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Krege S, Eckoldt F, Richter-Unruh A. [Differences in sexual development-S2k guideline update]. UROLOGIE (HEIDELBERG, GERMANY) 2024; 63:448-455. [PMID: 38573501 DOI: 10.1007/s00120-024-02326-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Human beings with a difference in sexual development (DSD) often underwent gender reassignment surgery during early childhood. However, the medical decision was often not congruent with the gender identity that affected persons developed later on. OBJECTIVES To represent the interests of affected persons, an interdisciplinary guideline in cooperation with support groups was written. MATERIALS AND METHODS The revision of the first version of the guideline, published in 2016, was edited by 18 professional societies and working groups as well as 3 support groups. A literature search was performed for each of the 12 chapters. Recommendations and statements created by the working groups were voted on during four consensus conferences. RESULTS The guideline highlights the right of self-determination of affected persons. In this context, new legal requirements are reported. Other than necessary primary diagnostics, medical procedures should be postponed. Most important is the psychological support of parents and patients. Tumor risk of the gonads and protection of fertility are analyzed and discussed in detail. CONCLUSION The content of the guideline represents a paradigm shift in dealing with human beings with a difference of sexual development. Projects as DSD Care and Empower-DSD help to promote the practical implementation of the guideline's recommendations.
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Affiliation(s)
- S Krege
- Direktorin der Klinik für Urologie, Kinderurologie und Urol. Onkologie, Ev. Kliniken Essen Mitte, Huyssens-Stiftung, Henricistr. 92, 45136, Essen, Deutschland.
| | - F Eckoldt
- Klinik für Kinderchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - A Richter-Unruh
- Triagon Dortmund, Hormonzentrum für Kinder und Jugendliche, Dortmund, Deutschland
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Juul A, Gravholt CH, De Vos M, Koledova E, Cools M. Individuals with numerical and structural variations of sex chromosomes: interdisciplinary management with focus on fertility potential. Front Endocrinol (Lausanne) 2023; 14:1160884. [PMID: 37214245 PMCID: PMC10197804 DOI: 10.3389/fendo.2023.1160884] [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] [Received: 02/07/2023] [Accepted: 04/10/2023] [Indexed: 05/24/2023] Open
Abstract
Diagnosis and management of individuals who have differences of sex development (DSD) due to numerical or structural variations of sex chromosomes (NSVSC) remains challenging. Girls who have Turner syndrome (45X) may present with varying phenotypic features, from classical/severe to minor, and some remain undiagnosed. Boys and girls who have 45,X/46,XY chromosomal mosaicism may have Turner syndrome-like features and short stature; therefore, unexplained short stature during childhood requires karyotype analysis in both sexes, particularly if characteristic features or atypical genitalia are present. Many individuals with Klinefelter syndrome (47XXY) remain undiagnosed or are only diagnosed as adults due to fertility problems. Newborn screening by heel prick tests could potentially identify sex chromosome variations but would have ethical and financial implications, and in-depth cost-benefit analyses are needed before nationwide screening can be introduced. Most individuals who have NSVSC have lifelong co-morbidities and healthcare should be holistic, personalized and centralized, with a focus on information, psychosocial support and shared decision-making. Fertility potential should be assessed individually and discussed at an appropriate age. Oocyte or ovarian tissue cryopreservation is possible in some women who have Turner syndrome and live births have been reported following assisted reproductive technology (ART). Testicular sperm cell extraction (TESE) is possible in some men who have 45,X/46,XY mosaicism, but there is no established protocol and no reported fathering of children. Some men with Klinefelter syndrome can now father a child following TESE and ART, with multiple reports of healthy live births. Children who have NSVSC, their parents and DSD team members need to address possibilities and ethical questions relating to potential fertility preservation, with guidelines and international studies still needed.
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Affiliation(s)
- Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Claus H. Gravholt
- Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
- Institute for Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michel De Vos
- Brussels IVF, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ekaterina Koledova
- Global Medical Affairs Cardiometabolic and Endocrinology, Merck Healthcare KGaA, Darmstadt, Germany
| | - Martine Cools
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- Pediatric Endocrinology Service, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
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Peard LM, Morin J, Flores V, Graham K, Taylor AS, Pope JC, Halstead V, Cost NG, Roberts EM, Makari JH, Cranford W, Saltzman AF. Gonadal tumors in a contemporary cohort of patients with differences in sex development undergoing surgery - A multi-site study from the Pediatric Urologic Oncology Working Group of the societies for pediatric urology. J Pediatr Urol 2023:S1477-5131(23)00136-5. [PMID: 37117082 DOI: 10.1016/j.jpurol.2023.04.008] [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] [Received: 12/29/2022] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Disturbances in gonadal development lead to increased risk of gonadal malignancy in some but not all patients with differences in sex development (DSD). However, the natural history of these tumors is poorly described, and the literature remains sparse. OBJECTIVE The objective of this study was to describe the incidence of germ cell neoplasia in situ (GCNIS) and germ cell tumor (GCT) in a contemporary cohort of patients with DSD undergoing surgery and to provide long-term oncologic outcomes for these patients. STUDY DESIGN Patients with DSD who have undergone gonadectomy or gonadal biopsy were identified at four institutions. Clinical characteristics, pathology, and treatment details were obtained retrospectively. Patients were stratified into risk categories based on DSD diagnosis. Oncologic treatment and outcomes were recorded. Descriptive statistics are reported using parametric methods. RESULTS 83 patients were identified. Distribution of diagnoses is summarized in the summary table. 14 (16.9%) patients underwent gonadal biopsy, and 71 (85.5%) patients underwent gonadectomy (50/71 gonadectomies were bilateral). 8/83 (9.6%) patients had GCNIS or GCT (7 GCNIS, 1 GCT). Median age at surgery was 2.95 years (y) (interquartile range [IQR] 0.6-12.2) and 14y (IQR 0.85-16.9) in patients without and with GCNIS/GCT, respectively. All 8 patients with GCNIS/GCT had high or intermediate risk DSD diagnoses (4 mixed gonadal dysgenesis, 3 Turner with Y, 1 partial gonadal dysgenesis). Of the patients with high-risk diagnoses, 8/54 (15%) had GCNIS/GCT. No patient received adjuvant therapy, no patient had a recurrence, and all patients were living with mean follow up 6.4y. DISCUSSION The risk of gonadal malignancy is heterogeneous in the DSD population and can vary based on DSD diagnosis as well as maturation, testicularization, and location of the gonads. The most recent consensus recommendations on gonadal management emphasize risk stratification and consideration of gonadal surveillance based on gender of rearing, but supporting literature remains sparse. In this contemporary cohort of DSD patients who underwent gonadal surgery, most patients did not have evidence of adverse pathology, all patients with malignant or premalignant pathology had a high/intermediate risk DSD diagnosis, and all patients with GCNIS/GCT were treated with surgery alone without recurrence. CONCLUSIONS The distribution of patients with premalignant and malignant gonadal pathology and DSD in this cohort aligns with prior literature, and oncologic outcomes were excellent. These data add valuable information to the current literature and highlight the necessity to develop appropriate screening regimens for retained gonads.
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Affiliation(s)
- Leslie M Peard
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA; Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Jacqueline Morin
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
| | - Viktor Flores
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Kyle Graham
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Abby S Taylor
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - John C Pope
- Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, USA.
| | - Valeska Halstead
- Department of Surgery, Division of Urology, Surgical Oncology Program at Children's Hospital Colorado, University of Colorado School of Medicine, Children's Hospital of Colorado, 13123 E. 16th Ave., Aurora, CO 80045, USA.
| | - Nicholas G Cost
- Department of Surgery, Division of Urology, Surgical Oncology Program at Children's Hospital Colorado, University of Colorado School of Medicine, Children's Hospital of Colorado, 13123 E. 16th Ave., Aurora, CO 80045, USA.
| | - Evan M Roberts
- Section of Pediatric Urology, Children's Hospital and Medical Center, Omaha, NE; Division of Urology, University of Nebraska Medical Center, 8200 Dodge St., Omaha, NE 68114, USA.
| | - John H Makari
- Section of Pediatric Urology, Children's Hospital and Medical Center, Omaha, NE; Division of Urology, University of Nebraska Medical Center, 8200 Dodge St., Omaha, NE 68114, USA.
| | - Will Cranford
- Department of Biostatistics, College of Public Health, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
| | - Amanda F Saltzman
- Department of Urology, University of Kentucky, 800 Rose St., Lexington, KY 40536, USA.
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Reyes AP, León NY, Frost ER, Harley VR. Genetic control of typical and atypical sex development. Nat Rev Urol 2023:10.1038/s41585-023-00754-x. [PMID: 37020056 DOI: 10.1038/s41585-023-00754-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 04/07/2023]
Abstract
Sex development relies on the sex-specific action of gene networks to differentiate the bipotential gonads of the growing fetus into testis or ovaries, followed by the differentiation of internal and external genitalia depending on the presence or absence of hormones. Differences in sex development (DSD) arise from congenital alterations during any of these processes, and are classified depending on sex chromosomal constitution as sex chromosome DSD, 46,XY DSD or 46,XX DSD. Understanding the genetics and embryology of typical and atypical sex development is essential for diagnosing, treating and managing DSD. Advances have been made in understanding the genetic causes of DSD over the past 10 years, especially for 46,XY DSD. Additional information is required to better understand ovarian and female development and to identify further genetic causes of 46,XX DSD, besides congenital adrenal hyperplasia. Ongoing research is focused on the discovery of further genes related to typical and atypical sex development and, therefore, on improving diagnosis of DSD.
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Affiliation(s)
- Alejandra P Reyes
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- Genetics Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Nayla Y León
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Emily R Frost
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Vincent R Harley
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.
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Guerrero-Fernández J, González-Peramato P, Rodríguez Estévez A, Alcázar Villar MJ, Audí Parera L, Azcona San Julián MC, Carcavilla Urquí A, Castaño González LA, Martos Tello JM, Mora Palma C, Moreno Macián MF, Yeste Fernández D, Nistal M. Guía de consenso sobre la gonadectomía profiláctica en el desarrollo sexual diferente. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Guerrero-Fernández J, González-Peramato P, Rodríguez Estévez A, Alcázar Villar MJ, Audí Parera L, Azcona San Julián MC, Carcavilla Urquí A, Castaño González LA, Martos Tello JM, Mora Palma C, Moreno Macián MF, Yeste Fernández D, Nistal M. Consensus guide on prophylactic gonadectomy in different sex development. ENDOCRINOL DIAB NUTR 2022; 69:629-645. [PMID: 36369235 DOI: 10.1016/j.endien.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 11/06/2021] [Indexed: 06/16/2023]
Abstract
The risk of suffering from gonadal germ cell tumors (GCT) is increased in some patients with different sexual development (DSD), mainly in those with Y chromosome material. This risk, however, varies considerably depending on a multitude of factors that make the decision for prophylactic gonadectomy extremely difficult. In order to make informed recommendations on the convenience of this procedure in cases where there is potential for malignancy, this consensus guide evaluates the latest clinical evidence, which is generally low, and updates the existing knowledge in this field.
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Affiliation(s)
- Julio Guerrero-Fernández
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Servicio de Endocrinología Pediátrica, Hospital Infantil La Paz, Madrid, Spain.
| | - Pilar González-Peramato
- Departamento de Anatomía Patológica, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - María José Alcázar Villar
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Unidad de Endocrinología Pediátrica, Hospital de Fuenlabrada, Fuenlabrada, Spain
| | - Laura Audí Parera
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Vall d'Hebron Institut de Recerca (VHIR), CIBER de Enfermedades Raras (CIBERER), Hospital Vall d'Hebron, Barcelona, Spain
| | - María Cristina Azcona San Julián
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Unidad de Endocrinología Pediátrica, Departamento de Pediatría, Clínica Universidad de Navarra, Pamplona, Spain
| | - Atilano Carcavilla Urquí
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Servicio de Endocrinología Pediátrica, Hospital Infantil La Paz, Madrid, Spain
| | - Luis Antonio Castaño González
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Instituto BioCruces - Endocrinología Pediátrica, Hospital Universitario Cruces, Barakaldo, Spain
| | - José María Martos Tello
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Unidad de Endocrinología Pediátrica, Hospital Universitario Virgen de La Arrixaca, Murcia, Spain
| | - Cristina Mora Palma
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Servicio de Endocrinología Pediátrica, Hospital Infantil La Paz, Madrid, Spain
| | - Maria Francisca Moreno Macián
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Servicio de Endocrinología Pediátrica, Hospital La Fe, Valencia, Spain
| | - Diego Yeste Fernández
- Grupo de Trabajo Sobre ADS/DSD de la Sociedad Española de Endocrinología Pediátrica (SEEP), Spain; Servicio de Endocrinología Pediátrica, Hospital Materno Infantil Vall d'Hebron, CIBER de Enfermedades Raras (CIBERER), EndoERN, Barcelona, Spain
| | - Manuel Nistal
- Departamento de Anatomía, Histología y Neurociencias. Universidad Autónoma de Madrid, Madrid, Spain
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McGlacken-Byrne SM, Achermann JC, Conway GS. Management of a Girl With Delayed Puberty and Elevated Gonadotropins. J Endocr Soc 2022; 6:bvac108. [PMID: 35935072 PMCID: PMC9351373 DOI: 10.1210/jendso/bvac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Indexed: 11/19/2022] Open
Abstract
A girl presenting with delayed puberty and elevated gonadotropins may have a range of conditions such as Turner syndrome (TS), primary ovarian insufficiency (POI), and 46,XY disorders of sexual development (DSD). An organized and measured approach to investigation can help reach a timely diagnosis. Management of young people often requires specialist multidisciplinary input to address the endocrine and nonendocrine features of these complex conditions, as well as the psychological challenges posed by their diagnosis. Next-generation sequencing within the research setting has revealed several genetic causes of POI and 46,XY DSD, which may further facilitate an individualized approach to care of these young people in the future. Pubertal induction is required in many and the timing of this may need to be balanced with other issues specific to the condition (eg, allowing time for information-sharing in 46,XY DSD, optimizing growth in TS). Shared decision-making and sign-posting to relevant support groups from the outset can help empower young people and their families to manage these conditions. We describe 3 clinical vignettes of girls presenting with delayed puberty and hypergonadotropic amenorrhea and discuss their clinical management in the context of current literature and guidelines.
