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

46, XX Ovotesticular disorder of sex development (true hermaphroditism) with seminoma: A case report

RATIONALE

Ovotesticular disorder of sex development (DSD), previously known as true hermaphroditism, is a disorder in which individuals have both testicular and ovarian tissues. Instances of tumors arising in the gonads of individuals with 46,XX ovotesticular DSD are uncommon.

PATIENT CONCERNS

We report a case of a 36-year-old phenotypical male with a chief complaint of an abdominal mass for 3 months. He reported normal erections and regular menses. Computerized tomography showed a large tumor measuring 15 × 10 cm in size, a uterus, and a cystic ovary.

DIAGNOSIS

46, XX ovotesticular DSD with seminoma.

INTERVENTIONS

The patient was treated with neochemotherapy (etoposide and cisplatin), surgery, chemotherapy, and testosterone replacement.

OUTCOMES

At the 13-month follow-up, the patient reported satisfactory erections, and no evidence of disease was found.

CONCLUSION

Cases of 46,XX ovotesticular DSD with seminoma are uncommon. Our case reveals the importance of surgery combined with neochemotherapy, chemotherapy, and testosterone replacement in these patients to improve the prognosis.

An XX male with an intratubular undifferentiated germ cell neoplasia

OBJECTIVE

To report a case of a 46,XX male with an intratubular undifferentiated germ cell neoplasia within an extra-abdominal gonad.

DESIGN

Case report.

SETTING

Molecular, cytogenetic, pathologic, and clinical units of three tertiary hospitals.

PATIENT(S)

A male with ambiguous genitalia at birth and descended testes observed in a pediatric endocrinology setting.

INTERVENTION(S)

Physical examination, hormonal assays, cytogenetic investigation, molecular analysis, surgical intervention for biopsies and bilateral orchiectomy, and pathologic evaluation.

MAIN OUTCOME MEASURE(S)

Pathologic evaluation with immunostaining for placental alkaline phosphatase and C-kit.

RESULT(S)

Conventional chromosome analysis revealed a 46,XXq- karyotype, and fluorescence in situ hybridization experiments with the SRY probe found a signal at the short arm of the deleted X chromosome. Molecular analysis indicated the presence of a portion of the short arm of the Y chromosome including the proto-oncogene TSPY. Pathologic evaluation of the gonads revealed an intratubular undifferentiated germ cell neoplasia.

CONCLUSION(S)

This is the first case of a 46,XX male with descended testes in whom an intratubular undifferentiated germ cell neoplasia developed. When proposals of management in this subgroup of disorders of sexual differentiation are formulated, the risk of germ cell malignancy must be taken into account.

Uterine tumor resembling ovarian sex cord tumor: report of a case with t(X;6)(p22.3;q23.1) and t(4;18)(q21.1;q21.3)

Uterine tumor resembling ovarian sex cord tumor (UTROSCT) is a rare tumor of reproductive-age and postmenopausal women. We present the first case of UTROSCT with cytogenetic analysis. The tumor occurred in a 34-year-old woman who presented with menorrhagia and a uterine mass. Histologic examination showed tumor with features of sex cord-like epithelium and abundant fibromuscular stroma without an endometrial stromal sarcoma component. The tumor cells expressed cytokeratin, CD99, vimentin, desmin, smooth muscle actin, and estrogen and progesterone receptors. The majority of the cells analyzed by cytogenetic studies showed two balanced chromosomal translocations: t(X;6)(p22.3;q23.1) and t(4;18)(q21.1;q21.3). Several known tumor-related genes (bcl-2, MALT-1, FVT1, SCCA1, SCCA2, and DCC at 18q21; RAP1 at 4q21; and STL at 6q23) and a gonadal-development related gene (H-Y regulator gene at Xp22.3) are located at or near the translocation breakpoints. The tumor cells of sex cord-like elements were strongly and diffusely immunoreactive for bcl-2 antibody. These cytogenetic and immunohistochemical data may suggest potential molecular mechanisms of tumorigenesis of UTROSCT.

True hermaphroditism: clinical features, genetic variants and gonadal histology

True hermaphroditism is a rare cause of intersexuality in which both ovarian and testicular tissue is present in the same individual. We present the clinical findings, karyotype, gonadal histology and management of eight patients with true hermaphroditism. Their ages ranged from 43 days to 12 years at the first evaluation. The presenting symptoms were ambiguous genitalia (6 patients), isolated clitoromegaly (1 patient) and hypospadias (1 patient). The most common karyotype was 46,XX (6 patients). In one patient the karyotype was 46,XY and in another 45,XO/46,XY mosaicism, which is rare in the literature. A vagina was found by genitography in all patients, and at laparotomy the uterus was found normal in five patients, hypoplastic in one patient, as a fibrous band in one, and absent in the remaining patient. Histological investigation of the gonads revealed bilateral ovotestis in two patients, ovotestis plus ovary in two patients, and ovary on one side and testis on the other side in three patients. Five patients were assigned to the female sex, and three to the male sex. One of these patients was changed from male to female after evaluation.

