Gonadoblastoma: ultrastructural evidence for testicular origin

Seminoma with focal gonadoblastoma in anatomically normal male: A rare case report

Gonadoblastomas are unusual gonadal neoplasias that frequently appear in dysgenetic gonads. Approximately 80% of patients are phenotypic females and 20% are males. A very high frequency is associated with malignant germ cell tumor. We present a case of 37-year-old normal fertile man with descended testis who presented with swelling and pain in left testis since 6 months. On examination, left testis was swollen, hard, and tender. Ultrasound examination of left testis showed hypoechoic lesion neoplastic with multiple enlarged lymph nodes in pre- and para-aortic region. After high left inguinal orchidectomy, histopathology of specimen showed tumor tissue composed of cells arranged in large nests separated by fibrous stroma infiltrated by lymphocytes with focal area showing nests of cells with vesicular nucleus and moderate amount of eosinophilic cytoplasm with eosinophilic material which was calcified, suggestive of seminoma testis with focal area of gonadoblastoma.

Gonadoblastoma: an immunohistochemical study and comparison to Sertoli cell nodule with intratubular germ cell neoplasia, with pathogenetic implications

AIMS

To investigate the immunohistochemical properties of the sex cord cells of gonadoblastoma and Sertoli cell nodule with intratubular germ cell neoplasia unclassified (IGCNU) as a means of objective distinction and to provide insight into the pathogenesis.

METHODS AND RESULTS

Immunohistochemical stains for SOX9, FoxL2 and SF-1 were performed on 10 gonadoblastomas (all phenotypical females) and 14 Sertoli cell nodules with IGCNU in normal phenotypical males with coexisting germ cell tumours. The sex cord cells of gonadoblastomas showed strong, diffuse FoxL2 and SF-1 positivity and focal weak to moderate SOX9 reactivity, whereas those of Sertoli cell nodules with IGCNU were uniformly, strongly positive for SOX9 and SF-1, while negative for FoxL2.

CONCLUSIONS

Coexpression of SOX9 and FoxL2 in the sex cord cells of gonadoblastomas provides evidence that these morphologically ambiguous sex cord cells are incompletely differentiated. The strong, diffuse SOX9 and SF-1 positivity and absence of FoxL2 reactivity in the Sertoli cell nodules with IGNCU support full Sertoli cell differentiation of the sex cord cells and distinguish them from gonadoblastomas. Deficient SOX9 expression in gonadoblastoma supports a current model of pathogenesis where immature germ cells, in the absence of well-formed Sertoli cells, retain a fetal phenotype and susceptibility to malignant transformation.

Clinical pathologic correlation: primary amenorrhoea and bilateral adnexal tumors

A case of bilateral gonadoblastoma in 46,XY gonadal dysgenesis is presented and discussed by both clinician and pathologist, in this traditional clinico-pathologic conference. The discussion includes the differential diagnoses of primary amenorrhoea.

False-positive pregnancy test associated with gonadoblastoma

Gonadoblastomas are known to be hormonally active tumors that occur in streak or dysgenetic gonads of patients with intersex abnormalities. Several reports document their ability to produce beta-human chorionic gonadotropin (HCG), but none have documented an elevated peripheral serum beta-HCG. We report on the case of a patient with pure gonadal dysgenesis with XY karyotype who was found to have an elevated peripheral serum beta-HCG after a positive pregnancy test. Knowledge of gonadoblastoma's potential to elevate serum beta-HCG levels may prevent unnecessary searches for other causes.

Ovarian sex cord-stromal tumours in cattle, with particular reference to the lamination of basal laminae

Three cases of bovine sex cord-stromal tumours, including a sex cord tumour with annular tubules and two granulosa cell tumours, are described. These tumours had tubular structures and hyaline or eosinophilic bodies, composed of multilayered basal laminae. The present study suggests that bovine granulosa cell tumours of the ovary are able to show morphology similar to that of Sertoli cell tumours of the testis and that sex cord tumours with annular tubules arise from granulosa cells but indicate Sertoli cell differentiation.