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Affiliation(s)
- Sinéad M McGlacken-Byrne
- Institute for Women’s Health, University College London, London WC1E 6AU, UK
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Paediatric Endocrinology, Great Ormond Street Hospital, London WC1N 3JH, UK
| | - John C Achermann
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Gerard S Conway
- Institute for Women’s Health, University College London, London WC1E 6AU, UK
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Dejonckheere C, Moyson C, de Zegher F, Antonio L, Van Buggenhout G, Decallonne B. Neoplasia in Turner syndrome: a retrospective cohort study in a tertiary referral centre in Belgium. Acta Clin Belg 2022; 77:86-92. [PMID: 32780684 DOI: 10.1080/17843286.2020.1805237] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Patients with Turner syndrome (TS), the most common sex chromosome abnormality in women, can suffer from a variety of well-researched reproductive, cardiovascular, metabolic, and autoimmune comorbidities. Few studies investigate the neoplasia risk. We assessed the general neoplasia risk in TS women, and more specifically, the gonadoblastoma/dysgerminoma risk in the subgroup with Y chromosome mosaicism, and evaluated potential risk factors for neoplasia development, such as karyotype, metabolic and autoimmune comorbidity, and treatment with growth hormone and/or estrogen replacement. DESIGN 10-year retrospective cohort study in a tertiary referral centre in Belgium. RESULTS 105 TS women were included (median age 29; range 2-69). Six malignant tumours were detected in 5 (4.8%) patients (SIR = 0.6, 95% CI 0.2-1.0). In addition, 2 benign meningiomas were observed, resulting in 3 (2.9%) tumours of the central nervous system (CNS; SIR = 19.9, 95% CI 4.0-35.8). No breast cancer was noted. Benign neoplasms occurred in 22 women (21.0%), with skin lesions being the most frequent. All patients with Y chromosome mosaicism (n = 9; 8.6%) underwent prophylactic gonadectomy, but gonadoblastoma/dysgerminoma was not detected. A weak association was found between any tumour type and autoimmune comorbidity (r = 0.24; p = 0.02). CONCLUSION The overall malignancy risk was not increased, but a different pattern of occurrence is apparent, with an increased risk of CNS and skin tumours and a decreased breast cancer risk. Gonadoblastoma/dysgerminoma was not reported. There is a need for centralised multidisciplinary care and prospective research to unravel and predict the neoplasia risk.
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Affiliation(s)
- Cas Dejonckheere
- Faculty of Medicine, Catholic University Leuven, Leuven, Belgium
| | - Carolien Moyson
- Department of Adult Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Francis de Zegher
- Department of Paediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Leen Antonio
- Department of Adult Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | | | - Brigitte Decallonne
- Department of Adult Endocrinology, University Hospitals Leuven, Leuven, Belgium
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Lu L, Luo F, Wang X. Gonadal tumor risk in pediatric and adolescent phenotypic females with disorders of sex development and Y chromosomal constitution with different genetic etiologies. Front Pediatr 2022; 10:856128. [PMID: 35935368 PMCID: PMC9353051 DOI: 10.3389/fped.2022.856128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This retrospective study sought to investigate the risk and proportion of gonadal neoplasms in phenotypic female pediatric patients with DSD and the presence of the Y chromosome and different genetic backgrounds in a single Chinese center. MATERIALS AND METHODS From January 2012 to December 2020, pediatric and adolescent patients with DSD and the presence of the Y chromosome who had unambiguous female genitalia and underwent bilateral gonadectomy or gonadal biopsy were included in this study. Patients' demographics, karyotype, laboratory test results, gross pathology, and histology of gonadal tissue were all collected. The patients were divided into three groups based on their different genetic backgrounds, and the percentage of gonadal tumors was calculated to assess the risk of gonadal tumor and malignancy by etiology. RESULTS A total of 22 patients with DSD and an unambiguous female phenotype with a Y chromosome were recruited. The mean age was 10.91 ± 4.99 years (9 months to 19 years). Gonadal neoplasia was confirmed in six (27.3%) cases by pathological examination of surgical gonadal tissue samples. Among 44 gonadal samples from these 22 patients, the following were identified: five gonadoblastomas, three dysgerminomas, and two Leydig cell tumors. The youngest patient with a tumor was a 2-year-old girl with 46,XY complete gonadal dysgenesis (46,XY CGD or Swyer syndrome) and bilateral gonadoblastoma. Patients with 46,XY complete gonadal dysgenesis (4/6; 66.7%) had the highest tumor occurrence rate. Among 10 patients with Turner syndrome with the presence of the Y chromosome, only one patient was diagnosed with a gonadal tumor. Leydig cell tumor was diagnosed in only one of six patients with 46,XY androgen synthesis/action disorders. CONCLUSION Pediatric patients with 46,XY complete gonadal dysgenesis had a significantly increased risk of developing gonadal tumors and underwent prophylactic gonadectomy as soon as the diagnosis was confirmed, whereas those with Turner syndrome with Y chromosome and 46,XY androgen synthesis/action disorders had a relatively low risk. In view of the limited number of patients, a large multicenter study with close follow-ups is needed to support these conclusions.
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Affiliation(s)
- Liangsheng Lu
- Division of Pediatric Urology, Children's Hospital of Fudan University, Shanghai, China
| | - Feihong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Xiang Wang
- Division of Pediatric Urology, Children's Hospital of Fudan University, Shanghai, China
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O'Connell MA, Atlas G, Ayers K, Sinclair A. Establishing a molecular genetic diagnosis in children with Differences of Sex Development - a clinical approach. Horm Res Paediatr 2021; 96:128-143. [PMID: 34781289 DOI: 10.1159/000520926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022] Open
Abstract
Background Despite distinct underlying aetiologies, the clinical phenotypes and hormonal profiles of children with various differences of sex development (DSD) are often similar, which presents challenges to ascertaining an accurate diagnosis on clinical grounds alone. Associated features and important clinical outcomes can, however, vary significantly in different DSD, thus establishing an accurate molecular diagnosis may have important implications for decision-making and management planning in a given individual. Summary The wider availability of next generation sequencing techniques in recent years has led to recommendations for earlier integration of genetic testing in the diagnostic pathway of children with DSD. This review provides a practical overview of the clinical applications, advantages and limitations of the more commonly available diagnostic genetic tests and outlines a suggested approach to testing. The potential clinical implications of a confirmed genetic diagnosis on subsequent management pathways for individuals with DSD, as well as challenges that remain to be addressed are also outlined. Key messages Despite significant improvements in our understanding of the complex genetic pathways that underlie DSD, an accurate diagnosis still eludes many affected individuals. Establishing a molecular diagnosis provides aetiological certainty, enabling improved information for families and individualised clinical management, including monitoring or prophylactic intervention where higher longer-term health risks exist. A stepwise approach to genomic testing is recommended to afford highest diagnostic yield from available resources. Looking forward, collaborative multicentre prospective studies will be required to assess the true impact of a genetic diagnosis on improving clinical care pathways and health, wellbeing and patient-reported outcomes for individuals with DSD.
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Syryn H, Van De Vijver K, Cools M. Ovotesticular Difference of Sex Development: Genetic Background, Histological Features, and Clinical Management. Horm Res Paediatr 2021; 96:180-189. [PMID: 34469891 DOI: 10.1159/000519323] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ovotesticular disorder/difference of sex development (DSD) refers to the co-presence of testicular and ovarian tissue in one individual. Childhood management is challenging as there are many uncertainties regarding etiology, gonadal function, and gender outcome. SUMMARY Ovotesticular DSD should mainly be considered in 46,XX children with atypical genitalia and normal adrenal steroid profiles. Various underlying genetic mechanisms have been described. Histological assessment of ovotestes requires expert revision and has many pitfalls. Neonatal sex assignment is essential, but as gender outcome is unpredictable, this should be regarded as provisional until a stable gender identity has developed. Therefore, it is crucial not to perform any irreversible medical or surgical procedure in affected individuals until adolescents can give their full informed consent. Gonadal function mostly allows for spontaneous pubertal development; however, fertility is compromised, especially in boys. Specific long-term outcome data for ovotesticular DSD are lacking but can be extrapolated from studies in other DSD populations. Key Messages: Management of ovotesticular DSD has changed in recent years, prioritizing the child's future right for autonomy and self-determination. The benefits and pitfalls of this new approach have not been documented yet and require intensive monitoring on an international scale.
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Affiliation(s)
- Hannes Syryn
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | | | - Martine Cools
- Department of Internal Medicine and Pediatrics, Ghent University and Pediatric Endocrinology Service, Ghent University Hospital, Ghent, Belgium
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12
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Hansel DE. A 25 year perspective on advances in the pathologic assessment and diagnosis of urologic cancers. Urol Oncol 2021; 39:582-594. [PMID: 34215506 DOI: 10.1016/j.urolonc.2021.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/05/2021] [Accepted: 05/09/2021] [Indexed: 12/15/2022]
Abstract
Over the past 25 years, diagnostic categories in genitourinary pathology have changed dramatically. Prostate cancer reporting incorporated numerous new variant categories, recognized the importance of intraductal carcinoma, and introduced the concept of Grade Groups. Pathologic diagnosis of bladder cancer not only added new variant categories, but also modified the grading of non-invasive urothelial neoplasms and refined staging definitions. Kidney cancer classification expanded from a handful of diagnostic categories to a broad array of additional cancer types defined by unique immunohistochemical and molecular findings. Segregation of penile carcinoma by human papillomavirus status more accurately reflected pathogenesis and helped improve prediction of cancer behavior. Testicular pathology research advanced understanding of germ cell tumor subtypes and their impact on patient outcomes. Finally, adrenal gland pathology has evolved to incorporate a broader recognition of morphological variation and risk factors associated with tumor progression. Taken together, changes in pathology over the past quarter century have revolutionized our approach to genitourinary cancers. This review seeks to highlight some of the many significant changes in genitourinary pathology that have occurred during the past 25 years and emphasize impacts on clinical outcomes or therapy, as relevant.
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Affiliation(s)
- Donna E Hansel
- Department of Pathology & Laboratory Medicine, Oregon Health & Science University, Portland, OR.
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Zhou Y, Xue X, Shi P, Lu Q, Lv S. Multidisciplinary team management of 46,XY 17α-hydroxylase deficiency: a case report and literature review. J Int Med Res 2021; 49:300060521993965. [PMID: 33761789 PMCID: PMC8165845 DOI: 10.1177/0300060521993965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We report here a case study of 17α-hydroxylase deficiency in a phenotypic girl with male karyotype (46,XY). We also review the relevant literature to deepen our understanding of the disease, reduce the rate of missed diagnosis, and emphasize that holistic management of this disease requires collaborative multidisciplinary teamwork. CASE PRESENTATION A 14-year-old patient with a female phenotype visited the endocrinology department because of hypertension. The patient had primary amenorrhea and lacked secondary sexual characteristics. Initial laboratory evaluation revealed normal levels of electrolytes, a hypergonadotropic hypogonadal state with high progesterone and low testosterone levels, and a 46,XY karyotype. She was referred to the urology department for gonadectomy and transferred to the gynecological endocrine clinic. On the basis of the patient's medical history and genetic testing results, a diagnosis of 46,XY 17α-hydroxylase deficiency was made. The patient was provided with glucocorticoids, estrogens, metformin, and psychological support. CONCLUSIONS Patients with 17α-hydroxylase deficiency, a rare cause of congenital adrenal hyperplasia, should be treated by a multidisciplinary team. Relevant experts from different disciplines should set up a systematic and comprehensive individualized management plan to optimize the physical and mental health and quality of life of affected patients.
