Early manifestations of testicular dysgenesis in children: pathological phenotypes, karyotype correlations and precursor stages of tumour development

Testicular dysgenesis derives from abnormal gonadal development caused by chromosome aberrations/mosaicisms or mutations/deletions in SRY or other genes responsible for testicular differentiation. Dysgenetic male pseudohaermaphroditism has bilateral dysgenetic testes characterized by a cortical network of anastomosing seminiferous cords that penetrate a thin albuginea. In asymmetric gonadal differentiation (or Mixed Gonadal Dysgenesis) a dysgenetic testis associates with a streak gonad with primitive sex cords embedded in an ovarian-like stroma. Uni- or bilateral ovotestes identify true haermaphroditism. Fluorescent in situ hybridisation studies demonstrate that the sex chromosomes of mosaic patients do not distribute homogeneously in asymmetric gonads. 45,X lines predominate over 46,XY in streak gonads, while the relationship between these two is more equivalent in dysgenetic testes, suggesting that testicular or streak differentiation is related to the balance between X0 and XY lines. Testicular dys-genesis is more severe when there is a frank predominance of X0 or XX cells. Higher percentages of XY cells coincide with lesser degrees of dysgenesis. DNA densitometry indicate a higher incidence of neoplastic transformation than previously anticipated. Various specimens showed clear aneuploid histograms but no clear indication of a cytological CIS phenotype. There was a wide cytological variation in aneuploid germ cells, ranging from normally looking big infantile spermatogonia to gonocyte/CIS cells. Aneuploidy probably precedes the full expression of the CIS phenotype. In case of doubt we recommend DNA densitometry to either confirm or discard their neoplastic nature. The earliest recognizable change in germ cell tumorigenesis is probably the polyploidisation of fetal germ cells, followed by the expression of the CIS phenotype in isolated germ cells scattered along infantile seminiferous tubules that later proliferate to give an adult type CIS pattern.

Association between testicular dysgenesis syndrome (TDS) and testicular neoplasia: evidence from 20 adult patients with signs of maldevelopment of the testis

Based on a well established association between testicular cancer and undescended testis and more recent publications on epidemiological links between these disorders and male infertility, we proposed the existence of a testicular dysgenesis syndrome (TDS). In most cases TDS presents with impaired spermatogenesis, only in rare cases the full range of its signs, including genital malformations and testicular cancer can be seen in one patient. In order to further corroborate our hypothesis about the presence of testicular dysgenesis in patients with testicular abnormalities, we decided to re-analyse recent testicular biopsies derived from patients with infertility, hypospadias and undescended testis. We searched for histological signs of testicular dysgenesis: microliths, Sertoli-cell-only tubules, immature seminiferous tubules with undifferentiated Sertoli cells, and tubules containing carcinoma in situ (CIS) cells. We identified 20 patients who fulfilled the histological criteria for testicular dysgenesis, 9 of whom were diagnosed with uni- or bilateral testicular germ cell neoplasia, and the remaining ones with subfertility. The presence of CIS was detected in 5 patients (3 of them with overt contralateral germ cell tumours). In all but one of the CIS cases, at least one additional sign of testicular dysgenesis was detected. Clinical records of all patients were subsequently analysed. The majority of cases had oligozoospermia or azoospermia. Their reproductive hormone profiles correlated with the results of semen sampling and testicular histology. In conclusion, our study of 20 patients with various reproductive abnormalities provided evidence that TDS is a real clinical entity. We speculate that most of these abnormalities are caused by adverse environmental effects rather than specific gene mutations.

[Pathogenesis and clinical morphology of congenital disorders of sex differentiation]

Bisexual structure of genitalia presents difficulties for clinical diagnosis. Therefore, knowledge of pathogenesis and clinical morphology of congenital disturbances of sexual differentiation helps to establish earlier hermaphroditism variant, appropriate surgery for complete social-psychological adaptation of this group of patients.

A case of 46,X,der(X)(pter-->q21::p21-->pter) with gonadal dysgenesis, tall stature, and endometriosis

OBJECTIVE

To report a case of 46,X,der(X)(pter-->q21::p21-->pter) with gonadal dysgenesis, tall stature, and endometriosis.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A 20-year-old primary amenorrheal woman receiving estrogen-progestogen substitution.

INTERVENTION(S)

G-banding, comparative genomic hybridization, fluorescence in situ hybridization (FISH), and laparoscopy.

MAIN OUTCOME MEASURE(S)

A recombinant X chromosome, 46,X,der(X)(pter-->q21::p21-->pter), and pelvic endometriosis.

RESULT(S)

The patient's chromosomal abnormality was misjudged by the use of G-banding as a distal part deletion of the long arm in one X chromosome. Comparative genomic hybridization and fluorescence in situ hybridization analyses with locus-specific probes revealed 46,X,der(X)(pter-->q21::p21-->pter). The laparoscopic examination showed bilateral streak gonads and blue berry spots at the pelvic peritoneum, which were confirmed by evaluation of biopsy specimens.

CONCLUSION(S)

Recent advances of genetic strategies make it easy to determine karyotype and phenotype abnormalities. We have to keep our mind on the potential of endometriosis with patients who are receiving estrogen-progestogen substitution.

Morphometry and histology of gonads from 13 children with dysgenetic male pseudohermaphroditism

BACKGROUND

Dysgenetic male pseudohermaphroditism (DMP) is a sexual differentiation disorder characterized by bilateral dysgenetic testes, persistent müllerian structures, and cryptorchidism in individuals with a 46,XY karyotype. However, the histologic criteria for the diagnosis of DMP are poorly established.

OBJECTIVE

To determine gonadal histology in children with DMP.