Case report: A rapidly expanding testicular mass due to a ruptured ovarian follicle

An ovotestis is the commonest gonad in the small number of patients who are true hermaphrodites. In the majority of ovotestes, testicular and ovarian tissue is arranged end-to-end. There has been only one previous report of the sonographic appearances of an ovotestis. We present the sonographic findings in a patient who developed a rapidly enlarging upper pole testicular mass, which was found on histology to be a ruptured ovarian follicle with spermatogenesis occurring within the adjacent testicular tissue.

True hermaphroditism: geographical distribution, clinical findings, chromosomes and gonadal histology

We reviewed 283 cases of human true hermaphroditism published from 1980 to 1992. Of the 96 cases described in Africa 96.9% showed a 46,XX karyotype. In Europe 40.5% of 74 cases and 21.0% of the patients in North America had chromosomal mosaicism. The 46,XY karyotype is extremely rare (7%) and equally distributed through Asia, Europe and North America. Of 283 cases 87 were of black or black mixed origin with a 46,XX chromosomal constellation. The most common gonad in patients with true hermaphroditism, an ovotestis, was found in 44.4% of 568 gonads. Gonads with testicular tissue were more frequent on the right side of the body, while pure ovarian tissue was more common on the left. Histologically the testicular tissue was described to be immature and only twice was spermatogenesis reported while the ovarian portion often appeared normal. This coincides with 21 pregnancies reported in ten true hermaphrodites while only one true hermaphrodite apparently has fathered a child. Of the patients 4.6% were reported to have gonadal tumours. Position and type of the genital ducts, frequency of clinical findings such as genital abnormalities and gynaecomastia, correlations between assigned sex and karyotype as well as the age at diagnosis are reported.

True hermaphroditism with bilateral ovotestis: a case report

A true hermaphrodite with a 46 XX/47 XXY karyotype, gynaecomastia, hypospadia and scrotal gonads was investigated. Gonadectomy performed at 14 years of age revealed bilateral ovotestes. The ovarian portion contained follicles of all developmental stages. The testicular portion was immature consisting of seminiferous cords with Sertoli cells at various steps of differentiation and few germ cells within massive aggregates of collagenous connective tissue. Leydig cells as well as germ cells remained in an embryonic stage of development. Sections of a differentiated Wolffian duct (ductuli efferentes, epididymis, vas deferens) as well as of a Müllerian duct (hypoplastic fallopian tube) were found adjacent to both gonads. Postoperative treatment consisted of androgen substitution therapy leading to progression of puberty.

A proposed growth regulatory function for the serologically detectable sex-specific antigen H-Ys

It is widely believed that the serologically detectable sex-specific antigen H-Ys plays a major role in the primary determination of sex. The cellular distribution of the antigen, however, seems to be at odds with its postulated function. Consideration of this apparent paradox has prompted the suggestion that the H-Ys antigen functions as a growth regulator, and that its role in the primary determination of sex can be accounted for on this basis. Circumstantial evidence is adduced that H-Ys is a growth regulator in the embryo, and this is supported by evidence from several sources not immediately related to embryonic growth or development. Genes coding for growth regulators can function as oncogenes in situations involving disordered regulation, and it is suggested that this accounts for the high incidence of ovarian neoplasms in H-Ys positive, but not in H-Ys negative, female patients with 46,XY gonadal dysgenesis (Swyer's syndrome). A postulated growth regulatory function of H-Ys lends weight to the contention of others, not only that the direction of differentiation of the indifferent gonad in the embryo is determined by its growth rate, but also that a common mechanism underlies genotypic sex determination and environmental sex determination.

Nephroblastoma in an ovotestis of a true hermaphrodite: a case report

We describe a patient who presented with a painful mass in the left inguinoscrotal region, gynecomastia, perineal hypospadias with chordee and a bifid scrotum with a small gonad in the right hemiscrotum. At operation the left mass was found to be an ovotestis with hemorrhage in a corpus luteum cyst. A rudimentary uterus and fallopian tube were situated next to the ovotestis. The right gonad also was an ovotestis with a tiny focus of small cell malignancy that was suggestive of nephroblastoma.

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.