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Engels M, Span PN, van Herwaarden AE, Sweep FCGJ, Stikkelbroeck NMML, Claahsen-van der Grinten HL. Testicular Adrenal Rest Tumors: Current Insights on Prevalence, Characteristics, Origin, and Treatment. Endocr Rev 2019; 40:973-987. [PMID: 30882882 DOI: 10.1210/er.2018-00258] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022]
Abstract
This review provides the reader with current insights on testicular adrenal rest tumors (TARTs), a complication in male patients with congenital adrenal hyperplasia (CAH). In recent studies, an overall TART prevalence of 40% (range, 14% to 89%) in classic patients with CAH is found. Reported differences are mainly caused by the method of detection and the selected patient population. Biochemically, histologically, and molecularly, TARTs exhibit particular adrenal characteristics and were therefore thought to originate from aberrant adrenal cells. More recently, TARTs have been found to also exhibit testicular characteristics. This has led to the hypothesis of pluripotent cells as the origin of TARTs. High concentrations of ACTH could cause hyperplasia of these pluripotent cells, as TARTs appear to be associated with poor hormonal control with concomitant elevated ACTH. Unfortunately, as yet there are no methods to prevent the development of TARTs, nor are there guidelines to treat patients with TARTs. Intensified glucocorticoid treatment could improve fertility status in some cases, although studies report contradicting results. TARTs can also lead to irreversible testicular damage, and therefore semen cryopreservation could be offered to patients with TARTs. Further research should focus on the etiology and pharmacological treatment to prevent TART development or to treat TARTs and improve the fertility status of patients with TARTs.
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Affiliation(s)
- Manon Engels
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N Span
- Department of Radiation Oncology, Radiotherapy and OncoImmunology Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Nistal M, Paniagua R, González-Peramato P, Reyes-Múgica M. Perspectives in Pediatric Pathology, Chapter 22. Testicular Involvement in Systemic Diseases. Pediatr Dev Pathol 2017; 19:431-451. [PMID: 25333836 DOI: 10.2350/14-09-1556-pb.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Normal testicular physiology requires appropriate function of endocrine glands and other tissues. Testicular lesions have been described in disorders involving the hypothalamus-hypophysis, thyroid glands, adrenal glands, pancreas, liver, kidney, and gastrointestinal tract. Testicular abnormalities can also associate with chronic anemia, obesity, and neoplasia. Although many of the disorders that affect the above-mentioned glands and tissues are congenital, acquired lesions may result in hypogonadism in children and adolescents.
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Affiliation(s)
- Manuel Nistal
- 1 Department of Pathology, Hospital La Paz, Universidad Autónoma de Madrid, Madrid 28029, Spain
| | - Ricardo Paniagua
- 2 Department of Cell Biology, Universidad de Alcala, Madrid, Spain
| | - Pilar González-Peramato
- 1 Department of Pathology, Hospital La Paz, Universidad Autónoma de Madrid, Madrid 28029, Spain
| | - Miguel Reyes-Múgica
- 3 Department of Pathology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15224, USA
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Bulsari K, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Endocrine 2017; 55:19-36. [PMID: 27928728 DOI: 10.1007/s12020-016-1189-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency is a rare autosomal recessive genetic disorder. It is caused by reduced or absent activity of 11β-hydroxylase (CYP11B1) enzyme and the resultant defects in adrenal steroidogenesis. The most common clinical features of 11 beta-hydroxylase deficiency are ambiguous genitalia, accelerated skeletal maturation and resultant short stature, peripheral precocious puberty and hyporeninemic hypokalemic hypertension. The biochemical diagnosis is based on raised serum 11-deoxycortisol and 11-deoxycorticosterone levels together with increased adrenal androgens. More than 100 mutations in CYP11B1 gene have been reported to date. The level of in-vivo activity of CYP11B1 relates to the degree of severity of 11 beta-hydroxylase deficiency. Clinical management of 11 beta-hydroxylase deficiency can pose a challenge to maintain adequate glucocorticoid dosing to suppress adrenal androgen excess while avoiding glucocorticoid-induced side effects. The long-term outcomes of clinical and surgical management are not well studied. This review article aims to collate the current available data about 11 beta-hydroxylase deficiency and its management.
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Affiliation(s)
- Krupali Bulsari
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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Ben-Mordechay D, Ben-Shlush A, Raviv-Zilka L, Jacobson JM, Soudack M. Sonographic Detection of Accessory Adrenal Tissue in Neonates. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:959-963. [PMID: 27072156 DOI: 10.7863/ultra.15.05048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/25/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to describe the incidence and appearance of accessory adrenal tissue in neonates, as diagnosed by high-resolution sonography, and increase the awareness of this entity. METHODS We examined the adrenal glands in 153 neonates referred for renal and urinary tract sonography at our institution between January 2014 and January 2015. All kidneys and adrenal glands, except for ectopic kidneys, were scanned with the neonate prone and a linear array transducer with frequency of 11 or 14 MHz. RESULTS In 9 neonates (5.9%), sonography showed a round, well-defined structure adjacent to the adrenal gland with a hyperechoic center and hypoechoic periphery, similar to the echogenicity of the normal adrenal medulla and cortex, respectively. The largest diameter of the structure measured 2.9 to 4.5 mm. On follow-up studies, which were available for 7 neonates, the structure was not evident, and the suprarenal area was normal. CONCLUSIONS Accessory adrenal tissue can be identified in the suprarenal area in neonates with high-resolution sonography. Radiologists and sonographers caring for neonates should be aware of this finding and not confuse it with disease.
