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Wang Z, Wang R, Wang X, Zheng S, Li M, Yu Y, Liu Z, Sun S, Zhan W. Infertility risk assessment with ultrasound in congenital adrenal hyperplasia male patients. Sci Rep 2024; 14:12058. [PMID: 38802468 PMCID: PMC11130187 DOI: 10.1038/s41598-024-62954-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
Testicular adrenal rest tumor (TART) is a prevalent complication associated with congenital adrenal hyperplasia (CAH), culminating in gonadal dysfunction and infertility. Early hormonal intervention is preventive, but excessive glucocorticoid poses risks. Developing reliable methods for early TART diagnosis and monitoring is crucial. The present study aims to formulate a scoring system to identify high-risk infertility through analysis of TART ultrasound features. Grayscale and power Doppler ultrasound were employed in this retrospective study to evaluate testicular lesions in male CAH patients. Lesion assessment encompassed parameters such as range, echogenicity, and blood flow, and these were subsequently correlated with semen parameters. Results of 49 semen analyzes from 35 patients demonstrated a notable inverse correlation between lesion scores and both sperm concentration (rs = - 0.83, P < 0.001) and progressive motility (rs = - 0.56, P < 0.001). The ROC curve areas for evaluating oligospermia and asthenozoospermia were calculated as 0.94 and 0.72, respectively. Establishing a lesion score threshold of 6 revealed a sensitivity of 75.00% and specificity of 93.94% for oligospermia and a sensitivity of 53.85% and specificity of 100.00% for asthenozoospermia. These findings underscore the potential utility of incorporating ultrasound into routine CAH patient management, facilitating timely interventions to preserve male fertility.
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Affiliation(s)
- Zhiqian Wang
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
- Department of Ultrasound, Ruijin-Hainan Hospital Shanghai Jiao Tong University School of Medicine Hainan Boao Research Hospital, Hainan, 571437, People's Republic of China
| | - Ronghui Wang
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Xing Wang
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Sichang Zheng
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Min Li
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Yifei Yu
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Zhenhua Liu
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Shouyue Sun
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China.
| | - Weiwei Zhan
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China.
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Balagamage C, Arshad A, Elhassan YS, Ben Said W, Krone RE, Gleeson H, Idkowiak J. Management aspects of congenital adrenal hyperplasia during adolescence and transition to adult care. Clin Endocrinol (Oxf) 2023. [PMID: 37964596 DOI: 10.1111/cen.14992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/11/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023]
Abstract
The adolescent period is characterised by fundamental hormonal changes, which affect sex steroid production, cortisol metabolism and insulin sensitivity. These physiological changes have a significant impact on patients with congenital adrenal hyperplasia (CAH). An essential treatment aim across the lifespan in patients with CAH is to replace glucocorticoids sufficiently to avoid excess adrenal androgen production but equally to avoid cardiometabolic risks associated with excess glucocorticoid intake. The changes to the hormonal milieu at puberty, combined with poor adherence to medical therapy, often result in unsatisfactory control exacerbating androgen excess and increasing the risk of metabolic complications due to steroid over-replacement. With the physical and cognitive maturation of the adolescent with CAH, fertility issues and sexual function become a new focus of patient care in the paediatric clinic. This requires close surveillance for gonadal dysfunction, such as irregular periods/hirsutism or genital surgery-associated symptoms in girls and central hypogonadism or testicular adrenal rest tumours in boys. To ensure good health outcomes across the lifespan, the transition process from paediatric to adult care of patients with CAH must be planned carefully and early from the beginning of adolescence, spanning over many years into young adulthood. Its key aims are to empower the young person through education with full disclosure of their medical history, to ensure appropriate follow-up with experienced physicians and facilitate access to multispecialist teams addressing the complex needs of patients with CAH.
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Affiliation(s)
- Chamila Balagamage
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Amynta Arshad
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- The Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yasir S Elhassan
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Wogud Ben Said
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ruth E Krone
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Helena Gleeson
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jan Idkowiak
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University of Birmingham, Birmingham, UK
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Schröder MAM, Neacşu M, Adriaansen BPH, Sweep FCGJ, Ahmed SF, Ali SR, Bachega TASS, Baronio F, Birkebæk NH, de Bruin C, Bonfig W, Bryce J, Clemente M, Cools M, Elsedfy H, Globa E, Guran T, Güven A, Amr NH, Janus D, Taube NL, Markosyan R, Miranda M, Poyrazoğlu Ş, Rees A, Salerno M, Stancampiano MR, Vieites A, de Vries L, Yavas Abali Z, Span PN, Claahsen-van der Grinten HL. Hormonal control during infancy and testicular adrenal rest tumor development in males with congenital adrenal hyperplasia: a retrospective multicenter cohort study. Eur J Endocrinol 2023; 189:460-468. [PMID: 37837609 DOI: 10.1093/ejendo/lvad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/28/2023] [Accepted: 09/19/2023] [Indexed: 10/16/2023]
Abstract
IMPORTANCE Testicular adrenal rest tumors (TARTs), often found in male patients with congenital adrenal hyperplasia (CAH), are benign lesions causing testicular damage and infertility. We hypothesize that chronically elevated adrenocorticotropic hormone exposure during early life may promote TART development. OBJECTIVE This study aimed to examine the association between commencing adequate glucocorticoid treatment early after birth and TART development. DESIGN AND PARTICIPANTS This retrospective multicenter (n = 22) open cohort study collected longitudinal clinical and biochemical data of the first 4 years of life using the I-CAH registry and included 188 male patients (median age 13 years; interquartile range: 10-17) with 21-hydroxylase deficiency (n = 181) or 11-hydroxylase deficiency (n = 7). All patients underwent at least 1 testicular ultrasound. RESULTS TART was detected in 72 (38%) of the patients. Prevalence varied between centers. When adjusted for CAH phenotype, a delayed CAH diagnosis of >1 year, compared with a diagnosis within 1 month of life, was associated with a 2.6 times higher risk of TART diagnosis. TART onset was not predicted by biochemical disease control or bone age advancement in the first 4 years of life, but increased height standard deviation scores at the end of the 4-year study period were associated with a 27% higher risk of TART diagnosis. CONCLUSIONS AND RELEVANCE A delayed CAH diagnosis of >1 year vs CAH diagnosis within 1 month after birth was associated with a higher risk of TART development, which may be attributed to poor disease control in early life.
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Affiliation(s)
- Mariska A M Schröder
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboudumc Graduate School, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mihaela Neacşu
- Department of Laboratory Medicine, Radboudumc Graduate School, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bas P H Adriaansen
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboudumc Graduate School, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboudumc Graduate School, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
- Office of Rare Conditions, University of Glasgow, Glasgow, United Kingdom
| | - Salma R Ali
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
- Office of Rare Conditions, University of Glasgow, Glasgow, United Kingdom
| | - Tânia A S S Bachega
- Laboratory of Hormones and Molecular Genetics-LIM 42, Department of Endocrinology and Metabolism, University of Sao Paulo, Sao Paulo, Brazil
| | - Federico Baronio
- Department Hospital of Woman and Child, Pediatric Unit, IRCCS AOU di Bologna, Policlinico di S.Orsola, Bologna, Italy
| | - Niels Holtum Birkebæk
- Department of Pediatrics and Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Christiaan de Bruin
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Walter Bonfig
- Department of Pediatrics, Technical University Munich, Munich, Germany
- Department of Pediatrics, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Jillian Bryce
- Office of Rare Conditions, University of Glasgow, Glasgow, United Kingdom
| | - Maria Clemente
- Pediatric Endocrinology Unit, Hospital Vall d'Hebron, Autonomous University of Barcelona, CIBERER, Barcelona, Spain
| | - Martine Cools
- Pediatric Endocrinology, Internal Medicine and Pediatric Research Unit, University Hospital Ghent, Ghent University, Ghent, Belgium
| | - Heba Elsedfy
- Pediatrics Department, Ain Shams University, Cairo, Egypt
| | - Evgenia Globa
- Ukrainian Research Center of Endocrine Surgery, Endocrine Organs and Tissue Transplantation, MOH of Ukraine, Kyiv, Ukraine
| | - Tulay Guran
- Pediatric Endocrinology and Diabetes, Marmara University, Istanbul, Turkey
| | - Ayla Güven
- Baskent University Medical Faculty, Istanbul Hospital, Pediatrics Department, Ain Shams University, Cairo, Egypt
| | | | - Dominika Janus
- Department of Pediatric and Adolescent Endocrinology, Institute of Pediatrics, Jagiellonian University Medical College, and Children's University Hospital, Krakow, Poland
| | - Nina Lenherr Taube
- Department of Pediatrics, Division of Endocrinology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Mirela Miranda
- Laboratory of Hormones and Molecular Genetics-LIM 42, Department of Endocrinology and Metabolism, University of Sao Paulo, Sao Paulo, Brazil
| | - Şükran Poyrazoğlu
- İstanbul Faculty of Medicine, Unit of Pediatric Endocrinology, İstanbul University, İstanbul, Turkey
| | - Aled Rees
- Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Mariacarolina Salerno
- Pediatric Endocrine Unit, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Marianna Rita Stancampiano
- Department of Pediatrics, Endocrine Unit, IRCCS San Raffaele Scientific Institute, Endo-ERN Center for Rare Endocrine Conditions, Milan, Italy
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas Buenos Aires, Buenos Aires, Argentina
| | - Liat de Vries
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel and Felsenstein Medical Research Center at Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zehra Yavas Abali
- Pediatric Endocrinology and Diabetes, Marmara University, Istanbul, Turkey
| | - Paul N Span
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboudumc Graduate School, Radboud University Medical Center, Nijmegen, The Netherlands
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Sarafoglou K, Merke DP, Reisch N, Claahsen-van der Grinten H, Falhammar H, Auchus RJ. Interpretation of Steroid Biomarkers in 21-Hydroxylase Deficiency and Their Use in Disease Management. J Clin Endocrinol Metab 2023; 108:2154-2175. [PMID: 36950738 PMCID: PMC10438890 DOI: 10.1210/clinem/dgad134] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
The most common form of congenital adrenal hyperplasia is 21-hydroxylase deficiency (21OHD), which in the classic (severe) form occurs in roughly 1:16 000 newborns worldwide. Lifelong treatment consists of replacing cortisol and aldosterone deficiencies, and supraphysiological dosing schedules are typically employed to simultaneously attenuate production of adrenal-derived androgens. Glucocorticoid titration in 21OHD is challenging as it must balance the consequences of androgen excess vs those from chronic high glucocorticoid exposure, which are further complicated by interindividual variability in cortisol kinetics and glucocorticoid sensitivity. Clinical assessment and biochemical parameters are both used to guide therapy, but the specific purpose and goals of each biomarker vary with age and clinical context. Here we review the approach to medication titration for children and adults with classic 21OHD, with an emphasis on how to interpret adrenal biomarker values in guiding this process. In parallel, we illustrate how an understanding of the pathophysiologic and pharmacologic principles can be used to avoid and to correct complications of this disease and consequences of its management using existing treatment options.