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Affiliation(s)
- Yang Zhou
- Department of Gynecology, Affiliated Hospital of Northwestern Polytechnical University, Xi'an, Shaanxi, China
| | - Xue Xue
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Panpan Shi
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qinrui Lu
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Shulan Lv
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Santi M, Graf S, Zeino M, Cools M, Van De Vijver K, Trippel M, Aliu N, Flück CE. Approach to the Virilizing Girl at Puberty. J Clin Endocrinol Metab 2021; 106:1530-1539. [PMID: 33367768 PMCID: PMC8063244 DOI: 10.1210/clinem/dgaa948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Indexed: 11/19/2022]
Abstract
UNLABELLED Virilization is the medical term for describing a female who develops characteristics associated with male hormones (androgens) at any age, or when a newborn girl shows signs of prenatal male hormone exposure at birth. In girls, androgen levels are low during pregnancy and childhood. A first physiologic rise of adrenal androgens is observed at the age of 6 to 8 years and reflects functional activation of the zona reticularis of the adrenal cortex at adrenarche, manifesting clinically with first pubic and axillary hairs. Early adrenarche is known as "premature adrenarche." It is mostly idiopathic and of uncertain pathologic relevance but requires the exclusion of other causes of androgen excess (eg, nonclassic congenital adrenal hyperplasia) that might exacerbate clinically into virilization. The second modest physiologic increase of circulating androgens occurs then during pubertal development, which reflects the activation of ovarian steroidogenesis contributing to the peripheral androgen pool. However, at puberty initiation (and beyond), ovarian steroidogenesis is normally devoted to estrogen production for the development of secondary female bodily characteristics (eg, breast development). Serum total testosterone in a young adult woman is therefore about 10- to 20-fold lower than in a young man, whereas midcycle estradiol is about 10- to 20-fold higher. But if androgen production starts too early, progresses rapidly, and in marked excess (usually more than 3 to 5 times above normal), females will manifest with signs of virilization such as masculine habitus, deepening of the voice, severe acne, excessive facial and (male typical) body hair, clitoromegaly, and increased muscle development. Several medical conditions may cause virilization in girls and women, including androgen-producing tumors of the ovaries or adrenal cortex, (non)classical congenital adrenal hyperplasia and, more rarely, other disorders (also referred to as differences) of sex development (DSD). The purpose of this article is to describe the clinical approach to the girl with virilization at puberty, focusing on diagnostic challenges. The review is written from the perspective of the case of an 11.5-year-old girl who was referred to our clinic for progressive, rapid onset clitoromegaly, and was then diagnosed with a complex genetic form of DSD that led to abnormal testosterone production from a dysgenetic gonad at onset of puberty. Her genetic workup revealed a unique translocation of an abnormal duplicated Y-chromosome to a deleted chromosome 9, including the Doublesex and Mab-3 Related Transcription factor 1 (DMRT1) gene. LEARNING OBJECTIVES Identify the precise pathophysiologic mechanisms leading to virilization in girls at puberty considering that virilization at puberty may be the first manifestation of an endocrine active tumor or a disorder/difference of sex development (DSD) that remained undiagnosed before and may be life-threatening. Of the DSDs, nonclassical congenital adrenal hyperplasia occurs most often.Provide a step-by-step diagnostic workup plan including repeated and expanded biochemical and genetic tests to solve complex cases.Manage clinical care of a girl virilizing at puberty using an interdisciplinary team approach.Care for complex cases of DSD manifesting at puberty, such as the presented girl with a Turner syndrome-like phenotype and virilization resulting from a complex genetic variation.
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Affiliation(s)
- Maristella Santi
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefanie Graf
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mazen Zeino
- Department of Pediatric Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martine Cools
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | | | - Mafalda Trippel
- Institute of Pathology, Inselspital, University of Bern, Bern, Switzerland
| | - Nijas Aliu
- University Clinic for Pediatrics, Human Genetics, Inselspital, University of Bern, Bern, Switzerland
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of BioMedical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Correspondence: Christa E. Flück, Pediatric Endocrinology and Diabetology, University Children’s Hospital, Freiburgstrasse 15 / C845, 3010 Bern, Switzerland. E-mail:
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Cellular fate of intersex differentiation. Cell Death Dis 2021; 12:388. [PMID: 33846307 PMCID: PMC8041806 DOI: 10.1038/s41419-021-03676-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 02/02/2023]
Abstract
Infertile ovotestis (mixture of ovary and testis) often occurs in intersex individuals under certain pathological and physiological conditions. However, how ovotestis is formed remains largely unknown. Here, we report the first comprehensive single-cell developmental atlas of the model ovotestis. We provide an overview of cell identities and a roadmap of germline, niche, and stem cell development in ovotestis by cell lineage reconstruction and a uniform manifold approximation and projection. We identify common progenitors of germline stem cells with two states, which reveal their bipotential nature to differentiate into both spermatogonial stem cells and female germline stem cells. Moreover, we found that ovotestis infertility was caused by degradation of female germline cells via liquid-liquid phase separation of the proteasomes in the nucleus, and impaired histone-to-protamine replacement in spermatid differentiation. Notably, signaling pathways in gonadal niche cells and their interaction with germlines synergistically determined distinct cell fate of both male and female germlines. Overall, we reveal a cellular fate map of germline and niche cell development that shapes cell differentiation direction of ovotestis, and provide novel insights into ovotestis development.
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Duranteau L, Rapp M, van de Grift TC, Hirschberg AL, Nordenskjöld A. Participant- and Clinician-Reported Long-Term Outcomes After Surgery in Individuals with Complete Androgen Insensitivity Syndrome. J Pediatr Adolesc Gynecol 2021; 34:168-175. [PMID: 33248216 DOI: 10.1016/j.jpag.2020.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/24/2020] [Accepted: 11/14/2020] [Indexed: 01/01/2023]
Abstract
STUDY OBJECTIVE To evaluate the outcomes of genital surgery through participant's and observer's satisfaction with the anatomical and functional result. DESIGN AND SETTING Multicenter cross-sectional study in 14 clinics in 6 European countries in 2014-2015. PARTICIPANTS Seventy-one individuals with complete androgen insensitivity syndrome (≥16 years old). INTERVENTIONS Data from clinical report files, an optional gynecological examination, patient-reported outcomes on received surgical interventions, satisfaction with appearance and function after surgery, and effect of the surgical procedure on life. MAIN OUTCOME MEASURES Outcomes were calculated per different surgical treatments. Linear regression models were used for associations with vaginal satisfaction. RESULTS Sixty-three participants had received surgery: 62 gonadectomies, 12 vaginal surgeries with or without vaginal dilations, 9 vaginal dilations only, and 2 breast enlargements. More than half of the participants took part in the gynecological examination. Vaginal length was similar in those without (60 mm) and with (67 mm) vaginoplasty and/or vaginal dilations. Participant- and observer-reported appearance of the genitals were generally satisfactory to good. Sexual complaints (pain or bleeding during/after intercourse) were common. Vaginal satisfaction was strongly associated with satisfaction with sex life in general, whereas vaginal interventions and number of surgeries were not. Many participants reported a negative effect of gonadectomy on their life. CONCLUSION Despite good genital appearance, functional problems are commonly reported, across the different nonsurgical and surgical regimens. Patient-reported outcomes should be evaluated before and after surgical procedures. Because of the negative effect on life and the low risk of malignancy, gonadectomy should be deferred to adulthood with regular follow-up.
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Affiliation(s)
- Lise Duranteau
- Adolescent and Young Adult Gynecology Unit, Centre de Reference des Maladies Rares du Developpement Genital, Hôpital Bicêtre, AP.HP Paris Saclay University, Le Kremlin Bicêtre, France
| | - Marion Rapp
- Klinik fur Kinder- und Jugendmedizin, Universitat zu Lubeck, Lubeck, Germany
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Department of Medical Psychology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Angelica L Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, and Department of Gynaecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health and Centre for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden; Paediatric Surgery, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden.
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17
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Debo B, Van Loocke M, De Groote K, De Leenheer E, Cools M. Multidisciplinary Approach to the Child with Sex Chromosomal Mosaicism Including a Y-Containing Cell Line. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18030917. [PMID: 33494433 PMCID: PMC7908257 DOI: 10.3390/ijerph18030917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 01/15/2023]
Abstract
Children born with sex chromosomal mosaicism including material derived from the Y chromosome may present with a broad phenotypical spectrum. Both boys and girls can present with Turner features and functional health problems typically associated with Turner syndrome, but the presence of Y-chromosomal material can modify some aspects of the condition. We retrospectively analyzed the results of our cohort of 21 individuals (14 boys, 7 girls) with sex chromosomal mosaicism including Y-derived material followed at Ghent University Hospital according to our local multidisciplinary Turner surveillance protocol. Results were compared with literature data, focusing on similarities and differences between girls and boys with this condition. Age at diagnosis was lower in boys compared to girls but the difference was not significant. Short stature is a key feature of the condition both in girls and boys, but skeletal maturation may be different between groups. The effects of growth-hormone therapy remain unclear. Cardiac (33%), ear-nose- throat (ENT) (77.8%) and renal (28.6%) problems were as prevalent in boys as in girls from our cohort, and did not differ from literature data. In line with literature reports, a significant difference in the presence of premalignant germ cell tumors between males (0%) and females (42.9%) was found (p = 0.026). Taken together, this study demonstrates the similarities between girls with Turner syndrome and children with sex chromosomal mosaicism including Y-derived material, regardless of the child’s gender. Nowadays, girls with Turner syndrome are offered a dedicated multidisciplinary follow-up in many centers. We advocate a similar follow-up program for all children who have sex chromosomal mosaicism that includes Y-derived material, with special attention to growth, cardiac and ear-nose-throat problems, gonadal function and malignancies.
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Affiliation(s)
- Bauke Debo
- Internal Medicine and Pediatrics, Ghent University and Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, 9000 Ghent, Belgium; (B.D.); (M.V.L.)
| | - Marlies Van Loocke
- Internal Medicine and Pediatrics, Ghent University and Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, 9000 Ghent, Belgium; (B.D.); (M.V.L.)
| | - Katya De Groote
- Internal Medicine and Pediatrics, Department of Pediatrics, Division of Pediatric Cardiology, Ghent University Hospital, Ghent University, 9000 Ghent, Belgium;
| | - Els De Leenheer
- Department of Otorhinolaryngology, Ghent University Hospital, Ghent University, 9000 Ghent, Belgium;
| | - Martine Cools
- Internal Medicine and Pediatrics, Ghent University and Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, 9000 Ghent, Belgium; (B.D.); (M.V.L.)
- Correspondence:
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Li Z, Liu J, Peng Y, Chen R, Ge P, Wang J. 46, XX Ovotesticular disorder of sex development (true hermaphroditism) with seminoma: A case report. Medicine (Baltimore) 2020; 99:e22530. [PMID: 33019456 PMCID: PMC7535655 DOI: 10.1097/md.0000000000022530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Morin J, Peard L, Saltzman AF. Gonadal malignancy in patients with differences of sex development. Transl Androl Urol 2020; 9:2408-2415. [PMID: 33209714 PMCID: PMC7658134 DOI: 10.21037/tau-19-726] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Differences of sexual development (DSD) are known to be associated with an elevated risk of malignant and pre-malignant tumors. However, given the rarity of DSD and tumors in patients with DSD, more robust, large scale, prospective literature is required to truly determine the extent of this association, long-term outcomes and the nuances associated with the wide variety of DSD diagnoses. In addition, the spectrum of diagnoses and nomenclature has been ever-changing, limiting assessment of long-term patient outcomes. This review aims to provide an overview of the pathogenesis of DSD conditions, potential malignancies associated with the diagnoses, the available screening for malignancy, and the most recent data on stratification for each DSD diagnosis and association with malignancy.