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Affiliation(s)
| | - Aviva Ben-Shlush
- Department of Pediatric Imaging, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Lisa Raviv-Zilka
- Department of Pediatric Imaging, Chaim Sheba Medical Center, Ramat-Gan, IsraelSackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jeffrey M Jacobson
- Department of Pediatric Imaging, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Michalle Soudack
- Department of Pediatric Imaging, Chaim Sheba Medical Center, Ramat-Gan, IsraelSackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Kavoussi PK, Summers-Colquitt RB, Odenwald KC, Kressin M, Kavoussi KM, Pool TB, Kavoussi SK. Sperm retrieval and concomitant tumor resection in azoospermic men with congenital adrenal hyperplasia and bilateral testicular adrenal rest tumors: a case report. J Assist Reprod Genet 2016; 33:545-8. [PMID: 26861965 PMCID: PMC4818631 DOI: 10.1007/s10815-016-0665-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/20/2016] [Indexed: 11/06/2022] Open
Abstract
Purpose The objective of this study was to offer a new treatment approach for sperm retrieval simultaneously with tumor resection in azoospermic men with congenital adrenal hyperplasia (CAH), orchialgia, and bilateral testicular adrenal rest tumors (TARTs) who fail to respond to medical treatment. Methods This is a retrospective chart review from a couple’s fertility center. Results Between May 2013 and May 2015, two azoospermic men with CAH and bilateral TARTs, with orchialgia, and desire to conceive underwent bilateral TART resection in the same surgical setting as sperm retrieval after remaining azoospermic with normalization of gonadotropins with treatment with human chorionic gonadotropin (hCG). Both men had adequate sperm retrieved for in vitro fertilization/intracytoplasmic sperm retrieval (IVF/ICSI) at the time of bilateral TART resections. They had complete TART resections with resolution of orchialgia. The wife of one patient had a successful pregnancy with use of retrieved sperm resulting in a live birth, and the sperm from the other man is cryopreserved for future use. Conclusions It is feasible to perform successful sperm retrieval simultaneously with TART resection in azoospermic men with CAH after medical treatments with persistent azoospermia, rather than subjecting these men to multiple invasive procedures.
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Affiliation(s)
- Parviz K Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA.
| | - Roxanne B Summers-Colquitt
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Kate C Odenwald
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Megan Kressin
- Department of Pathology, St. David's South Austin Medical Center, 901 W. Ben White Blvd, Austin, TX, 78704, USA
| | - Keikhosrow M Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Thomas B Pool
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Shahryar K Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
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Yu MK, Jung MK, Kim KE, Kwon AR, Chae HW, Kim DH, Kim HS. Clinical manifestations of testicular adrenal rest tumor in males with congenital adrenal hyperplasia. Ann Pediatr Endocrinol Metab 2015; 20:155-61. [PMID: 26512352 PMCID: PMC4623344 DOI: 10.6065/apem.2015.20.3.155] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/19/2015] [Accepted: 09/21/2015] [Indexed: 11/20/2022] Open
Abstract
PURPOSE In male patients with congenital adrenal hyperplasia (CAH), the presence of testicular adrenal rest tumors (TARTs) have been reported, however their prevalence and clinical manifestations are not well known. Untreated TARTs may lead to testicular structural damage and infertility. This study was conducted to investigate the prevalence of TARTs in male patients with CAH, and characterize the manifestations to identify contributing factors to TART. METHODS Among 102 CAH patients aged 0-30 years, 24 male patients have been regularly followed up in our outpatient clinic at Severance Children's Hospital from January 2000 to December 2014. In order to reveiw the characteristics of TART patients, we calculated the mean levels of hormones during the 5 years before the time of investigation. Five patients underwent follow-up scrotal ultrasonography (US) after adjusting the dosage of glucocorticoids. RESULTS TARTs were detected in 8 of the 13 patients (61.5%). The median age of TARTs diagnosis was 20.2 years with the youngest case being 15.5 years old. The mean serum level of adrenocorticotropic hormone (ACTH) was higher in the TARTs patient group compared to the non-TARTs group (P<0.05). The tumor size decreased in 3 cases, slightly increased in 1 case, and had no change in another case. CONCLUSION The serum ACTH level might be associated with the growth promoting factor for TARTs, but the exact mechanism has not been clearly identified. Screening for TARTs using US is important in male patients with CAH for early-detection and prevention of ongoing complications, such as infertility.