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Affiliation(s)
- Kyriakie Sarafoglou
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN 55454, USA
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN 55455, USA
| | - Deborah P Merke
- Department of Pediatrics, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, 80336 Munich, Germany
| | - Hedi Claahsen-van der Grinten
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - Richard J Auchus
- Departments of Pharmacology and Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Aycan Z, Keskin M, Lafcı NG, Savaş-Erdeve Ş, Baş F, Poyrazoğlu Ş, Öztürk P, Parlak M, Ercan O, Güran T, Hatipoğlu N, Uçaktürk AS, Çatlı G, Akyürek N, Önder A, Kılınç S, Çetinkaya S. Genotype of congenital adrenal hyperplasia patients with testicular adrenal rest tumor. Eur J Med Genet 2022; 65:104654. [DOI: 10.1016/j.ejmg.2022.104654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 09/25/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
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Schröder MAM, Sweep FCGJ, van Herwaarden AE, Mitchell RT, Eliveld J, van Pelt AMM, Rowan AE, Korbie D, Stikkelbroeck NMML, Claahsen-van der Grinten HL, Span PN. Transcriptional comparison of testicular adrenal rest tumors with fetal and adult tissues. Eur J Endocrinol 2022; 187:607-615. [PMID: 36047744 PMCID: PMC7613903 DOI: 10.1530/eje-22-0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Testicular adrenal rest tumors (TART) are a common complication of unknown cellular origin in patients with congenital adrenal hyperplasia (CAH). These benign tumors have both adrenal and testicular characteristics and are hypothesized to either derive from cells of adrenal origin from the fetal adrenogonadal primordium or by atypical differentiation of adult Leydig-progenitor cells. OBJECTIVE This study aims to unravel the identity and etiology of TART. METHODS Co-expression of adrenal-specific CYP11B1 and Leydig cell-specific HSD17B3 in TART was studied using immunohistochemistry. We studied the possibility of TART being derived from atypical differentiation of adult Leydig-progenitor cells by the quantification of adrenal-specific enzyme expression upon adrenocorticotrophic hormone (ACTH)-like stimulation of ex vivo cultured platelet-derived growth factor receptor alpha-positive cells. By comparing the transcriptome of TART (n = 16) with the transcriptome of fetal adrenal (n = 13), fetal testis (n = 5), adult adrenal (n = 11), and adult testis (n = 10) tissues, we explored the identity of TART. RESULTS We demonstrate co-expression of adrenal-specific CYP11B1 and testis-specific HSD17B3 in TART cells, indicating the existence of a distinct TART cell exhibiting both adrenal and testicular characteristics. Ex vivo cultured adult Leydig-progenitor cells did not express the ACTH-receptor MC2R but did express CYP11B1 upon stimulation. Unsupervised clustering of transcriptome data showed that TART was most similar to adult adrenal tissue, followed by adult testis tissue, and least similar to either fetal tissue. CONCLUSION Our data suggest that TART is induced - most likely via activation of a cAMP/protein kinase A-dependent receptor - from a progenitor cell into a unique mature adrenal-like cell type, sometimes exhibiting both adrenal and testicular features.
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Affiliation(s)
- Mariska A M Schröder
- Department of Pediatrics, Radboud Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rod T Mitchell
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Jitske Eliveld
- Center for Reproductive Medicine, Reproductive Biology Laboratory, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ans M M van Pelt
- Center for Reproductive Medicine, Reproductive Biology Laboratory, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alan E Rowan
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, Queensland, Australia
| | - Darren Korbie
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, Queensland, Australia
| | | | | | - Paul N Span
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
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7
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Planinić A, Marić T, Bojanac AK, Ježek D. Reinke crystals: Hallmarks of adult Leydig cells in humans. Andrology 2022; 10:1107-1120. [DOI: 10.1111/andr.13201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/26/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Ana Planinić
- Department of Histology and Embryology University of Zagreb School of Medicine
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine University of Zagreb School of Medicine
| | - Tihana Marić
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine University of Zagreb School of Medicine
- Department of Medical Biology University of Zagreb School of Medicine
| | - Ana Katušić Bojanac
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine University of Zagreb School of Medicine
- Department of Medical Biology University of Zagreb School of Medicine
| | - Davor Ježek
- Department of Histology and Embryology University of Zagreb School of Medicine
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine University of Zagreb School of Medicine
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 172] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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9
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Schröder MAM, Turcu AF, O’Day P, van Herwaarden AE, Span PN, Auchus RJ, Sweep FCGJ, Claahsen-van der Grinten HL. Production of 11-Oxygenated Androgens by Testicular Adrenal Rest Tumors. J Clin Endocrinol Metab 2022; 107:e272-e280. [PMID: 34390337 PMCID: PMC8684463 DOI: 10.1210/clinem/dgab598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Indexed: 11/28/2022]
Abstract
CONTEXT Testicular adrenal rest tumors (TART) are a common complication in males with classic 21-hydroxylase deficiency (21OHD). TART are likely to contribute to the androgen excess in 21OHD patients, but a direct quantification of steroidogenesis from these tumors has not been yet done. OBJECTIVE We aimed to define the production of 11-oxygenated 19-carbon (11oxC19) steroids by TART. METHODS Using liquid chromatography-tandem mass spectrometry, steroids were measured in left (n = 7) and right (n = 4) spermatic vein and simultaneously drawn peripheral blood (n = 7) samples from 7 men with 21OHD and TART. For comparison, we also measured the peripheral steroid concentrations in 5 adrenalectomized patients and 12 age- and BMI-matched controls. Additionally, steroids were quantified in TART cell- and adrenal cell-conditioned medium, with and without adrenocorticotropic hormone (ACTH) stimulation. RESULTS Compared with peripheral blood from 21OHD patients with TART, the spermatic vein samples displayed the highest gradient for 11β-hydroxytestosterone (11OHT; 96-fold) of the 11oxC19 steroids, followed by 11-ketotestosterone (47-fold) and 11β-hydroxyandrostenedione (11OHA4; 29-fold), suggesting production of these steroids in TART. TART cells produced higher levels of testosterone and lower levels of A4 and 11OHA4 after ACTH stimulation compared with adrenal cells, indicating ACTH-induced production of testosterone in TART. CONCLUSION In patients with 21OHD, TART produce 11oxC19 steroids, but in different proportions than the adrenals. The very high ratio of 11OHT in spermatic vs peripheral vein blood suggests the 11-hydroxylation of testosterone by TART, and the in vitro results indicate that this metabolism is ACTH-sensitive.
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Affiliation(s)
- Mariska A M Schröder
- Department of Pediatrics, Radboud Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Patrick O’Day
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Paul N Span
- Radiotherapy & OncoImmunology Laboratory, Department of Radiation Oncology, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Hedi L Claahsen-van der Grinten
- Department of Pediatrics, Radboud Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
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10
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Kolli V, da Cunha IW, Kim S, Iben JR, Mallappa A, Li T, Gaynor A, Coon SL, Quezado MM, Merke DP. Morphologic and Molecular Characterization of Adrenals and Adrenal Rest Affected by Congenital Adrenal Hyperplasia. Front Endocrinol (Lausanne) 2021; 12:730947. [PMID: 34616364 PMCID: PMC8488225 DOI: 10.3389/fendo.2021.730947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/26/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction Adrenocortical hyperplasia and adrenal rest tumor (ART) formation are common in congenital adrenal hyperplasia (CAH). Although driven by excessive corticotropin, much is unknown regarding the morphology and transformation of these tissues. Our study objective was to characterize CAH-affected adrenals and ART and compare with control adrenal and gonadal tissues. Patients/Methods CAH adrenals, ART and control tissues were analyzed by histology, immunohistochemistry, and transcriptome sequencing. We investigated protein expression of the ACTH receptor (MC2R), steroidogenic (CYP11B2, CYP11B1, CYB5A) and immune (CD20, CD3, CD68) biomarkers, and delta-like 1 homolog (DLK1), a membrane bound protein broadly expressed in fetal and many endocrine cells. RNA was isolated and gene expression was analyzed by RNA sequencing (RNA-seq) followed by principle component, and unsupervised clustering analyses. Results Based on immunohistochemistry, CAH adrenals and ART demonstrated increased zona reticularis (ZR)-like CYB5A expression, compared to CYP11B1, and CYP11B2, markers of zona fasciculata and zona glomerulosa respectively. CYP11B2 was mostly absent in CAH adrenals and absent in ART. DLK1 was present in CAH adrenal, ART, and also control adrenal and testis, but was absent in control ovary. Increased expression of adrenocortical marker MC2R, was observed in CAH adrenals compared to control adrenal. Unlike control tissues, significant nodular lymphocytic infiltration was observed in CAH adrenals and ART, with CD20 (B-cell), CD3 (T-cell) and CD68 (macrophage/monocyte) markers of inflammation. RNA-seq data revealed co-expression of adrenal MC2R, and testis-specific INSL3, HSD17B3 in testicular ART indicating the presence of both gonadal and adrenal features, and high expression of DLK1 in ART, CAH adrenals and control adrenal. Principal component analysis indicated that the ART transcriptome was more similar to CAH adrenals and least similar to control testis tissue. Conclusions CAH-affected adrenal glands and ART have similar expression profiles and morphology, demonstrating increased CYB5A with ZR characteristics and lymphocytic infiltration, suggesting a common origin that is similarly affected by the abnormal hormonal milieu. Immune system modulators may play a role in tumor formation of CAH.
