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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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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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Öztürk İnal Z, Gergerlioğlu N, Küçükosmanoğlu İ, Karanis Mİ. Androjen duyarsızlık sendromunda bilateral Sertoli hücreli adenom olgusu. EGE TIP DERGISI 2017. [DOI: 10.19161/etd.393585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Nistal M, Paniagua R, González-Peramato P, Reyes-Múgica M. Perspectives in Pediatric Pathology, Chapter 6. Male Undermasculinization. Pediatr Dev Pathol 2015; 18:279-96. [PMID: 25105706 DOI: 10.2350/14-04-1465-pb.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Normal male development requires three conditions: (1) adequate differentiation of the fetal testis; (2) synthesis and secretion of testicular hormones; and (3) effective action of these hormones on target organs. This requires the combined action of the inhibitory anti-müllerian hormone (AMH, secreted by Sertoli cells) to block the development of the uterus and fallopian tubes from the müllerian duct, together with the trophic stimulus of testosterone (a Leydig cell product), which leads to virilization of the wolffian ducts. Additionally, the development of external genitalia depends on the conversion of testosterone to dihydrotestosterone by the enzyme 5-α-reductase. Failure of any of these mechanisms leads to deficient virilization or the so-called "male pseudohermaphroditism" syndromes.
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Affiliation(s)
- Manuel Nistal
- 1 Pathology, Hospital La Paz, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo #2, Madrid 28029, Spain
| | - Ricardo Paniagua
- 2 Department of Cell Biology, Universidad de Alcala, Madrid, Spain
| | - Pilar González-Peramato
- 1 Pathology, Hospital La Paz, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo #2, Madrid 28029, Spain
| | - Miguel Reyes-Múgica
- 3 Department of Pathology, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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Ozdemir O, Sari ME, Akmut E, Selimova V, Unal T, Atalay CR. Complete androgen insensitivity syndrome with a large gonadal serous papillary cystadenofibroma. J Hum Reprod Sci 2014; 7:148-50. [PMID: 25191030 PMCID: PMC4150143 DOI: 10.4103/0974-1208.138875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 04/21/2014] [Accepted: 05/26/2014] [Indexed: 11/21/2022] Open
Abstract
We present a patient with complete androgen insensitivity syndrome (CAIS) diagnosed with a serous papillary cystadenofibroma. A 41-year-old married female with a mass in the left inguinal region and a history of primary amenorrhea. A bulging mass of 13.7 cm × 8 cm × 12.4 cm in the left inguinal region extending from the hip joint to the level of labia majus, and a 3.2 cm × 2.8 cm mass in her right inguinal region were found by ultrasonography and magnetic resonance imaging. We performed bilateral gonadectomy. The pathology showed testicular tissue in the right inguinal mass and a serous papillary cystadenofibroma in the left one. CAIS is an infrequent clinical entity, occurrence of serous papillary cystadenofibroma is even rarer in this syndrome serous cystadenofibroma should come to mind in patients with a huge inguinal mass. Gonadectomy should be performed right after puberty to prevent the risk of malignancy development in the testes.
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Affiliation(s)
- Ozhan Ozdemir
- Department of Gynecology and Obstetrics, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Mustafa Erkan Sari
- Department of Gynecology and Obstetrics, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Evren Akmut
- Department of Gynecology and Obstetrics, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Vafa Selimova
- Department of Gynecology and Obstetrics, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Tugba Unal
- Department of Clinical Pathology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Cemal Reşat Atalay
- Department of Gynecology and Obstetrics, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Asl Zare M, Kalantari MR, Asadpour AA, Kamalati A. Bilateral laparoscopic gonadectomy in a patient with complete androgen insensitivity syndrome and bilateral sertoli-leydig cell tumor: a case report and brief review of the literature. Nephrourol Mon 2014; 6:e15278. [PMID: 25032133 PMCID: PMC4090667 DOI: 10.5812/numonthly.15278] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 12/02/2013] [Accepted: 01/11/2014] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Complete androgen insensitivity syndrome (previously called testicular feminization) is specified by a 46 XY karyotype and negative sex chromatin, bilateral undescended testes, female genitalia appearance, and lack of mullerian derivatives. CASE PRESENTATION A 28-year-old woman with complete (severe) androgen resistance underwent prophylactic laparoscopic bilateral gonadectomy because of the eventually increased risk of gonadal malignancy. Although the gonads appeared grossly normal, microscopic examination revealed bilateral well differentiated sertoli-leydig cell tumor (SLCT). DISCUSSION Our Medline search revealed that this is the first reported case of bilateral sertoli-leydig cell tumor (SLCT) in androgen insensitivity syndrome.