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Affiliation(s)
- Min Kyung Yu
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Mo Kyung Jung
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Eun Kim
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ah Reum Kwon
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hee Kim
- Department of Pediatrics, Sohwa Children's Hospital, Seoul, Korea
| | - Ho-Seong Kim
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Rohayem J, Tüttelmann F, Mallidis C, Nieschlag E, Kliesch S, Zitzmann M. Restoration of fertility by gonadotropin replacement in a man with hypogonadotropic azoospermia and testicular adrenal rest tumors due to untreated simple virilizing congenital adrenal hyperplasia. Eur J Endocrinol 2014; 170:K11-7. [PMID: 24394723 DOI: 10.1530/eje-13-0449] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT Classical congenital adrenal hyperplasia (CAH), a genetic disorder characterized by 21-hydroxylase deficiency, impairs male fertility, if insufficiently treated. PATIENT A 30-year-old male was referred to our clinic for endocrine and fertility assessment after undergoing unilateral orchiectomy for a suspected testicular tumor. Histopathological evaluation of the removed testis revealed atrophy and testicular adrenal rest tumors (TARTs) and raised the suspicion of underlying CAH. The remaining testis was also atrophic (5 ml) with minor TARTs. Serum 17-hydroxyprogesterone levels were elevated, cortisol levels were at the lower limit of normal range, and gonadotropins at prepubertal levels, but serum testosterone levels were within the normal adult range. Semen analysis revealed azoospermia. CAH was confirmed by a homozygous mutation g.655A/C>G (IVS2-13A/C>G) in CYP21A2. Hydrocortisone (24 mg/m(2)) administered to suppress ACTH and adrenal androgen overproduction unmasked deficient testicular testosterone production. As azoospermia persisted due to sustained hypogonadotropic hypogonadism, a combined s.c. gonadotropin replacement with human chorionic gonadotropin (hCG) (1500 IU twice weekly) and FSH (human menopausal gondadotropin (hMG) 150 IU three times weekly) was initiated. RESULTS Normalization of testosterone levels and a stable low sperm concentration (0.5 mill/ml) with good sperm motility (85% A+B progressive) were achieved within 21 months of treatment. Despite persisting TARTs, while receiving treatment, the patient successfully impregnated his wife twice, the latter impregnation leading to the birth of a healthy girl. CONCLUSIONS TARTs in unrecognized (simple virilizing) CAH may lead to unnecessary orchiectomy. In hypogonadotropic, azoospermic CAH, a combined treatment with oral corticosteroids and subcutaneously administered hCG and FSH can successfully restore testicular testosterone production and fertility, even if only one hypoplastic and atrophic testis with adrenal rest tumors is present.
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Affiliation(s)
- Julia Rohayem
- Center of Reproductive Medicine and Andrology, Clinical Andrology, University of Muenster, Albert-Schweitzer-Campus 1, Building D11, D-48149 Muenster, Germany
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Reichman DE, White PC, New MI, Rosenwaks Z. Fertility in patients with congenital adrenal hyperplasia. Fertil Steril 2014; 101:301-9. [DOI: 10.1016/j.fertnstert.2013.11.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 01/31/2023]
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Pierre P, Despert F, Tranquart F, Coutant R, Tardy V, Kerlan V, Sonnet E, Baron S, Lorcy Y, Emy P, Delavierre D, Monceaux F, Morel Y, Lecomte P. Adrenal rest tissue in gonads of patients with classical congenital adrenal hyperplasia: multicenter study of 45 French male patients. ANNALES D'ENDOCRINOLOGIE 2012; 73:515-22. [PMID: 23131470 DOI: 10.1016/j.ando.2012.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 06/10/2012] [Accepted: 09/10/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Several cases of testicular adrenal rest tumours have been reported in men with congenital adrenal hyperplasia (CAH) due to the classical form of 21-hydroxylase deficiency but the prevalence has not been established. The aims of this report were to evaluate the frequency of testicular adrenal rest tissue in this population in a retrospective multicentre study involving eight endocrinology centres, and to determine whether treatment or genetic background had an impact on the occurrence of adrenal rest tissue. MATERIAL AND METHODS Testicular adrenal rest tissue (TART) was sought clinically and with ultrasound examination in forty-five males with CAH due to the classical form of 21-hydroxylase deficiency. When the diagnosis of testicular adrenal rest tumours was sought, good observance of treatment was judged on biological concentrations of 17-hydroxyprogesterone (17OHP), delta4-androstenedione, active renin and testosterone. The results of affected and non-affected subjects were compared. RESULTS TART was detected in none of the 18 subjects aged 1 to 15years but was detected in 14 of the 27 subjects aged more than 15years. Five patients with an abnormal echography result had no clinical signs. Therapeutic control evaluated at diagnosis of TART seemed less effective when diagnosis was made in patients with adrenal rest tissue compared to TART-free subjects. Various genotypes were observed in patients with or without TART. CONCLUSION Due to the high prevalence of TART in classical CAH and the delayed clinical diagnosis, testicular ultrasonography must be performed before puberty and thereafter regularly during adulthood even if the clinical examination is normal.
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Affiliation(s)
- Peggy Pierre
- Adult Endocrinology Unit, University Hospital of Tours, 2, boulevard Tonnelé, 37044 Tours cedex 9, France.
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Marchini GS, Cocuzza M, Pagani R, Torricelli FC, Hallak J, Srougi M. Testicular adrenal rest tumor in infertile man with congenital adrenal hyperplasia: case report and literature review. SAO PAULO MED J 2011; 129:346-51. [PMID: 22069134 PMCID: PMC10868949 DOI: 10.1590/s1516-31802011000500010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 08/03/2010] [Accepted: 03/16/2011] [Indexed: 11/22/2022] Open
Abstract
CONTEXT Synthesis of cortisol and aldosterone is impaired in patients with congenital adrenal hyperplasia (CAH) because of 21-hydroxylase deficiency. Men with CAH have low fertility rates compared with the normal population, and this is related to testicular adrenal rest tumors. Findings of azoospermia in combination with a testicular tumor on ultrasound are likely to have a mechanical cause, especially when in the testicular mediastinum. The preferred treatment method consists of intensive corticoid therapy. However, when the tumor is unresponsive to steroid therapy, surgical treatment should be considered. CASE REPORT We present the case of a male patient with CAH due to 21-hydroxylase deficiency who presented a testicular tumor and azoospermia. Treatment with low daily corticoid doses had previously been started by an endocrinologist, but after 12 months, no significant change in sperm count was found. Although the adrenocorticotrophic hormone and 17-hydroxyprogesterone levels returned to normal values, the follicle-stimulating hormone (FSH), luteinizing hormone and testosterone levels remained unchanged. Ultrasound examination confirmed that the testicles were small and heterogenous bilaterally, and revealed a mosaic area at the projection of the testis network bilaterally. Magnetic resonance imaging confirmed the finding. Testicular biopsy revealed the presence of preserved spermatogenesis and spermiogenesis in 20% of the seminiferous tubules in the right testicle. The patient underwent testis-sparing tumor resection. After 12 months of follow-up, there was no tumor recurrence but the patient still presented azoospermia and joined an intracytoplasmic sperm injection program.