PATIENTS AND METHODS

Between 1996 and 1998, 13 patients with DMP were evaluated on our service. The clinical diagnosis of DMP was based on a 46,XY karyotype, sex ambiguity, high levels of follicle-stimulating hormone and low levels of antimüllerian hormone, a decreased testosterone response to human chorionic gonadotropin stimulation without accumulation of testosterone precursors, and the presence of müllerian structures. Molecular sequencing the HMGbox region of the SRY gene did not reveal any mutations. Biopsies were performed for 22 of 26 gonads (patient age at the time of biopsy, 16 months to 10 years). Conventional microscopy was used to evaluate mean tubular diameter, tubular fertility index, and number of Sertoli cells per tubular profile.

RESULTS

All 26 gonads were located outside of the labioscrotal folds. Their histologic features varied from only a reduction in tubular size to features of a streak gonad. Five of the 22 gonads grossly resembled a streak gonad. The mean tubular diameter was severely reduced (>30% reduction relative to the normal tubular diameter for the patient's age) in 4 gonads, markedly reduced (10%-30%) in 11 gonads, slightly reduced (<10%) in one gonad, and normal in one gonad. The tubular fertililty index, expressed as the percentage of tubular profiles containing germ cells, was severely reduced (<30% of normal values) in 9 gonads, markedly reduced (50%-30%) in 2 gonads, and normal in 6 gonads. The number of Sertoli cells per tubular profile was elevated in 16 gonads and normal in one gonad. Thin tubules surrounded by fibrous tissue were occasionally observed.

CONCLUSION

The histologic findings confirmed the clinical diagnosis of DMP in every patient in the present series. However, gonadal histology was variable, and careful morphometric evaluation may be necessary to establish the diagnosis.

Nuclear DNA content and proliferative potential of human carcinoma in situ cells in testes of intersex children

Gonocytes, fetal germ cells, when persisted beyond infantile period of life are considered as preinvasive testicular germ cell cancer (carcinoma in situ--CIS). The aim of the study was to investigate nuclear DNA content and proliferative potential of CIS cells together with the expression of placental-like alkaline phosphatase (PLAP), a marker of CIS and germ cell cancer. In dysgenetic testes of 4 intersex children proliferating cell nuclear antigen (PCNA) and PLAP were examined immunohistochemically. DNA content was assessed by densitometry of nucleus in Feulgen stained histologic sections. High incidence of aneuploidy (95.1-97.6% of CIS cells with 2.6-6.8c) was found with the predominant DNA pattern of tri- and tetraploidy in children aged 1 to 3 years. The incidence of triploidy (65-78.1% of cells) was similar to the incidence of the expression of PCNA (53.4-62%), what indicates that part of hyperploid germ cells might represent phase S of cell cycle, but the rest of hyperploid cells might represent neoplastic transformation. In turn, germ cells of 8-months-old patient were predominantly diploid with low incidence of PCNA positive cells which indicate that proliferation/neoplastic transformation of abnormal germ cells is significant mostly after 1 year of age in intersex children. The frequency of PLAP expression in CIS cells (3.1-27% of cells) was weakly related to the frequency of aneuploidy what limits the usefulness of PLAP reaction for the detection of CIS cells.

A novel mutation of desert hedgehog in a patient with 46,XY partial gonadal dysgenesis accompanied by minifascicular neuropathy

We describe a patient with 46,XY partial gonadal dysgenesis (PGD) who presented with polyneuropathy. Sural nerve pathology revealed peculiar findings characterized by extensive minifascicular formation within the endoneurium and with a decreased density of myelinated fibers. We found, in the patient, a homozygous missense mutation (ATG-->ACG) at the initiating codon in exon 1 of the desert hedgehog (DHH) gene, which predicts a failure of translation of the gene. The same heterozygous mutation was found in the patient's father. This is the first report of a human DHH gene mutation, and the findings demonstrate that mutation of the DHH gene may cause 46, XY PGD associated with minifascicular neuropathy.

Sexual development in marsupials: genetic characterization of bandicoot siblings with scrotal and testicular maldevelopment

In marsupials testis determination requires the presence of a Y chromosome. The sex determining region on the Y gene (SRY) is necessary for testicular development in eutherians and it is assumed to play a similar role in marsupials. Relatively few studies have investigated the genetic basis of sexual development, and as yet there is no direct evidence that SRY is required for testis development in marsupials. Studies on intersexual marsupials have revealed a fundamental difference between marsupial and eutherian sex determination. The scrotum of marsupials is analogous, not homologous, to the eutherian scrotum and is under the control of X-linked genes not androgens. The current study describes two bandicoot (Isoodon macrourus) siblings. Both siblings had underdeveloped male reproductive tracts and testicular dysgenesis, one was ascrotal and the other had a diminutive scrotum. Their karyotypes were normal for this species which eliminates the Y chromosome from some somatic tissues. SRY was detected by Southern blotting. SRY, ubiquitin activating enzyme-1 on the Y (UBE1Y) and glucose 6-phosphate dehydrogenase (G6PD) gene expression were examined. UBE1Y was widely expressed in many tissues. SRY gene expression was much lower than normal in the abnormal siblings and may be responsible for their failure of testicular and epididymal development. The cause of their scrotal abnormalities is unknown. It is possible that the separate defects of scrotal and testis development in the two siblings, which had normal relatives, were due to a mutation in a gene common to both developmental pathways.

Tumors of the testis in intersex syndromes

Patients with intersex syndrome are rare in the general population. In these patients, cryptorchid gonads that have an Y chromosome or Y chromosomal material are at risk for development of germinal and non-germinal neoplasm and non-neoplastic masses. Diagnosis of individual patients should be accurate for optimal care and risk assessment.