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Affiliation(s)
- Jacqueline Morin
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Leslie Peard
- Department of Urology, University of Kentucky, Lexington, KY, USA
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Morin J, Peard L, Vanadurongvan T, Walker J, Dönmez Mİ, Saltzman AF. Oncologic outcomes of pre-malignant and invasive germ cell tumors in patients with differences in sex development - A systematic review. J Pediatr Urol 2020; 16:576-582. [PMID: 32564942 DOI: 10.1016/j.jpurol.2020.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/14/2020] [Accepted: 05/04/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To describe the rates of GCNIS-free and GCT-free pathology based on age at gonadal surgery and to describe long-term oncologic outcomes in patients with DSD who have GCNIS or GCT at the time of gonadal surgery. STUDY DESIGN A systematic review was conducted using MEDLINE to identify patients with DSD who underwent gonadal surgery. DSD diagnoses were stratified based on malignancy risk. GCNIS/GCT and GCT-free survival by age of gonadal surgery, RFS and OS were calculated using the Kaplan-Meier method, with groups compared using log-rank testing. RESULTS 386 articles from 1951 to 2017 were included (2037 patients). Median age at gonadal surgery was 17 years (y) (IQR 11-20), median follow-up was 60 months (m) (IQR 30-68.1). GCNIS/GCT- and GCT-free survival at the time of gonadal surgery was lowest for those in the high/intermediate risk group (p < 0.001) but decreased sharply around age 15y, regardless of risk category. 5y RFS and OS was similar for those with no GCNIS/GCT and GCNIS and was worse for those with GCT (p < 0.001). DISCUSSION When patients undergo gonadal surgery, regardless of indication (i.e. prophylactic vs. tumor), it appears that GCTs are more commonly found when surgery is done around age 15 y or older, despite risk category. This is similar to ovarian and testicular GCTs. Patients with GCNIS can be reassured that long-term oncologic outcomes are excellent. While RFS and OS for GCTs are not as good as for ovarian and testicular GCTs (95%), they are still >80%. This similar trend was found in a COG review of 9 patients with DSD and ovarian GCT. There were several limitations to this study. This is a retrospective analysis that included aa wide time frame of publications. The indication for surgical intervention was not addressed in the majority of publications. Thus these data provide pathologic outcomes based on age at gonadal surgery rather than the age at which GCNIS/GCT develops over a lifetime, if at all. CONCLUSIONS The risk of GCNIS or GCT at the time of gonadal surgery appears to increase with age, accelerating between 15 and 20y regardless of risk category. 5y RFS and OS for those with GCNIS is equivalent to those without GCNIS/GCT but is worse for those with GCT. These data may be used when counseling families on timing of gonadal surgery and quantification of outcomes should GCNIS or malignancy be identified.
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Affiliation(s)
- Jacqueline Morin
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Leslie Peard
- Department of Urology, University of Kentucky, Lexington, KY, USA
| | - Timothy Vanadurongvan
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan Walker
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
| | - M İrfan Dönmez
- Department of Surgery, Division of Urology, University of Colorado School of Medicine, Aurora, CO, USA
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Guerra F, Quintana S, Giustina S, Mendeluk G, Jufe L, Avagnina MA, Díaz LB, Palaoro LA. Investigation of EGFR/pi3k/Akt signaling pathway in seminomas. Biotech Histochem 2020; 96:125-137. [PMID: 32597316 DOI: 10.1080/10520295.2020.1776393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Activation of the receptor for epidermal growth factor (EGFR) in some testicular tumors activates several signaling pathways. Some components of these pathways are phosphorylated or mutated in testicular germ tumors (TCGT), including EGFR, Kirstein ras oncogen (KRAS) and cell surface protein of the germ cell (KIT). The latter two activate RAF ⁄MEK⁄ERK and PI3 K⁄AKT, and interconnect with the EGFR/pI3 k/Akt pathway. We investigated the expression of EGFR/pI3 k/Akt pathway proteins in seminomas and in their precursor lesion, germinal cell neoplasia in situ (GCNIS) and related genetic mutations. We used immunohistochemistry for pEGFR, pI3 k and pAkt expression with a scoring system for 46 seminoma surgical specimens: 36 classical and 10 GCNIS. In 17 samples, the mutations of EGFR (exons 19 - 21), KIT (exons 11, 17) and KRAS (exons 2, 3) were investigated using qPCR and sequencing. Of the 36 seminomas studied, 22 (61%) expressed pEGFR. Ten samples exhibited high scores for pEGFR, pI3 k and pAkt. In 5 of 17 cases (33%) some mutation was exhibited in the exons studied: 21 of EGFR (2), 17 of EGFR (1), 3 of KRAS (1) and 11 of KIT (1). Six cases exhibited nuclear translocation of EGFR; of these, four exhibited mutations of EGFR, KRAS and KIT. Eight of ten of the GCNIS expressed a high pEGFR score (80%). In 2 of 6 cases (33%), mutation was detected in exon 21 of EGFR and one smear showed EGFR translocation to the nucleus. The translocation represents a subpopulation with worse prognosis for TCGT. The EGFR/pI3 k/Akt signaling pathway is linked to TDRG1, which regulates chemosensitivity to cisplatin; this is a mechanism of resistance to treatment. TDRG1 and the EGFR/pI3 k/pAkt pathway could be therapeutic targets for seminomas resistant to cisplatin.
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Affiliation(s)
- F Guerra
- Department of Clinical Biochemistry, Clinical Hospital (UBA), C.A.B.A., INFIBIOC , Córdoba, Argentina
| | - S Quintana
- Fares Taie Institute , Mar Del Plata, Buenos Aires, Argentina
| | - S Giustina
- Fares Taie Institute , Mar Del Plata, Buenos Aires, Argentina
| | - G Mendeluk
- Department of Clinical Biochemistry, Clinical Hospital (UBA), C.A.B.A., INFIBIOC , Córdoba, Argentina
| | - L Jufe
- Laboratory of Pathology, Ramos Mejía Hospital, C.A.B.A ., Argentina
| | - M A Avagnina
- Department of Pathology, Clinical Hospital (UBA), C.A.B.A ., Córdoba, Argentina
| | - L B Díaz
- Department of Pathology, Clinical Hospital (UBA), C.A.B.A ., Córdoba, Argentina
| | - L A Palaoro
- Department of Clinical Biochemistry, Clinical Hospital (UBA), C.A.B.A., INFIBIOC , Córdoba, Argentina
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22
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Johnson EK, Finlayson C, Finney EL, Harris CJ, Tan SY, Laronda MM, Lockart BA, Chen D, Rowell EE, Cheng EY, Yerkes EB. Gonadal Tissue Cryopreservation for Children with Differences of Sex Development. Horm Res Paediatr 2020; 92:84-91. [PMID: 31509845 DOI: 10.1159/000502644] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/11/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Infertility is common for individuals with differences of sex development (DSD) and is a significant concern to these individuals. Fertility potential in many DSD conditions is poorly understood. Gonadal tissue cryopreservation (GTC) for fertility preservation (FP) is offered to children with cancer undergoing gonadotoxic therapy. Our team sought to expand the field of FP by offering and evaluating the success of GTC for individuals with DSD. MATERIALS AND METHODS GTC was offered to patients with DSD undergoing prophylactic gonadectomy, after extensive multidisciplinary counseling. For those who elected to attempt GTC, data were retrospectively abstracted, including: DSD diagnosis, age at gonadectomy, indication for gonadectomy, pathology results, and final decision about long-term gonadal tissue storage. RESULTS Ten patients were enrolled to attempt GTC, with a mean age of 11.5 years (range 1-18). Five of the 10 patients had germ cells (GCs) present. Diagnoses (age at gonadectomy) for patients with GCs included ovotesticular DSD (13 months), mixed gonadal dysgenesis (17 months), partial gonadal dysgenesis (3 years), partial androgen insensitivity syndrome (11 years), and mixed gonadal dysgenesis (12 years). Four of the 5 subjects with GCs elected for GTC. One opted against GTC, citing immature gametes that did not match gender identity. CONCLUSION GTC at the time of gonadectomy for patients with DSD is feasible. In many patients, GCs are present. While questions remain about the timing of gonadectomy, quality of GCs, and future success for use of the tissue based on technological advancement, GTC represents a novel approach to experimental FP for individuals with DSD.
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Affiliation(s)
- Emilie K Johnson
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA, .,Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA,
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Esther L Finney
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Courtney J Harris
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Serena Y Tan
- Department of Pathology and Laboratory Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Monica M Laronda
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Barbara A Lockart
- Division of Hematology, Oncology, and Stem Cell Transplantation, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Diane Chen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Potocsnak Family Division of Adolescent and Young Adult Medicine and Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Erin E Rowell
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Earl Y Cheng
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elizabeth B Yerkes
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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23
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Bever YV, Brüggenwirth HT, Wolffenbuttel KP, Dessens AB, Groenenberg IAL, Knapen MFCM, De Baere E, Cools M, van Ravenswaaij-Arts CMA, Sikkema-Raddatz B, Claahsen-van der Grinten H, Kempers M, Rinne T, Hersmus R, Looijenga L, Hannema SE. Under-reported aspects of diagnosis and treatment addressed in the Dutch-Flemish guideline for comprehensive diagnostics in disorders/differences of sex development. J Med Genet 2020; 57:581-589. [PMID: 32303604 PMCID: PMC7476274 DOI: 10.1136/jmedgenet-2019-106354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 01/02/2020] [Accepted: 01/22/2020] [Indexed: 12/14/2022]
Abstract
We present key points from the updated Dutch-Flemish guideline on comprehensive diagnostics in disorders/differences of sex development (DSD) that have not been widely addressed in the current (inter)national literature. These points are of interest to physicians working in DSD (expert) centres and to professionals who come across persons with a DSD but have no (or limited) experience in this area. The Dutch-Flemish guideline is based on internationally accepted principles. Recent initiatives striving for uniform high-quality care across Europe, and beyond, such as the completed COST action 1303 and the European Reference Network for rare endocrine conditions (EndoERN), have generated several excellent papers covering nearly all aspects of DSD. The Dutch-Flemish guideline follows these international consensus papers and covers a number of other topics relevant to daily practice. For instance, although next-generation sequencing (NGS)-based molecular diagnostics are becoming the gold standard for genetic evaluation, it can be difficult to prove variant causality or relate the genotype to the clinical presentation. Network formation and centralisation are essential to promote functional studies that assess the effects of genetic variants and to the correct histological assessment of gonadal material from DSD patients, as well as allowing for maximisation of expertise and possible cost reductions. The Dutch-Flemish guidelines uniquely address three aspects of DSD. First, we propose an algorithm for counselling and diagnostic evaluation when a DSD is suspected prenatally, a clinical situation that is becoming more common. Referral to ultrasound sonographers and obstetricians who are part of a DSD team is increasingly important here. Second, we pay special attention to healthcare professionals not working within a DSD centre as they are often the first to diagnose or suspect a DSD, but are not regularly exposed to DSDs and may have limited experience. Their thoughtful communication to patients, carers and colleagues, and the accessibility of protocols for first-line management and efficient referral are essential. Careful communication in the prenatal to neonatal period and the adolescent to adult transition are equally important and relatively under-reported in the literature. Third, we discuss the timing of (NGS-based) molecular diagnostics in the initial workup of new patients and in people with a diagnosis made solely on clinical grounds or those who had earlier genetic testing that is not compatible with current state-of-the-art diagnostics.
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Affiliation(s)
- Yolande van Bever
- Department of Clinical Genetics and DSD Expert Center Erasmus Medical Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hennie T Brüggenwirth
- Department of Clinical Genetics and DSD Expert Center Erasmus Medical Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Katja P Wolffenbuttel
- Department of Pediatric Urology and DSD Expert Center Erasmus Medical Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arianne B Dessens
- Department of Child and Adolescent Psychiatry and DSD Expert Center Erasmus Medical Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irene A L Groenenberg
- Department of Obstetrics and Prenatal Medicine and DSD Expert Center Erasmus Medical Center, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Maarten F C M Knapen
- Department of Obstetrics and Prenatal Medicine and DSD Expert Center Erasmus Medical Center, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Elfride De Baere
- Center for Medical Genetics, University Hospital Ghent Center Medical Genetics, Ghent, Belgium
| | - Martine Cools
- Department of Internal Medicine and Paediatrics and Department of Pediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | | | - Birgit Sikkema-Raddatz
- Department of Genetics and DSD team, University Medical Center Groningen, Groningen, The Netherlands
| | - Hedi Claahsen-van der Grinten
- Department of Pediatric Endocrinology and DSD Expert Center Radboud UMC, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Marlies Kempers
- Department of Clinical genetics and DSD Expert Center Radboud UMC, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tuula Rinne
- Department of Clinical genetics and DSD Expert Center Radboud UMC, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Remko Hersmus
- Department of Pathology, DSD Expert Center ErasmusMC, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
| | - Leendert Looijenga
- Department of Pathology, DSD Expert Center ErasmusMC, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands.,Department of Pathology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Sabine E Hannema
- Department of Pediatric Endocrinology and DSD Expert Center ErasmusMC, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands.,Department of Pediatrics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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24
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Dabrowski E, Johnson EK, Patel V, Hsu Y, Davis S, Goetsch AL, Habiby R, Brickman WJ, Finlayson C. Turner Syndrome with Y Chromosome: Spontaneous Thelarche, Menarche, and Risk of Malignancy. J Pediatr Adolesc Gynecol 2020; 33:10-14. [PMID: 31465855 PMCID: PMC7413626 DOI: 10.1016/j.jpag.2019.08.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/06/2019] [Accepted: 08/19/2019] [Indexed: 01/05/2023]
Abstract
STUDY OBJECTIVE Girls with Turner syndrome with Y-chromosome material (TS + Y) are assumed to have nonfunctional gonads with increased tumor risk, therefore prophylactic gonadectomy is recommended at diagnosis. In this study we aimed to determine rates of spontaneous thelarche (ST) and spontaneous menarche (SM), and prevalence of gonadal tumor and malignancy in girls with TS + Y, to further inform discussions about gonadectomy. DESIGN Retrospective review of clinical and pathology data. SETTING Multicenter study involving 4 United States children's hospitals. PARTICIPANTS Patients included those with a genetically proven diagnosis of TS + Y and phenotypically female genitourinary exam. INTERVENTIONS Demographic characteristics, pubertal development, and gonadal pathology data were abstracted from clinical records. Data for ST were analyzed for patients aged 13 years and older and SM for patients older than 15 years. MAIN OUTCOME MEASURES ST, SM, prevalence of gonadal tumor, and malignancy. RESULTS Forty-four patients met inclusion criteria. Nineteen patients were 13 years or older; 8/19 (42%) had ST and reached Tanner stages 2-4 and 2 (11%) had normal ovarian pathology. Nineteen patients were 15 years or older; 2/19 (11%) had SM. Thirty-seven patients underwent gonadectomy; 35 had available pathology results. Gonadoblastoma was identified in 35/7 patients (19%), 1 in situ germ cell neoplasia, and 1 dysgerminoma (3%). One patient with bilateral gonadoblastoma had ST and SM. CONCLUSION In this multicenter cohort, 42% of girls with TS + Y entered puberty spontaneously and 11% had SM, supportive of gonadal function. Risk of tumor was similar to previous reports. To achieve informed decision-making, discussions about gonadectomy should incorporate potential for gonadal function and tumor risk.