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Affiliation(s)
- Giovanni Scala Marchini
- Department of Urology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Kang MJ, Kim JH, Lee SH, Lee YA, Shin CH, Yang SW. The prevalence of testicular adrenal rest tumors and associated factors in postpubertal patients with congenital adrenal hyperplasia caused by 21-hydroxylase deficiency. Endocr J 2011; 58:501-8. [PMID: 21521928 DOI: 10.1507/endocrj.k11e-034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Development of a testicular adrenal rest tumor (TART) is common in males with congenital adrenal hyperplasia, and it can be an important cause of infertility. In the present study, we observed the prevalence of TARTs, and analyzed its associated factors in patients with 21-hydroxylase deficiency. Testicular ultrasonography was performed in 48 postpubertal male patients aged 10.6 to 27.1 years. To determine whether patients were undertreated, we analyzed the serum 17-hydroxyprogesterone (17-OHP) levels to the time of ultrasonographic measurement and calculated the percentage of measurements when serum 17-OHP level was >10 ng/mL relative to the total number of measurements during the follow-up period. We divided the 6-year period before ultrasonographic measurement (time 0) into three 2-year intervals and calculated the average concentration of serum 17-OHP in each interval to give a -2(nd) to 0 year-average concentration (-2-0YAC), -4-2YAC and -6-4YAC. A TART was detected by ultrasonography in 31 of 48 patients (64.6%) and the median maximal cross-sectional area of the TARTs was 0.71 (0.03, 4.95) cm(2). The corrected final adult height was lower, and -4-2YAC and body mass index were higher in patients with TART than in those without. After controlling for the type of 21-hydroxylase deficiency, hydrocortisone-equivalent dose, age, and -6-4YAC, the size of TART was associated with a high undertreatment percentage with a marginal statistical significance. These results suggest that strict disease control is mandatory and regular examination with testicular ultrasonography is recommended in male patients, regardless of the type of 21-hydroxylase deficiency.
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Affiliation(s)
- Min Jae Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, 110-769, Korea
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Mouritsen A, Jørgensen N, Main KM, Schwartz M, Juul A. Testicular adrenal rest tumours in boys, adolescents and adult men with congenital adrenal hyperplasia may be associated with the CYP21A2 mutation. ACTA ACUST UNITED AC 2009; 33:521-7. [PMID: 19531083 DOI: 10.1111/j.1365-2605.2009.00967.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder with impaired function of the adrenal cortex caused by mutations in the CYP21A2 gene. Deficiency of steroid 21-hydroxylase accounts for 80-95% of CAH cases. Testicular adrenal rest tumours (TART) may be prevalent in up to 95% of CAH adults and may already appear during childhood. Whether genotype sub-types can account for the development of TART has not been investigated previously. We therefore investigated this by coupling clinical information of CAH patients with information of their genetic mutation. In 49 male patients (age 2.6-40.3 years) with 21-hydroxylase deficiency, testicular ultrasound examinations were performed and CYP21A2 genotypes determined. These were grouped according to the residual 21-hydroxylase activity: group Null (complete enzyme impairment), group A (almost complete enzyme impairment), group B (severe enzyme impairment) and group C (partial impairment). TART were observed in 27 of 49 patients (55%). For the 23 patients younger than 18 years, TART were present in 11 (48%), the youngest patient being 7.5 years old. The presence of TART was dependent on the CYP21A2 genotype: 27 of 37 patients (73%) with the most severe mutations (groups Null and A) had TART, whereas none of 12 patients with the milder mutations (groups B and C) had TART. We conclude that TART were most frequently detected in patients with severe CYP21A2 mutations, and may occur already in early childhood in such patients.
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Affiliation(s)
- Annette Mouritsen
- University Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark.
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Mirzaei MR, Rezvanian H, Siavash M, Parham M, Mahzouni P. A patient with refractory testicular adrenal rest tumour in the setting of cyp11b1 deficiency congenital adrenal hyperplasia. BMJ Case Rep 2009; 2009:bcr06.2008.0280. [PMID: 21686875 DOI: 10.1136/bcr.06.2008.0280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Testicular adrenal rest tumour (TART) due to CYP11B1 deficiency is a very rare clinical finding. Only seven cases have been reported previously. Here, the case of a 19-year-old boy with classic CYP11B1 deficiency and large testicles refractory to medical treatment that led to orchidectomy is reported. The clinical and laboratory manifestations of this patient are discussed and compared with that of the previously reported cases. The patient presented with rapid body growth, precocious puberty, hypertension, recurrent hypokalaemic paralysis and testicular enlargement. The most important differential diagnosis of his latter presentation is Leydig cell tumour (LCT). It was found that positive family history of congenital adrenal hyperplasia (CAH), hypertension, bilaterality, hypokalaemia and multiple hypoechoic masses on ultrasonography of the testes are in favour of a diagnosis of TART. Conversely, high titres of tumour markers and presence of Reinke crystalloids are supportive of a diagnosis of LCT.