Identification of a new missense mutation (Gly95Glu) in a highly conserved codon within the high-mobility group box of the sex-determining region Y gene: report on a 46,XY female with gonadal dysgenesis and yolk-sac tumor

Leydig cells and Sertoli cells of the testes produce hormones that cause male differentiation, if receptors are present. The Y chromosomal SRY gene (sex determining Region Y gene) acts as TDF and is required for regular male sex determination. SRY represents a transcription factor belonging to the superfamily of genes sharing the HMG-box motif(high-mobility group-box), which acts as DNA binding region. Here, we describe a nonmosaic XY sex-reversed female with pure gonadal dysgenesis (46,XY karyotype, completely female external genitalia, normal Müllerian ducts, absence of Wolffian ducts, streak gonads) who harbored a yolk-sac tumor and was referred for the assessment of primary amenorrhea. Using genomic PCR analysis, a 423-bp PCR product, encompassing the HMG-box of the SRY gene, was amplified from the proposita, her father, and her three brothers, whereas no band was visible in the patient's mother and her three sisters. The PCR products were sequenced for mutations subsequently. A new de novo missense mutation within the HMG-box of the SRY gene was discovered in the proposita. A G is replaced by an A in codon 95 at position +284, resulting in the replacement of the nonpolar aminoacid glycine by the polar amino acid glutamate. The glycine at codon 95 is highly conserved between the family of HMG-box proteins and between species. This point mutation has not been described earlier and brings the total number of SRY mutations described so far to 36, each mutation being unique. This mutation was not detected in the patient's father and her male siblings. The present data provide further evidence to support the functional importance of the putative DNA binding activity of the SRY HMG-box domain.

Management of males with 45,X/46,XY gonadal dysgenesis

Males with the 45,X/46,XY karyotype and malformations of the external genitalia carry an increased risk of developing germ cell neoplasia of the gonads. We have studied gonadal tissue from 10 individuals, 0.3-17 years of age, with a male phenotype and either hypospadias and/or cryptorchidism. Four patients, 0.3-15 years of age, had carcinoma in situ, 1 boy had Sertoli-cell-only pattern and the remainder prepubertal histology. Gonadoblastoma or invasive carcinoma was not found. On the basis of our current knowledge we propose a strategy for management and follow-up of these boys in order to detect possible premalignant histological changes early and prevent development of a gonadal tumour.

XY gonadal dysgenesis in an adolescent with chronic renal failure: a case of Frasier syndrome

STUDY OBJECTIVE

To report a case of XY gonadal dysgenesis in an adolescent with renal failure and to review the literature on this association.

METHODS

In this case report from the Tertiary Care University Medical Center, a 16-year-old female with chronic renal failure presenting with primary amenorrhea was studied. Interventions included laparotomy with bilateral gonadectomy and hormone replacement therapy.

MAIN OUTCOME MEASURES

Karyotype, gonadal histology.

RESULTS

Diagnosis of gonadal dysgenesis. Presence of a gonadoblastoma.

CONCLUSIONS

Gonadal dysgenesis should be considered in any female adolescent with renal disease presenting with pubertal delay or primary amenorrhea.

Failure of testicular development associated with a rearrangement of 9p24.1 proximal to the SNF2 gene

In 46,XY individuals, testes are determined by the activity of the SRY gene (sex-determining region Y), located on the short arm of the Y chromosome. The other genetic components of the cascade that leads to testis formation are unknown and may be located on the X chromosome or on the autosomes. Evidence for the existence of several loci associated with failure of male sexual development is indicated by reports of 46,XY gonadal dysgenesis associated with structural abnormalities of the X chromosome or of autosomes (chromosomes 9, 10, 11 and 17). In this report, we describe the investigation of a child presenting with multiple congenital abnormalities, mental retardation and partial testicular failure. The patient had a homogeneous de novo 46,XY,inv dup(9)(pter-->p24.1::p21.1-->p23.3::p24.1-->qter) chromosome complement. No deletion was found by either cytogenetic or molecular analysis. The SRY gene and DSS region showed no abnormalities. Southern blotting dosage analysis with 9p probes and fluorescent in situ hybridisation data indicated that the distal breakpoint of the duplicated fragment was located at 9p24.1, proximal to the SNF2 gene. We therefore suggest that a gene involved in normal testicular development and/or maintenance is present at this position on chromosome 9.

MR imaging of intersexuality

Intersexuality involves an intermingling of the characteristics of each sex in varying degrees as a result of some flaw in embryonic development. Accurate demonstration of genital anatomy is essential for proper gender assignment and for treatment of intersexual disorders. Genital anatomy is well demonstrated with MR imaging, which offers unsurpassed soft-tissue contrast, multiplanar capability, and no radiation exposure. Intersexual disorders can be categorized into female pseudohermaphroditism, male pseudohermaphroditism, gonadal dysgenesis or agenesis, and true hermaphroditism. In female pseudohermaphroditism, MR images show normal internal female genitalia with masculinized external genitalia. In male pseudohermaphroditism, MR images show normal or mildly defective testes with incompletely masculinized external genitalia. In gonadal dysgenesis, combinations of normal, dysgenetic, and streak gonads are seen on MR images; in gonadal agenesis, no gonads are evident. In true hermaphroditism, both testicular and ovarian tissue is seen on MR images. MR imaging is essential for management of intersexual disorders.

Rete testis dysgenesis. A characteristic lesion of undescended testes

OBJECTIVE

To evaluate the status of the intratesticular spermatic duct system (rete testis, RT) in patients with cryptorchidism.

MATERIALS AND METHODS

We examined 40 surgical orchiectomy specimens from postpubertal patients with undescended testis from pathology files at La Paz Hospital, Madrid, Spain. Special attention was given to the intratesticular spermatic duct system, mainly the RT.

