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McCann-Crosby B, Mansouri R, Dietrich JE, McCullough LB, Sutton VR, Austin EG, Schlomer B, Roth DR, Karaviti L, Gunn S, Hicks MJ, Macias CG. State of the art review in gonadal dysgenesis: challenges in diagnosis and management. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2014; 2014:4. [PMID: 24731683 PMCID: PMC3995514 DOI: 10.1186/1687-9856-2014-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 03/14/2014] [Indexed: 11/25/2022]
Abstract
Gonadal dysgenesis, a condition in which gonadal development is interrupted leading to gonadal dysfunction, is a unique subset of disorders of sexual development (DSD) that encompasses a wide spectrum of phenotypes ranging from normally virilized males to slightly undervirilized males, ambiguous phenotype, and normal phenotypic females. It presents specific challenges in diagnostic work-up and management. In XY gonadal dysgenesis, the presence of a Y chromosome or Y-chromosome material renders the patient at increased risk for developing gonadal malignancy. No universally accepted guidelines exist for identifying the risk of developing a malignancy or for determining either the timing or necessity of performing a gonadectomy in patients with XY gonadal dysgenesis. Our goal was to evaluate the literature and develop evidence-based medicine guidelines with respect to the diagnostic work-up and management of patients with XY gonadal dysgenesis. We reviewed the published literature and used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) system when appropriate to grade the evidence and to provide recommendations for the diagnostic work-up, malignancy risk stratification, timing or necessity of gonadectomy, role of gonadal biopsy, and ethical considerations for performing a gonadectomy. Individualized health care is needed for patients with XY gonadal dysgenesis, and the decisions regarding gonadectomy should be tailored to each patient based on the underlying diagnosis and risk of malignancy. Our recommendations, based on the evidence available, add an important component to the diagnostic and management armament of physicians who treat patients with these conditions.
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Affiliation(s)
- Bonnie McCann-Crosby
- Division of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Roshanak Mansouri
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Jennifer E Dietrich
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Laurence B McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Elise G Austin
- Department of Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Bruce Schlomer
- Division of Pediatric Urology, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - David R Roth
- Division of Pediatric Urology, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Lefkothea Karaviti
- Division of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Sheila Gunn
- Division of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - M John Hicks
- Department of Pathology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
| | - Charles G Macias
- Evidence-Based Outcomes Center, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA
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Jorgensen EV, Steffensen T, Gilbert-Barness E, Nora F, Witt LC. Clinical pathologic correlation: primary amenorrhoea and bilateral adnexal tumors. Fetal Pediatr Pathol 2008; 27:245-58. [PMID: 19065322 DOI: 10.1080/15513810802447920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A case of bilateral gonadoblastoma in 46,XY gonadal dysgenesis is presented and discussed by both clinician and pathologist, in this traditional clinico-pathologic conference. The discussion includes the differential diagnoses of primary amenorrhoea.
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Affiliation(s)
- E Verena Jorgensen
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA
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Abstract
BACKGROUND/PURPOSE Germ cell tumors are relatively common in the fetus and neonate and are the leading neoplasms in some perinatal reviews. The purpose of this study is to focus on the fetus and neonate in an attempt to determine the various ways germ cell tumors differ clinically and morphologically from those occurring in the older child and adult and to show that certain types of tumors have a better prognosis than others. METHODS The author conducted a retrospective review of perinatal teratomas and other germ cell tumors reported in the literature and of patients treated and followed up at Children's Hospital San Diego and Children's Hospital Los Angeles. Only fetuses and infants less than 2 months of age with adequate clinical and pathologic data were accepted for review. RESULTS Five hundred thirty-four fetuses and neonates presented with teratomas diagnosed prenatally (n = 226) and at birth (n = 309). The most common initial finding was a mass, noted either by antenatal sonography or by physical examination during the neonatal period, with signs and symptoms referable to the site of origin. Overall polyhydramnios was next followed by respiratory distress and stillbirth. The number of mature and immature teratomas was approximately the same. The incidence of teratoma with yolk sac tumor either at presentation or at recurrence was 5.8%, and the survival rate was 39%. Sacrococcygeal teratomas had the highest incidence of yolk sac tumor at 10%. Recurrent disease in the form of either teratoma or yolk sac tumor developed in 5% of patients. All individuals with teratomas who survived received surgical resection. CONCLUSIONS Some germ cell tumors of the fetus and neonate have a better prognosis than others. Neonates with gastric teratomas have the best survival rates, and those with intracranial germ cell tumors the worst. Fetuses with teratomas detected antenatally have 3 times the mortality rate compared with postnatally diagnosed neonates. Although perinatal teratomas have a relatively low recurrence rate of 5%, close follow-up with imaging studies and serum alpha-fetoprotein determinations is is strongly recommended. Surgical resection alone may be adequate therapy for teratomas with nonmetastatic, microscopic foci of yolk sac tumor. In the nonteratoma group, patients with pure yolk sac tumor and gonadoblastoma have a much better outcome than those with choriocarcinoma, which has a very low survival of rate of 12%. Currently, the use of platinum-based combination chemotherapy has significantly improved the survival rate of infants with advanced malignant germ cell tumor disease.