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Affiliation(s)
- Mohammad Reza Mirzaei
- Isfahan University of Medical Sciences, Isfahan Endocrine and Metabolism Research Center, Sedigheh Tahereh Medical Research Complex, Khorram Street, Isfahan, 8187698191, Islamic Republic of Iran
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Claahsen-van der Grinten HL, Otten BJ, Stikkelbroeck MML, Sweep FCGJ, Hermus ARMM. Testicular adrenal rest tumours in congenital adrenal hyperplasia. Best Pract Res Clin Endocrinol Metab 2009; 23:209-20. [PMID: 19500764 DOI: 10.1016/j.beem.2008.09.007] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In adult patients with congenital adrenal hyperplasia (CAH) the presence of testicular adrenal rest tumours (TART) is an important cause of gonadal dysfunction and infertility. In the last decade several papers have focused on the origin and pathogenesis of these tumours. In this paper we review the embryological, histological, biochemical and clinical features of TART and discuss the treatment options. Furthermore, we propose a new five-stage classification of TART, based on sonographic, clinical and biochemical parameters, that may lead to a better follow up and treatment of patients with TART.
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Testicular adrenal rest tumours in congenital adrenal hyperplasia. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2009; 2009:624823. [PMID: 19956703 PMCID: PMC2777016 DOI: 10.1155/2009/624823] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 01/13/2009] [Indexed: 11/17/2022]
Abstract
In adult patients with congenital adrenal hyperplasia (CAH), the presence
of testicular adrenal rest tumours (TART) is an important complication leading to
gonadal dysfunction and infertility. These tumours can be already found in childhood and puberty. In this paper, we review the embryological, histological, biochemical,
and clinical features of TART and discuss treatment options.
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16
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Ribagnac M, Brac De La Perrière A, Lyonnet D, Rouvière O. [Testicular adrenal rests: the role of imaging]. ACTA ACUST UNITED AC 2007; 88:631-8. [PMID: 17541355 DOI: 10.1016/s0221-0363(07)89869-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Testicular adrenal rests are encountered in ACTH hypersecretion syndromes, most often in congenital adrenal hyperplasia attributable to a deficit in 21-hydroxylase. They are discovered clinically or on systematic sonography, generally in the young adult. On sonography, they appear as confluent hypoechogenic masses, often bilateral, that have developed in the region of the testicular hilum. At a late stage, they take on a highly suggestive attenuating aspect. In color Doppler, they have a regular vascular architecture. They generally regress or stabilize with replacement glucocorticosteroid treatment. They can sometimes progress, which then poses the problem of the type of lesion. Biopsy or spermatic vein samples are not reliable. MRI contributes very little more than sonography. Diagnosis comes with follow-up or, as a last resort, orchidectomy.
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Affiliation(s)
- M Ribagnac
- Service de Radiologie Urinaire et Vasculaire, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69437 Lyon
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17
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Hyperplasie congénitale des surrénales à révélation tardive par déficit partiel en 21-hydroxylase. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1155-1941(07)44867-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Fitoz S, Atasoy C, Adiyaman P, Berberoglu M, Erden I, Ocal G. Testicular adrenal rests in a patient with congenital adrenal hyperplasia: US and MRI features. Comput Med Imaging Graph 2006; 30:465-8. [PMID: 17049208 DOI: 10.1016/j.compmedimag.2006.09.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Revised: 09/04/2006] [Accepted: 09/11/2006] [Indexed: 10/24/2022]
Abstract
We present ultrasonographic and magnetic resonance imaging findings of intratesticular adrenal rests in a 16-year-old patient with congenital adrenal hyperplasia. Scrotal ultrasonography showed bilateral well-delineated homogenous hypoechoic lesions located around the mediastinum testis, which were highly vascularized on power Doppler ultrasonography. Relative to normal testicular parenchyma the lesions were iso- or hyperintense on T1-weighted and hypointense on T2-weighted images. T2-weighted images also showed a target-like appearance caused by a more hypointense peripheral halo around the lesions. The lesions enhanced remarkably on post-contrast images. This case suggests that radiological evaluation of testes, even in the presence of normal physical examination findings, should be included in periodical follow-up of patients with congenital adrenal hyperplasia. Magnetic resonance (MR) imaging is useful in demonstrating the lesions, because the contrast resolution better than with ultrasonography.
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Affiliation(s)
- Suat Fitoz
- Ankara University, Medical School, Department of Radiology, Ibn-i Sina Hospital, 06100 Sihhiye, Ankara, Turkey.
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19
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Aso C, Enríquez G, Fité M, Torán N, Piró C, Piqueras J, Lucaya J. Gray-Scale and Color Doppler Sonography of Scrotal Disorders in Children: An Update. Radiographics 2005; 25:1197-214. [PMID: 16160106 DOI: 10.1148/rg.255045109] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ultrasonography (US) is well suited to the study of pathologic conditions of the scrotum in children. US provides excellent anatomic detail; when color Doppler and power Doppler imaging are added, testicular perfusion can be assessed. Gray-scale, color Doppler, and power Doppler US were used to study a spectrum of scrotal disorders in 750 boys aged 1 day to 17 years. The entities studied included processus vaginalis-related disorders (cryptorchidism, inguinal-scrotal hernia, and hydrocele); varicocele; acute scrotum (epididymo-orchitis, torsion of the testicular appendages, and testicular torsion); scrotal tumors; testicular microlithiasis; scrotal trauma; and systemic diseases with scrotal involvement. When combined with the results of clinical and physical examination, the information obtained with US is sufficient to enable diagnosis in most cases of scrotal disease. Moreover, color Doppler imaging is essential for differentiation between processes such as epididymo-orchitis or torsion of the testicular appendages and testicular torsion, which have similar clinical manifestations (pain, swelling, and redness) but are managed differently.