RESULTS

In all cases, the RT was underdeveloped and was lined by columnar or large cuboidal cells (dysgenetic RT). According to the configuration of the mediastinal RT, the lesions were classified as diffuse hypoplastic RT (37.5%), hypoplastic-cystic RT (50%), or adenomatous pseudohyperplastic RT (12.5%).

CONCLUSION

Although these changes could have resulted from incomplete pubertal maturation, many other data suggest that a primary abnormality of the RT is present. Important clinical considerations are derived from the fact that a functional obstruction of the sperm-conducting mechanism is determined by these abnormalities of the RT. The presence of intraluminal spermatozoa in epididymis and RT suggest that at least some of these patients are potentially fertile.

Familial inv(X) (p22q22): ovarian dysgenesis in two sisters with del Xq and fertility in one male carrier

A recombinant chromosome with Xp duplication and Xq deletion was found in two sisters with normal height and gonadal dysgenesis. Their mother and other four relatives, including a fertile male, carried an inv(X) (p22q22); the inverted X was randomly inactivated in one female carrier. The abnormal X chromosome showed inactivation in all the examined cells. This is the tenth report of a recombinant X chromosome. A review of the literature shows that: i) most female carriers of inv(X) are phenotypically normal and fertile; ii) recombinants having short-arm duplication and long-arm deletion are associated with ovarian failure and normal or tall stature, whereas the reciprocal recombinants are compatible with fertility but cause short stature; and iii) except for one index case, all male carriers have a normal phenotype and 11 of them (from eight families) are of proven fertility. Moreover, no instance of male infertility has been documented.

XX-agonadism in a fetus with multiple dysraphic lesions: a new syndrome

We report on a 19-week-old fetus with a 46,XX karyotype, normal female external genitalia, complete gonadal agenesis, large encephalocele, spina bifida, and omphalocele. We postulate a new syndrome. Hitherto no consistent malformation patterns have been observed in agonadism patients. True agonadism, including even the unusual finding of an XX gonosomal status, is obviously not as rare as suggested.

Phenotypic diversity in siblings with partial androgen insensitivity syndrome

The androgen insensitivity syndrome is a heterogeneous disorder with a wide spectrum of phenotypic abnormalities, ranging from complete female to ambiguous forms that more closely resemble males. The primary abnormality is a defective androgen receptor protein due to a mutation of the androgen receptor gene. This prevents normal androgen action and thus leads to impaired virilisation. A point mutation of the androgen receptor gene affecting two siblings with partial androgen insensitivity syndrome is described. One had cliteromegaly and labial fusion and was raised as a girl, whereas the other sibling had micropenis and penoscrotal hypospadias and was raised as a boy. Both were shown to have the arginine 840 to cysteine mutation. The phenotypic variation in this family is thus dependent on factors other than abnormalities of the androgen receptor gene alone.

Leukodystrophy in patients with ovarian dysgenesis

We describe clinical, biochemical, pathological, and spectroscopic findings in 4 women, aged 15 to 29 years, from three unrelated families who had a unique combination of a central nervous system white matter disease and primary ovarian failure. All had normal initial development but 3 had borderline low IQ and academic difficulties in primary school. Puberty did not develop in 2 patients and was arrested in a third patient. The fourth patient had premature ovarian failure at the age of 13 years. Head magnetic resonance imaging showed diffuse white matter disease, with frontal cortical atrophy in the most clinically advanced patient. All patients had normal karyotype and normal findings on extensive evaluations for known leukodystrophies, for other metabolic diseases, and for causes of ovarian failure. Proton magnetic resonance spectroscopic imaging showed reduction of choline-containing compounds in the affected white matter in all patients and reduction of N-acetylaspartate in the unaffected frontal white matter of 2 patients. All patients had evidence of primary gonadal insufficiency with a normal hypothalamic-hypophyseal axis. Pathological analysis showed streak ovaries in 1 patient and signs of hypomyelination, and gliosis on brain biopsy in another patient. In conclusion, we present a novel group of patients who have in common leukodystrophy, primary ovarian dysfunction, and magnetic resonance spectroscopic abnormalities.

Gonadal dysgenesis: associations between clinical features and sex of rearing

The purpose of this study was to review the phenotypic and endocrine features or a series of patients with ambiguous genitalia or sex-reversal due to gonadal dysgenesis (GD) and to analyse the impact of these on the decision about sex of rearing. This study is a retrospective analysis of 22 patients with GD treated between 1964 and 1994. We assessed external genitalia, internal genitalia, internal genital structures, gonadal morphology (n = 22), basal and human CG (hCG) stimulated serum testosterone levels (n = 11) and serum gonadotropin levels (n = 13) in patients with GD. Basal and hCG stimulated testosterone levels were also measured for 43 control patients. There were no significant associations or correlations between internal or external genital phenotype, endocrine function and gonadal morphology. There was a significant association between sex of rearing and external genitalia (P = 0.03). Patients with gonadal dysgenesis had significantly lower stimulated/basal testosterone levels than the controls (P = 0.0001). Given that the clinical features of various forms of GD overlap considerably, gonadal biopsy should remain the investigation of choice when attempting to define the pathology.

The vanishing testis: anatomical and histological findings

OBJECTIVES

To review anatomical and histological findings in 105 vanishing testes.

METHODS

Records of 2,509 boys with 3,064 cryptorchid testes treated at our hospital between 1969 and 1995 were reviewed.