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Affiliation(s)
- Vipula Kolli
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | | | - SunA Kim
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, United States
| | - James R. Iben
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Tianwei Li
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Alison Gaynor
- National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Steven L. Coon
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Martha M. Quezado
- Laboratory of Pathology, National Cancer Institute, Bethesda, MD, United States
| | - Deborah P. Merke
- National Institutes of Health Clinical Center, Bethesda, MD, United States
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
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11
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Bouzidi L, Triki M, Charfi S, Ameur HB, Dhaou MB, Bouaziz T, Boudawara T. Incidental Finding of Bilateral Ovarian Adrenal Rest Tumor in a Patient With Congenital Adrenal Hyperplasia: A Case Report and Brief Review. Pediatr Dev Pathol 2021; 24:137-141. [PMID: 33433255 DOI: 10.1177/1093526620980614] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ovarian adrenal rest tumors (OART) are tumors that develop in females with congenital adrenal hyperplasia (CAH). In contrast to their counterpart in testicles, they are exceptional and few cases have been reported in the literature. In this report, we present clinicopathological findings of a female patient with CAH due to 21-hydroxylase deficiency who was incidentally diagnosed with OART with a review of the literature. The 14-year-old patient, who was raised as a boy, developed a virilizing syndrome with high testosterone levels that were attributed to non adherence to her replacement corticosteroid therapy. She consulted for sex reassignment surgery. Pelvic ultrasound was normal. She underwent hysterectomy and bilateral adnexectomy. No abnormalities were noticed during the operation. Grossly, both ovaries were variegated with well circumscribed and lobulated, brownish-yellow nodules. Histologically, the nodules were composed of nests of large polygonal cells with centrally located nuclei and prominent nucleoli. There was mild atypia and no crystals of Reinke. Thus, the findings of the histopathological examination were consistent with bilateral OART. Histological differential diagnosis of OART can be challenging particularly with leydig cell tumor, stromal luteoma and steroid cell tumors, not otherwise specified. OART must be considered in women with CAH and persistent virilizing symptoms despite negative imaging results.
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Affiliation(s)
- Lobna Bouzidi
- Department of Pathology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Meriam Triki
- Department of Pathology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Slim Charfi
- Department of Pathology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Hana Ben Ameur
- Department of Pediatric Surgery, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Mahdi Ben Dhaou
- Department of Pediatric Surgery, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Touraya Bouaziz
- Department of Pediatrics, Hedi Chaker University Hospital, Sfax, Tunisia
| | - Tahya Boudawara
- Department of Pathology, Habib Bourguiba University Hospital, Sfax, Tunisia
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12
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Ma L, Xia Y, Wang L, Liu R, Huang X, Ye T, Zhang L, Zhu Q, Li J, Jiang Y. Sonographic features of the testicular adrenal rests tumors in patients with congenital adrenal hyperplasia: a single-center experience and literature review. Orphanet J Rare Dis 2019; 14:242. [PMID: 31694673 PMCID: PMC6836335 DOI: 10.1186/s13023-019-1231-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/22/2019] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Testicular adrenal rests tumor (TART) is a rare kind of benign tumor in the testis. It usually occurred secondary to congenital adrenal hyperplasia (CAH), a hormonal disorder caused by hydroxylase deficiency. As the first-line examination method, ultrasound provides crucial diagnostic information for TART, although misdiagnosis to malignancy is quite common because of its rare prevalence. We aimed to summarize the sonographic manifestations of TART to improve the diagnostic accuracy and specificity. METHODS Eight CAH patients with TART identified by ultrasound in our medical center were retrospectively reviewed. Clinical and hormonal profile, semen analysis and treatment choices were collected. Sonographic examinations were performed at the first evaluation and interpreted by experienced radiologists individually. All patients received regular follow-up, and 5 patients undertook repeated scrotal ultrasound. A literature review of TART in CAH patients was conducted, with 123 patients from 23 articles since 1990 included. RESULTS A total of 8 patients aged between 4 to 27 years old were enrolled. 7 of 8 (87.5%) patients exhibited bilateral testicular lesions. The sizes of the testicular lesions were between 0.18 ml to 5.68 ml, and all showed a clear boundary. 10/15 (66.7%) lesions were homogenously hypoechoic, 4/15 (26.7%) were heterogeneously iso-hypoechoic, and 1/15 (6.7%) were homogenously isoechoic. 10/15 (66.7%) lesions were hyper-vascular. The longitudinal follow-up of 5 patients showed testicular lesions changed in terms of size, echogenicity, and vascularity after steroid treatment. A potential correlation may exist between ACTH levels and tumor size (p = 0.066). From the literature review, 100/123 (81%) patients got bilateral lesions, and 95% of them were located near the mediastinum. 80/103 (78%) lesions exhibited a clear boundary, and predominant lesions (74%) were hypoechogenic. Vascularity was with great diversity. Seventy-nine lesions of 44 patients were followed-up by scrotal ultrasound, among which 29 (37%) remained unchanged, 29(37%) shrank, and 21(27%) disappeared. CONCLUSIONS Key sonographic characteristics of TART are: resembled lesions on both testes, located near the mediastinum, clear boundary, and changed in size or echogenicity after steroid treatment. These features can help radiologists to make an accurate diagnosis of TART.
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Affiliation(s)
- Li Ma
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Yu Xia
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Linlin Wang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
- Department of Ultrasound, Harrison International Peace Hospital, Hebei, China
| | - Ruifeng Liu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Xuepei Huang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Tiantian Ye
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Li Zhang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Qingli Zhu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Jianchu Li
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China
| | - Yuxin Jiang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1, Dongcheng District, Beijing, 100730, China.
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13
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Jha S, El-Maouche D, Marko J, Mallappa A, Veeraraghavan P, Merke DP. Individualizing Management of Infertility in Classic Congenital Adrenal Hyperplasia and Testicular Adrenal Rest Tumors. J Endocr Soc 2019; 3:2290-2294. [PMID: 31745525 PMCID: PMC6853670 DOI: 10.1210/js.2019-00227] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 10/11/2019] [Indexed: 12/31/2022] Open
Abstract
Testicular adrenal rest tumors (TARTs) are a common cause of male infertility in patients with classic congenital adrenal hyperplasia (CAH). These tumors are located in the rete testis and can lead to impaired blood flow and functional impairment of seminiferous tubules. We describe restoration of fertility in a man with CAH and bilateral TARTs with use of lower-dose glucocorticoid therapy than previously described. A 28-year-old man with classic salt-wasting CAH presented with impaired fertility. Biochemical evaluation showed poor CAH control despite reported compliance with prednisone 5 mg every morning and fludrocortisone 50 μg twice daily. Semen analysis showed azoospermia. Testicular ultrasonography showed TARTs occupying 16% of total testicular volume. After 5 months of dexamethasone 250 μg at bedtime, total TART volume decreased 90%, biochemical control improved, and semen analysis showed a sperm count of 132 × 106 million per milliliter. The patient’s wife was confirmed to be pregnant 9 months after the initial visit and delivered a healthy full-term baby girl. The patient’s glucocorticoid therapy was changed to prednisone 3 mg twice daily, and 2 years later he continues to show adequate CAH control, stable TART volume, and normal semen analysis, and his wife is pregnant again. Management of CAH in men with TARTs needs to be individualized, and high-dose dexamethasone may not be indicated. The use of a long-acting glucocorticoid at typical recommended dosages can decrease TART size and reverse male infertility. Prednisone given once daily does not adequately control the ACTH-driven complications of CAH.
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Affiliation(s)
- Smita Jha
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland.,Clinical and Investigative Orthopedics Surgery Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Diala El-Maouche
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jamie Marko
- Department of Radiology and Imaging Sciences, National Institutes of Health, Bethesda, Maryland
| | - Ashwini Mallappa
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Padmasree Veeraraghavan
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Deborah P Merke
- Section on Congenital Disorders, National Institutes of Health Clinical Center, Bethesda, Maryland.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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14
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Engels M, Span PN, van Herwaarden AE, Sweep FCGJ, Stikkelbroeck NMML, Claahsen-van der Grinten HL. Testicular Adrenal Rest Tumors: Current Insights on Prevalence, Characteristics, Origin, and Treatment. Endocr Rev 2019; 40:973-987. [PMID: 30882882 DOI: 10.1210/er.2018-00258] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022]
Abstract
This review provides the reader with current insights on testicular adrenal rest tumors (TARTs), a complication in male patients with congenital adrenal hyperplasia (CAH). In recent studies, an overall TART prevalence of 40% (range, 14% to 89%) in classic patients with CAH is found. Reported differences are mainly caused by the method of detection and the selected patient population. Biochemically, histologically, and molecularly, TARTs exhibit particular adrenal characteristics and were therefore thought to originate from aberrant adrenal cells. More recently, TARTs have been found to also exhibit testicular characteristics. This has led to the hypothesis of pluripotent cells as the origin of TARTs. High concentrations of ACTH could cause hyperplasia of these pluripotent cells, as TARTs appear to be associated with poor hormonal control with concomitant elevated ACTH. Unfortunately, as yet there are no methods to prevent the development of TARTs, nor are there guidelines to treat patients with TARTs. Intensified glucocorticoid treatment could improve fertility status in some cases, although studies report contradicting results. TARTs can also lead to irreversible testicular damage, and therefore semen cryopreservation could be offered to patients with TARTs. Further research should focus on the etiology and pharmacological treatment to prevent TART development or to treat TARTs and improve the fertility status of patients with TARTs.
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Affiliation(s)
- Manon Engels
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N Span
- Department of Radiation Oncology, Radiotherapy and OncoImmunology Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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15
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Fouques C, Fatfouta I, Hieronimus S, Sadoul JL, Bongain A. Two cases of male patients followed for a classical form of congenital adrenal hyperplasia (CAH), presenting an azoospermia: analysis and review of the literature. Basic Clin Androl 2019; 29:10. [PMID: 31143447 PMCID: PMC6532123 DOI: 10.1186/s12610-019-0084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 02/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Congenital hyperplasia of the adrenal glands is a rare pathology, which can have an impact on male fertility. We report 2 cases of azoospermia in patients followed for a classical form of congenital adrenal hyperplasia. Cases presentation 1st case: After 18 months of infertility of the couple, explorations showed a high level of ACTH on the hormonal biological analysis. A therapeutic strategy combining hydrocortisone with dexamethasone induced a normal semen analysis, and the female partner of the patient subsequently had three spontaneous pregnancies.2nd case: After two years of infertility of the couple, explorations showed adrenal testicular inclusions invading the 4/5th of the testis with a hypergonadotropic hypogonadism, the therapeutic reinforcement did not allow the improvement of semen analysis. Discussion Sertolian deficiency can be explained by: gonadotropic deficiency by excess of adrenal androgens and adrenal testicular lesions (risk of major spermatic alteration). Conclusion Congenital hyperplasia of the adrenal glands is a rare pathology in the context of male infertility. A semen analysis could be performed after puberty and a semen preservation may be proposed.