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Affiliation(s)
- Celestino Aso
- Department of Pediatric Radiology, Vall d'Hebron Children's Hospital, Barcelona, Spain
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20
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Abstract
Congenital adrenal hyperplasia (CAH) due to deficiency of 21-hydroxylase is a disorder of the adrenal cortex characterised by cortisol deficiency, with or without aldosterone deficiency, and androgen excess. Patients with the most severe form also have abnormalities of the adrenal medulla and epinephrine deficiency. The severe classic form occurs in one in 15,000 births worldwide, and the mild non-classic form is a common cause of hyperandrogenism. Neonatal screening for CAH and gene-specific prenatal diagnosis are now possible. Standard hormone replacement fails to achieve normal growth and development for many children with CAH, and adults can experience iatrogenic Cushing's syndrome, hyperandrogenism, infertility, or the development of the metabolic syndrome. This Seminar reviews the epidemiology, genetics, pathophysiology, diagnosis, and management of CAH, and provides an overview of clinical challenges and future therapies.
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Affiliation(s)
- Deborah P Merke
- Pediatric and Reproductive Endocrinology Branch, National Institute of Child Health and Human Development and the Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD 20892-1932, USA.
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21
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Stikkelbroeck NMML, Suliman HM, Otten BJ, Hermus ARMM, Blickman JG, Jager GJ. Testicular adrenal rest tumours in postpubertal males with congenital adrenal hyperplasia: sonographic and MR features. Eur Radiol 2003; 13:1597-603. [PMID: 12835972 DOI: 10.1007/s00330-002-1786-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2002] [Revised: 10/21/2002] [Accepted: 11/25/2002] [Indexed: 11/28/2022]
Abstract
The purpose of this study was to investigate the prevalence of testicular adrenal rest tumours in patients with congenital adrenal hyperplasia (CAH), and to describe sonographic and MR features of these lesions. Seventeen postpubertal male CAH patients underwent scrotal sonography, with colour Doppler, and in 16 of them pre- and postcontrast enhanced T1- and T2-weighted MR images of the testes were obtained. Ultrasound revealed lesions in 16 of 17 patients (94%), bilateral in 10 patients and unilateral in 6 patients. The lesions were typically located adjacent to the mediastinum testis. The maximal diameter of the lesions varied from 2 to 40 mm. Margins were blurred in 11 of 31 lesions. Seventeen of the 20 lesions smaller than 2 cm in diameter were hypoechoic, whereas all 11 lesions larger than 2 cm showed hyperechoic reflections. On MR all lesions were isointense on T1- and hypointense on T2-weighted images and lesion margins were clearly defined. Enhancement of the lesions after intravenous contrast was seen in 13 of 15 patients. In our series the prevalence of testicular adrenal rest tumours in postpubertal CAH patients is much higher than in other reported studies. The lesions may develop from some small, hypoechoic, and multifocal nodules and coalesce to large hypoechoic lesions with hyperechoic reflections on ultrasound. As our results suggest that ultrasonography and MR show the lesions equally well, ultrasonography should be the method of first choice for detection and follow-up of these lesions, because it is the cheapest and quickest imaging technique. In case of a partial orchiectomy, MR is recommended because it shows lesion margins optimally.
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Affiliation(s)
- Nike M M L Stikkelbroeck
- Department of Paediatric Endocrinology, University Medical Centre Nijmegen, internal post 435, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
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22
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Ghazi AAM, Hadayegh F, Khakpour G, Azizi F, Melby JC. Bilateral testicular enlargement due to adrenal remnant in a patient with C11 hydroxylase deficiency congenital adrenal hyperplasia. J Endocrinol Invest 2003; 26:84-7. [PMID: 12602540 DOI: 10.1007/bf03345128] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The case of a 15-yr-old boy with C11 hydroxylase deficiency congenital adrenal hyperplasia is reported who was diagnosed and treated as true precocious puberty at the age of 2 yr because of virilization and bilateral testicular enlargement. He later developed hyperpigmentation, hypertension and short stature and because of an increase in testes size he underwent testicular biopsy with the assumption of Leydig cell tumor. With the intake of glucocorticoids his testes size, hypertension and hyperpigmentation improved markedly. We could find only 6 such cases in the literature and have reviewed their clinical and laboratory data. All patients showed the picture of virilization with hypertension. Leydig cell tumor was proposed as the differential diagnosis in all cases except ours. Ultrasonography was able to show testicular adrenal-like tissue in all those in whom the procedure was undertaken. In the 5 patients of whom we could find enough data, 1 responded partially and 4 responded markedly to corticosteroid therapy with shrinkage of testicular tumors. We conclude that clinical findings and US are very important in the early diagnosis of these patients and with adequate treatment most cases show shrinkage in testicular tumors.
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Affiliation(s)
- A A M Ghazi
- Endocrine Research Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.