RESULTS

691 (23%) testes were clinically impalpable. Exploration in 691 impalpable testes revealed absent testis in 144 (21%). In 39 (27%) of the 144 absent testes, there was complete agenesis of testis along with the epididymis and vas deferens whereas 105 (73%) were associated with blind-ending cord structures-the vanishing testis. The site of blind-ending cord structures in 105 vanishing testes was intra-abdominal in 22 (21%), inguinal canal in 62 (59%), superficial inguinal ring in 19 (18%) and scrotum in 2 (2%). Histological information was available in 47 vanishing testes and revealed vas, epididymis, or both in 32 (68%), fibrous/vascular tissue in 11 (23%) and testicular cords in 4 (9%). Dystrophic calcification and/or haemosiderin were present in 7 (15%).

CONCLUSIONS

Our data show that the incidence of vanishing testis in boys with non-palpable testes is over twice the incidence of testicular agenesis. The most common site of blind-ending cord structures is distal to the internal inguinal ring. The finding of viable testicular tissue at the end of the attenuated cord structures in 4 of our patients, and also reported in other series, suggests that inguinal exploration should be carried out in all patients who on laparoscopy are found to have cord structures entering the internal ring.

An infant with a mosaic 45,X/46,X,psu dic(Y) (pter-->q11.2::q11.2-->pter) karyotype and mixed gonadal dysgenesis studied for extent of mosaicism in the gonads

AN infant with mixed gonadal dysgenesis was found to have a 45,X/46,Xpsu dic(Y) karyotype. A low level (8%) of mosaicism for the dic(Y) cell line was observed in peripheral blood lymphocytes and skin fibroblasts. The dicentric nature of the Y chromosome became apparent in fluorescence in situ hybridization studies. The presence of Y centromeric sequences was demonstrated in the paraffin-embedded testis and streak ovary sections. The ration of Y-positive cells was higher in the testis than in the streak ovary.

Intersexual phenotypes and sex chromosome complements of five South American opossums (Monodelphis domestica)

Intersexual opossums (Monodelphis domestica) from a large captive colony are described. These are the first naturally existing New World (didelphoid) intersexual marsupials for which reproductive phenotype and sex chromosome constitution are reported. One animal was XX, two were XY, and two were XO; all had lower body weight than normal males or females and the overall appearance of females. They were first recognized as abnormal by the presence of a small flaccid, nonstalked scrotum, markedly smaller than the scrotum of a normal male but in an equivalent position cranial to the cloacal aperture. Each scrotum contained a core of fatty connective tissue, but none contained testicular tissue. Teat patterns, seen only after close shaving of the hair over the area of the teat field, varied within and between the various sex genotypes, with one XY and one XO having the paired rudiments typical of normal males. All individuals had gonads, with no transabdominal migration. In the XX intersex there were mature ovaries with Graffian follicles, but in the XY and XO intersexes there was gonadal dysgenesis. The urogenital tract of all was female in appearance but was immature except in the XX intersex. Development of the scrotum and of the teat primordia can be explained on the basis of regulatory gene influences on the X chromosome. Intersex incidence in the colony is probably much higher than that observed because of ascertainment bias.

Testicular dysgenesis does not affect expression of anti-müllerian hormone by Sertoli cells in premeiotic seminiferous tubules

Anti-Müllerian hormone (AMH) immunoreactivity was studied on paraffin sections obtained from archival testicular biopsies of 29 children with intersex disorders and of 22 controls. Strong AMH immunoreactivity was observed in Sertoli cell cytoplasm from 8 fetal weeks until puberty. During pubertal maturation, in both normal and intersex patients, AMH expression was present in premeiotic seminiferous tubules, but was no longer detected in neighboring tubules with meiotic development. AMH immunostaining was abolished in the testis of one patient with persistent Müllerian ducts due to a mutation of the AMH gene, but was conserved in the testes of two patients with mutations of the AMH receptor gene. Testicular dysgenesis usually results in sexual ambiguity, with low testosterone and AMH serum levels and persistence of Müllerian derivatives. AMH immunoreactivity was conserved in premeiotic seminiferous tubules of dysgenetic testes, and also in sex-cord cells of a gonadoblastoma. In patients with asymmetric gonadal differentiation, the streak gonad was AMH-negative. In conclusion, secretion of AMH is a constitutive feature of the immature Sertoli cell and its expression is altered only by mutations of the AMH gene, but not by gonadal dysgenesis. The degree of regression of Müllerian ducts and serum AMH levels reflect the number, not the functional value, of Sertoli cells present in the immature testis.

Ovarian epithelial tumour in gonadal dysgenesis. A case report and literature review

A patient with gonadal dysgenesis was found to have a mucinous epithelial ovarian tumour on the left side and a streak gonad on the right. The preponderance of mucinous tumours (5 of 8) over other epithelial tumours in these patients is noted but the significance is not fully understood. Two models of pathogenesis (incessant ovulation and hypergonadotrophic hypogonadism) were proposed but neither satisfactorily explains the development of the tumours. Further ultrastructural, chromosomal and molecular biological study of these tumours may help to elucidate the underlying cause and pathogenesis.

Incomplete gonadal dysgenesis

A 21-year-old phenotypic male with ambiguous external genitalia and hypospadias was referred for cytogenetic studies. Exploratory laparotomy revealed presence of a small atropic uterus, unilateral gonadal dysgenesis with fallopian tubes on both sides and a cryptorchid testis on the left side. No gonad could be traced on the right side. Chromosomal analysis from peripheral whole blood culture revealed a 46,XY cell line. No mosaicism was detected. Endocrine studies showed elevated levels of serum FSH and LH with low borderline testosterone level and failure to respond to HCG stimulation. The presence of fallopian tube next to testis suggests absence of anti-Mullerian hormone secretion by Sertoli cells. The absence of Wolffian duct derivatives indicates insufficient secretion of testosterone by Leydig cells.