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Affiliation(s)
- Elizabeth Dabrowski
- Division of Pediatric Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vrunda Patel
- Division of Adolescent Medicine and Pediatric Gynecology, Children's National Medical Center, Wilmington, Delaware
| | - YeoChing Hsu
- Division of Pediatric Endocrinology, Cohen Children's Medical Center, Northwell Health, Zucker School of Medicine at Hofstra/Northwell
| | - Shanlee Davis
- Division of Pediatric Endocrinology, University of Colorado, Denver, Colorado
| | - Allison L Goetsch
- Division of Genetics, Birth Defects and Metabolism, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Reema Habiby
- Division of Pediatric Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Wendy J Brickman
- Division of Pediatric Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Courtney Finlayson
- Division of Pediatric Endocrinology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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25
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A Management Protocol for Gonad Preservation in Patients with Androgen Insensitivity Syndrome. J Pediatr Adolesc Gynecol 2019; 32:605-611. [PMID: 31233832 PMCID: PMC6917890 DOI: 10.1016/j.jpag.2019.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022]
Abstract
Historically, individuals with androgen insensitivity syndrome (AIS) were managed with removal of gonadal tissue at various ages to avert the risk of gonadal malignancy. Recently, clinical practice changed, with gonadectomy being postponed until late adolescence. Adolescents and adults with complete AIS have questioned this approach. Additionally, testicular germ cell tumors are increasingly believed to be quite rare with rates as low as 0% in molecularly confirmed individuals with AIS. Gonadectomy deprives patients of the benefits of their endogenous hormones and potential fertility. Furthermore, human rights organizations advocate for deferring irreversible surgery in conditions known as differences of sex development, which includes AIS, to allow patient autonomy in decision-making. Recent literature supports an approach that uses risk stratification to manage gonads in AIS. Herein we review what is known about malignancy risk in the different subtypes of AIS and propose a management protocol for gonad retention.
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26
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García-Acero M, Moreno-Niño O, Suárez-Obando F, Molina M, Manotas MC, Prieto JC, Forero C, Céspedes C, Pérez J, Fernandez N, Rojas A. Disorders of sex development: Genetic characterization of a patient cohort. Mol Med Rep 2019; 21:97-106. [PMID: 31746433 PMCID: PMC6896350 DOI: 10.3892/mmr.2019.10819] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/09/2019] [Indexed: 12/19/2022] Open
Abstract
Disorders of sex development (DSDs) are congenital conditions in which the external appearance of the individual does not coincide with the chromosomal constitution or the gonadal sex. In other words, there is an ambiguous or intermediate condition between the male and female phenotypes of the anatomical sex. These atypical conditions are manifested in several ways, ranging from genital ambiguity to phenotypes that are so attenuated that they can go unnoticed or appear normal. Currently, there is a lack of understanding of the factors responsible for these outcomes; however, they are likely to be conditioned by genetic, hormonal and environmental factors during prenatal and postnatal development. The present study determined the genetic etiology of DSDs in Colombian patients by conventional cytogenetic analysis, FISH and MLPA (for SF1, DAX1, SOX9, SRY and WNT4). A cohort of 43 patients with clinical phenotypes of sex development disorder was used in the present study. Using this multistep experimental approach, a diagnostic percentage of 25.58% was obtained: 17 patients (39.53%) were classified as having gonadal development disorders, the majority of which were ovotesticular disorders with numerical and/or structural alterations of the sex chromosomes, 9 patients (20.93%) were classified as having testicular DSD with a 46,XY karyotype, and 3 patients (6.98%) as having ovarian DSD with a 46,XX karyotype. The remaining 14 patients (32.56%) were classified as 'other' since they could not be grouped into a specific class of gonadal development, corresponding to hypospadias and multiple congenital anomalies. These findings highlight the importance of histological and cytogenetic studies in a gonadal biopsy. In 11/43 cases, the multistep experimental protocol presented in the present study yielded etiological or histological findings that could be used to define the medical management of patients with DSDs. In conclusion, for the etiological diagnosis of DSDs, a broad‑spectrum approach that includes endocrinological tests, conventional karyotyping, molecular karyotyping by FISH and, molecular tests is required, in addition to gonadal tissue analyses, to identify genetic alterations.
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Affiliation(s)
- Mary García-Acero
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Olga Moreno-Niño
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Fernando Suárez-Obando
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Mónica Molina
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - María Carolina Manotas
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Juan Carlos Prieto
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Catalina Forero
- Pediatric Endocrinology, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Camila Céspedes
- Pediatric Endocrinology, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Jaime Pérez
- Division of Urology, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Nicolas Fernandez
- Division of Urology, Hospital Universitario San Ignacio, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
| | - Adriana Rojas
- Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá 110231, Colombia
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27
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Predicting Gonadal Germ Cell Cancer in People with Disorders of Sex Development; Insights from Developmental Biology. Int J Mol Sci 2019; 20:ijms20205017. [PMID: 31658757 PMCID: PMC6834166 DOI: 10.3390/ijms20205017] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/03/2019] [Accepted: 10/05/2019] [Indexed: 01/03/2023] Open
Abstract
The risk of gonadal germ cell cancer (GGCC) is increased in selective subgroups, amongst others, defined patients with disorders of sex development (DSD). The increased risk is due to the presence of part of the Y chromosome, i.e., GonadoBlastoma on Y chromosome GBY region, as well as anatomical localization and degree of testicularization and maturation of the gonad. The latter specifically relates to the germ cells present being at risk when blocked in an embryonic stage of development. GGCC originates from either germ cell neoplasia in situ (testicular environment) or gonadoblastoma (ovarian-like environment). These precursors are characterized by presence of the markers OCT3/4 (POU5F1), SOX17, NANOG, as well as TSPY, and cKIT and its ligand KITLG. One of the aims is to stratify individuals with an increased risk based on other parameters than histological investigation of a gonadal biopsy. These might include evaluation of defined susceptibility alleles, as identified by Genome Wide Association Studies, and detailed evaluation of the molecular mechanism underlying the DSD in the individual patient, combined with DNA, mRNA, and microRNA profiling of liquid biopsies. This review will discuss the current opportunities as well as limitations of available knowledge in the context of predicting the risk of GGCC in individual patients.
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28
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Abstract
Human germ cell tumours (GCTs) are derived from stem cells of the early embryo and the germ line. They occur in the gonads (ovaries and testes) and also in extragonadal sites, where migrating primordial germ cells are located during embryogenesis. This group of heterogeneous neoplasms is unique in that their developmental potential is in effect determined by the latent potency state of their cells of origin, which are reprogrammed to omnipotent, totipotent or pluripotent stem cells. Seven GCT types, defined according to their developmental potential, have been identified, each with distinct epidemiological and (epi)genomic features. Heritable predisposition factors affecting the cells of origin and their niches likely explain bilateral, multiple and familial occurrences of the different types of GCTs. Unlike most other tumour types, GCTs are rarely caused by somatic driver mutations, but arise through failure to control the latent developmental potential of their cells of origin, resulting in their reprogramming. Consistent with their non-mutational origin, even the malignant tumours of the group are characterized by wild-type TP53 and high sensitivity for DNA damage. However, tumour progression and the rare occurrence of treatment resistance are driven by embryonic epigenetic state, specific (sub)chromosomal imbalances and somatic mutations. Thus, recent progress in understanding GCT biology supports a comprehensive developmental pathogenetic model for the origin of all GCTs, and provides new biomarkers, as well as potential targets for treatment of resistant disease.
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Affiliation(s)
- J Wolter Oosterhuis
- Laboratory for Experimental Patho-Oncology, Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, Netherlands.
| | - Leendert H J Looijenga
- Laboratory for Experimental Patho-Oncology, Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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29
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Schaffar R, Pant S, Bouchardy C, Schubert H, Rapiti E. Testicular cancer in Geneva, Switzerland, 1970-2012: incidence trends, survival and risk of second cancer. BMC Urol 2019; 19:64. [PMID: 31291913 PMCID: PMC6621969 DOI: 10.1186/s12894-019-0494-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper describes the testicular cancer trends for incidence, survival, socio-economic status (SES) disparities and second cancer occurrence in Geneva, Switzerland, a high-risk population. METHODS We included all testicular germ-cell tumors recorded in the population-based Geneva cancer registry during the period 1970-2012. Changes in incidence trends were assessed using Joinpoint regression to calculate the annual percentage change (APC). Overall and cancer-specific survivals (OS, CSS) were estimated by Kaplan Meyer methods. To evaluate the risk of a second cancer we calculated the Standardized Incidence Ratios (SIR) using the Geneva population incidence rates. RESULTS The average annual testicular cancer rate was 7.32/100 000 men, with a non-significant increasing trend during the study period. The highest rates were observed among men younger than 39 years. Despite a trend toward earlier diagnosis, 14% of patients were diagnosed at a late stage. Patients with non-seminoma tumours and patients with low SES were more often diagnosed with an advanced stage. Both OS and CSS improved during the study period but with strong differences by age, stage, morphology and SES. The risk for developing a second cancer was more than doubled. This risk was particularly high for a contralateral testicular cancer, bladder cancer and pancreatic cancer. CONCLUSIONS Overall, there was no substantial increase in the incidence of testicular cancer in Geneva in recent decades, however the prognosis has improved. The high risk of developing a second cancer, the differences in stage at diagnosis and survival by SES, require enhanced awareness and surveillance by clinicians, patients and men in general.
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Affiliation(s)
- Robin Schaffar
- Geneva Cancer Registry, Global Health Institute, University of Geneva, Geneva, Switzerland
| | - Samaksha Pant
- Geneva Cancer Registry, Global Health Institute, University of Geneva, Geneva, Switzerland
| | - Christine Bouchardy
- Geneva Cancer Registry, Global Health Institute, University of Geneva, Geneva, Switzerland
| | - Hyma Schubert
- Geneva Cancer Registry, Global Health Institute, University of Geneva, Geneva, Switzerland
| | - Elisabetta Rapiti
- Geneva Cancer Registry, Global Health Institute, University of Geneva, Geneva, Switzerland
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30
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León NY, Reyes AP, Harley VR. A clinical algorithm to diagnose differences of sex development. Lancet Diabetes Endocrinol 2019; 7:560-574. [PMID: 30803928 DOI: 10.1016/s2213-8587(18)30339-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 12/15/2022]
Abstract
The diagnosis and management of children born with ambiguous genitalia is challenging for clinicians. Such differences of sex development (DSDs) are congenital conditions in which chromosomal, gonadal, or anatomical sex is atypical. The aetiology of DSDs is very heterogenous and a precise diagnosis is essential for management of genetic, endocrine, surgical, reproductive, and psychosocial issues. In this Review, we outline a step-by-step approach, compiled in a diagnostic algorithm, for the clinical assessment and molecular diagnosis of a patient with ambiguity of the external genitalia on initial presentation. We appraise established and emerging technologies and their effect on diagnosis, and discuss current controversies.
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Affiliation(s)
- Nayla Y León
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Alejandra P Reyes
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Genetics Department, Children's Hospital of Mexico Federico Gómez, Mexico City, Mexico
| | - Vincent R Harley
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Melbourne, VIC, Australia.