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23
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White PC, Speiser PW. Long-term consequences of childhood-onset congenital adrenal hyperplasia. Best Pract Res Clin Endocrinol Metab 2002; 16:273-88. [PMID: 12064893 DOI: 10.1053/beem.2002.0198] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a general term applied to several diseases caused by inherited defects of cortisol synthesis. The most common of these is steroid 21-mono-oxygenase (also termed 21-hydroxylase) deficiency (CAH-21OHD), found in approximately 1:10 000-1:15 000 live births. Potentially lethal adrenal insufficiency is characteristic of about two-thirds to three-quarters of patients with the classic salt-wasting form of CAH-21OHD. Non-salt-wasting forms of CAH-21OHD may be diagnosed based in part on genital ambiguity in affected newborn females, and/or by later evidence of androgen excess in members of either sex. Non-classical CAH-21OHD may be detected in up to 1-3% of certain populations, and is often mistaken for idiopathic precocious pubarche in children or polycystic ovary syndrome in young women. This chapter addresses issues relating to long-term consequences in adult life of CAH-21OHD diagnosed in early childhood or adolescence.
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Affiliation(s)
- Perrin C White
- Division of Pediatric Endocrinology and Professor of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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24
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Abstract
Congenital adrenal hyperplasia (CAH) is a group of disorders caused by inborn errors of steroid metabolism. The most common form owing to 21-hydroxylase deficiency (CAH-21OHD) is present in about 1:10,000- 1:15,000 live births worldwide. In its classic salt-wasting form (-66-75% of cases) patients may suffer potentially lethal adrenal insufficiency. Non-salt-wasting forms of CAH-21 OHD are recognized by genital ambiguity in affected females, and by signs of androgen excess in later childhood in males. Non-classic CAH-21 OHD may be detected in up to 1-3% of certain populations, and is often mistaken for idiopathic precocious pubarche in children or polycystic ovary syndrome in young women. This chapter will address issues relating to transition of CAH care from the pediatric to the adult endocrinologist.
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Affiliation(s)
- P W Speiser
- Division of Pediatric Endocrinology, North Shore-Long Island Jewish Health System, New York, USA.
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25
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Abstract
Congenital adrenal hyperplasia (CAH) owing to 21-hydroxylase deficiency is the most common cause of genital ambiguity in the newborn and is present in about 1 in 15,000 live births worldwide. The disease is further characterized in its classic salt-wasting form (approximately 75% of cases) by potentially lethal adrenal insufficiency. A non-salt-wasting form of classic CAH with 21-hydroxylase deficiency is also recognized by genital ambiguity in affected females and by signs of androgen excess in later childhood in males. Nonclassic CAH with 21-hydroxylase deficiency may be detected in 1% to 3% of populations and is often mistaken for idiopathic precocious pubarche in children or polycystic ovary syndrome in young women. This article presents an overview of clinical and genetic aspects of the various forms of CAH with 21-hydroxylase deficiency.
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Affiliation(s)
- P W Speiser
- Division of Pediatric Endocrinology, North Shore-Long Island Jewish Health System, Manhasset, New York.
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26
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Abstract
More than 90% of cases of congenital adrenal hyperplasia (CAH, the inherited inability to synthesize cortisol) are caused by 21-hydroxylase deficiency. Females with severe, classic 21-hydroxylase deficiency are exposed to excess androgens prenatally and are born with virilized external genitalia. Most patients cannot synthesize sufficient aldosterone to maintain sodium balance and may develop potentially fatal "salt wasting" crises if not treated. The disease is caused by mutations in the CYP21 gene encoding the steroid 21-hydroxylase enzyme. More than 90% of these mutations result from intergenic recombinations between CYP21 and the closely linked CYP21P pseudogene. Approximately 20% are gene deletions due to unequal crossing over during meiosis, whereas the remainder are gene conversions--transfers to CYP21 of deleterious mutations normally present in CYP21P. The degree to which each mutation compromises enzymatic activity is strongly correlated with the clinical severity of the disease in patients carrying it. Prenatal diagnosis by direct mutation detection permits prenatal treatment of affected females to minimize genital virilization. Neonatal screening by hormonal methods identifies affected children before salt wasting crises develop, reducing mortality from this condition. Glucocorticoid and mineralocorticoid replacement are the mainstays of treatment, but more rational dosing and additional therapies are being developed.
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Affiliation(s)
- P C White
- Division of Pediatric Endocrinology, University of Texas Southwestern Medical Center, Dallas 75390-9063, USA.
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27
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Jääskeläinen J, Kiekara O, Hippeläinen M, Voutilainen R. Pituitary gonadal axis and child rate in males with classical 21-hydroxylase deficiency. J Endocrinol Invest 2000; 23:23-7. [PMID: 10698047 DOI: 10.1007/bf03343671] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Though appropriate glucocorticoid substitution therapy should abolish both cortisol deficiency and adrenal androgen excess in patients with 21-hydroxylase deficiency (21-OHD), the long-term outcome is not always satisfactory. There are several reports on low adult height in both male and female patients, and impaired fertility has been reported in females with 21-OHD. There are only few reports on gonadal function of adult male patients with 21 -OHD. In this study, we calculated the child rate of all the 29 diagnosed adult Finnish males with classical 21-OHD and compared it with the mean child rate of the whole Finnish male population with equal age distribution. Sixteen males with 21-OHD and their age-matched healthy controls were further examined in a cross-sectional study. Auxology and pituitary gonadal axis were examined in both patients and controls. Testicular ultrasonography of the patients was also performed. The mean child rate of the 29 males with 21-OHD was 0.07 which was significantly lower (p<0.001) than that in the Finnish male population of the same age (0.34). In the cross-sectional study, males with 21-OHD had serum testosterone, inhibin B, LH and FSH concentrations comparable to those of healthy controls and reference values. Serum DHEA-S concentrations were remarkably low, even in the undersubstituted males with 21-OHD (p<0.001, compared with the healthy controls). In the patient group, serum inhibin B concentration did not correlate with serum FSH concentration. Adrenal rest tumors of the testicles were found in two undersubstituted males with 21-OHD. In conclusion, our study suggests normal pituitary and gonadal function but reduced child rate in adult males with 21-OHD. This might be explained by suboptimal psychosocial adaptation to the chronic disease. However, the patients in this study were young and the final child rate may become essentially higher.