[Human gonadal hilar cells--histogenesis, differentiation, role]

Identification hilar cells in fetus and adult gonads two sex and dysgenetic gonads were based on histochemical and immunohistochemical methods. The hilar cells were detected in 40% of fetus gonads (ovarian testis), two time more in adult and dysgenetic gonads. The attention was put to their connection with nervous system. On the bases of specific markers there was established their mesenchymal origin, ability to response to gonadotropin induction and synthetization steroid hormones, mainly androgens. Hilar cells in dysgenetic gonads and postmenopausal women may be responsible for clinical manifestation of virilisation.

Gonadal dysgenesis in del(18p) syndrome

We report on a girl with syndromal gonadal dysgenesis and a de novo del(18p). Genetic factors controlling gonadal development are located not only on the X chromosome, but also on autosomes. The present case suggests that one of these genes is situated on 18p. We conclude that patients with del(18p) syndrome should be evaluated for gonadal dysgenesis.

Nephropathy with Wilms tumour or gonadal dysgenesis: incomplete Denys-Drash syndrome or separate diseases?

We report three children, one presenting with nephropathy, bilateral Wilms tumour (WT) and cryptorchism, one with combined nephropathy and gonadal dysgenesis and one with nephropathy which developed 13 years after a WT. The first case was recognized as typical Denys-Drash syndrome (DDS) which is characterized by the combination of nephropathy, intersex disorders and WT. The two other patients, who did not express the full spectrum of the syndrome, were older than 10 years, when they reached and stage renal failure. The fact that nephropathy in childhood is combined with such rare diseases like gonadal dysgenesis and/or WT, supports the concept of a common aetiology with DDS. Therefore, the patients were analysed for possible Wilms tumour suppressor gene (WT1) mutations. In all three individuals mutations in the heterozygous configuration could be demonstrated.

CONCLUSION

These results provide evidence that incomplete and complete DDS are diseases of the same spectrum. WT1 analysis of more children with two symptoms of the triad of DDS should be helpful in establishing genotype-phenotype correlations and in understanding differences in the clinical picture of DDS.

Aod1, the immunoregulatory locus controlling abrogation of tolerance in neonatal thymectomy-induced autoimmune ovarian dysgenesis, maps to mouse chromosome 16

Mice thymectomized at three days of age (D3Tx) develop during adulthood a variety of organ-specific autoimmune diseases, including autoimmune ovarian dysgenesis (AOD). The phenotypic spectrum of AOD is characterized by the development of anti-ovarian autoantibodies, oophoritis, and atrophy. The D3Tx model of AOD is unique in that disease induction depends exclusively on perturbation of the normal developing immune system, is T-cell-mediated, and is strain specific. For example, D3Tx A/J mice are highly susceptible to AOD, whereas C57BL/6J mice are resistant. After D3Tx, self ovarian antigens, expressed at physiological levels, trigger an autoimmune response capable of eliciting disease. The D3Tx model provides, therefore, the opportunity to focus on the mechanisms of self-tolerance that are relevant to disease pathogenesis. Previous studies indicate that the principal mechanisms involved in AOD susceptibility are genetically controlled and govern developmental processes associated with the induction and maintenance of peripheral tolerance. We report here the mapping of the Aod1 locus to mouse chromosome 16 within a region encoding several loci of immunologic relevance, including scid, Igl1, VpreB, Igll, Igl1r, Mtv6 (Mls-3), Ly-7, Ifnar, and Ifgt.

Diaphragmatic hernia in Denys-Drash syndrome

We report on a newborn infant with male pseudohermaphroditism and glomerular lesions (Denys-Drash syndrome) but without Wilms tumor. A constitutional heterozygous mutation in the WT1 gene (366Arg to His) was identified. In addition the child had a large diaphragmatic hernia, so far not described in Denys-Drash syndrome. The expression of the WT1 gene in pleural and abdominal mesothelium and the occurrence of diaphragmatic hernia in transgenic mice with a homozygous WT1 deletion strongly suggests that the diaphragmatic hernia in this patient is part of the malformation pattern caused by WT1 mutations.

Analysis of sex chromosome distribution in the gonadal tissue of a 45,X/47,XYY mosaic by fluorescence in situ hybridization

45,X/47,XYY mosaicism is a rare condition with scarce information on the tissue-specific distribution of the different cell lines. Fluorescence in situ hybridization with repetitive, chromosome-specific DNA probes was applied to gain insight into the tissue-specific distribution of the two cell lines in biopsies of the streak gonad and dysgenetic testis of a 2-year-old individual exhibiting 45,X/47,XYY mosaicism. The distribution of the 45,X/47,XYY cells within different tissues was found to be nonrandom. The coelomic epithelium, the vascular endothelium, and the prepuberal germ cells exhibited predominantly a 47,XYY karyotype. In contrast, Sertoli cells exhibited both karyotypes, and the remaining tissue was predominantly composed of 45,X cells. The contribution of the two cell lines to gonadal development is discussed.

46,XX gonadal agenesis in a neonate with multiple congenital anomalies: case report and review of the literature

We report a neonate with 46,XX gonadal agenesis, a rare disorder, confirmed by autopsy, karyotype determination, and fluorescent in situ hybridization examination of intact cells. Multiple other anomalies, including diaphragmatic hernia, a doomed bicuspid aortic valve, and müllerian derivative defects, were present. There was no sexual ambiguity. The age of this patient and the presence of anatomically dispersed congenital anomalies are unique among reported examples of 46,XX gonadal agenesis. Review of the literature reveals that all five previously reported cytogenetically confirmed patients with 46,XX gonadal agenesis were 17 to 25 years of age, none were diagnosed before their teens, all had female phenotype with sexual infantilism, three had müllerian derivative anomalies, and none had nongenitourinary anomalies. The abnormalities in this case may represent a polytopic field defect due to unknown insults occurring at approximately 6 weeks of developmental age.

