True hermaphroditism with sex cord tumor with annular tubules (SCTAT): a rare case report and review of the literature

Is it possible to separate the testicular and ovarian components of an ovotestis?

The presence of an ovotestis is a rare etiology of differences of sex development. Histologically, ovotestis come in two forms: 1) Mixed or 2) Bipolar.

OBJECTIVE

We hypothesize that it is surgically impossible to cleanly separate and preserve either the testicular or ovarian component of an ovotestis.

STUDY DESIGN

Twenty human gonads with a previous diagnosis of ovotestis were re-sectioned in entirety and re-stained with markers for testicular (SOX9, TSPY, SALL4, DDX4, cP450, AR, α-actin) and ovarian tissue (FOXL2, SALL4, DDX4). Histologic sections were photographed at low power to confirm the presence of the entire cross section of the ovotestis. High power was used to confirm an ovotestis based on the presence of both seminiferous cords (testis) and follicles (ovary).

RESULTS

Six of twenty ovotestis did not meet our criterion for the diagnosis of ovotestis lacking the histologic evidence of both testicular and ovarian tissue (lacking ovarian follicles). The remaining 13 patients in which 14 separate specimens were evaluated, contained ovotestis defined by the presence of both seminiferous cords and ovarian follicles. Seven of these specimens had low power confirmational histologic images that included the entire ovotestis and could be completely evaluated for a potential surgical plane of separation. The other seven specimens were consistent with an ovotestis biopsy without complete borders. For the seven specimens that included the entire ovotestis, 6 of the 7 had ovotesticular cords and 3 had the presence of ovotesticular follicles.

DISCUSSION

None of the seven complete specimens had a clear surgical plane where testicular or ovarian components could be isolated cleanly. Often the ovarian component was composed of a thin layer of follicles, surrounded the testicular component with an in-between, mixed layer of both seminiferous cords and follicles. The remaining seven ovotestis biopsy specimens also did not have a clear plane for surgically isolating either the testicular or ovarian compartment.

CONCLUSION

Based on the histologic evaluation of the entire ovotestis as well as ovotestis biopsy specimens it does not appear possible to surgically separate the testicular and ovarian component. We have reservations with the concept in both mixed and bipolar ovotestis that it is possible to surgically preserve either the ovarian or testicular component without leaving incongruent tissue. The clinical implications of leaving gonadal tissue inconsistent with the patient's gender identity remains unknown.

[Sex cord tumor with annular tubules]

Sex cord tumor with annular tubules is a rare type of ovarian tumor, which seems to arise from Sertoli cells. Most tumors are associated with Peutz-Jeghers syndrome and have a benign course and favorable prognosis; however, about 20% of sporadic sex cord tumors with annular tubules have a high risk of developing metastases. We present a case report about 18-year-old patient who presented with irregular menstruation and abdominal pain. Based on the histological features and immunohistochemical results, the diagnosis of a sex cord tumor with annular tubules was confirmed. The above-described ovarian tumor is rare in childhood and adolescence compared to the general population, which, combined with nonspecific clinical manifestations, can result certain diagnostic difficulties in this age group of patients.

Relevance of Molecular Pathology for the Diagnosis of Sex Cord-Stromal Tumors of the Ovary: A Narrative Review

Ovarian sex cord-stromal tumors (SCSTs) account for 8% of all primary ovarian neo-plasms. Accurate diagnosis is crucial since each subtype has a specific prognostic and treatment. Apart from fibrosarcomas, stromal tumors are benign while sex cord tumors may recur, sometimes with a significant time to relapse. Although the diagnosis based on morphology is straightforward, in some cases the distinction between stromal tumors and sex cord tumors may be tricky. Indeed, the immunophenotype is usually nonspecific between stromal tumors and sex cord tumors. Therefore, molecular pathology plays an important role in the diagnosis of such entities, with pathognomonic or recurrent alterations, such as FOXL2 variants in adult granulosa cell tumors. In addition, these neoplasms may be associated with genetic syndromes, such as Peutz-Jeghers syndrome for sex cord tumors with annular tubules, and DICER1 syndrome for Sertoli-Leydig cell tumors (SLCTs), for which the pathologist may be in the front line of syndromic suspicion. Molecular pathology of SCST is also relevant for patient prognosis and management. For instance, the DICER1 variant is associated with moderately to poorly differentiated SLCTS and a poorer prognosis. The present review summarizes the histomolecular criteria useful for the diagnosis of SCST, using recent molecular data from the literature.