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Affiliation(s)
- J Jääskeläinen
- Department of Pediatrics, Kuopio University Hospital, Finland.
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28
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Affiliation(s)
- P W Speiser
- Department of Pediatrics, New York University Medical Center, New York, USA
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29
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Karnak I, Senocak ME, Göğüş S, Büyükpamukçu N, Hiçsönmez A. Testicular enlargement in patients with 11-hydroxylase deficiency. J Pediatr Surg 1997; 32:756-8. [PMID: 9165472 DOI: 10.1016/s0022-3468(97)90027-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Testicular nodules or tumors have been well described in patients with congenital adrenal hyperplasia (CAH) and usually associated with 21-hydroxylase deficiency. The authors report on a 11-hydroxylase--deficient patient presenting bilateral testicular enlargement and review the literature. Testicular biopsy was not very helpful to make differential diagnosis between adrenal rest hyperplasia and Leydig cell tumor. The size of testes regressed after steroid replacement therapy, and this observation was suggestive for adrenal rest hyperplasia. These findings suggest that bilateral testicular enlargement in patients with CAH may occur after excessive adrenocorticotrophic hormone stimulation of cells differentiated from unknown origin. Orchiectomy is not required but bilateral testicular biopsy must be performed.
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Affiliation(s)
- I Karnak
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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30
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31
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Walker BR, Skoog SJ, Winslow BH, Canning DA, Tank ES. Testis Sparing Surgery for Steroid Unresponsive Testicular Tumors of the Adrenogenital Syndrome. J Urol 1997. [DOI: 10.1016/s0022-5347(01)65023-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Brady R. Walker
- From the Divisions of Urology, Oregon Health Sciences University, Portland, Oregon, and Medical College of Virginia, Norfolk, Virginia, and Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven J. Skoog
- From the Divisions of Urology, Oregon Health Sciences University, Portland, Oregon, and Medical College of Virginia, Norfolk, Virginia, and Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Boyd H. Winslow
- From the Divisions of Urology, Oregon Health Sciences University, Portland, Oregon, and Medical College of Virginia, Norfolk, Virginia, and Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas A. Canning
- From the Divisions of Urology, Oregon Health Sciences University, Portland, Oregon, and Medical College of Virginia, Norfolk, Virginia, and Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Edward S. Tank
- From the Divisions of Urology, Oregon Health Sciences University, Portland, Oregon, and Medical College of Virginia, Norfolk, Virginia, and Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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32
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Abstract
Fusion of the testis with adrenal remnants is a relatively common incidental finding during orchidopexy. Splenogonadal fusion has been described in several cases. Herein the authors report a case of hepatogonadal fusion. To their knowledge, this is the first such case in the literature. Ectopic liver tissue has been encountered in a variety of locations, but had not been found in a testicle. The trapping of hepatocyte-destined mesenchyma in different areas may explain the presence of heterotopic liver tissue in different organs. If these cell aggregates are trapped in the area of peritoneum where the testis is forming, heterotopic liver tissue can end up in the testis.
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Affiliation(s)
- F Ferro
- Department of Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy
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33
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Dieckmann K, Lecomte P, Despert F, Maurage C, Sirinelli D, Rolland JC. [Congenital adrenal hyperplasia and testicular hypertrophy]. Arch Pediatr 1995; 2:1167-72. [PMID: 8547996 DOI: 10.1016/0929-693x(96)89917-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Testicular tumors have been reported in boys and adolescents with congenital adrenal hyperplasia (CAH) inadequately controlled by hormonal therapy. CASE REPORTS Two adolescents were treated for CAH due to 21-hydroxylase deficiency. They developed hyperplastic nodular testes at the age of 16 and 17 years, respectively. CAH in both was inadequately controlled as confirmed by hormonal studies. The tumors regressed after adequate steroid therapy in the first patient but persisted in the second patient despite normalization of 17-OH progesterone and plasma renin activity. CONCLUSION Testicular ultrasonography should be systematic in all male patients with CAH since radiological findings are earlier than clinical manifestations. The ACTH-dependent tumors require intensification of hormonal therapy in order to obtain tumoral regression and to prevent infertility.
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Affiliation(s)
- K Dieckmann
- Service de pédiatrie R, CHU Gatien-de-Clocheville, Tours, France
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34
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Abstract
The child presenting with abnormal pubertal development elicits great parental concern and presents a diagnostic challenge to the managing pediatrician. The appropriate workup of children with disorders of pubertal development relies heavily on the synthesis of history, physical examination, pertinent laboratory tests, and medical imaging. This review addresses female and male disturbances in pubertal development and includes isosexual and heterosexual precocious puberty and delayed development. Discussion is focussed on the tailored algorithmic approach to imaging; integrating clinical and laboratory information. Bone-age determination, ultrasonography, and MRI are emphasized as they relate to this complex and challenging clinical problem.
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Affiliation(s)
- G L Hedlund
- Department of Pediatric Imaging, Children's Hospital of Alabama, Birmingham 35233
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