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Affiliation(s)
- Mohammad Asl Zare
- Department of Urology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Mahmood Reza Kalantari
- Department of Pathology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Amir Abbas Asadpour
- Department of Urology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Ali Kamalati
- Department of Urology, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, IR Iran
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Nakhal RS, Hall-Craggs M, Freeman A, Kirkham A, Conway GS, Arora R, Woodhouse CRJ, Wood DN, Creighton SM. Evaluation of Retained Testes in Adolescent Girls and Women with Complete Androgen Insensitivity Syndrome. Radiology 2013; 268:153-60. [DOI: 10.1148/radiol.13121068] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Bilateral Sertoli cell tumors of the testis-a likely new extracolonic manifestation of familial adenomatous polyposis. Virchows Arch 2012; 461:713-5. [PMID: 23090627 DOI: 10.1007/s00428-012-1332-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 09/24/2012] [Accepted: 10/15/2012] [Indexed: 12/19/2022]
Abstract
Testicular Sertoli cell tumors are rare and usually sporadic and unifocal. The large cell calcifying Sertoli cell tumor variant is known to be associated with Carney and Peutz-Jeghers syndromes and can be bilateral in these patient populations. There has been no documented association of Sertoli cell tumor with familial adenomatous polyposis (FAP) in the literature. The case presented is a bilateral Sertoli cell tumor occurring in a 34-year-old patient with FAP. The tumor had a conventional Sertoli cell tumor morphology, but with different morphology in the left and right sites. Beta-catenin immunostain showed strong nuclear reactivity in the tumor cells but not the nonneoplastic Sertoli cells. The presence of bilaterality as well as overexpression of beta-catenin by this tumor supports an association of the development of Sertoli cell tumor with the patient's FAP syndrome and adenomatous polyposis coli inactivation.
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Ozülker T, Ozpaçaci T, Ozülker F, Ozekici U, Bilgiç R, Mert M. Incidental detection of Sertoli-Leydig cell tumor by FDG PET/CT imaging in a patient with androgen insensitivity syndrome. Ann Nucl Med 2009; 24:35-9. [PMID: 19957213 DOI: 10.1007/s12149-009-0321-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 09/10/2009] [Indexed: 01/15/2023]
Abstract
A 29-year-old female patient who was being followed up for differentiated papillary thyroid carcinoma was referred to us for exploration of any possible metastasis since her serum thyroglobulin levels were high. The patient underwent an F-18 fluorodeoxyglucose positron emission tomography study, and a pathologically increased FDG uptake at the left lower abdomen was detected corresponding to a solid, cystic lesion on CT images. The patient had a history of primary amenorrhea and, together with the magnetic resonance imaging findings of absent uterus, short and blind end vagina, a diagnosis of androgen insensitivity syndrome was made. The patient underwent laparoscopic left pelvic mass resection, and the histopathology of the lesion revealed Sertoli-Leydig cell tumor.
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Affiliation(s)
- Tamer Ozülker
- Department of Nuclear Medicine, Okmeydani Training and Research Hospital, Istanbul, Turkey.
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Cheikhelard A, Thibaud E, Morel Y, Jaubert F, Lortat-Jacob S, Polak M, Nihoul-Fekete C. Complete androgen insensitivity syndrome: diagnosis and management. Expert Rev Endocrinol Metab 2009; 4:565-573. [PMID: 30780790 DOI: 10.1586/eem.09.31] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Complete androgen insensitivity syndrome (CAIS) is an X-linked genetic disorder affecting 46,XY individuals, characterized by the loss of function of the androgen receptor gene resulting in complete peripheral androgen resistance. Patients have a nonambiguous female phenotype with normal female external genitalia. Gonads are undescended testes (either intra-abdominal or inguinal), there is no uterus and the length of the vagina is usually very short. Gender identity is always female. This review focuses on the importance of accurate diagnosis of CAIS versus partial androgen insensitivity syndrome and other disorders of sex development by genotyping the androgen receptor, and raises issues of the optimal management of these patients. In the era of the Consensus Statement on Management of Intersex Disorders, we provide new insights into CAIS screening, surgical management of the gonads (balancing between hormonal production and malignancy risk) and of vaginal adequacy, and the ethics concerned with the disclosure to patients and their families.