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Affiliation(s)
- Clélia Fouques
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Imène Fatfouta
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Sylvie Hieronimus
- 2Departments of Endocrinology, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - Jean-Louis Sadoul
- 2Departments of Endocrinology, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
| | - André Bongain
- 1Department of Gynecology-Obstetrics, Archet 2 Hospital, 151 route Sainte-Antoine de Ginestière CS 23079, 06202 Nice, Cedex 3 France
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16
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Lottspeich C, Müller-Lisse U, Seiler L, Schmitt-Graeff AH, Reincke M, Reisch N. Three Cases of Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia-A Diagnostic and Therapeutic Challenge. Urology 2019; 129:24-28. [PMID: 30898461 DOI: 10.1016/j.urology.2019.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/22/2019] [Accepted: 03/08/2019] [Indexed: 12/31/2022]
Affiliation(s)
| | | | | | | | - Martin Reincke
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany.
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17
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Kolli V, Kim H, Torky A, Lao Q, Tatsi C, Mallappa A, Merke DP. Characterization of the CYP11A1 Nonsynonymous Variant p.E314K in Children Presenting With Adrenal Insufficiency. J Clin Endocrinol Metab 2019; 104:269-276. [PMID: 30299480 PMCID: PMC6607962 DOI: 10.1210/jc.2018-01661] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/03/2018] [Indexed: 12/15/2022]
Abstract
CONTEXT Cholesterol side-chain cleavage enzyme (P450scc), encoded by CYP11A1, catalyzes the first step of steroidogenesis. Complete P450scc deficiency leads to primary adrenal insufficiency (PAI) and 46,XY disordered sexual development. Partial impairment can cause variable adrenal and gonadal dysfunction. OBJECTIVE Our aim was to evaluate the effects of the CYP11A1 variant p.E314K, identified in patients with PAI, specifically on P450scc enzyme stability and function. PATIENTS AND METHODS We studied four boys from two unrelated families presenting with PAI during childhood (3.6 to 9 years old). All patients were compound heterozygous for c.940G>A (p.E314K), a CYP11A1 nonsynonymous variant likely to be pathogenic by some but not all in silico prediction models, and c.835delA (p.I79Yfs*10), a known pathogenic variant. HEK293T cells were transfected with wild type (WT) and p.E314K mutant vectors, and a cycloheximide chase assay was performed to analyze protein stability. Pregnenolone production was assayed from cells expressing WT and p.E314K-F2 fusion proteins. RESULTS Two boys experienced spontaneous puberty but then developed evidence of primary gonadal failure at 14 and 18 years old. Two boys had testicular adrenal rest tumor (TART), detected by ultrasound at ages 8.6 and 16 years. Compared with WT, mutant protein synthesis was reduced (P = 0.0006) with increased protein turnover, and mutant P450scc half-life was decreased by ~50%. p.E314K mutant P450scc retained 60% of WT enzymatic activity (P = 0.007). CONCLUSIONS The CYP11A1 p.E314K variant impairs P450scc stability and is a possible cause of PAI in childhood. Pathogenic CYP11A1 variants potentially affect both adrenal and gonadal function, and male patients may develop TART.
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Affiliation(s)
- Vipula Kolli
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Hannah Kim
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Ahmed Torky
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Qizong Lao
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Christina Tatsi
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Correspondence and Reprint Requests: Deborah P. Merke, MD, National Institutes of Health Clinical Center, Building 10, Room 1-2740, 10 Center Drive, Bethesda, Maryland 20892-1932. E-mail:
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18
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Kim MS, Koppin CM, Mohan P, Goodarzian F, Ross HM, Geffner ME, De Filippo R, Kokorowski P. Absence of Testicular Adrenal Rest Tumors in Newborns, Infants, and Toddlers with Classical Congenital Adrenal Hyperplasia. Horm Res Paediatr 2019; 92:157-161. [PMID: 31747670 PMCID: PMC7004842 DOI: 10.1159/000504135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/14/2019] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Testicular adrenal rest tumors (TART) are a known consequence for males with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. TART are associated with potential infertility in adults. However, little is known about TART in very young males with CAH. OBJECTIVE We assessed the presence of TART in newborn, infant, and toddler males with classical CAH via scrotal ultrasound. METHODS Males with CAH had scrotal ultrasounds during the first 4 years of life, evaluating testes for morphology, blood flow, and presence of TART. Newborn screen 17-hydroxyprogesterone (17-OHP) and serum 17-OHP at the time of ultrasound were recorded. Bone ages were considered very advanced if ≥2 SD above chronological age. RESULTS Thirty-one ultrasounds in 16 males were performed. An initial ultrasound was obtained in four newborns at diagnosis (6.8 ± 2.1 days), six infants (2.2 ± 0.9 months), and six toddlers (2.4 ± 0.9 years). Eleven males had at least one repeat ultrasound. A large proportion (11/16) were in poor hormonal control with an elevated 17-OHP (325 ± 298 nmol/L). One infant was in very poor hormonal control (17-OHP 447 nmol/L) at initial ultrasound, and two toddlers had advanced bone ages (+3.2 and +4.5 SD) representing exposure to postnatal androgens. However, no TART were detected in any subjects. CONCLUSIONS TART were not found by scrotal ultrasound in males up to 4 years of age with classical CAH despite settings with expected high ACTH drive. Further research into the occurrence of TART in CAH may elucidate factors that contribute to the detection and individual predisposition to TART.
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Affiliation(s)
- Mimi S. Kim
- Corresponding Author: Mimi Kim, M.D., M.Sc., Children’s Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #61, Los Angeles, CA 90027, , Phone: +1 323-361-1358
| | - Christina M. Koppin
- Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Pankhuri Mohan
- Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Fariba Goodarzian
- Children’s Hospital Los Angeles, Los Angeles, California, United States of America,Keck School of Medicine of University of Southern California,Department of Radiology, Children’s Hospital Los Angeles
| | - Heather M. Ross
- Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California, United States of America
| | - Mitchell E. Geffner
- Center for Endocrinology, Diabetes, and Metabolism, Children’s Hospital Los Angeles, Los Angeles, California, United States of America,Keck School of Medicine of University of Southern California,The Saban Research Institute
| | - Roger De Filippo
- Children’s Hospital Los Angeles, Los Angeles, California, United States of America,Keck School of Medicine of University of Southern California,Division of Pediatric Urology, Children’s Hospital Los Angeles
| | - Paul Kokorowski
- Children’s Hospital Los Angeles, Los Angeles, California, United States of America,Keck School of Medicine of University of Southern California,Division of Pediatric Urology, Children’s Hospital Los Angeles
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Armas-Alvarez AL, Salinas-Sánchez AS, Atienzar-Tobarra M, Virseda-Rodriguez JA. Testicular adrenal rest tumors. Rev Int Androl 2018; 16:128-130. [DOI: 10.1016/j.androl.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 10/15/2017] [Indexed: 10/17/2022]
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Chaudhari M, Johnson EK, DaJusta D, Nahata L. Testicular adrenal rest tumor screening and fertility counseling among males with congenital adrenal hyperplasia. J Pediatr Urol 2018; 14:155.e1-155.e6. [PMID: 29330018 DOI: 10.1016/j.jpurol.2017.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 11/10/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Reduced fertility is a common potential problem among males with congenital adrenal hyperplasia (CAH), with nearly half experiencing impaired sperm production. The major cause of oligo/azoospermia in CAH is testicular adrenal rest tumors (TARTs). Studies indicate that ultrasound screening for TARTs should begin during childhood, yet it remains unclear whether boys with CAH are routinely screened for TARTs and/or counseled about infertility risk and potential interventions such as fertility testing and/or preservation. OBJECTIVE The purpose of this study was to examine TART screening and fertility counseling practices among boys with CAH. STUDY DESIGN An IRB-approved retrospective chart review was conducted of all males with ICD-9/10 codes for CAH (2007-2016) at a large pediatric academic center to examine: age and indication for diagnosis; age at first and last documented pediatric endocrinology and urology visit; history of ultrasound examinations; and documentation of fertility counseling. RESULTS Forty-six patients were included, of whom 38 had 21-hydroxylase deficiency. Median age at diagnosis was 2 weeks (range 7 days-10 years). Median age at the most recent pediatric endocrinology clinic visit was 14 years (range 2-42 years). Twenty-nine patients were >11 years old (63% of the sample) at the time of the study and 14 of these were >18 years old (30% of the sample). Seven patients (15%) had a screening ultrasound at some point in their care, of whom three had TARTs. Fertility was mentioned in the records of six subjects (13% of the sample). Six of the subjects (13%) had any mention of fertility in their records. None of the patients had biochemical testing or semen analysis to assess gonadal function, and none were offered fertility preservation. Only one patient was seen by a pediatric urologist. DISCUSSION Despite the limitations of a single-center retrospective design, our findings highlight that TART screening and fertility counseling remain underutilized in boys with CAH. There is a need for increased awareness and development of practice guidelines within pediatric urology and endocrinology to address this common and understudied problem. CONCLUSION In addition to a screening ultrasound in puberty and consideration of semen analysis after puberty, these boys may benefit from seeing a pediatric urologist independently or in an interdisciplinary program. Boys with CAH and their families should be educated about infertility risk and potential interventions, with the goal of improving reproductive outcomes in this population.
