Incomplete regression of müllerian ducts in the androgen insensitivity syndrome

The biochemical and histological features of two related patients with the complete form of the androgen insensitivity syndrome (AIS) coexisting with incomplete regression of the Müllerian ducts are described. Both patients presented unilateral Müllerian derivatives (fallopian tube) identified by microscopic examination of surgically excised internal genital tissue. Biochemical studies performed in genital skin-derived fibroblasts from one of the affected subjects showed the existence of a specific and saturable 8.2 to 8.4 S cytosolic and 3.4 S nuclear androgen receptor exhibiting a Kd of 1.32 nmol/L. These mutant cells, however, clearly presented a significantly low maximal nuclear [3H]-5 alpha-dihydrotestosterone uptake (71.0 fmol/mg of deoxyribonucleic acid [DNA]; control strain, 284 fmol/mg DNA). Thus, an impaired uptake of the androgen receptor complex at the nuclear level was probably the cause of the complete absence of phenotypic expression of androgen action in this family. The overall findings are on line with the well-demonstrated genetic and molecular heterogeneity of the AIS.

[Malignant germ cell tumor in XY gonadal dysgenesis (Swyer syndrome)]

Case of a 20-year-old patient with severe abdominal pain, right adnexal mass, positive beta-HCG titre and free fluid in the abdominal cavity, as diagnosed by ultrasound. Laparotomy resulted in a ruptured ovarian tumour (chorionic carcinoma). Despite chemotherapy, the tumour developed fulminant metastases with a follow-up of 3 months.

FINAL DIAGNOSIS

Gonadal dysgenesis, XY female type (Swyer-Syndrome).

A case of mixed gonadal dysgenesis (MGD)--with a review of MGD patients reported in Japan

A 17-year-old patient with mixed gonadal dysgenesis (MGD) showing ambiguous genitalia and hypergonadotropic hypogonadism was described. By intraabdominal exploration, a poorly developed uterus with a fallopian tube and a streak gonad was found on the right side and a poorly developed testis with epidydimis and vas deferens on the left. Chromosomal analysis on cultured peripheral lymphocytes and bone marrow cells showed 45,X karyotype, while among the majority of 45,X cells small numbers of 46,X+ mar cells (3-23%) were found in cultured fibroblasts from the abdominal skin and various organ tissues. We compared our patient with the Japanese patients with MGD reported in the literatures.

Studies on gonadal dysgenesis: variable expressivity of the XY testicular dysgenesis syndrome; two case reports

Two adult unrelated XY phenotypically female individuals with sexual infantilism and genital ambiguity were studied. Mosaicism was ruled out by the assessment of a normal 46,XY karyotype in four different cell lines. Persistently elevated LH and FSH serum levels with concomitant normal pituitary Gn-RH responsiveness were found. Baseline serum testosterone concentrations were low, but they exhibited a slight though significant rise following HCG stimulation. Surgical and histological findings included the presence of Mullerian and Wolffian derivatives and small bilateral dysgenetic testes with absence of germ cell epithelium, scarce Sertoli cells, and hyperplastic Leydig cells. The overall data indicated an anatomo-functional testicular impairment particularly confined to the tubular compartment. By comparing the clinical and endocrine features of this incomplete form of the XY testicular dysgenesis with the complete and other unusual forms, further evidence is provided of a wide heterogeneity of the syndrome, and a more detailed classification is proposed.

Unilateral biorchism associated with contralateral rudimentary uterus

A healthy 5-year-old boy presented with two palpable masses in the right hemiscrotum. An examination also showed a palpable mass in the left groin. During surgery, he was found to have right-sided biorchism and a left groin nodule attached to the left vas deferens and spermatic cord. The nodule was excised and histologic examination showed the presence of persistent Mullerian structures. A chromosome analysis showed the normal male karyotype. Both conditions have been previously reported, but this is the first report of both conditions occurring in the same patient.