Abnormal sexual differentiation and neoplasia

The prevalence of neoplasia is increased in individuals with certain disorders of sexual differentiation. Etiology and frequency of neoplasia vary with the particular disorder. In uncomplicated cryptorchidism, the testis is at least 10 times more likely to undergo neoplastic transformation than a normal scrotal testis. Neoplasia probably is a function of both testicular location (intraabdominal) and underlying dysgenetic structure. If cryptorchidism is unilateral, and if orchiopexy has not been performed prior to age 6-10 years, orchiectomy should be encouraged. In those forms of gonadal dysgenesis not associated with a Y chromosome (e.g., 45,X; 45,X/46,XX; 46,XX) there is no definite increase in neoplasia, suggesting that elevated gonadotropin levels per se are not carcinogenic. Gonadal tumors are found in at least 30% of individuals with XY gonadal dysgenesis and are particularly frequent (55%) in H-Y antigen-positive patients. These tumors are almost always gonadoblastomas or dysgerminomas. Similar tumors are found in 15%-20% of 45,X/46,XY individuals. In either situation the neoplastic transformation could be a) secondary to the existence of XY gonadal tissue in an inhospitable environment, or b) integrally related to that process--genetic or cytogenetic--producing the dysgenetic gonads. The risk of neoplasia is sufficiently high that most of these patients should be offered early gonadal extirpation. The prevalence of gonadal tumors is not increased in Klinefelter's syndrome, further indicating that gonadotropins are not carcinogenic per se. However, Klinefelter patients are 20 times more likely to develop a carcinoma of the breast than are 46,XY males. Extragonadal germ cell tumors also are more common. In female pseudohermaphrodites there is probably no increased risk of neoplasia, whereas, in true hermaphrodites neoplasia is unusual but does occur. Neoplasia occurs in patients with complete testicular feminization (complete androgen insensitivity) but rarely in those with incomplete testicular feminization/Reifenstein's syndrome, 5 alpha-reductase deficiency, anorchia, agonadia, or testosterone biosynthetic defects. In complete testicular feminization the risk of malignant tumors is small prior to age 25. After age 25, it is about 2%-5%. Orchiectomy is recommended after pubertal feminization.

Ovarian sex cord tumor with annular tubules

A pathologic study was done on four cases of ovarian sex cord tumor with annular tubules. All four tumors occurred in young women (11-24 years of age) and were not associated with the Peutz-Jeghers syndrome. Two patients had evidence of hyperestrinism. One patient who had metastasis to the retroperitoneum, left supraclavicular lymph node, and liver confirmed the malignant potential of this tumor. Gross examination revealed tumors that were solid, yellowish, and unilateral, with varying degrees of cystic degeneration. Microscopic examination showed simple or complex annular tubules with prominent basement membranes. Many tumor cells contained lipid in the cytoplasm. Ultrastructural study showed Charcot-Bottcher filaments in all four cases, indicating Sertoli cell differentiation. True lumens and microvilli were identified in one case. The classification of the sex cord tumor with annular tubules as a Sertoli cell tumor, annular tubular type was proposed on the basis of ultrastructural findings.

An ovarian regression syndrome in the platyfish, Xiphophorus maculatus

The highly inbred Coatzacoalcos (Cp) strain of the platyfish, Xiphophorus maculatus, was noted for a high percentage of infertile females (XX). The ovaries of approximately one-quarter of all females regress. The time of gonadal atrophy varied from before sexual maturation up to 11 months of age. The gonadotropic zone of the pituitary was hypertrophied in regressed females. Transplants of immature testes and ovarian tissue into the caudal musculature of regressed females and the subsequent maturation of the grafts demonstrated that the ovarian degeneration was not due to pituitary or hypothalamic malfunction or an autoimmune disease. The cause of the gonadal degeneration was apparently localized to the ovary itself. This phenomenon was never observed in males (XY). Regressed ovaries fell into two categories, designated types I and II, with all being characterized by the presence of ductlike structures which resembled male efferent ducts, lined by Sertoli cells. Type I ovaries bore a marked similarity to certain mammalian dysgenetic gonads, while type II ovaries contained many proliferating germ cells and could be compared to the human neoplasm termed gonadoblastoma. It is suggested that the physiological lesion responsible for the ovarian regression syndrome involves the processes that control the determination and differentiation of the germ cells similar to those found in human 46,XY gonadal dysgenesis.