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Affiliation(s)
- Monika Chaudhari
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Emilie K Johnson
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Urology and Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Daniel DaJusta
- Division of Pediatric Urology, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Leena Nahata
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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21
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Falhammar H, Frisén L, Norrby C, Almqvist C, Hirschberg AL, Nordenskjöld A, Nordenström A. Reduced Frequency of Biological and Increased Frequency of Adopted Children in Males With 21-Hydroxylase Deficiency: A Swedish Population-Based National Cohort Study. J Clin Endocrinol Metab 2017; 102:4191-4199. [PMID: 28945916 DOI: 10.1210/jc.2017-01139] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/08/2017] [Indexed: 02/13/2023]
Abstract
CONTEXT Fertility in males with 21-hydroxylase deficiency (21OHD) is unclear. OBJECTIVE Study fertility outcome in males with congenital adrenal hyperplasia. DESIGN, SETTING, AND PARTICIPANTS Males ≥15 years old with 21OHD (n = 221) were compared with controls matched for sex and year and place of birth (n = 22,024). Data were derived by linking national population-based registers. Subgroup analyses were performed regarding phenotype [salt-wasting (SW), simple virilizing (SV), and nonclassic (NC)] and CYP21A2 genotype (null, I2 splice, I172N, and P30L) and stratified by the introduction of neonatal screening. MAIN OUTCOME MEASURES Number of biological and adopted children. RESULTS Males with 21OHD were less likely to be fathers of biological children [odds ratio (OR), 0.5; 95% confidence interval (CI), 0.4 to 0.7; after adjusting for socioeconomic characteristics: OR, 0.4; 95% CI, 0.2 to 0.5]. This was true for SW, SV, I2 splice, and I172N, but not for NC, null, and P30L groups (all adjusted). Among patients born before the neonatal screening introduction, fewer were fathers (adjusted OR, 0.3; 95% CI, 0.2 to 0.5), but this normalized in those born afterward. Adoption was more common in the 21OHD males (OR, 2.9; 95% CI, 1.0 to 7.9) and the SV and I172N subgroups. Age at becoming a father, marriage, region of residence, and education were similar, but fewer patients had high incomes. NC and I172N groups had, however, higher academic degrees and NC patients were more often married, whereas SW and I2 splice patients were more often divorced. CONCLUSIONS 21OHD was associated with a reduced frequency of biological children and an increased frequency of adopted children, suggesting impaired fertility, although some subgroups had normal fertility.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism, and Diabetes, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77 Stockholm, Sweden
- Child and Adolescent Psychiatry Research Center, SE-171 77 Stockholm, Sweden
| | - Christina Norrby
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, SE-171 64 Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, SE-171 64 Stockholm, Sweden
- Lung and Allergy Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-171 64 Stockholm, Sweden
| | - Angelica Linden Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Agneta Nordenskjöld
- Department of Women's and Children's Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, SE-171 76 Stockholm, Sweden
- Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-171 64 Stockholm, Sweden
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, SE-171 64 Stockholm, Sweden
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22
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Dumic M, Duspara V, Grubic Z, Oguic SK, Skrabic V, Kusec V. Testicular adrenal rest tumors in congenital adrenal hyperplasia-cross-sectional study of 51 Croatian male patients. Eur J Pediatr 2017; 176:1393-1404. [PMID: 28879515 DOI: 10.1007/s00431-017-3008-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 08/24/2017] [Accepted: 08/27/2017] [Indexed: 11/26/2022]
Abstract
UNLABELLED Testicular adrenal rest tumors (TARTs) are common cause of infertility in males with congenital adrenal hyperplasia (CAH). We studied the role of genotype and disease regulation on TART development, their impact on gonadal function, and frequency in 47 21-hydroxylase deficiency (21-OHD) and four 11-hydroxylase deficiency (11-OHD) male patients. Testicular ultrasound (TU), genotype, hormonal measurement in 51, and spermiogram in five patients were performed. TARTs were detected in 14 SW21-OHD and one 11-OHD patient: 1/8 patients aged <7 years (1.8 years old is the youngest), 1/8 patients aged <12 years, 5/17 patients aged <18 years, and in 8/18 adults. All 21-OHD TART patients had exclusively severe mutations of CYP21A2 gene. Poor hormonal control in 8/15 patients with and 12/36 patients without TART indicates correlation of tumor development with poor disease control. None of the TART patients fathered a child. Low inhibin-B was found in 7/15 TART patients. Azoospermia was found in four and oligoasthenozoospermia in one patient. CONCLUSION TART was detected exclusively in patients with severe CYP21A2 mutations. Disease regulation plays a role in development of TART that impairs testicular function and increases the risk of infertility. Screening for TART by TU is indicated from early childhood. What is Known: • Due to improved diagnostic and therapeutic possibilities, majority of the male patients with congenital adrenal hyperplasia nowadays reach adulthood and screening for long-term complications is becoming more important. • Testicular adrenal rest tumors (TARTs) are common cause of infertility and impaired gonadal function in males with CAH. What is New: • A 1.8-year-old boy described in this paper is the youngest reported patient with TART. • Screening for TART by testicular ultrasound from early childhood, especially in patients with severe CYP21A mutations, is recommended.
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Affiliation(s)
- Miroslav Dumic
- Department of Pediatrics, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Vlatko Duspara
- Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Zorana Grubic
- Tissue Typing Centre, Department of Transfusion Medicine and Transplantation Biology, Department of Laboratory Medicine, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Sasa Kralik Oguic
- Endocrinological Laboratory, Department of Laboratory Medicine, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Veselin Skrabic
- Department of Pediatrics, Clinical Hospital Centre Split, University of Split Medical School, Split, Croatia
| | - Vesna Kusec
- Endocrinological Laboratory, Department of Laboratory Medicine, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Zagreb, Croatia
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Naouar S, Braiek S, El Kamel R. Testicular tumors of adrenogenital syndrome: From physiopathology to therapy. Presse Med 2017; 46:572-578. [PMID: 28549629 DOI: 10.1016/j.lpm.2017.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 04/04/2017] [Accepted: 05/03/2017] [Indexed: 11/26/2022] Open
Abstract
Testicular tumor of adrenogenital syndrome is a rare and benign anomaly usually presenting as bilateral testicular masses. It is the most important cause of infertility in adult male congenital adrenal hyperplasia. Distinction between testicular tumors of adrenogenital syndrome and Leydig cell tumors can be problematic; it is based on clinical, histopathologic, immunohistochemical and endocrine features. Biopsy is advised in cases of longstanding tumors in infertile patients and when surgery is indicated. Fertility preservation is a key management goal in testicular tumor of adrenogenital syndrome. In stages 2 and 3, intensified glucocorticoid treatment is recommended as a first step treatment. Sparing surgical approach is preferred for tumors of stage 4 and steroid unresponsive masses. Magnetic resonance imaging is recommended before surgery. The only indication of surgery in stage 5 is testicular pain.
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Affiliation(s)
- Sahbi Naouar
- Ibn El Jazzar teaching hospital, Les Aghlabides surgical division, urology department, 3100 Kairouan, Tunisia.
| | - Salem Braiek
- Ibn El Jazzar teaching hospital, Les Aghlabides surgical division, urology department, 3100 Kairouan, Tunisia
| | - Rafik El Kamel
- Ibn El Jazzar teaching hospital, Les Aghlabides surgical division, urology department, 3100 Kairouan, Tunisia
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24
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Choi JH, Yoo HW. Management issues of congenital adrenal hyperplasia during the transition from pediatric to adult care. KOREAN JOURNAL OF PEDIATRICS 2017; 60:31-37. [PMID: 28289431 PMCID: PMC5346506 DOI: 10.3345/kjp.2017.60.2.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/21/2016] [Accepted: 02/13/2016] [Indexed: 11/27/2022]
Abstract
Steroid 21-hydroxylase deficiency is the most prevalent form of congenital adrenal hyperplasia (CAH), accounting for approximately 95% of cases. With the advent of newborn screening and hormone replacement therapy, most children with CAH survive into adulthood. Adolescents and adults with CAH experience a number of complications, including short stature, obesity, infertility, tumor, osteoporosis, and reduced quality of life. Transition from pediatric to adult care and management of long-term complications are challenging for both patients and health-care providers. Psychosocial issues frequently affect adherence to glucocorticoid treatment. Therefore, the safe transition of adolescents to adult care requires regular follow-up of patients by a multidisciplinary team including pediatric and adult endocrinologists. The major goals for management of adults with 21-hydroxylase deficiency are to minimize the long-term complications of glucocorticoid therapy, reduce hyperandrogenism, prevent adrenal or testicular adrenal rest tumors, maintain fertility, and improve quality of life. Optimized medical or surgical treatment strategies should be developed through coordinated care, both during transition periods and throughout patients' lifetimes. This review will summarize current knowledge on the management of adults with CAH, and suggested appropriate approaches to the transition from pediatric to adult care.
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Affiliation(s)
- Jin-Ho Choi
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Wook Yoo
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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25
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Pretorius E, Arlt W, Storbeck KH. A new dawn for androgens: Novel lessons from 11-oxygenated C19 steroids. Mol Cell Endocrinol 2017; 441:76-85. [PMID: 27519632 DOI: 10.1016/j.mce.2016.08.014] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 07/28/2016] [Accepted: 08/08/2016] [Indexed: 10/21/2022]
Abstract
The abundant adrenal C19 steroid 11β-hydroxyandrostenedione (11OHA4) has been written off as a dead-end product of adrenal steroidogenesis. However, recent evidence has demonstrated that 11OHA4 is the precursor to the potent androgenic 11-oxygenated steroids, 11-ketotestosterone and 11-ketodihydrotestosterone, that bind and activate the human androgen receptor similarly to testosterone and DHT. The significance of this discovery becomes apparent when considering androgen dependent diseases such as castration resistant prostate cancer and diseases associated with androgen excess, e.g. congenital adrenal hyperplasia and polycystic ovary syndrome. In this review we describe the production and metabolism of 11-oxygenated steroids. We subsequently discuss their androgenic activity and highlight the putative role of these androgens in disease states.
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Affiliation(s)
- Elzette Pretorius
- Department of Biochemistry, Stellenbosch University, Stellenbosch, 7600, South Africa
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Karl-Heinz Storbeck
- Department of Biochemistry, Stellenbosch University, Stellenbosch, 7600, South Africa.
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26
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Bulsari K, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Endocrine 2017; 55:19-36. [PMID: 27928728 DOI: 10.1007/s12020-016-1189-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency is a rare autosomal recessive genetic disorder. It is caused by reduced or absent activity of 11β-hydroxylase (CYP11B1) enzyme and the resultant defects in adrenal steroidogenesis. The most common clinical features of 11 beta-hydroxylase deficiency are ambiguous genitalia, accelerated skeletal maturation and resultant short stature, peripheral precocious puberty and hyporeninemic hypokalemic hypertension. The biochemical diagnosis is based on raised serum 11-deoxycortisol and 11-deoxycorticosterone levels together with increased adrenal androgens. More than 100 mutations in CYP11B1 gene have been reported to date. The level of in-vivo activity of CYP11B1 relates to the degree of severity of 11 beta-hydroxylase deficiency. Clinical management of 11 beta-hydroxylase deficiency can pose a challenge to maintain adequate glucocorticoid dosing to suppress adrenal androgen excess while avoiding glucocorticoid-induced side effects. The long-term outcomes of clinical and surgical management are not well studied. This review article aims to collate the current available data about 11 beta-hydroxylase deficiency and its management.
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Affiliation(s)
- Krupali Bulsari
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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27
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Reichman D, Rosenwaks Z. The impact of genetic steroid disorders on human fertility. J Steroid Biochem Mol Biol 2017; 165:131-136. [PMID: 27125451 DOI: 10.1016/j.jsbmb.2016.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 04/21/2016] [Accepted: 04/23/2016] [Indexed: 11/29/2022]
Abstract
Human fertility requires an exquisitely complex orchestration of steroid hormone action to affect the necessary elements of reproduction, including folliculogenesis, endometrial advancement, ovulation, and implantation. Individuals affected by genetic steroid disorders often face substantial challenges to these crucial elements of fertility, in addition to the broader health implications of their diseases. In the following article, we review the impact of genetic steroid disorders on human reproduction, as well as the treatments, where available, aimed at circumventing such hurdles. Adrenal disorders will first be described, followed by rare gonadal steroid disorders.