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31
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CHEN G, WANG X, TANG D. [Progress on evaluation, diagnosis and management of disorders of sex development]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2019; 48:358-366. [PMID: 31901037 PMCID: PMC8800683 DOI: 10.3785/j.issn.1008-9292.2019.08.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/30/2019] [Indexed: 06/10/2023]
Abstract
Disorders of sex development (DSD) refer to a group of diseases characterized by abnormal congenital development of chromosomes, gonad or genitals with different pathophysiological changes and clinical manifestations. DSD is more common in neonates and adolescents, and neonates often show genital abnormalities while adolescents show abnormal sexual development during puberty. It is the international consensus that the scope of DSD should include basic clinical evaluation (internal and external genitalia and endocrine hormones), diagnostic confirmation (chromosome, genetic diagnosis), psychological assessment for children and family, treatment (sex assignment, hormone replacement and surgical intervention), potential fertility protection and long-term follow-up, which require the expertise of pediatric endocrinology, pediatric urology, clinical psychology, genetic disciplines, medical images and other related disciplines; that is, individualized management of children with DSD requires an experienced multidisciplinary team (MDT). This article reviews the recent progress on the evaluation, diagnosis and management of disorders of sex development.
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Affiliation(s)
| | | | - Daxing TANG
- 唐达星(1961—), 男, 博士, 硕士生导师, 主任医师, 主要从事小儿泌尿外科学研究; E-mail:
;
https://orcid.org/0000-0003-2103-4931
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32
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Giudice MG, Del Vento F, Wyns C. Male fertility preservation in DSD, XXY, pre-gonadotoxic treatments - Update, methods, ethical issues, current outcomes, future directions. Best Pract Res Clin Endocrinol Metab 2019; 33:101261. [PMID: 30718080 DOI: 10.1016/j.beem.2019.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This paper aims at reviewing the fertility preservation strategies that could be considered in several conditions at risk of spermatogonial depletion such as 46,XY disorders of sexual development, Klinefelter syndrome and after gonadotoxic treatment in males highlighting current knowledge on diseases and processes involved in infertility as well as future directions along with their specific ethical issues. While sperm cryopreservation after puberty is the only validated technique for fertility preservation, for prepubertal boys facing gonadotoxic therapies or at risk of testicular tissue degeneration where testicular sperm is not present, cryopreservation of spermatogonial cells may be an option to ensure future parenthood. Promising results with transplantation and in vitro maturation of spermatogonial cells were achieved in animals but so far none of the techniques was applied in humans.
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Affiliation(s)
- Maria Grazia Giudice
- Department of Gynecology-Andrology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium; Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium
| | - Federico Del Vento
- Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium
| | - Christine Wyns
- Department of Gynecology-Andrology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium; Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium.
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33
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Lanciotti L, Cofini M, Leonardi A, Bertozzi M, Penta L, Esposito S. Different Clinical Presentations and Management in Complete Androgen Insensitivity Syndrome (CAIS). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16071268. [PMID: 30970592 PMCID: PMC6480640 DOI: 10.3390/ijerph16071268] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 01/08/2023]
Abstract
Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive genetic disorder resulting from maternally inherited or de novo mutations involving the androgen receptor gene, situated in the Xq11-q12 region. The diagnosis is based on the presence of female external genitalia in a 46, XY human individual, with normally developed but undescended testes and complete unresponsiveness of target tissues to androgens. Subsequently, pelvic ultrasound or magnetic resonance imaging (MRI) could be helpful in confirming the absence of Mullerian structures, revealing the presence of a blind-ending vagina and identifying testes. CAIS management still represents a unique challenge throughout childhood and adolescence, particularly regarding timing of gonadectomy, type of hormonal therapy, and psychological concerns. Indeed this condition is associated with an increased risk of testicular germ cell tumour (TGCT), although TGCT results less frequently than in other disorders of sex development (DSD). Furthermore, the majority of detected tumoral lesions are non-invasive and with a low probability of progression into aggressive forms. Therefore, histological, epidemiological, and prognostic features of testicular cancer in CAIS allow postponing of the gonadectomy until after pubertal age in order to guarantee the initial spontaneous pubertal development and avoid the necessity of hormonal replacement therapy (HRT) induction. However, HRT is necessary after gonadectomy in order to prevent symptoms of hypoestrogenism and to maintain secondary sexual features. This article presents differential clinical presentations and management in patients with CAIS to emphasize the continued importance of standardizing the clinical and surgical approach to this disorder.
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Affiliation(s)
- Lucia Lanciotti
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Marta Cofini
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Alberto Leonardi
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Mirko Bertozzi
- Pediatric Surgery, Azienda Ospedaliera Santa Maria della Misericordia, 20122 Perugia, Italy.
| | - Laura Penta
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
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Faure Conter C, Brindusa Gorduza D, Mure PY, Pracros JP, Mouriquand P, Bouvattier C, Siffroi JP, Plotton I, Gay CL, Cools M, Dijoud F. [Atypical genital development and tumor risk]. Bull Cancer 2019; 106:461-467. [PMID: 30910228 DOI: 10.1016/j.bulcan.2019.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/14/2019] [Accepted: 01/23/2019] [Indexed: 11/16/2022]
Abstract
Atypical genital development (AGD), also called disorders of sex development are a set of miscellaneous pathologies who have in common a morphological and/or functional abnormality of the internal and/or external genital organs. The Chicago classification identifies 3 major groups based on karyotype, hormone balance and genetic studies. Some AGD predispose to the occurrence of tumors, mainly malignant germ cell tumors. The tumor risk depends on many factors: the type of AGD, the position of the gonad, the age of the patient, the phenotype, the function of the gonad and the presence of germ cells in the gonad. AGD with the highest tumor risk are those with gonadal dysgenesis, implying an incomplete differentiation of the bipotential gonad (dysplasia). Monitoring of patients with AGD and indication of prophylactic gonadectomies should be individualized according to tumor risk.
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Affiliation(s)
- Cécile Faure Conter
- Institut d'hématologie et d'oncologie pédiatrique, IHOPe, 69008 Lyon, France.
| | - Daniela Brindusa Gorduza
- Groupement hospitalier Est, Hospices Civils de Lyon, département de chirurgie pédiatrique, 69500 Bron, France
| | - Pierre-Yves Mure
- Groupement hospitalier Est, Hospices Civils de Lyon, département de chirurgie pédiatrique, 69500 Bron, France
| | - Jean-Pierre Pracros
- Groupement hospitalier Est, Hospices Civils de Lyon, département de radiologie pédiatrique, 69500 Bron, France
| | - Pierre Mouriquand
- Groupement hospitalier Est, Hospices Civils de Lyon, département de chirurgie pédiatrique, 69500 Bron, France
| | - Claire Bouvattier
- Hôpital Bicêtre, département d'endocrinologie pédiatrique, 94270 Le Kremlin Bicetre, France
| | - Jean-Pierre Siffroi
- Hôpital d'Enfants Armand Trousseau, département de génétique médicale, 75012 Paris, France
| | - Ingrid Plotton
- Groupement hospitalier Est, Hospices Civils de Lyon, Centre de biologie moléculaire, 69500 Bron, France
| | - Claire-Lise Gay
- Groupement hospitalier Est, département d'endocrinologie pédiatrique, 69500 Bron, France
| | - Martine Cools
- Hôpital universitaire de Gand, département de médecine interne et de pédiatrie université de Gand, 9000 Gand, Belgique
| | - Frédérique Dijoud
- Groupement hospitalier Est, hospices Civils de Lyon, institut Multisite de pathologie, 69500 Bron, France
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Molecular heterogeneity and early metastatic clone selection in testicular germ cell cancer development. Br J Cancer 2019; 120:444-452. [PMID: 30739914 PMCID: PMC6461884 DOI: 10.1038/s41416-019-0381-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/27/2018] [Indexed: 02/07/2023] Open
Abstract
Background Testicular germ cell cancer (TGCC), being the most frequent malignancy in young Caucasian males, is initiated from an embryonic germ cell. This study determines intratumour heterogeneity to unravel tumour progression from initiation until metastasis. Methods In total, 42 purified samples of four treatment-resistant nonseminomatous (NS) TGCC were investigated, including the precursor germ cell neoplasia in situ (GCNIS) and metastatic specimens, using whole-genome and targeted sequencing. Their evolution was reconstructed. Results Intratumour molecular heterogeneity did not correspond to the supposed primary tumour histological evolution. Metastases after systemic treatment could be derived from cancer stem cells not identified in the primary cancer. GCNIS mostly lacked the molecular marks of the primary NS and comprised dominant clones that failed to progress. A BRCA-like mutational signature was observed without evidence for direct involvement of BRCA1 and BRCA2 genes. Conclusions Our data strongly support the hypothesis that NS is initiated by whole-genome duplication, followed by chromosome copy number alterations in the cancer stem cell population, and accumulation of low numbers of somatic mutations, even in therapy-resistant cases. These observations of heterogeneity at all stages of tumourigenesis should be considered when treating patients with GCNIS-only disease, or with clinically overt NS.
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Lobo J, Gillis AJM, Jerónimo C, Henrique R, Looijenga LHJ. Human Germ Cell Tumors are Developmental Cancers: Impact of Epigenetics on Pathobiology and Clinic. Int J Mol Sci 2019; 20:E258. [PMID: 30634670 PMCID: PMC6359418 DOI: 10.3390/ijms20020258] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/25/2018] [Accepted: 01/07/2019] [Indexed: 02/03/2023] Open
Abstract
Current (high throughput omics-based) data support the model that human (malignant) germ cell tumors are not initiated by somatic mutations, but, instead through a defined locked epigenetic status, representative of their cell of origin. This elegantly explains the role of both genetic susceptibility as well as environmental factors in the pathogenesis, referred to as 'genvironment'. Moreover, it could also explain various epidemiological findings, including the rising incidence of this type of cancer in Western societies. In addition, it allows for identification of clinically relevant and informative biomarkers both for diagnosis and follow-up of individual patients. The current status of these findings will be discussed, including the use of high throughput DNA methylation profiling for determination of differentially methylated regions (DMRs) as well as chromosomal copy number variation (CNV). Finally, the potential value of methylation-specific tumor DNA fragments (i.e., XIST promotor) as well as embryonic microRNAs as molecular biomarkers for cancer detection in liquid biopsies will be presented.
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Affiliation(s)
- João Lobo
- Cancer Biology and Epigenetics Group, Research Center of Portuguese Oncology Institute of Porto (GEBC CI-IPOP), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
- Department of Pathology, Portuguese Oncology Institute of Porto (IPOP), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
- Department of Pathology and Molecular Immunology, Institute of Biomedical Sciences Abel Salazar, University of Porto (ICBAS-UP), Rua Jorge Viterbo Ferreira 228, 4050-513 Porto, Portugal;.
| | - Ad J M Gillis
- Laboratory of Experimental Patho-Oncology (LEPO), Josephine Nefkens Building, Erasmus MC, Department of Pathology, University Medical Center, Cancer Institute, Be-432A, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands.
| | - Carmen Jerónimo
- Cancer Biology and Epigenetics Group, Research Center of Portuguese Oncology Institute of Porto (GEBC CI-IPOP), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
- Department of Pathology and Molecular Immunology, Institute of Biomedical Sciences Abel Salazar, University of Porto (ICBAS-UP), Rua Jorge Viterbo Ferreira 228, 4050-513 Porto, Portugal;.
| | - Rui Henrique
- Cancer Biology and Epigenetics Group, Research Center of Portuguese Oncology Institute of Porto (GEBC CI-IPOP), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
- Department of Pathology, Portuguese Oncology Institute of Porto (IPOP), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal.
- Department of Pathology and Molecular Immunology, Institute of Biomedical Sciences Abel Salazar, University of Porto (ICBAS-UP), Rua Jorge Viterbo Ferreira 228, 4050-513 Porto, Portugal;.
| | - Leendert H J Looijenga
- Laboratory of Experimental Patho-Oncology (LEPO), Josephine Nefkens Building, Erasmus MC, Department of Pathology, University Medical Center, Cancer Institute, Be-432A, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands.
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Gardner M, Sandberg DE. Navigating Surgical Decision Making in Disorders of Sex Development (DSD). Front Pediatr 2018; 6:339. [PMID: 30510925 PMCID: PMC6252317 DOI: 10.3389/fped.2018.00339] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 10/22/2018] [Indexed: 11/24/2022] Open
Abstract
Surgical management of disorders of sex development (DSD) is associated with contentious debate between and within stakeholder communities. While the intent of surgical management of the genitals and gonads is to benefit the patient physically and psychosocially, these goals have not always been achieved; reports of harm have surfaced. Harm experienced by some patients has resulted in the emergence of an activist platform calling for a moratorium on all surgical procedures during childhood-excepting those forestalling threats to life within the childhood years. This ban is not universally endorsed by patient advocacy groups. Parents, meanwhile, continue to need to make decisions regarding surgical options for their young children. Constructive paths forward include implementation of Consensus Statement recommendations that call for comprehensive and integrated team care, incorporating mental health services, and adopting shared decision making.