The number of spermatogonia in various congenital testicular disorders

Various congenital testicular disorders, including monorchism, retractile testis, cryptorchidism and male intersex, were investigated by counting the number of spermatogonia per seminiferous tubule. The results showed that all 7 cases of monorchism had normal numbers of spermatogonia per seminiferous tubule. However, in 29 cases of a retractile testis a normal testis was observed in 13 (44.8 per cent). Therefore testicular dysgenesis is suggested to exist in more than half of cases of the retractile testis. Of 150 cases of cryptorchidism 82 were bilateral and 68 were unilateral. There was no significant difference in the number of spermatogonia per seminiferous tubule between these 2 groups. The higher the testes were located the worse the ratio of spermatogonia per seminiferous tubule. Fewer or absent spermatogonia were observed in 2 patients less than 2 years old. Of 28 contralateral scrotal testes in patients with unilateral cryptorchidism 4 (14.3 per cent) had no spermatogonia per seminiferous tubule and 8 (28.0 per cent) had a decreased number of spermatogonia per seminiferous tubule. The male intersex patients had much damage even in the scrotal testes. From these results it is suggested that these congenital testicular disorders, except monorchism, have similar histological features. Moreover, these conditions are possibly related in etiology to the phenomenon of deficient androgen stimulation.

X-chromosomal monosomy (77,X0) in a Doberman Pinscher with gonadal dysgenesis

A 6-month-old stunted female Doberman Pinscher was found to have a 77,X0 chromosomal complement. The ovaries were small, consisting primarily of interstitial-type cells and solid epithelial cords. The dam, sire, and a male littermate had normal karyotypes.

Hormonal characterization of female SL/Ni mice: a small thymus gland strain exhibiting ovarian dysgenesis

Female SL/Ni mice have a small thymus gland and show accelerated aging of the reproductive system characterized by an early loss of the follicular apparatus and early onset of ovarian tumors. At 9 months of age, circulating levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were higher in the SL/Ni animals than in controls while prolactin (PRL) was lower in the SL/Ni mice. The trends of these hormones are consistent with the loss of the follicular apparatus which is responsible for estradiol production. The high levels of gonadotropins which precede the onset of the tumors confirm the hypothesis that prolonged stimulation by gonadotropins can be a cause of ovarian tumorigenesis. Further, these data suggest that aging of the reproductive system may be a thymus-dependent phenomenon.

Unusual dual genital duct remnants in true hermaphroditism

A case of true hermaphroditism is reported in which a 46,XY karyotype was associated with a testis and an ovotestis. The dual presence of a Fallopian tube and a vas deferens on the side of the ovotestis is documented as a previously unreported finding.

47,XXX chromosome constitution, ovarian dysgenesis, and genito-urinary malformation

We describe the second known reported fetus with 47,XXX chromosome constitution and ovarian dysgenesis, in this instance with an unusual urinary tract malformation, nonimmune fetal ascites and meconium peritonitis.

Persistent müllerian duct syndrome in a man with transverse testicular ectopia

A 33-year-old Pakistani man with transverse testicular ectopia underwent surgery for repair of a left inguinal hernia. At operation a uterine structure with attached vasa deferentia was found in the left inguinal area and it was removed. Transverse testicular ectopia has been reported previously in association with the persistent müllerian duct syndrome. A deficiency of activity of a müllerian inhibiting substance during gestation is believed to be responsible for this syndrome. Most patients usually are sterile. Cloning of the gene for a müllerian inhibiting substance should permit studies of the pathogenesis of the persistent müllerian duct syndrome.