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Affiliation(s)
- David Reichman
- The Ronald O. Perelman & Claudia Cohen Center for Reproductive Medicine, USA; Weill Cornell Medical College, USA
| | - Zev Rosenwaks
- The Ronald O. Perelman & Claudia Cohen Center for Reproductive Medicine, USA; Weill Cornell Medical College, USA.
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28
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Abstract
Adrenal gland diagnostics can pose significant challenges. In most academic and community practice settings, adrenal gland resections are encountered less frequently than other endocrine or genitourinary specimens, leading to less familiarity with evolving classifications and criteria. The unique dichotomy between cortical and medullary lesions reflects the developmental evolution of these functionally independent components. Adrenal cortical lesions at resection include hyperplasia, adenoma, and carcinoma, with some cases straddling the boundary between these distinct clinical classifications. The lack of immunohistochemical or molecular markers to definitively categorize these intermediate lesions enhances the diagnostic challenge. In addition, modified terminology for oncocytic and myxoid cortical lesions has been proposed. Medullary lesions are somewhat easier to categorize; however, the prediction of aggressive behavior in pheochromocytomas remains a challenge due to a lack of reliable prognostic biomarkers. Recent work by the Cancer Genome Atlas Project and other research groups has identified a limited subset of molecular and signaling pathway alterations in these 2 major neoplastic categories. Ongoing research to better define prognostic and predictive biomarkers in cortical and medullary lesions has the potential to enhance both pathologic diagnosis and patient therapy.
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29
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Stangler Herodež Š, Fijavž L, Zagradišnik B, Kokalj Vokač N. Detection of mutations in the CYP21A2 gene: genotype-phenotype correlation in Slovenian couples with conceiving problems. Balkan J Med Genet 2016; 18:25-32. [PMID: 27785393 PMCID: PMC5026265 DOI: 10.1515/bjmg-2015-0082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The objective of this study was to compare the CYP 21A2 genetic profiles of couples with unexplained fertility problems (UFP) with genetic profiles of healthy controls (HCs). Furthermore, we analyzed associations between mutations in the CYP21A2 gene and various clinical and laboratory parameters. Allele-specific polymerase chain reaction (PCR) was used in 638 probands with UFP and 200 HCs. Statistic analysis with χ2 was used to study the association of mutations with infertility. The effect of mutations on particular clinical and laboratory parameters was assessed with the analysis of variance (ANOVA) test. With regard to the CYP21A2 gene, 0.6% of probands with UFP and 0.5% of HCs were positive for the c.290-13A/C>G mutation; 0.6% of probands with UFP and 1.5% of HCs were positive for the p.I172N mutation; there were no probands with UFP positive for the p.P30L mutation, whereas 0.5% of HCs were; and 0.2% of probands with UFP and 0.5% of HCs were found to have the p.V281L mutation. We found a significant association between c.290-13A/C>G mutation and the frequency of significant hormone deviations (χ2 = 6.997, p = 0.008). Similar association was also observed between the c.29013A/C>G mutation and the frequency of polycystic ovary syndrome (PCOS) (χ2 = 16.775, p = 0.000). Our findings indicate that no significant difference in the prevalence of CYP 21A2 mutations can be found in probands with UFP when compared with HCs without infertility history. The results also imply the significant association of the c.290-13A/ C>G mutation in the CYP21A2 gene, not only with the frequency of PCOS, but also with the frequency of significant hormone deviations.
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Affiliation(s)
- Š Stangler Herodež
- Laboratory of Medical Genetics, University Clinical Centre Maribor, Maribor, Slovenia
| | - L Fijavž
- Medical Faculty, University of Maribor, Maribor, Slovenia
| | - B Zagradišnik
- Laboratory of Medical Genetics, University Clinical Centre Maribor, Maribor, Slovenia
| | - N Kokalj Vokač
- Laboratory of Medical Genetics, University Clinical Centre Maribor, Maribor, Slovenia; Medical Faculty, University of Maribor, Maribor, Slovenia
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Abstract
PURPOSE OF REVIEW In recent years, important steps have been taken to improve the treatment of congenital adrenal hyperplasia (CAH), a relatively stagnant area for decades. In this review, we summarize these advances and propose future lines of investigation. RECENT FINDINGS The two main goals of CAH treatment are to replace the deficient hormones when necessary and to dampen the adrenocorticotropin activation and the ensuing adrenal androgen excess. Glucocorticoids have been the mainstay of CAH treatment, but available preparations only partially meet the clinical needs. Recent efforts have focused on improving the delivery of glucocorticoid replacement agents, to closer mimic the physiologic secretion pattern. Examples include modified release oral glucocorticoids and continuous subcutaneous hydrocortisone pumps. Furthermore, nonglucocorticoid approaches to address the androgen excess have emerged, such as inhibition of key androgenic enzymes and adrenocorticotropin secretion blockade by corticotropin-releasing hormone receptor antagonists. SUMMARY The promising recent progress made in CAH treatment brings new perspectives for individualized care in this complex disease.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology and Diabetes, Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, USA
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King TFJ, Lee MC, Williamson EEJ, Conway GS. Experience in optimizing fertility outcomes in men with congenital adrenal hyperplasia due to 21 hydroxylase deficiency. Clin Endocrinol (Oxf) 2016; 84:830-6. [PMID: 26666213 DOI: 10.1111/cen.13001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/19/2015] [Accepted: 12/09/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Men with congenital adrenal hyperplasia (CAH) have impaired fertility. We aimed to assess fertility outcomes and the importance of hypogonadotropic hypogonadism, testicular failure and the presence of testicular adrenal rest tumours (TART). DESIGN Retrospective analysis of men attending an adult CAH clinic in a tertiary centre. PATIENTS Fifty men with CAH due to 21 hydroxylase deficiency were identified of whom 35 were salt wasting and 15 were non-salt-wasting. MEASUREMENTS Review of fertility history and parameters including luteinizing hormone (LH), follicle-stimulating hormone (FSH), androstenedione, 17-hydroxyprogesterone (17-OHP), semen analysis and the presence of testicular adrenal rest tissue (TART) on ultrasound. RESULTS TART were detected by ultrasound in 21 (47%), and their presence was associated with an elevated FSH (P = 0·01). Severe oligospermia was present in 11 of 23 (48%), and this was associated with an elevated FSH (P = 0·02), suppressed LH (P < 0·01) and TART (P = 0·03) when compared to those with a sperm count >5 × 10(6) per ml. Of those that desired fertility, 10 of 17 (59%) required treatment intensification and four underwent in vitro fertilization. Intensification resulted in a rise in median LH (0·6-4·3 IU/l; P = 0·01). Live birth rate was 15 of 17 (88%) with a median (range) time to conception of 8 (0-38) months. CONCLUSIONS Suppressed LH is a marker for subfertility and is often reversible. Testicular failure is closely associated with TART formation. If TART are detected, sperm cryopreservation should be offered given the risk of progression to irreversible testicular failure. Male fertility in CAH can be improved by intensified treatment and assisted reproductive technology.
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Affiliation(s)
- Thomas F J King
- Department of Endocrinology, University College London Hospitals, London, UK
- Institute for Women's Health, University College London Hospitals, London, UK
| | - Marilyn Cheng Lee
- Department of Endocrinology, University College London Hospitals, London, UK
- Institute for Women's Health, University College London Hospitals, London, UK
| | | | - Gerard S Conway
- Department of Endocrinology, University College London Hospitals, London, UK
- Institute for Women's Health, University College London Hospitals, London, UK
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Turcu AF, Nanba AT, Chomic R, Upadhyay SK, Giordano TJ, Shields JJ, Merke DP, Rainey WE, Auchus RJ. Adrenal-derived 11-oxygenated 19-carbon steroids are the dominant androgens in classic 21-hydroxylase deficiency. Eur J Endocrinol 2016; 174:601-9. [PMID: 26865584 PMCID: PMC4874183 DOI: 10.1530/eje-15-1181] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/09/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To comprehensively characterize androgens and androgen precursors in classic 21-hydroxylase deficiency (21OHD) and to gain insights into the mechanisms of their formation. DESIGN Serum samples were obtained from 38 patients (19 men) with classic 21OHD, aged 3-59, and 38 sex- and age-matched controls; 3 patients with 11β-hydroxylase deficiency; 4 patients with adrenal insufficiency; and 16 patients (8 men) undergoing adrenal vein sampling. Paraffin-embedded normal (n = 5) and 21OHD adrenal tissues (n = 3) were used for immunohistochemical studies. METHODS We measured 11 steroids in all sera by liquid chromatography-tandem mass spectrometry. Immunofluroescence localized 3β-hydroxysteroid dehydrogenase type 2 (HSD3B2) and cytochrome b5 (CYB5A) within the normal and 21OHD adrenals. RESULTS Four 11-oxygenated 19-carbon (11oxC19) steroids were significantly higher in male and female 21OHD patients than in controls: 11β-hydroxyandrostenedione, 11-ketoandrostenedione 11β-hydroxytestosterone, and 11-ketotestosterone (3-4-fold, P < 0.0001). For 21OHD patients, testosterone and 11-ketotestosterone were positively correlated in females, but inversely correlated in males. All 11oxC19 steroids were higher in the adrenal vein than in the inferior vena cava samples from men and women and rose with cosyntropin stimulation. Only trace amounts of 11oxC19 steroids were found in the sera of patients with 11β-hydroxylase deficiency and adrenal insufficiency, confirming their adrenal origin. HSD3B2 and CYB5A immunoreactivities were sharply segregated in the normal adrenal glands, whereas areas of overlapping expression were identified in the 21OHD adrenals. CONCLUSIONS All four 11oxC19 steroids are elevated in both men and women with classic 21OHD. Our data suggest that 11oxC19 steroids are specific biomarkers of adrenal-derived androgen excess.