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Affiliation(s)
| | - David E. Sandberg
- Division of Pediatric Psychology and the Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, United States
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38
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Tack LJW, Maris E, Looijenga LHJ, Hannema SE, Audi L, Köhler B, Holterhus PM, Riedl S, Wisniewski A, Flück CE, Davies JH, T'Sjoen G, Lucas-Herald AK, Evliyaoglu O, Krone N, Iotova V, Marginean O, Balsamo A, Verkauskas G, Weintrob N, Ellaithi M, Nordenström A, Verrijn Stuart A, Kluivers KB, Wolffenbuttel KP, Ahmed SF, Cools M. Management of Gonads in Adults with Androgen Insensitivity: An International Survey. Horm Res Paediatr 2018; 90:236-246. [PMID: 30336477 DOI: 10.1159/000493645] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Complete and partial androgen insensitivity syndrome (CAIS, PAIS) are associated with an increased risk of gonadal germ cell cancer (GGCC). Recent guidelines recommend gonadectomy in women with CAIS in late adolescence. Nevertheless, many adult women prefer to retain their gonads. AIMS This study aims to explore attitudes towards gonadectomy in AIS in centres around the world, estimate the proportion of adults with retained gonads and/or who developed GGCC, and explore reasons for declining gonadectomy. METHODS A survey was performed among health care professionals who use the International DSD Registry (I-DSD). RESULTS Data were provided from 22 centres in 16 countries on 166 women (CAIS) and 26 men (PAIS). In CAIS, gonadectomy was recommended in early adulthood in 67% of centres; 19/166 (11.4%) women refused gonadectomy. Among 142 women who had gonadectomy, evidence of germ cell neoplasm in situ (GCNIS), the precursor of GGCC, was reported in 2 (1.4%) out of 8 from whom pathology results were formally provided. Nine out of 26 men with PAIS (34.6%) had retained gonads; 11% of centres recommended routine gonadectomy in PAIS. CONCLUSION Although development of GGCC seems rare, gonadectomy after puberty is broadly recommended in CAIS; in PAIS this is more variable. Overall, our data reflect the need for evidence-based guidelines regarding prophylactic gonadectomy in AIS.
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Affiliation(s)
- Lloyd J W Tack
- Division of Paediatric Endocrinology, Department of Paediatrics, Ghent University Hospital, Department of Internal Medicine and Paediatrics, Ghent University, Ghent,
| | - Ellen Maris
- Division of Paediatric Endocrinology, Department of Paediatrics, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Leendert H J Looijenga
- Laboratory for Experimental Patho-Oncology, Department of Pathology, Josephine Nefkens Building, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Laura Audi
- Growth and Development Research Unit, Vall d'Hebron Research Institute (VHIR), Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Birgit Köhler
- Klinik für Pädiatrische Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Paul-Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel, Kiel, Germany
| | - Stefan Riedl
- Department of Pediatric Pulmology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
- Department of Pediatrics, St. Anna Children´s Hospital, Medical University of Vienna, Vienna, Austria
| | - Amy Wisniewski
- Department of Urology, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Christa E Flück
- Paediatric Endocrinology, Diabetology and Metabolism, Department of Paediatrics and Department of BioMedical Research, Bern University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Justin H Davies
- Department of Endocrinology, University Hospital Southampton, Southampton, United Kingdom
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Angela K Lucas-Herald
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, United Kingdom
| | - Olcay Evliyaoglu
- Department of Paediatric Endocrinology, Faculty of Medicine, İstanbul University Cerrahpaşa, İstanbul, Turkey
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Violeta Iotova
- Department of Paediatrics, Medical University Varna, Varna, Bulgaria
| | - Otilia Marginean
- First Paediatric Clinic, University of Medicine and Pharmacy Victor Babes, Timisoara, Romania
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Paediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Gilvydas Verkauskas
- Centre of Paediatric Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Naomi Weintrob
- Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Department of Paediatrics, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mona Ellaithi
- Faculty of Medical Laboratory Sciences, Al-Neelain University, Khartoum, Sudan
| | - Anna Nordenström
- Department of Women's and Children's Health, Paediatric Endocrinology Q2: 04, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Annemarie Verrijn Stuart
- Department of Paediatrics, Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Kirsten B Kluivers
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Katja P Wolffenbuttel
- Department of Urology and Paediatric Urology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
| | - Martine Cools
- Division of Paediatric Endocrinology, Department of Paediatrics, Ghent University Hospital, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
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Cools M, Wolffenbuttel KP, Hersmus R, Mendonca BB, Kaprová J, Drop SLS, Stoop H, Gillis AJM, Oosterhuis JW, Costa EMF, Domenice S, Nishi MY, Wunsch L, Quigley CA, T'Sjoen G, Looijenga LHJ. Malignant testicular germ cell tumors in postpubertal individuals with androgen insensitivity: prevalence, pathology and relevance of single nucleotide polymorphism-based susceptibility profiling. Hum Reprod 2018; 32:2561-2573. [PMID: 29121256 DOI: 10.1093/humrep/dex300] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 09/14/2017] [Indexed: 01/29/2023] Open
Abstract
STUDY QUESTION What is the prevalence of malignant testicular germ cell tumors (TGCT) and its precursors, (pre-) germ cell neoplasia in situ (GCNIS), in late teenagers and adults who have androgen insensitivity syndrome (AIS) and the impact of an individual's genetic susceptibility to development of TGCT? SUMMARY ANSWER No GCNIS or TGCT was diagnosed, but pre-GCNIS was identified in 14 and 10% of complete and partial AIS patients, respectively, and was associated with a higher genetic susceptibility score (GSS), with special attention for KITLG (rs995030) and ATFZIP (rs2900333). WHAT IS KNOWN ALREADY Many adult women with AIS decline prophylactic gonadectomy, while data regarding the incidence, pathophysiology and outcomes of TGCT in postpubertal individuals with AIS are lacking. The relevance of genetic factors, such as single nucleotide polymorphisms (SNPs), in predisposing AIS individuals to TGCT is unknown. STUDY DESIGN, SIZE, DURATION This multicenter collaborative study on prophylactically removed gonadal tissue was conducted in a pathology lab specialized in germ cell tumor biology. PARTICIPANTS/MATERIALS, SETTING, METHODS Material from 52 postpubertal individuals with molecularly confirmed AIS (97 gonadal samples) was included; the median age at surgery was 17.5 (14-54) years. Immunohistochemical studies and high-throughput profiling of 14 TGCT-associated SNPs were performed. The main outcome measures were the prevalence of pre-GCNIS, GCNIS and TGCT, and its correlation with a GSS, developed based on the results of recent genome-wide association studies. MAIN RESULTS AND ROLE OF CHANCE The earliest recognizable change preceding GCNIS, referred to as pre-GCNIS, was present in 14% of individuals with complete and 10% of those with partial AIS at a median age of 16 years. No GCNIS or invasive TGCT were found. The median GSS was significantly greater for those with, compared to those without, pre-GCNIS (P = 0.01), with an overlap between groups. Our data suggest important roles for risk alleles G at KITLG (rs995030) and C at ATFZIP (rs2900333), among the 14 studied TGCT-associated SNPs. LARGE SCALE DATA N/A. LIMITATIONS REASONS FOR CAUTION A limited number of cases were included. WIDER IMPLICATIONS OF THE FINDINGS Our data suggest that the prevalence of pre-GCNIS in individuals with AIS beyond puberty is around 15%. Genetic susceptibility likely contributes to pre-GCNIS development in AIS but factors related to malignant progression remain unclear. Although data in older patients remain scarce, malignant progression appears to be a rare event, although the natural history of the premalignant lesion remains unknown. Therefore, the practice of routine prophylactic gonadectomy in adults with AIS appears questionable and the patient's preference, after having been fully informed, should be decisive in this matter. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by research grants from the Research Foundation Flanders (FWO) (to M.C.), the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq G0D6713N) (to B.B.M. and M.C.) and the European Society for Pediatric Endocrinology (ESPE), granted by Novo Nordisk AB (to J.K.). There are no competing interests.
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Affiliation(s)
- M Cools
- Pediatrics and Genetics, Ghent University and Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - K P Wolffenbuttel
- Department of Pediatric Urology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - R Hersmus
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - B B Mendonca
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - J Kaprová
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Pediatrics, Charles University, 2nd Faculty of Medicine and University Hospital Motol, Prague, Czech Republic
| | - S L S Drop
- Department of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - H Stoop
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - A J M Gillis
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - J W Oosterhuis
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - E M F Costa
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - S Domenice
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - M Y Nishi
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - L Wunsch
- Department of Pediatric Urology, Universitätsklinikum Schleswig-Holstein and Universität zu Lübeck, Lübeck, Germany
| | - C A Quigley
- Pediatric Endocrinology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - G T'Sjoen
- Internal Medicine, Ghent University and Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - L H J Looijenga
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
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Abstract
Testicular cancer is the most common malignancy among men between 14 and 44 years of age, and its incidence has risen over the past two decades in Western countries. Both genetic and environmental factors contribute to the development of testicular cancer, for which cryptorchidism is the most common risk factor. Progress has been made in our understanding of the disease since the initial description of carcinoma in situ of the testis in 1972 (now referred to as germ cell neoplasia in situ), which has led to improved treatment options. The combination of surgery and cisplatin-based chemotherapy has resulted in a cure rate of >90% in patients with testicular cancer, although some patients become refractory to chemotherapy or have a late relapse; an improved understanding of the molecular determinants underlying tumour sensitivity and resistance may lead to the development of novel therapies for these patients. This Primer provides an overview of the biology, epidemiology, diagnosis and current treatment guidelines for testicular cancer, with a focus on germ cell tumours. We also outline areas for future research and what to expect in the next decade for testicular cancer.
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41
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[Identification of diagnostic tumour markers and therapeutic targets in testicular tumours]. DER PATHOLOGE 2018; 39:215-220. [PMID: 30206653 DOI: 10.1007/s00292-018-0493-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Today, tumour classification has been expanded due to immunohistochemical and molecular-pathological analyses due to corresponding patterns/profiles of protein and gene expression. The latter analyses often include growth factors and their ligands, intracellular signalling pathways, DNA-binding proteins, and oncogenes and suppressor genes, thus functionally including primarily the regulation of growth including angiogenesis and apoptosis as well as the induction of metastases to adhesion and migration disorders. Based on observations that testicular tumours often show microcalcifications, possibly due to impaired calcium metabolism, we focused on calcium-dependent transmembrane proteins, particularly cadherins, in the search for new tumour markers and therapeutic targets. N‑cadherin is expressed differently in the various subtypes of germ cell tumours and is useful in N‑cadherin-positive germ cell tumours as a novel therapeutic targeting structure, particularly in cisplatin resistance, due to functional analysis. In the tumours of the sex cord stroma beta-catenin and the transcription factor SOX-9 give a clear classification of these tumours. Thus, morphological investigations prove to be pilot experiments to purposefully narrow the spectrum of functionally important proteins and thus to establish promising new differential diagnostic markers or target structures.
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42
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Al-Juraibah FN, Lucas-Herald AK, Alimussina M, Ahmed SF. The evaluation and management of the boy with DSD. Best Pract Res Clin Endocrinol Metab 2018; 32:445-453. [PMID: 30086868 DOI: 10.1016/j.beem.2018.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Atypical genitalia in a boy may have a very wide and diverse aetiology and a definitive diagnosis is often challenging to reach. Detailed clinical evaluation integrated with extensive biochemical and genetic studies play an important role in this process. Such care should be undertaken in highly specialized centres that can also provide access to a multidisciplinary team for optimal long-term care.
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Affiliation(s)
- F N Al-Juraibah
- Developmental Endocrinology Research Group, University of Glasgow, UK; Department of Paediatrics, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - A K Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, UK
| | - M Alimussina
- Developmental Endocrinology Research Group, University of Glasgow, UK
| | - S F Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, UK.