Large cell calcifying Sertoli tumor of the testis. Light microscopic and ultrastructural study

Large cell calcifying Sertoli tumor of the testis was found in a 16-year-old boy who had presented with gynecomastia. Serum estrogen level, which had been elevated preoperatively, returned to normal following orchiectomy. Charcot-Bottcher crystalloids are demonstrated in the neoplastic Sertoli cells.

Gonadal tumors in patients with gonadal dysgenesis and sex chromosomal rings and fragments

Patients with female phenotypes and dysgenetic gonads harboring testicular tissue have a markedly increased risk of developing gonadal tumors. Cytogenetic demonstration of Y chromatin is the currently accepted criterion for performing prophylactic gonadectomies in these women. We studied four patients with dysgenetic gonads containing either testicular tissue or germ cell tumors. All had small sex chromosomal fragments which could not be characterized by conventional cytogenetic studies. Clinical features, DNA replication studies, and immunologic assays of Xga and H-Y antigens failed to correlate consistently with the gonadal histology. We recommend prophylactic gonadectomies and subsequent hormone replacement in all patients with female phenotypes, gonadal dysgenesis, and cytogenetically indeterminate sex chromosomal fragments.

Invasive dysgerminoma in a girl with 45,X/46,X; mar mosaicism

We report a 16-year-old girl with features of Turner's syndrome from whom an invasive dysgerminoma was removed. Cytotoxic drugs were given for the next 12 months. Mosaicism of two karyotypes (45,X/46,X; mar) was found in various tissues. The literature is reviewed with special regard to cytogenetic findings and prognosis of malignant growth and differentiation of dysgenetic gonads.

Gynandroblastoma: its ultrastructure

Gynandroblastoma is a rare, sex-cord stromal tumor of the ovary that shows morphologic evidence of female and male differentiation. Such a tumor produced masculinization in a 24-year-old woman, whose symptoms disappeared following removal of the tumor. By electron microscopy, the granulosa cell nests displayed Call-Exner (CE) bodies of the hyaline type composed of multiple layers of basal lamina resembling CE bodies of the normal graafian follicle. In contrast, CE bodies of a classic granulosa theca cell tumor were of the spongiform type, consisting of a space limited by a single basal lamina containing altered granulosa cells and cell processes. Both types of CE bodies are believed to arise following secretion by and/or degeneration of granulosa cells, the variation in morphology between the two resulting from differences in amounts of basal lamina deposited. The tubular components of the tumor resembled more closely the rete ovarii than did Sertoli cells, and its proposed that such structures be called by the alternate and less specific term "androblastoma." The identity of Leydig cells was established by demonstrated of intracytoplasmic Reinke crystals. Despite a difference in architectural pattern, there was a close ultrastructural resemblance between the different sex-cord components of the gynandroblastoma.

Crystals in a gastric schwannoma

A gastric schwannoma containing large numbers of intracytoplasmic crystals is described. The latter are compared with intracytoplasmic crystals found in the cells of other tumors and their nonneoplastic cell counterparts. The extreme morphologic and histochemical heterogeneity of the different types of crystals is emphasized.

Sertoli tumors of the ovary. A clinicopathologic study of 28 cases with ultrastructural observations

The clinical and pathologic features of 28 Sertoli tumors of the ovary are presented. Seventeen of the 18 neoplasms had a functional effect. The effects were hyperestrinism (eight women), isosexual precocious puberty (three girls), virilization (four women), a progestational decidual reaction on the peritoneum (one woman), and a combination of virilizing and estrinizing signs (one woman). There were three histologic patterns: simple tubular, complex tubular, and folliculome lipidique. Two neoplasms recurred, both of which had the distinctive feature of invasion of the supporting stroma by individual and columns of tumor cells in the original tumors. Electron microscopic evaluation of three neoplasms disclosed. Charcot-Böttcher filaments unequivocally identifying the Sertoli differentiation of the predominant cells in the neoplasm. The identification by electron microscopy of a smaller population of cells within the three tumors similar to typical ovarian stromal cells suggests that Sertoli tumors arise from ovarian stromal cells.