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Affiliation(s)
- Adina F Turcu
- Division of MetabolismEndocrinology and Diabetes, University of Michigan, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109, USA
| | - Aya T Nanba
- Division of MetabolismEndocrinology and Diabetes, University of Michigan, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109, USA
| | - Robert Chomic
- Michigan Metabolomics and Obesity CenterUniversity of Michigan, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109, USA
| | - Sunil K Upadhyay
- Division of MetabolismEndocrinology and Diabetes, University of Michigan, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109, USA
| | - Thomas J Giordano
- Department of PathologyUniversity of Michigan, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109, USA
| | - James J Shields
- Department of RadiologyUniversity of Michigan, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109, USA
| | - Deborah P Merke
- Pediatric ServicesNational Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Center Drive, Bethesda, MD, 20892, USA
| | - William E Rainey
- Division of MetabolismEndocrinology and Diabetes, University of Michigan, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109, USA Department of Molecular and Integrative Physiology and MedicineUniversity of Michigan, Ann Arbor, Michigan, USA
| | - Richard J Auchus
- Division of MetabolismEndocrinology and Diabetes, University of Michigan, 1150 W Medical Center Drive, Ann Arbor, Michigan, 48109, USA Department of PharmacologyUniversity of Michigan, Ann Arbor, Michigan, USA
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Sha YK, Sha YW, Ding L, Liu WW, Song YQ, Lin J, He XM, Qiu PP, Zhang L, Li P. A Case of Bilateral Testicular Tumors Subsequently Diagnosed as Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2016; 9:574-80. [PMID: 26985347 PMCID: PMC4793180 DOI: 10.22074/ijfs.2015.4618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 09/16/2014] [Indexed: 11/28/2022]
Abstract
21-hydroxylase deficiency (21-OHD) caused congenital adrenal hyperplasia (CAH) is a
group of autosomal recessive genetic disorders resulting from mutations in genes involved
with cortisol (CO) synthesis in the adrenal glands. Testicular adrenal rest tumors (TARTs)
are rarely the presenting symptoms of CAH. Here, we describe a case of simple virilizing
CAH with TARTs, in a 15-year-old boy. The patient showed physical signs of precocious
puberty. The levels of blood adrenocorticotropic hormone (ACTH), urinary 17-ketone
steroids (17-KS), dehydroepiandrosterone sulfate (DHEA-S), and serum progesterone
(PRGE) were elevated, whereas those of follicle-stimulating hormone (FSH), luteinizing
hormone (LH), and CO were reduced. Computed tomography (CT) of the adrenal glands
and magnetic resonance imaging (MRI) of the testes showed a soft tissue density (more
pronounced on the right side) and an irregularly swollen mass (more pronounced on the
left side), respectively. Pathological examination of a specimen of the mass indicated
polygonal/circular eosinophilic cytoplasm, cord-like arrangement of interstitial cells, and
lipid pigment in the cytoplasm. Immunohistochemistry results precluded a diagnosis of
Leydig cell tumors. DNA sequencing revealed a hackneyed homozygous mutation, I2g,
on intron 2 of the CYP21A2 gene. The patient’s symptoms improved after a three-month
of dexamethasone therapy. Recent radiographic data showed reduced hyperplastic adrenal nodules and testicular tumors. A diagnosis of TART should be considered and prioritized in CAH patients with testicular tumors. Replacement therapy using a sufficient
amount of dexamethasone in this case helps combat TART.
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Affiliation(s)
- Yan-Kun Sha
- Department of Nephrology, First Affiliated Hospital of Liaoning Medical University, Jinzhou City 121000, Liaoning Province, China
| | - Yan-Wei Sha
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Lu Ding
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Wei-Wu Liu
- Department of Radiation, The Second Hospital of Jilin University, Changchun City 130041, Jilin Province, China
| | - Yue-Qiang Song
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Jin Lin
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Xue-Mei He
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Ping-Ping Qiu
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Ling Zhang
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Ping Li
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
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Kavoussi PK, Summers-Colquitt RB, Odenwald KC, Kressin M, Kavoussi KM, Pool TB, Kavoussi SK. Sperm retrieval and concomitant tumor resection in azoospermic men with congenital adrenal hyperplasia and bilateral testicular adrenal rest tumors: a case report. J Assist Reprod Genet 2016; 33:545-8. [PMID: 26861965 PMCID: PMC4818631 DOI: 10.1007/s10815-016-0665-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/20/2016] [Indexed: 11/06/2022] Open
Abstract
Purpose The objective of this study was to offer a new treatment approach for sperm retrieval simultaneously with tumor resection in azoospermic men with congenital adrenal hyperplasia (CAH), orchialgia, and bilateral testicular adrenal rest tumors (TARTs) who fail to respond to medical treatment. Methods This is a retrospective chart review from a couple’s fertility center. Results Between May 2013 and May 2015, two azoospermic men with CAH and bilateral TARTs, with orchialgia, and desire to conceive underwent bilateral TART resection in the same surgical setting as sperm retrieval after remaining azoospermic with normalization of gonadotropins with treatment with human chorionic gonadotropin (hCG). Both men had adequate sperm retrieved for in vitro fertilization/intracytoplasmic sperm retrieval (IVF/ICSI) at the time of bilateral TART resections. They had complete TART resections with resolution of orchialgia. The wife of one patient had a successful pregnancy with use of retrieved sperm resulting in a live birth, and the sperm from the other man is cryopreserved for future use. Conclusions It is feasible to perform successful sperm retrieval simultaneously with TART resection in azoospermic men with CAH after medical treatments with persistent azoospermia, rather than subjecting these men to multiple invasive procedures.
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Affiliation(s)
- Parviz K Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA.
| | - Roxanne B Summers-Colquitt
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Kate C Odenwald
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Megan Kressin
- Department of Pathology, St. David's South Austin Medical Center, 901 W. Ben White Blvd, Austin, TX, 78704, USA
| | - Keikhosrow M Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Thomas B Pool
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Shahryar K Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
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Metachronous Bilateral Testicular Leydig-Like Tumors Leading to the Diagnosis of Congenital Adrenal Hyperplasia (Adrenogenital Syndrome). Case Rep Pathol 2015; 2015:459318. [PMID: 26351608 PMCID: PMC4553183 DOI: 10.1155/2015/459318] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 07/28/2015] [Indexed: 11/21/2022] Open
Abstract
A 33-year-old male with a history of left testis Leydig cell tumor (LCT), 3-month status after left radical orchiectomy, presented with a rapidly enlarging (0.6 cm to 3.7 cm) right testicular mass. He underwent a right radical orchiectomy, sections interpreted as showing a similar Leydig cell-like oncocytic proliferation, with a differential diagnosis including metachronous bilateral LCT and metachronous bilateral testicular tumors associated with congenital adrenal hyperplasia (a.k.a. “testicular adrenal rest tumors” (TARTs) and “testicular tumors of the adrenogenital syndrome” (TTAGS)). Additional workup demonstrated a markedly elevated serum adrenocorticotropic hormone (ACTH) and elevated adrenal precursor steroid levels. He was diagnosed with congenital adrenal hyperplasia, 3β-hydroxysteroid dehydrogenase deficiency (3BHSD) type, and started on treatment. Metachronous bilateral testicular masses in adults should prompt consideration of adult presentation of CAH. Since all untreated CAH patients are expected to have elevated serum ACTH, formal exclusion of CAH prior to surgical resection of a testicular Leydig-like proliferation could be accomplished by screening for elevated serum ACTH.
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Woo LL, Ross JH. The role of testis-sparing surgery in children and adolescents with testicular tumors. Urol Oncol 2015; 34:76-83. [PMID: 26094168 DOI: 10.1016/j.urolonc.2015.05.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/04/2015] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
Abstract
Organ-sparing approaches have been applied to the treatment of a variety of urologic tumors in both the realms of adult and pediatric urology, with the goals of minimizing overtreatment of benign lesions, preserving function, and providing durable cure. The predominance of benign tumors in prepubertal patients and the reliability of both ultrasound and intraoperative frozen sections have resulted in a marked shift toward testis-sparing approaches over the last few decades. The role of testis sparing in the adolescent population is presently unclear, although there have been increasing reports of successful organ-sparing surgery for testis tumors in the adult literature. This review presents recent trends in testis-sparing approaches for both pediatric and adolescent patients, the operative technique, and some of the controversies related to testis-sparing surgery.
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Affiliation(s)
- Lynn L Woo
- Department of Pediatric Urology, Rainbow Babies & Children׳s Hospital/University Hospitals Case Medical Center, Cleveland, OH.
| | - Jonathan H Ross
- Department of Pediatric Urology, Rainbow Babies & Children׳s Hospital/University Hospitals Case Medical Center, Cleveland, OH
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Claahsen-van der Grinten HL, Dehzad F, Kamphuis-van Ulzen K, de Korte CL. Increased prevalence of testicular adrenal rest tumours during adolescence in congenital adrenal hyperplasia. Horm Res Paediatr 2015; 82:238-44. [PMID: 25195868 DOI: 10.1159/000365570] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 06/18/2014] [Indexed: 12/20/2022] Open
Abstract
UNLABELLED Testicular adrenal rest tumours (TART) are one of the most important causes of infertility in adult male patients with congenital adrenal hyperplasia (CAH). These benign tumours are already detected in children, but screening of TART is not routinely performed. OBJECTIVE To define retrospectively the prevalence of TART in 41 paediatric male CAH patients aged 0-19 years regularly followed by high-frequency (Fcentral 12-MHz) ultrasound techniques. RESULTS Above the age of 10 years, there was a clear increase in the prevalence of TART: 10-12 years, 28% (2 of 7 patients), 13-14 years, 50% (4/8), and 15-16 years, 75% (3/4). Above the age of 16 years, TART were detected in 100% of the patients (7/7). The tumours were not detectable by palpation. CONCLUSION TART is already present in childhood with an increasing prevalence after onset of puberty. We recommend regular ultrasound from the onset of puberty in all boys with classic CAH.
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Auchus RJ. Management considerations for the adult with congenital adrenal hyperplasia. Mol Cell Endocrinol 2015; 408:190-7. [PMID: 25643980 DOI: 10.1016/j.mce.2015.01.039] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/26/2015] [Accepted: 01/26/2015] [Indexed: 11/18/2022]
Abstract
The congenital adrenal hyperplasias (CAH) are a group of genetic defects in cortisol biosynthesis, most commonly steroid 21-hydroxylase deficiency (21OHD). With the advent of cortisone therapy in the 1960s and newborn screening in the 1990s, most children with 21OHD now reach adulthood. The needs and concerns of adults with 21OHD overlap with those of children, but the focus and approach shift as these patients reach adulthood. Cohort studies suggest that adults with 21OHD experience significant health concerns such as infertility, obesity, short stature, neoplasia, and bone loss, as well as reduced quality of life. Nevertheless, the spectrum of health status and disease severity is broad, but only some of the reasons for these disparities are known. This review will summarize the current state of knowledge and suggested approaches to management adults with classic 21OHD, plus a few major considerations for adults with nonclassic 21OHD.
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Affiliation(s)
- Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, Department of Pharmacology, and the Program for Disorders of Sexual Development, University of Michigan, Room 5560A, MSRBII, 1150 West Medical Center Drive, Ann Arbor, MI 48109, USA.