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43
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Cools M, Nordenström A, Robeva R, Hall J, Westerveld P, Flück C, Köhler B, Berra M, Springer A, Schweizer K, Pasterski V. Caring for individuals with a difference of sex development (DSD): a Consensus Statement. Nat Rev Endocrinol 2018; 14:415-429. [PMID: 29769693 PMCID: PMC7136158 DOI: 10.1038/s41574-018-0010-8] [Citation(s) in RCA: 165] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The term differences of sex development (DSDs; also known as disorders of sex development) refers to a heterogeneous group of congenital conditions affecting human sex determination and differentiation. Several reports highlighting suboptimal physical and psychosexual outcomes in individuals who have a DSD led to a radical revision of nomenclature and management a decade ago. Whereas the resulting recommendations for holistic, multidisciplinary care seem to have been implemented rapidly in specialized paediatric services around the world, adolescents often experience difficulties in finding access to expert adult care and gradually or abruptly cease medical follow-up. Many adults with a DSD have health-related questions that remain unanswered owing to a lack of evidence pertaining to the natural evolution of the various conditions in later life stages. This Consensus Statement, developed by a European multidisciplinary group of experts, including patient representatives, summarizes evidence-based and experience-based recommendations for lifelong care and data collection in individuals with a DSD across ages and highlights clinical research priorities. By doing so, we hope to contribute to improving understanding and management of these conditions by involved medical professionals. In addition, we hope to give impetus to multicentre studies that will shed light on outcomes and comorbidities of DSD conditions across the lifespan.
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Affiliation(s)
- Martine Cools
- Department of Paediatric Endocrinology, Ghent University Hospital, University of Ghent, Ghent, Belgium.
| | - Anna Nordenström
- Department of Women's and Children's Health, Paediatric Endocrinology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ralitsa Robeva
- Clinical Center of Endocrinology and Gerontology, Medical University-Sofia, Medical Faculty, Sofia, Bulgaria
| | | | | | - Christa Flück
- Paediatric Endocrinology and Diabetology, Department of Paediatrics and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Birgit Köhler
- Department of Paediatric Endocrinology, Charité University Medicine, Humboldt University Berlin, Berlin, Germany
| | - Marta Berra
- Department of Obstetrics and Gynaecology, Ramazzini Hospital, AUSL Modena, Modena, Italy
| | - Alexander Springer
- Department of Paediatric Surgery, Medical University Vienna, Vienna, Austria
| | - Katinka Schweizer
- Institute for Sex Research and Forensic Psychiatry, University Clinic Hamburg-Eppendorf, Hamburg, Germany
| | - Vickie Pasterski
- Department of Psychology, University of Cambridge, Cambridge, UK
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Epigenetics and testicular germ cell tumors. Gene 2018; 661:22-33. [PMID: 29605605 DOI: 10.1016/j.gene.2018.03.072] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/07/2018] [Accepted: 03/21/2018] [Indexed: 11/20/2022]
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Nordenström A, Röhle R, Thyen U, Bouvattier C, Slowikowska-Hilczer J, Reisch N, Claahsen van der Grinten H, Brac de la Perriere A, Cohen-Kettenis PT, Köhler B. Hormone therapy and patient satisfaction with treatment, in a large cohort of diverse disorders of sex development. Clin Endocrinol (Oxf) 2018; 88:397-408. [PMID: 29149458 DOI: 10.1111/cen.13518] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 11/09/2017] [Accepted: 11/12/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe and investigate the hormone treatments in individuals with different forms of disorders of sex development (DSD) and the patients' own views on their treatment. DESIGN Multicentre cross-sectional clinical evaluation, dsd-LIFE in 6 European countries from February 2014 to September 2015. PARTICIPANTS A total of 1040 adolescents and adults (≥16 years) with different DSD conditions. MAIN OUTCOMES MEASURES Hormone replacement, information received and patient satisfaction. RESULTS Included were women with Turner syndrome (301), 46,XX GD (n = 20), and women with 45,X/46XY (n = 24). Individuals with Klinefelter syndrome (n = 218), 46,XX males (n = 6), individuals with different forms of 46,XY DSD (n = 243): 46,XY DSD conditions (n = 222), men with 45,X/46XY (n = 21) 46,XX CAH, (n = 226). Oestrogen ± progestin was used by 306 (81%) individuals, 72 (19%) received ethinylestradiol and 198 had testosterone treatment. The overall adherence was good, with 10% of women with oestrogen and 5% of those on testosterone had stopped the medication despite 20% reporting dissatisfaction with the treatment, mostly because of psychological side effects. Glucocorticoid replacement in patients with CAH was very seldom stopped. More than 75% were satisfied with the information about the treatment, but the satisfaction with information about treatment options and side effects was lower. CONCLUSIONS More than 50% in the total cohort had hormone replacement. Although adherence was generally good, this study shows that hormone replacement therapy may be improved. This may be achieved by better individualization of the treatment and by providing specific information to patients regarding both long-term and short-term hormonal effects and side effects.
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Affiliation(s)
- Anna Nordenström
- Department of Womens' and Childrens' Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Robert Röhle
- Charité Universitätsmedizin Koordinierungszentrum Klinische Studien (KKS), Berlin, Germany
| | - Ute Thyen
- Klinik für Kinder- und Jugendmedizin, Universität zu Lübeck, Lübeck, Germany
| | - Claire Bouvattier
- Department of Pediatric Endocrinology, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | | | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Department of Endocrinology, University Hospital Munich, Munich, Germany
| | | | | | - Peggy T Cohen-Kettenis
- Medical Center Amsterdam Department of Child Psychiatry, VU University, Amsterdam, The Netherlands
| | - Birgit Köhler
- Klinik für Pädiatrische Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
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Skakkebaek NE. A Brief Review of the Link between Environment and Male Reproductive Health: Lessons from Studies of Testicular Germ Cell Cancer. Horm Res Paediatr 2018; 86:240-246. [PMID: 26871895 DOI: 10.1159/000443400] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 12/16/2015] [Indexed: 11/19/2022] Open
Abstract
During the past few decades there has been a significantly increasing trend in germ cell tumours all over the world, particularly in countries with Caucasian populations. The changes in incidence have occurred so fast that only environmental factors can explain this development. This review focuses on the hypothesis that testicular germ cell cancer, which originates from germ cell neoplasia in situ, is of foetal origin and associated with other male reproductive problems through a testicular dysgenesis syndrome, also including foetal origin of impaired spermatogenesis, hypospadias and cryptorchidism. There is little doubt that environmental factors associated with modern lifestyles have - in a broad sense - had an adverse influence on male reproductive health. The hypothesis that exposure to endocrine-disrupting chemicals plays a fundamental role in this trend is plausible. This is based on evidence from animal studies that demonstrate adverse reproductive effects caused by a number of endocrine-disrupting chemicals to which humans are exposed as part of our modern lifestyle.
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Affiliation(s)
- Niels E Skakkebaek
- University Department of Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
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Clinical heterogeneity in children with gonadal dysgenesis associated with non-mosaic 46,XY karyotype. J Pediatr Urol 2017; 13:508.e1-508.e6. [PMID: 28434637 DOI: 10.1016/j.jpurol.2017.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/13/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Gonadal dysgenesis is unique in disorders of sex development (DSD), in that it can be associated with 46,XX, 46,XY or mosaic 45,X/46,XY karyotypes. Gonadal dysgenesis can be partial or complete. Gonadal dysgenesis associated with the Y-chromosome has increased risk of gonadal germ cell neoplasms. Most of the literature focus on 45,X/46,XY gonadal dysgenesis, while there are scanty data on the condition when the karyotype is non-mosaic 46,XY. OBJECTIVE To investigate the diversity of clinical pictures of children presenting with 46,XY DSD due to gonadal dysgenesis. METHODS A retrospective study on consecutive patients diagnosed with 46,XY gonadal dysgenesis at age ≤18 years in a tertiary center from 1985 to 2015. The clinical presentations, phenotypes, gonadal features and associated anomalies were investigated. RESULTS Twenty-eight patients with Y-chromosome gonadal dysgenesis were identified during the study period and six (21.4%) had non-mosaic 46,XY karyotype. Three had complete gonadal dysgenesis (CGD) with normal female phenotype, while the other three had partial gonadal dysgenesis (PGD). Of the three patients with CGD, two presented with the classical Swyer syndrome at adolescence, while the third presented at birth with multiple congenital anomalies. The three PGD patients presented with ambiguous genitalia at birth (n = 2), and isolated hypospadias (n = 1), which was associated with Frasier syndrome. Three patients had germ cell neoplasms: bilateral gonadoblastoma (n = 1), bilateral intratubular germ cell neoplasia unclassified (n = 1), and dysgerminoma + gonadoblastoma (n = 1). Two patients had global developmental delay with other congenital anomalies, and another patient had learning difficulties with borderline intelligence (Table). DISCUSSION The findings suggest that 46,XY gonadal dysgenesis is much rarer than 45,X/46,XY gonadal dysgenesis. Patients differed in their clinical presentations and well-established syndromes happened in half of them. Overall, the risk of germ cell neoplasms and the association with other somatic anomalies appeared to be high. The study was limited by: its small number, single-center experience, and the possibility of missing the diagnosis in some male patients with mild undervirilization. CONCLUSION Heterogeneity was noted in the clinical, phenotypic and gonadal features among pediatric patients with 46,XY gonadal dysgenesis.
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van Bever Y, Wolffenbuttel KP, Brüggenwirth HT, Blom E, de Klein A, Eussen BHJ, van der Windt F, Hannema SE, Dessens AB, Dorssers LCJ, Biermann K, Hersmus R, de Rijke YB, Looijenga LHJ. Multiparameter Investigation of a 46,XX/46,XY Tetragametic Chimeric Phenotypical Male Patient with Bilateral Scrotal Ovotestes and Ovulatory Activity. Sex Dev 2017; 12:145-154. [PMID: 28926831 DOI: 10.1159/000479946] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We report on an adult male initially presenting with gynecomastia and a painless scrotal mass without additional genital anomalies. Hyperpigmentation of the skin following the Blaschko's lines was identified. He underwent gonadectomy because of suspected cancer. Histological analyses revealed an ovotestis with ovulatory activity confirmed by immunohistochemistry with multiple markers. Karyotyping of cultured peripheral blood lymphocytes and a buccal smear revealed a 46,XX/46,XY chimeric constitution with different percentages. Multiple molecular analyses as well as blood typing implied a tetragametic origin. After the unilateral gonadectomy, the patient developed recurrent painful cystic swellings of the remaining gonad. Because of the wish to preserve hormonal activity as well as future fertility, the patient underwent surgical resection of a cystic gonadal area. The removed tissue showed ovulation-related features in addition to both testicular and ovarian tissue, diagnosed as an ovotestis. Testosterone therapy was initiated to suppress the persistently elevated gonadotropins and thereby suppress ovarian activity. During treatment, the recurrent pain complaints and cystic swellings ceased, although gonadotropin levels were not fully suppressed. Based on these observations, the importance of a detailed genetic and pathological diagnosis and the clinical dilemmas including the pros and cons of personalized treatment with gonadal preservative surgery are discussed.
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Affiliation(s)
- Yolande van Bever
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
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Abstract
CONTEXT - Precursor lesions of urologic malignancies are established histopathologic entities, which are important not only to recognize for clinical purposes, but also to further investigate at the molecular level in order to gain a better understanding of the pathogenesis of these malignancies. OBJECTIVE - To provide a brief overview of precursor lesions to the most common malignancies that develop within the genitourinary tract with a focus on their clinical implications, histologic features, and molecular characteristics. DATA SOURCES - Literature review from PubMed, urologic pathology textbooks, and the 4th edition of the World Health Organization Classification of Tumours of the Urinary System and Male Genital Organs. All photomicrographs were taken from cases seen at Weill Cornell Medicine or from the authors' personal slide collections. CONCLUSIONS - The clinical importance and histologic criteria are well established for the known precursor lesions of the most common malignancies throughout the genitourinary tract, but further investigation is warranted at the molecular level to better understand the pathogenesis of these lesions. Such investigation may lead to better risk stratification of patients and potentially novel treatments.
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Campo-Engelstein L, Chen D, Baratz AB, Johnson EK, Finlayson C. The Ethics of Fertility Preservation for Pediatric Patients With Differences (Disorders) of Sex Development. J Endocr Soc 2017; 1:638-645. [PMID: 28944319 PMCID: PMC5607629 DOI: 10.1210/js.2017-00110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Differences (disorders) of sex development are diverse conditions with variations in chromosomal, gonadal, and/or genital development. Fertility potential in this population is variable. Recent investigations into fertility potential in those previously thought to be infertile suggest that the majority may have fertility potential through experimental protocols. Fertility preservation may be more successful if pursued in childhood. As fertility research and techniques advance, it is important to carefully consider pediatric ethical issues specific to this population, including gonadectomy, consent/assent, experimental treatment and false hope, cost and insurance coverage, genetic transmission to offspring, and gender dysphoria.
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Affiliation(s)
- Lisa Campo-Engelstein
- Alden March Bioethics Institute, Department of Obstetrics and Gynecology, Albany Medical College, Albany, New York 12208
| | - Diane Chen
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
| | - Arlene B Baratz
- Division of Breast Imaging, West Penn Allegheny Health System, Temple University School of Medicine, Pittsburgh, Pennsylvania 15212
| | - Emilie K Johnson
- Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Urology and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
| | - Courtney Finlayson
- Division of Pediatric Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois 60611.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611
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