Female external genitalia and müllerian duct derivatives in a 46,XY infant with the smith-lemli-Opitz syndrome

We report on a 46,XY newborn infant with Smith-Lemli-Opitz (SLO) syndrome with female external genitalia, intraabdominal testes with epididymides and deferent ducts and a normally shaped uterus and vagina. Polydactyly, cleft palate, and several internal organ malformations were also present, and the patient died shortly after birth. Data on six reported male infants with SLO syndrome and female external genitalia suggest a correlation between degree of genital involvement and overall degree of severity. Scoring systems to quantify overall degree of severity (SLO score) and degree of genital involvement in males (genital score) were devised and applied to 122 reported cases from the literature. Statistical analyses showed a unimodal distribution of the SLO severity scores, and positive correlations between the SLO score and the genital score in males, the presence of polydactyly, and the presence of cleft palate. In 19 multiplex families the affected sibs were generally similar in their SLO scores. The above analyses suggest that the wide phenotypic variability in the SLO syndrome is determined by variable expressivity of the same entity as opposed to genetic heterogeneity. The observed phenotypic correlations naturally determine that males with complete feminization are among the more severe patients and tend to have polydactyly and cleft palate.

Pseudocysts of the tunica albuginea: benign invasion by testicular tubules

We describe a patient undergoing exploration for an epididymectomy in whom a unique apparently multicystic lesion of the testis resulted in orchiectomy. On microscopic examination the lesion was proved to be a benign, previously unreported condition wherein the tunica albuginea was split by an invasion of testicular tubules. We postulate that this condition is a developmental anomaly.

Non-mosaic isodicentric X-chromosome in a patient with secondary amenorrhea

An isodicentric X-chromosome idic(X) (pter----q26.1::q26.1----pter) was found in lymphocytes and ovarian tissue of a 40-year-old female patient with secondary amenorrhea. No mosaicism was observed. The phenotype-karyotype correlation of our case and of previously described non-mosaic cases of idic(X) (q::q) with different breakpoints is discussed.

Phenotypic spectrum of 45,X/46,XY individuals

We report on five patients with 45,X/46,XY mosaicism. In these subjects, as well as in 58 individuals from the literature with a similar chromosome constitution, we did not find a preponderance of 46,XY cells among patients showing ambiguous to abnormal male external genitalia when compared to those patients with slight or no virilization. However, the average frequency of 46,XY cells in blood in these mosaic individuals suggests that this sample includes mainly individuals whose mosaicism originated early in embryonic cell division. Those individuals whose mosaicism originated later are not significantly represented in this sample and would have higher frequencies of 46,XY cells. These individuals would be excluded from an intersex sample if they had well-virilized genitalia. This ascertainment bias suggests that the degree of virilization depends on the frequency of 46,XY cells.

Hyperplasia of spermatic cord nerves: a sign of testicular absence

The comparative histologic study of the spermatic cord in the absence of testis, epididymis-testis separation, and normal development of both testis and epididymis, revealed that there is nerve trunk hyperplasia and hypertrophy in absence of the testis. This finding may greatly aid the diagnosis of testicular absence in the management of impalpable testes.

Dysgenetic male pseudohermaphroditism in a 45,X/46,X,del(Y)(q11.1) mosaic infant

We describe an infant with dysgenetic male pseudohermaphroditism and the karyotype 45,X/46,X,del(Y)(q11.1). Histologic examination of the resected gonads showed cortical dysplasia indicative of incipient gonadoblastoma.

Morphotypic aspects in the cryptorchidic child

The morphotype of 40 children with cryptorchidism (18 bilateral, 22 unilateral), selected by complex endocrine examination, was assessed in relation to age and clinical form of cryptorchidism. The morphotype was established on the basis of 9 anthropometric parameters (weight, stature, pube-ground distance, a-a, thr-thr, thoracic, abdominal, hips and cephalic circumferences). The malformed lot consists of 28 children with common and 12 with symptome cryptorchidism (5 adiposogenital, 3 male Turner's syndrome and 3 with gonadal dysgenesis). In the child with symptom cryptorchidism, the morphogram reveals, irrespective of age, a morphotype which corresponds in point of absolute dimensions and proportions, to the somatotype in which cryptorchidism as a symptome is included. The child with common cryptorchidism has irrespective of age, a normal or short stature and is underweight. Compared to the stature, the head is small, the lower limbs are short, the trunk is long and the hips are well developed. In our series of common cryptorchid child, the most marked statural deficit was found between 11 and 15 years as well as under the age of 6.