Microscopic gonadoblastoma in dysgenetic gonad of an infant: an ultrastructural study

A microscopic gonadoblastoma found in the dysgenetic gonad of a six-month-old phenotypic female with a 46,XY genotype was studied with the electron microscope and compared with the cells from the testicular portion of the contralateral gonad. The germ cells within the tumor resembled the testicular germ cells and were not different from previously described germ cells in other gonadoblastomas of postpubertal patients. The sex cord cells of the present tumor were inactive and immature, but differed from the Sertoli cells of the patient's testis. The presence of hyalin globules and Call-Exner bodies in the epithelial tumor nests, coupled with the ultrastructural appearance of the sex cord cells is more consistent with them being immature granulosa rather than Sertoli cells. The immaturity of the sex cord cells in gonadoblastoma of this infant suggest that they are responsive to normal regulatory hormonal influences.

H-Y antigen in Swyer syndrome and the genetics of XY gonadal dysgenesis

The H-Y antigen is a plasma membrane antigen involved in the organogenesis of the mammalian testis. Its expression on human cells is determined by a Y-linked gene. Phenotypic females affected by 46,XY gonadal dysgenesis (Swyer's syndrome) can be either H-Y-positive or H-Y-negative. In this paper we report H-Y antigen and endocrine studies in a sibship with three affected sisters. Immunological studies were performed on two of the patients, and a clearly positive expression was detected in both cases. Endocrine studies consisted in the investigation of the hypothalamic-pituitary-gonadal axis, which revealed that gonadal hormone insufficiency is the only endocrine abnormality associated with the syndrome. A new genetic interpretation and calssification of XY gonadal dysgenesis is proposed.

True hermaphrodite with multiple gonadal neoplasms: report of a case with cytogenetic study

On account of the functioning bigonads, true hermaphrodites show a wide range of morphological anomalies. The patient under discussion had an ovary on one side and an ovotestis on the other side; both of them functioned to some extent to produce a rudimentary uterus, fallopian tubes and a few Woolfian remnants. The additional point of interest in this report was the presence of three gonadal neoplasms-namely Yolk Sac Carcinoma gonadoblastoma and seminoma. While the ovary on one side was replaced by yolk sac carcinoma, the ovotestis was partly destroyed by the other two. The cytogenetic study revealed a hypodiploid number and a mosaic sex chromosomal pattern. The karyotypic abnormalities noticed in the patient are also reviewed.

Seminoma in a 12-year-old male with 46 XY/45 XO karyotype

A pure seminoma in a 12-year-old boy with an undescended testis and 46 XY/45 XO karyotype is presented. The relationships between an undescended testis, an abnormal karyotype, dysgenetic gonads and cancer are discussed.

Lipid cell tumor of the ovary: an ultrastructural study

An ovarian lipid cell tumor without Reinke's crystalloids in a woman with secondary amenorrhea, minimal hirsutism, and elevated 17-ketosteroid excretion was studied by light and electron microscopy. Tumor cells were found in small clumps or scattered singly within a collagenous matrix. The cytoplasm of the tumor cells contained abundant smooth endoplasmic reticula, numerous mitochondria with tubular cristae, lipid droplets, lysosomal dense bodies, and concentric membranous whorls, characteristic of steroidogenic cells. In addition, "peripheral canalicular systems" were found at the outer margins of the nests of the tumor cells. These "peripheral canalicular systems" were bordered by the cell membranes and the surrounding collagenous stroma into which microvilli projected. Since the intercellular canalicular system present between the tumor cells was continuous with the "peripheral canalicular system," both systems probably have a common function related to steroid metabolism. The intercellular and "peripheral" canalicular systems and cytoplasmic microfilaments found in this tumor suggest that this ovarian lipid cell tumor was derived from the ovarian stroma.

Clinical, pathologic, and genetic findings in a case of 46,XY pure gonadal dysgenesis (Swyer's syndrome)

Cytogenetic, pathologic, and clinical studies were conducted on a phenotypically female patient with primary amenorrhea and infertility. Analysis of blood cultures with routine and Giemsa-banded preparations indicated that the chromosomal complement of the patient was 46,XY. Buccal and peripheral blood smears prepared for fluorescent analyses confirmed the presence of a single F-body (Y chromosome). Pathologic examination of tissues removed at total hysterectomy and bilateral salpingo-oophorectomy revealed a gonadoblastoma of the right gonad, dysgerminoma of the left gonad, and an infantile hypoplastic uterus. The data were consistent with a diagnosis of 46,XY pure gonadal dysgenesis (Swyer's syndrome).