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

Seminoma in a Male Phenotype 46XX True Hermaphrodite

Although true hermaphrodite is uncommon, it has been reported in more than 400 individuals. Tumours arising in the gonads of true hermaphrodite is a very rare finding and only very few cases have been reported in the literature. We report a case of a 35-year-old phenotype man with bilateral undescended testis with lump hypogastrium. On examination, he had an ovotestis on one side and pure seminoma arising in testis on the other side. The seminoma arising in the left undescended testis was successfully treated by excision and combination chemotherapy. Cytogenetic studies revealed that 46XX karyotype with primer specific for the sex-determining region of the Y chromosome was negative. The karyotypic abnormality noticed in the patient is also reviewed in the article.

Crossed ectopia of ovotestis in a case of true hermaphroditism

True hermaphroditism is a rare form of intersex disorder. The authors report a case of true hermaphroditism with crossed ectopia of an ovotestis from the left to the right scrotum. The karyotype of the patient was 46,XX, without mosaicism. The majority of the ovotestis was comprised of testicular tissue. In other cases of human true hermaphroditism, descent of a pure ovary has not been noted to occur, despite the presence of the contralateral testis. Additionally, in congenital adrenal hyperplasia occurring in genotypic female subjects, pure ovaries do not descend into the scrotum despite the high level of androgens. Taken together, we believe that the demonstrated descent of mostly testicular ovotestes supports the idea that the testis produces a substance other than androgen that is important in guiding its descent.

True hermaphrodite with bilateral ovotestes, bilateral gonadoblastomas and dysgerminomas, 46,XX/46,XY karyotype, and a successful pregnancy

The first case (to the authors' knowledge) is reported of a true hermaphrodite with bilateral ovotestes, bilateral gonadoblastomas and dysgerminomas, a 46, XX/46,XY karyotype, and a successful pregnancy. The true hermaphroditism was diagnosed during infancy. The patient was subsequently found to have a gonadoblastoma and a microscopic dysgerminoma in the gonad diagnosed as an ovotestis and excised during infancy. The successful pregnancy occurred when the patient was 29 years old. A year later a large gonadal tumor affecting the remaining gonad was excised. The gonad was found to be an ovotestis, and the tumor was a dysgerminoma arising from a gonadoblastoma. This case further emphasizes the malignant potential of the Y chromosome in patients with abnormal gonads.

Epithelial ovarian tumor in a phenotypic male

Laparotomy in a 41-year-old married man with non-treated left cryptorchidism revealed female internal genitals on the left side, and an epithelial ovarian tumor of intermediate malignancy. Germinal malignancies are frequent in intersexes, but non-germinal gonadal neoplasms are rare. This is the second reported case of epithelial ovarian tumor in intersexes, and the first case of epithelial ovarian tumor in an intersex registered as male.

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.

Seminoma in a 46,XX true hermaphrodite with positive H-Y antigen. A case report

This case study represents the first report of a 46,XX phenotypic male true hermaphrodite with a pure seminoma. Serologic testing of tissue demonstrated the presence of the H-Y antigen. This finding supports the theory that the H-Y gene is essential for primary sex determination and raises the possibility that it may also be the specific factor responsible for malignant degeneration of dysgenetic gonads.

Preservation of gonadal function in true hermaphroditism

Twelve documented cases of true hermaphroditism have been studied since 1965; there was histological evidence of both ovarian and testicular tissue in all cases. The clinical, anatomical, and therapeutic procedures are reviewed with special emphasis on gonadal morphology, histology, and function. Seven patients were reared as females, 5 as males; 6 are now postpubertal and 3 are more than 30 years old. Five underwent bilateral castration; in seven cases, only the discordant gonadal tissue has been removed so that these patients may have endogenous gonadal secretion in keeping with their sex of rearing.

Breast carcinoma in a 46, XX true hermaphrodite

Muscinous breast carcinoma occurred in a 67-year-old true hermaphrodite who had been reared as a male. The peripheral blood karyotype was 46, XX. A left ovary and right ovotestis were intra-abdominal. Other tumors included an ovarian thecoma and an intestinal leiomyoma. Two previously reported cases of breast cancer in true hermaphrodites are cited.