Is true hermaphroditism a primary germ cell disorder?

Eleven cases of true hermaphroditism, 6 raised as female and 5 as male, were seen in the 20-year period from 1965 to 1985. External genitalia varied from Prader types II to IV. The ovotestis (11/22) was the most common gonad, and a marked variation in macroscopic and microscopic appearances with five patterns of distribution of gonadal tissue was noted. Ovulation was observed in ovarian tissue, and spermatogonia, but no spermatozoa, in testicular tubules. A hypothesis is developed suggesting abnormal testicular differentiation, and a model is presented to explain observed patterns of gonadal tissue distribution. A uterus was present in all cases, but a hemiuterus or lateralized uterus was noted in the 5 cases in which only testicular or predominantly testicular tissue was observed on the contralateral side. Karyotype analysis showed 46 XX in 5 cases (1 with an H-Y antigen) and a mosaic involving 46 XY in the remaining 5. Spontaneous puberty was achieved in 3 of the females, and of the 4 males with residual testicular tissue, all are prepubertal.

Gonadoblastoma: unusual presentation in a patient lacking persistent müllerian ducts

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.

[Characteristics of the morphology and mitotic condensation of human Y chromosomes with structural rearrangements]

Parameters of the length and mitotic condensation were investigated in the following cases of Y-chromosome aberrations: isodicentric Y(q), Y-chromosome without heterochromatic block, and Y-chromosome with satellites. In the Ydic we revealed some differences between f-block, that is located near the inactive kinetochore, and the block near the active centromere. Satellites exert no influence on the mitotic function of Y chromosome, presumably owing to the presence of C-heterochromatic material. With the absence of heterochromatic region, a decline in condensation of the non-fluorescent segment was observed in addition to a simultaneous increase in its length. The mechanism of functioning of the structural heterochromatin is discussed.

Large prostatic utricles and related structures, urogenital sinus and other forms of urethrovaginal confluence

The urethrograms and clinical records of 106 children with a large prostatic utricle or related structures, urogenital sinus in intersex disorders and other types of urethrovaginal confluence were reviewed. There were 27 boys with normal external genitalia, 19 cases of male hypospadias, 1 case of male pseudohermaphroditism, 7 cases of mixed gonadal dysgenesis, 1 case of true hermaphroditism, 32 cases of female pseudohermaphroditism, 11 normal girls with urethrovaginal confluence and 8 cases of cloacal malformation. Among the patients of the first 2 groups 10 had an imperforate anus, 7 the prune belly syndrome, 6 Down's syndrome and 2 posterior urethral valves.

Spleno-gonadal fusion: anatomic and angiographic study of a case

The authors report a case of spleno-gonadal fusion in which the advantage of an angiographic study permitted, for the first time, an analysis of the vascularization of this malformation. The embryologic study explains the malformations associated with the continuous type of spleno-gonadal fusion.

Purported absence of the testis following surgical exploration: the need for further investigation

Two cases of purported absence of the testes following extensive surgical exploration are reported. On subsequent investigation both boys were found to have testes. It is recommended that when confronted with a patient with a similar history the operative record should be studied and the original surgeon should be contacted to ascertain that either a testis was removed or bind-ending internal spermatic vessels were found. If proper documentation is not available, further evaluation should be done.

XO syndrome in the mare

Only one X chromosome was found in each of the lymphocyte metaphases studied in an infertile mare. Karyotype analysis was made with the CBG and GTG banding techniques. The most obvious clinical abnormality was gonadal hypoplasia.

