33%. The results of our review confirmed the safety and efficacy of laparoscopic gonadectomy in DSD patients. In our mind, laparoscopic gonadectomy should be accepted as the treatment of choice in children and adolescents with these rare conditions. It thereby eliminates the risk of malignancies of gonadal origin with the advantages of a minimally invasive procedure, with lower morbidity, quicker postoperative recovery and excellent cosmetic results.
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Affiliation(s)
- Andres Calvo
- Department of Pediatric Surgery, Pediatric Children Hospital, Cordoba, Argentina
| | - Maria Escolino
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Alessandro Settimi
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Agnese Roberti
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Maria Grazia Caprio
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | - Ciro Esposito
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
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Higuchi T, Holmdahl G, Kaefer M, Koyle M, Wood H, Woodhouse C, Wood D. International Consultation on Urological Diseases: Congenital Anomalies of the Genitalia in Adolescence. Urology 2016; 94:288-310. [DOI: 10.1016/j.urology.2016.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Patel V, Casey RK, Gomez-Lobo V. Timing of Gonadectomy in Patients with Complete Androgen Insensitivity Syndrome-Current Recommendations and Future Directions. J Pediatr Adolesc Gynecol 2016; 29:320-5. [PMID: 26428189 DOI: 10.1016/j.jpag.2015.03.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 02/21/2015] [Accepted: 03/18/2015] [Indexed: 12/23/2022]
Abstract
This review highlights the controversy regarding timing of gonadectomy in patients with complete androgen insensitivity syndrome (CAIS). We will review the published literature regarding frequency of gonadal malignancy and summarize historical findings. Recent research suggests that gonadectomy may be deferred until adulthood due to the low risk of malignancy. An algorithm is also provided to help guide clinicians in management of patients with complete androgen insensitivity syndrome who have deferred gonadectomy.
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Affiliation(s)
- Vrunda Patel
- Department of Obstetrics and Gynecology, Christiana Care Health Services, Newark, Delaware.
| | - Rachel Kastl Casey
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center/Children's National Medical Center, Washington, DC
| | - Veronica Gomez-Lobo
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center/Children's National Medical Center, Washington, DC
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