XY gonadal dysgenesis and tetralogy of Fallot in an Angus calf

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Conjoined twin piglets with duplicated cranial and caudal axes

BACKGROUND

Twins with doubling of the cranial and caudal poles, yet having a single thorax, are rare.

METHODS

One set of diprosopus, dipygus porcine conjoined twins was studied.

RESULTS

In addition to the conjoining anomaly, these twins also exhibited ambiguous internal reproductive features. The twins had two snouts, three eyes, a single thorax, and were duplicated from the umbilicus caudally. Radiography indicated a single vertebral column in the cervical region. The vertebral columns were separate caudally from this point. There was a total of six limbs--one pair of forelimbs and two pairs of hindlimbs. Many medial structures failed to develop in these twins. Medial cranial nerves V-XII were absent or displaced although apparently normal laterally. The medial palates were present but shortened, whereas the medial mandibular rami had folded back on themselves rostrally to form a midline mass between the two chins. Each twin had only one lateral kidney and one lateral testis. Medial scrotal sacs were present but devoid of a testis. There was a midline, "uterine"-like structure which crossed between the twins. However, histological analysis of this structure revealed it to be dysplastic testicular tissue.

CONCLUSIONS

The relationship between the abnormal reproductive features in these twins and the conjoining is unclear. The anatomy of these twins, in addition to the literature reviewed, illustrates the internal anatomical heterogeneity of grossly similar conjoined twins. A review of the literature also suggests that conjoined twinning may be more common in swine than was previously suspected.

Heritable testicular hypoplasia in Nguni (Bos indicus) bulls: vascular characteristics and testosterone production

The biased unilateral occurrence of heritable gonadal hypoplasia was investigated by examining the gross- and microanatomy of the testicular artery and vein, testicular blood flow and testicular testosterone secretion in normal Nguni bulls and in Nguni bulls showing unilateral left, unilateral right and bilateral hypoplasia of the testis. A high incidence of branching of the testicular artery was found ipsilateral to hypoplastic testes. The branching occurs a short distance from the dorsal aorta: one branch proceeds to the testis, the other to the ipsilateral kidney. The association between arterial branching to the kidney and ipsilateral hypoplasia of the testis held for both unilaterally left and unilaterally right hypoplastic bulls. Variations in the anatomy of the testicular vein occurred in both normal and hypoplastic bulls but there was no specific association between the variations and ipsilateral hypoplasia. The lumen diameter of the testicular artery or branch correlated with testis mass. Wall thickness of the artery ipsilateral to hypoplastic testes was not different from that in normal bulls, discounting hyperplasia of the endothelium. Total blood flow to the testis correlated with testis mass. The secretion rate of testosterone from hypoplastic testes was lower than that of normal testes but there was no difference when compared on a unit mass basis.

Absence of Turner stigmata in a 46,XYp-female

A 46,XY female patient with streak gonads and a large deletion of Yp is described. The deletion included the Y chromosomal genes SRY, ZFY, and RPS4Y. The patient did not display any Turner stigmata, such as webbing of the neck, cardiac or other abnormalities. The findings argue against an important role of RPS4Y in the prevention of Turner stigmata in males and are consistent with a role of SRY in testis differentiation in humans.

The Management of the Impalpable Testis by Surgery Alone

We evaluated 68 prepubertal boys with 84 impalpable testes who were operated upon without using any other diagnostic maneuvers. Of the testes 18 (22%) were absent (anorchism or 'vanished') and 38 (45%) could be placed in a scrotal position with standard orchiopexy. A staged, Fowler-Stephens or microvascular procedure was required for 28 testes (33%), involving orchiectomy in 2 cases, and succeeded in a scrotal position for another 24 testes. In 1 boy 2 testes were fixed outside the inguinal canal. Reexamination after 3 to 9 years showed that 42 of 55 operated testes (76%) were in scrotal position without atrophy, 10 had atrophied and 3 were removed at the second stage operation. We conclude that an exclusive surgical approach has the advantage of providing diagnosis and therapy, and, therefore, it is an effective method.

An Absent Testis is Associated with Contralateral Testicular Hypertrophy

Surgical exploration was done in 109 boys ages birth through 9 years with unilateral impalpable testes by physical examination under anesthesia. Of the patients 51 (47%) had an absent testis and 58 had intra-abdominal testes. At open biopsy of the contralateral descended testis the 3 dimensions of the exposed testis were recorded and testicular volume was calculated. The mean volume of the contralateral descended testes of boys with an absent testis was greater than that of boys with intra-abdominal testes at all ages. The differences were significant (p = 0.0019 to 0.0117) from birth through year 4 but not from years 5 through 9. However, the standard deviations ranged from 27 to 74% of the means, and there was broad overlap of the volumes of the 2 groups. These findings indicate that, although the volume of the contralateral descended testis of boys with an absent testis is significantly greater than that of boys with intra-abdominal testes, the volume of the contralateral descended testis is not a reliable criterion for differentiating an absent testis from an intra-abdominal testis in a boy with a unilateral impalpable testis. Surgical exploration continues to be the method of choice for making the diagnosis of an absent testis.

The clitoral index: a determination of clitoral size in normal girls and in girls with abnormal sexual development

Clitoral measurements were obtained in normal children; small increases in clitoral dimensions were associated with growth and puberty. Patients with androgen excess had major increases in clitoral size, clearly different from normal values.

[Bilateral ovariectomy in gonadal dysgenesis with a Y chromosome]

The Authors report 4 cases of gonadal dysgenesis with a Y chromosome. Every patient underwent bilateral oophorectomy. Two cases of streak gonads, 1 case of streak gonad and gonadoblastoma and 1 case of non metastasizing bilateral gonadoblastoma with foci of dysgerminoma have been found. The Authors emphasize the importance of early bilateral gonadectomy in all cases of gonadal dysgenesis with a Y chromosome.