Nonneoplastic gonadal testosterone secretion as a cause of vaginal cell maturation in streak gonad syndrome

Endocrine studies were carried out on 3 patients with streak gonad syndrome, 2 of whom had slight proliferative vaginal smear patterns, and the 3rd had slight hirsutism with increased muscle mass but an atrophic type vaginal smear pattern. Simultaneous sampling of peripheral, adrenal and streak gonadal venous blood revealed mildly increased testosterone secretion by the streaks in the 2 patients who had proliferative cytohormonal patterns. Histologic examination of their streak gonads showed hilus cell hyperplasia. It might be suggested that hilus cell hyperplasia was the source of the increased testosterone secretion in these 2 patients and thus resulted in slight maturation of the vaginal epithelium.

The spectrum of splenogonadal fusion. Case report and review of 84 reported cases

Splenogonadal fusion is a rare congenital malformation in which there is an abnormal fusion between the spleen and the gonad or derivatives of the mesonephros. It can occur in both sexes but has been reported far more frequently in males. There are two types of this malformation: the continuous and the discontinuous type, depending on the presence or absence of a structural connection between the regular spleen and the ectopic splenic tissue that is fused to the gonad. In one-third of all reported cases splenogonadal fusion is associated with other congenital defects. This association is predominantly found within the continuous type. Peromelia is present in a high percentage of cases, varying from total absence of all limbs to absence of parts of the lower limbs. On the basis of a case report and a review of 84 published cases, the causal, pathogenetic and nosologic aspects of this malformation are discussed. We hypothesise that splenogonadal fusion with peromelia and splenogonadal fusion without peromelia represent two ends of one spectrum determined by the developmental stage during which the causal factor acts.

Juvenile granulosa cell tumor--another neoplasm associated with abnormal chromosomes and ambiguous genitalia. A report of three cases

Three infants, 3 months of age or younger with abnormal karyotypes and ambiguous genitalia, had gonadal juvenile granulosa cell tumors. Two of the patients had mixed gonadal dysgenesis and the third had an intersexual disorder of undetermined type. Two tumors arose in undescended testes, and the third in an undescended gonad of uncertain nature. The occurrence of this uncommon neoplasm in these infants indicates that it is another type of neoplasm that may develop in the gonad of a patient with an abnormal karyotype and ambiguous genitalia.

Unusual cause of short stature

A 24-year-old man evaluated for paresthesias and short stature was found to be hypocalcemic on initial presentation. Further evaluation showed that he had a low-normal parathormone level by amino-terminal assay, medullary stenosis of the long bones, and multiple ophthalmologic abnormalities. The remainder of his pituitary function, including growth hormone response to insulin-induced hypoglycemia, was normal. As no family history of similar findings was evident, a sporadic case of Kenny's or Kenny-Caffey syndrome was diagnosed. He became normocalcemic in response to vitamin D and calcium carbonate therapy. The results of testing in this patient and the findings in other patients previously described with the Kenny-Caffey syndrome are reviewed.

H-Y antigen in a 46,XX female with dysgenetic ovaries

Hypogonadism secondary to ovarian dysgenesis or resistant ovary syndrome was diagnosed in a 19-yr-old obese woman with primary amenorrhea, a 46,XX karyotype, and an H-Y+ cellular phenotype. Small ovoid gonads (1.5 X 0.6 cm) were found found bilaterally; these were encased in a dense venous network. The stroma was ovarian, and primordial follicles and some primary follicles were present, but there were no follicles at or beyond the antrum stage. There was no evidence of testicular tissue and no evidence of malignancy. Analysis of serological data indicated the possibility of residual H-Y antigen in the blood cells of the mother.

Coexistence of gonadal dysgenesis and uterine aplasia. A case report

A 16-year-old woman who presented with amenorrhea had absence of the uterus, a normal vagina and gonadal dysgenesis.