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Affiliation(s)
- Alaa Cheikhelard
- a Department of Pediatric Surgery and Urology, AP-HP Hôpital Necker Enfants-malades, 149, rue de Sèvres, 75743, Paris Cedex 15, France and Centre de Référence des Pathologies Gynécologiques Rares, AP-HP Hôpital Necker Enfants-malades, Paris, France.
| | - Elisabeth Thibaud
- b Department of Pediatric Endocrinology and Gynaecology, AP-HP Hôpital Necker Enfants-malades, 149, rue de Sèvres, 75743, Paris Cedex 15, France and Centre de Référence des Pathologies Gynécologiques Rares, AP-HP Hôpital Necker Enfants-malades, Paris, France
| | - Yves Morel
- c Department of Molecular Biology and Hormonology, Université Claude Bernard Lyon 1, Lyon, France
| | - Francis Jaubert
- d Department of Cytology and Pathology, AP-HP Hôpital Necker Enfants-malades, 149, rue de Sèvres, 75743, Paris Cedex 15, Paris, France and Université Paris Descartes, Paris, France
| | - Stephen Lortat-Jacob
- e Department of Pediatric Surgery and Urology, AP-HP Hôpital Necker Enfants-malades, 149, rue de Sèvres, 75743, Paris Cedex 15, France
| | - Michel Polak
- f Centre de Référence des Pathologies Gynécologiques Rares, AP-HP Hôpital Necker Enfants-malades, 149, rue de Sèvres, 75743, Paris Cedex 15, France and Department of Pediatric Endocrinology and Gynaecology, AP-HP Hôpital Necker Enfants-malades, 149, rue de Sèvres, 75743, Paris Cedex 15, France and Université Paris Descartes, Paris, France
| | - Claire Nihoul-Fekete
- g Department of Pediatric Surgery and Urology and Centre de Référence des Pathologies Gynécologiques Rares, AP-HP Hôpital Necker Enfants-malades, 149, rue de Sèvres, 75743, Paris Cedex 15, France and Université Paris Descartes, Paris, France
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A rare case of large epididymal cyst in androgen insensitivity syndrome removed laparoscopically. J Minim Invasive Gynecol 2009; 16:504-6. [PMID: 19573832 DOI: 10.1016/j.jmig.2009.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Revised: 04/21/2009] [Accepted: 04/26/2009] [Indexed: 11/23/2022]
Abstract
Androgen insensitivity syndrome is a disorder of sexual differentiation with 46XY karyotype. The gonad is at risk (33% by 50 years of age) for development of malignant tumors. Hence, gonadectomy is warranted. We present a case of a 22-year-old woman diagnosed with androgen insensitivity syndrome during investigation of primary amenorrhea. Ultrasonography showed intraabdominally-located gonads, with a large, nontender cyst of 9.2 x 5.6 x 5.4 cm size, with limited mobility, to the right of the midline. There was also a partial septum, with a wall thickness of 1 to 2 mm and containing clear fluid. Because of suspicion of malignancy, complete surgery including laparoscopic peritoneal cytologic study, gonadectomy, lymphadenectomy, and omentectomy were performed. Histopathologic study showed testis with an epididymal cyst. Formation of epididymal cyst is rare in these cases. The patient did well in the postoperative period. She was put on hormone replacement therapy and is doing well.
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Androgen insensitivity syndrome with serous gonadal cyst. Fertil Steril 2008; 90:2018.e9-11. [DOI: 10.1016/j.fertnstert.2008.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 05/29/2008] [Accepted: 06/05/2008] [Indexed: 10/21/2022]
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Nistal M, García-Fernández E, Mariño-Enríquez A, Serrano A, Regadera J, González-Peramato P. Valor de la biopsia gonadal en el diagnóstico de los desórdenes del desarrollo sexual. Actas Urol Esp 2007; 31:1056-75. [DOI: 10.1016/s0210-4806(07)73767-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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