A 46,XY female with mixed gonadal dysgenesis and a 48,XY, +7, +i(12p) chromosome pattern in a primary gonadal tumor

Cytogenetic analysis of a primary germ-cell tumor originating from the streak gonad of a 20-year-old phenotypic female with a 46,XY karyotype and mixed gonadal dysgenesis revealed a 48,XY, +7, +i(12p) chromosomal pattern. Germ-cell tumors originating from gonads of normal males are usually highly aneuploid. An isochromosome 12p as well as an overrepresentation of chromosome 7 material are among the specific changes most consistently observed. The present case shows that tumors of dysgenetic gonads, albeit being near-diploid, may exhibit similar chromosomal changes. This observation lends additional support to the hypothesis that these specific cytogenetic anomalies may play an important role in the pathogenesis of human germ-cell tumors.

Detection of gonadal carcinoma in situ in childhood and implications for management

Cells with the characteristic features of carcinoma in situ (CIS) were detected in histological sections of the gonads of three of seven children with clinical syndromes associated with a high risk of gonadal neoplasia. It is suggested that early detection of these cells may be useful in resolving problems of management, including gonadectomy and decisions about sex of rearing. Early detection of CIS cells may have a place in the management of the undescended testis.

Unilateral gonadal dysgenesis with both testis and fallopian tube on the same side in a 45,X/46,X inv (Y) mosaic male

A 5-year-old male with ambiguous external genitalia, hypospadias and microphallus without an urethral orifice was referred for cytogenetic studies. Exploratory laparotomy revealed presence of an infantile uterus and unilateral gonadal dysgenesis with both testes and fallopian tube on the right side. The metaphase cells from peripheral blood culture showed both 45,X/46,X inverted Y (p11.2q11.23) cell-lines (98:2). The inverted Y was found to be of paternal origin. Maternal chromosomal pattern was normal 46,XX. The presence of a fallopian tube next to testis suggest absence of secretion of anti-Mullerian hormone by Sertoli cells. The absence of Wolffian duct derivatives suggest insufficient secretion of testosterone by Leydig cells.

Ovarian dysgenesis in individuals with chromosomal abnormalities

To understand better the pathogenesis of ovarian dysgenesis in individuals with abnormalities such as 45,X Turner syndrome, trisomy 13, and trisomy 18, we have examined microscopically the ovaries of 36 infants with a number of chromosomal abnormalities confirmed by karyotype analysis. All infants with trisomy 13, trisomy 18, triploidy, and 45,X were found to have severe ovarian dysgenesis characterized by a virtual absence of primary oocytes. The ovaries of individuals with 21 trisomy and of those with partial deletion or duplication of an autosome demonstrated variable findings, which ranged from complete absence of oocytes to a mild diminution of oocyte numbers. The results of this study suggest that the attrition of germ cells in these infants is a result of faulty meiotic pairing and that ovarian dysgenesis is a more frequent finding in children with karyotypic abnormalities that has been realized previously.

[Gonadal dysgenesis and agenesis: anatomical expression]

The term of gonadal dysgenesis designates generically any anatomical alteration due to abnormal embryological development of a gonad. The spectrum of these gonadal abnormalities is large and includes the following entities: The gonadal agenesis is characterized by a rudimentary streak gonad. It is composed of a dense, hyalinized fibrous tissue in which the germ cells or the germ structures are entirely missing. Usually the gonadal dysgenesis is a bilateral and symmetrical lesion. The gonadal dysgenesis is characterized by the presence of residual germ structures (follicles or tubules). These structures can be more or less easily identified within a dense fibrous tissue. The gonadal dysgenesis alterations are often unilateral and always asymmetrical. Usually the ipsilateral gonad is a testis. The ovotestis is characterized by the coexistence within the same gonad of differentiated germ structures. Most commonly, the gonadal dysgenesis are associated with sexual chromosome abnormalities and an increased risk of neoplastic change (gonadoblastoma). This risk can reach 30% in the asymmetrical gonadal dysgenesis.

[Fertility in gonadal dysgenesis]

At the Second Gynaecological and Obstetric Clinic in Prague there are at present 78 phenotypic women with dysgenetic gonads in dispensary care. In 61.5% the main reason for examination in a specialized department was infertility. Based on a comprehensive examination, the authors demonstrate the relationship between chromosomal complement and histology of the gonads on one side and fertility on the other. 31% of women with dysgenetic sclerocystic gonads became pregnant after surgical and hormonal treatment. In 27% of the dispensarized group genital and extragenital tumours were detected.

Mixed gonadal dysgenesis. A review of 15 patients reporting single cases of malignant intratubular germ cell neoplasia of the testis, endometrial adenocarcinoma, and a complex vascular anomaly

The clinicopathologic features of 15 patients with mixed gonadal dysgenesis are presented with special regard to cardiovascular and neoplastic disease. Seven (47%) cases, all phenotypic females, had gonadal tumors: gonadoblastoma (5), germinoma (4), malignant intratubular germ cell neoplasia (1), and a unique gonadal stromal tumor (1). Gonadoblastoma was found in 4 of 10 testes and 4 of 17 streak gonads, and associated with germinoma in 4 cases. One patient developed grade 1 endometrial adenocarcinoma after estrogen therapy. Cardiovascular diseases (ie, bicuspid aortic valve, and a unique right aortic arch with a retroesophageal arch segment, aberrant left subclavian artery, coarctation, and dissection) are documented in our series. At the time of diagnosis of mixed gonadal dysgenesis, removal of streak gonads or testes will prevent further gonadal tumor development Cardiovascular examination may identify treatable and potentially lethal disease.