Carcinoma in situ of the testis in children with 45,X/46,XY gonadal dysgenesis

The frequency of gonadal tumors in intersex patients with a karyotype including a Y chromosome is very high. In other at-risk groups, testicular germ cell tumors have been shown to be preceded by carcinoma in situ (CIS) changes. We investigated gonadal tissue from four children, aged 1 month to 18 years, with 45,X/46,XY gonadal dysgenesis, and with male or ambiguous genitalia, for the presence of CIS germ cells. Twelve gonadal biopsies and gonadectomy specimens were analyzed by means of conventional histology and densitometric DNA measurements. CIS changes were detected in specimens from all four patients, and aneuploid DNA distributions of the CIS germ cells confirmed the malignant potential of these cells. In one case, electron microscopic analysis revealed the same ultrastructural features of the CIS germ cells as previously described in seminoma cells. These observations indicate that in all patients with 45,X/46XY gonadal dysgenesis and a male phenotype, gonadal biopsies should be considered as soon as the syndrome is diagnosed. We believe that the finding of CIS warrants gonadectomy.

[Mixed gonadal dysgenesis. Apropos of a series of 21 cases]

Twenty-one cases of mixed gonadal dysgenesis referred at age 1 to 16 years are studied. External genitalia were in most cases of types III-IV, with a small penis and posterior hypospadias, asymmetrical genital folds containing an externalized testis on one side. The internal genitalia varied according to the degree of dysgenesis of the gonads, and included an uterus and/or a vagina in 18 among the 21 cases. A chromosomal mosaicism XO/XY or XX/XY was found in 11 patients, the other 10 having a normal 46 XY caryotype. Pubertal follow-up was obtained in 10 cases, and showed always a male sexual development, without possibility to exactly evaluate the function of the testis. Choosing the sex assignment is relatively easy in newborns or infants with mixed gonadal dysgenesis. It relies more on anatomy (size of corpora cavernosa, feasibility of urethroplasty or vaginoplasty) than on the results of hormonal measurements. The presence of an Y chromosome is not by itself an argument to choose the male sex. In most cases, the choice of the female sex is the easiest and relies on strong clinical arguments, but it leads unavoidably to suppress both the testis and the dysgenetic gonad.

Chromosomal complements in primary gonadal failure

Twenty-nine patients underwent clinical, hormonal, endoscopic, and cytogenetic studies to determine the cause of primary amenorrhea or delayed sexual development. In 19 of them (mean age 17.6 years), the X chromosome was either missing or anomalous. In ten patients (mean age 25.5 years), the chromosomal complement was normal, 46 XX in six patients and 46 XY in four patients. Those with abnormal chromosomal complements were shorter (mean height, 141.9 cm) than patients with normal complements (158.7 cm). Somatic stigmas were observed more frequently in patients with chromosomally abnormal primary gonadal failure. In 23 patients (79.3%), the gonads were streaks, with fibrous stroma devoid of either follicles or tubules containing germ cells. In three patients the ovaries were hypoplastic, with few primordial follicles. Gonadoblastoma was present in two patients with XY and mixed XX/X/XY gonadal dysgenesis. In every patient with streak gonads and lack of germ cells, serum gonadotropin levels were elevated. Karyotype, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) assays, and eventually laparoscopy and gonadal biopsy are important in the management of patients with primary gonadal failure.

[Testicular tumors in male pseudohermaphroditism]

The data are summarized on the incidence and morphofunctional characteristics of gonadal tumors in different varieties of false male hermaphroditism, namely the testicular feminization syndrome (marked and unmarked forms), demonstrable masculinization and dysgenesis and compared with the disease clinical manifestations. The two syndromes--testicular feminization (marked form) and dysgenesis were found to be associated with a high risk of cancer development. In the first case there develop sertolioma-like tumors and in the second one, tumors similar to gonocytoma and dysgerminoma. These tumors became malignant in rare cases, they did not recur or metastasize. The treatment schedule for such patients has been developed. It includes the removal of the tumor-affected gonads and transfer of the tumor-free gonads into subcutaneous abdominal or scrotal areas and administration (during castration) of continuous substitution hormonotherapy according to the sex chosen.