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Affiliation(s)
- Hart Isaacs
- Department of Pathology, Children's Hospital San Diego, San Diego, CA 92123, USA
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Hung NA, Silver MM, Chitayat D, Provias J, Toi A, Jay V, Becker LE. Gonadoblastoid testicular dysplasia in Walker-Warburg syndrome. Pediatr Dev Pathol 1998; 1:393-404. [PMID: 9688764 DOI: 10.1007/s100249900054] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Two male fetuses (18 and 22 weeks gestation) and a 3-month-old male infant (full sibling of the younger fetus) who were diagnosed with Walker-Warburg syndrome (WWS) on the basis of neuropathologic autopsy findings in brain, eyes, and muscle also had micro-orchia and, microscopically, diffuse gonadoblastoid dysplasia in the testes. Both fetuses also had a miniature left ureter and cystic dysplastic left kidney. Testes from control fetuses of 17-24 weeks gestation with normal karyotype and no central nervous system abnormalities (group A, n = 50), a variety of central nervous system abnormalities (group B, n = 50), or an autosomal aneuploidy syndrome with or without central nervous system abnormalities (group C, n = 30) had no diffuse dysplasia, although a single gonadoblastoid seminiferous tubular profile was present in three controls. Testicular morphology was normal in older fetuses and infants with a wide variety of central nervous system malformations (group D, n = 50). We found no evidence of hypogonadotrophic hypogonadism in the three WWS cases to account for the small penis and incompletely descended testes commonly reported in this condition. We concluded that the apparent specificity of the gonadoblastoid testicular dysplasia to WWS suggests that the gene defect directly affects testicular development.
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Affiliation(s)
- N A Hung
- Division of Pathology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8
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Müller J, Visfeldt J, Philip J, Skakkebaek NE. Carcinoma in situ, gonadoblastoma, and early invasive neoplasia in a nine-year-old girl with 46,XY gonadal dysgenesis. APMIS 1992; 100:170-4. [PMID: 1554492 DOI: 10.1111/j.1699-0463.1992.tb00857.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Carcinoma in situ (CIS), gonadoblastoma, and early invasive neoplasia were detected in the dysgenetic gonad of a nine-year-old girl with 46,XY gonadal dysgenesis. A close relationship between the three neoplastic components was supported by morphological and immunohistochemical studies. Our findings support the hypothesis that all germ cell tumours, including gonadoblastomas, originate from CIS germ cells formed during early embryonic life.
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Affiliation(s)
- J Müller
- University Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
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Reuben BI, Dickman PS, Koyle M, Rajfer J. Gonadoblastoma: unusual presentation in a patient lacking persistent müllerian ducts. PEDIATRIC PATHOLOGY 1987; 7:209-15. [PMID: 3658844 DOI: 10.1080/15513818709177844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We report a patient with a disorder of sexual differentiation who presented with a 46,XY karyotype, absent internal Müllerian ducts, a vaginal pouch, hypospadias, and bilateral cryptorchidism with a gonadoblastoma in one testis. A human chorionic gonadotropin stimulation test and tissue 5-alpha-reductase and androgen receptor assays were normal. Except for the absence of internal Müllerian ducts, this patient most closely resembles the disorder of dysgenetic male pseudohermaphroditism (DMP). On this basis, we hypothesize that the internal Müllerian ducts in DMP may manifest anywhere along a spectrum that extends from normal to complete absence of structures depending on the degree of gonadal dysgenesis. This case also illustrates the importance of testicular biopsy in patients with dysgenetic testes because of the high likelihood of germ cell neoplasms in these gonads.
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Affiliation(s)
- B I Reuben
- Department of Pathology, Harbor-UCLA Medical Center, Torrance 90509
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