Estradiol benzoate treatment of an XY gonadal dysgenetic chacma baboon

Behavioral studies of an XY gonadal dysgenetic chacma baboon under estradiol benzoate treatment were carried out. The dysgenetic individual and two ovariectomized conspecific control females were given a total of three testing series. The dysgenetic individual showed progressive success in her sexual interactions with her male partners and during her third testing series she was copulated with to ejaculation by five of the eight male partners. This study provides the first supportive evidence from a nonhuman primate for the predicted development of female sexual behavior in a genetic male deprived of testes prior to the sensitive period for sexual differentiation.

Gonadal and müllerian duct agenesis in a girl with 46,X,i(Xq)

A unique case of gonadal agenesis and rudimentary müllerian duct development in association with a 46,X,i(Xq) karyotype is reported. The patient presented with short stature and subtle features of Turner syndrome. Endocrine evaluation revealed elevated gonadotropins and cytogenetic findings from both peripheral blood leukocytes and skin fibroblasts were consistent with a 46,X,i(Xq) karyotype. Laparoscopy revealed both uterus and gonads to be absent. Developmental failure of the müllerian system in association with gonadal agenesis in a patient with 46,X,i(Xq) has not been previously reported. The basis for müllerian duct regression in this patient remains unclear. Recommendations for treatment are made.

Leydig cell types in primary testicular disorders

Ultrastructural study of testicular biopsy specimens from 67 adults with primary testicular disorders (Klinefelter's syndrome, XX male syndrome, Del Castillo's syndrome, and cryptorchidism) revealed the following four Leydig cell types: 1) normal or nearly normal Leydig cells with abundant smooth endoplasmic reticulum, mitochondria with tubular cristae, lipid droplets, and Reinke's crystals; 2) abnormally differentiated Leydig cells without either lipid droplets or Reinke's crystals but with altered mitochondria, concentric unfenestrated cisternae of smooth endoplasmic reticulum, and both paracrystalline and filamentous inclusions; 3) multivacuolated Leydig cells containing abundant lipid droplets; and 4) immature Leydig cells with scarce development of the smooth endoplasmic reticulum and mitochondria, and numerous cytoplasmic microfilaments. Abnormally differentiated Leydig cells might represent dysgenetic cells, whereas immature, normal, and vacuolated Leydig cells might represent three progressive stages in the Leydig cell cycle (undifferentiated, mature, and old involuting Leydig cells). An inverse correlation between the proportion of abnormal Leydig cells and testosterone levels was observed in each of these testicular disorders.

Case report of dysgerminoma in a patient with 46,XX pure gonadal dysgenesis

A clinicopathological study of a 42-year-old female with pure gonadal dysgenesis and dysgerminoma was made. At the age of 29, the patient with primary amenorrhea had been evaluated clinically and cytogenetically. (1) The results of cytogenetic studies were X-chromatin positive and revealed a karyotype in peripheral blood leukocytes of 46,XX. (2) Laboratory studies indicated hypergonadotropic hypogonadism and no response of the gonads to the human menopausal gonadotropin stimulation test. (3) At laparotomy, the gonads were streak-like. Pathological examinations of biopsy specimens from both gonads revealed dense, fibrous connective tissue resembling ovarian stroma and no primary follicles. Eleven years after the laparotomy, the patient complained of lower abdominal distention and severe pain, and laparotomy then revealed a 15 X 17-cm right solid adnexal mass occupying the pelvic cavity. The histological diagnosis of tissues from the partially removed tumor was pure dysgerminoma. Second-look operation after Linac X-ray irradiation showed complete remission of the residual tumor. Insofar as we are aware, the present patient represents the first case of dysgerminoma which occurred in the dysgenetic gonads of a phenotypic female with normal 46,XX sex-chromosomal constitutions in peripheral blood leukocytes and the skin fibroblasts although a possibility exists that mosaicism was possibly present but undetected, particularly since the streak gonads were not analyzed chromosomally.