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Lottrup G, Nielsen JE, Skakkebæk NE, Juul A, Rajpert-De Meyts E. Abundance of DLK1, differential expression of CYP11B1, CYP21A2 and MC2R, and lack of INSL3 distinguish testicular adrenal rest tumours from Leydig cell tumours. Eur J Endocrinol 2015; 172:491-9. [PMID: 25609776 DOI: 10.1530/eje-14-0810] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Testicular adrenal rest tumours (TARTs) are a common finding in patients with congenital adrenal hyperplasia (CAH). These tumours constitute a diagnostic and management conundrum and may lead to infertility. TART cells share many functional and morphological similarities with Leydig cells (LCs), and masses consisting of such cells are occasionally misclassified as malignant testicular tumours, which may lead to erroneous orchiectomy in these patients. DESIGN In this study, we aimed to investigate the potential of LC developmental markers and adrenal steroidogenic markers in the differential diagnosis of TARTs and malignant LC tumours (LCTs). METHODS We investigated mRNA and protein expression of testicular steroidogenic enzymes; CYP11A1 and HSD3B1/2, markers of adrenal steroidogenesis; CYP11B1, CYP21A2 and ACTH receptor/melanocortin 2 receptor (MC2R), and markers of LC maturation; and delta-like 1 homolog (DLK1) and insulin-like 3 (INSL3) in testicular biopsies with TART, orchiectomy specimens with LCTs and samples from human fetal adrenals. RESULTS Expression of testicular steroidogenic enzymes was observed in all specimens. All investigated adrenal steroidogenic markers were expressed in TART, and weak reactions for CYP11B1 and MC2R were observed at the protein level in LTCs. TART and fetal adrenals had identical expression profiles. DLK1 was highly expressed and INSL3 not detectable in TART, whereas INSL3 was highly expressed in LCTs. CONCLUSIONS The similar expression profiles in TART and fetal adrenals as well as the presence of classical markers of adrenal steroidogenesis lend support to the hypothesis that TART develops from a displaced adrenal cell type. Malignant LCTs seem to have lost DLK1 expression and do not resemble immature LCs. The different expression pattern of DLK1, INSL3 and most adrenocortical markers adds to the elucidation of the histogenesis of testicular interstitial tumours and may facilitate histopathological diagnosis.
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Affiliation(s)
- Grete Lottrup
- Department of Growth and Reproductionand International Center for Research and Research Training in Endocrine Disrupting Effects on Male Reproduction & Child Health (EDMaRC), Copenhagen University Hospital, Section 5064, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - John E Nielsen
- Department of Growth and Reproductionand International Center for Research and Research Training in Endocrine Disrupting Effects on Male Reproduction & Child Health (EDMaRC), Copenhagen University Hospital, Section 5064, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Niels E Skakkebæk
- Department of Growth and Reproductionand International Center for Research and Research Training in Endocrine Disrupting Effects on Male Reproduction & Child Health (EDMaRC), Copenhagen University Hospital, Section 5064, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Anders Juul
- Department of Growth and Reproductionand International Center for Research and Research Training in Endocrine Disrupting Effects on Male Reproduction & Child Health (EDMaRC), Copenhagen University Hospital, Section 5064, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Ewa Rajpert-De Meyts
- Department of Growth and Reproductionand International Center for Research and Research Training in Endocrine Disrupting Effects on Male Reproduction & Child Health (EDMaRC), Copenhagen University Hospital, Section 5064, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
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Smeets EEJW, Span PN, van Herwaarden AE, Wevers RA, Hermus ARMM, Sweep FCGJ, Claahsen-van der Grinten HL. Molecular characterization of testicular adrenal rest tumors in congenital adrenal hyperplasia: lesions with both adrenocortical and Leydig cell features. J Clin Endocrinol Metab 2015; 100:E524-30. [PMID: 25485724 DOI: 10.1210/jc.2014-2036] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
CONTEXT Testicular adrenal rest tumors (TART) are one of the major long term complications in patients with congenital adrenal hyperplasia. Although several adrenal-like properties have been assigned to these benign lesions, the etiology has not been confirmed yet. OBJECTIVE The aim of this study was to describe TART in more detail by analyzing several (steroidogenic) characteristics that may be classified as adrenal cortex or Leydig cell specific. METHODS Gene expression analysis by qPCR was performed for 14 genes in TART tissue (n = 12) and compared with the expression in healthy control fibroblasts (nonsteroidogenic control). In addition, a comparison was made with the expression levels in testis tissue (n = 9) and adrenal tissue (n = 13). RESULTS Nearly all genes were highly expressed in TART tissue, including all genes that encode the key steroidogenic enzymes. TART expression levels are in the majority almost identical to those found in adrenal tissue. The expression of adrenal cortex specific genes (CYP11B1, CYP11B2, and MC2R) in both TART and adrenal tissue is approximately 1000-10 000 times higher compared to that in testes samples. In addition, the Leydig cell markers INSL3 and HSD17B3 were not only found in testes, but also in TART, both at significantly higher levels than in the adrenal (p < 0.01). CONCLUSION Our study shows for the first time that TART have multiple steroidogenic properties, which include not only the expression of adrenal cortex but also of Leydig cell markers. Therefore, the origin of these tumors might be a more totipotent embryonic cell type.
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Affiliation(s)
- Evelien E J W Smeets
- Departments of Pediatrics (E.E.J.W.S., H.L.C.-v.d.G.), Laboratory Medicine (E.E.J.W.S., A.E.v.H., R.A.W., F.C.G.J.S.,), Radiation Oncology (P.N.S.), and Internal Medicine (A.R.M.M.H.), Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
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Teixeira SR, Elias PCL, Andrade MTS, Melo AF, Elias Junior J. The role of imaging in congenital adrenal hyperplasia. ACTA ACUST UNITED AC 2014; 58:701-8. [DOI: 10.1590/0004-2730000003371] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 06/17/2014] [Indexed: 01/19/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is an autossomic recessive disorder caused by impaired steroidogenesis. Patients with CAH may present adrenal insufficiency with or without salt-wasting, as well as various degrees of virilization and fertility impairment, carrying a high incidence of testicular adrenal rest tumors and increased incidence of adrenal tumors. The diagnosis of CAH is made based on the adrenocortical profile hormonal evaluation and genotyping, in selected cases. Follow-up is mainly based on hormonal and clinical evaluation. Utility of imaging in this clinical setting may be helpful for the diagnosis, management, and follow-up of the patients, although recommendations according to most guidelines are weak when present. Thus, the authors aimed to conduct a narrative synthesis of how imaging can help in the management of patients with CAH, especially focused on genitography, ultrasonography, computed tomography, and magnetic resonance imaging.
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Claahsen-van der Grinten HL, Stikkelbroeck MML, Bulten J, den Heyer M. Ectopic adrenal rests in congenital adrenal hyperplasia as a cause of androgen excess after adrenalectomy detected by pelvic venous sampling. Horm Res Paediatr 2014; 80:293-8. [PMID: 24107716 DOI: 10.1159/000354659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 07/20/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with classic congenital adrenal hyperplasia (CAH) due to CYP21 deficiency are treated with supraphysiological doses of glucocorticoids to suppress elevated androgen production. This implies also side effects of high-dose glucocorticoids, possibly leading to iatrogenic Cushing's syndrome. Bilateral adrenalectomy has been suggested as the ultimate therapy in severe cases, when insufficient androgen suppression was obtained despite high glucocorticoid doses. Usually, ACTH levels rise after bilateral adrenalectomy, and this could imply an increased risk for the development of ectopic adrenal rests. In female CAH patients ovarian adrenal rests are not commonly detected by conventional radiological techniques. METHODS We report the case of an adult female CAH patient who underwent bilateral adrenalectomy in early puberty because of poorly controlled CAH. RESULTS AND CONCLUSIONS Several years after surgery, she developed secondary amenorrhea and hair loss as a result of androgen overproduction in ovarian adrenal rests that appeared to be detectable only by pelvic venous sampling. After unilateral oophorectomy androgen levels normalized.
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Rohayem J, Tüttelmann F, Mallidis C, Nieschlag E, Kliesch S, Zitzmann M. Restoration of fertility by gonadotropin replacement in a man with hypogonadotropic azoospermia and testicular adrenal rest tumors due to untreated simple virilizing congenital adrenal hyperplasia. Eur J Endocrinol 2014; 170:K11-7. [PMID: 24394723 DOI: 10.1530/eje-13-0449] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT Classical congenital adrenal hyperplasia (CAH), a genetic disorder characterized by 21-hydroxylase deficiency, impairs male fertility, if insufficiently treated. PATIENT A 30-year-old male was referred to our clinic for endocrine and fertility assessment after undergoing unilateral orchiectomy for a suspected testicular tumor. Histopathological evaluation of the removed testis revealed atrophy and testicular adrenal rest tumors (TARTs) and raised the suspicion of underlying CAH. The remaining testis was also atrophic (5 ml) with minor TARTs. Serum 17-hydroxyprogesterone levels were elevated, cortisol levels were at the lower limit of normal range, and gonadotropins at prepubertal levels, but serum testosterone levels were within the normal adult range. Semen analysis revealed azoospermia. CAH was confirmed by a homozygous mutation g.655A/C>G (IVS2-13A/C>G) in CYP21A2. Hydrocortisone (24 mg/m(2)) administered to suppress ACTH and adrenal androgen overproduction unmasked deficient testicular testosterone production. As azoospermia persisted due to sustained hypogonadotropic hypogonadism, a combined s.c. gonadotropin replacement with human chorionic gonadotropin (hCG) (1500 IU twice weekly) and FSH (human menopausal gondadotropin (hMG) 150 IU three times weekly) was initiated. RESULTS Normalization of testosterone levels and a stable low sperm concentration (0.5 mill/ml) with good sperm motility (85% A+B progressive) were achieved within 21 months of treatment. Despite persisting TARTs, while receiving treatment, the patient successfully impregnated his wife twice, the latter impregnation leading to the birth of a healthy girl. CONCLUSIONS TARTs in unrecognized (simple virilizing) CAH may lead to unnecessary orchiectomy. In hypogonadotropic, azoospermic CAH, a combined treatment with oral corticosteroids and subcutaneously administered hCG and FSH can successfully restore testicular testosterone production and fertility, even if only one hypoplastic and atrophic testis with adrenal rest tumors is present.
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Affiliation(s)
- Julia Rohayem
- Center of Reproductive Medicine and Andrology, Clinical Andrology, University of Muenster, Albert-Schweitzer-Campus 1, Building D11, D-48149 Muenster, Germany
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Han TS, Walker BR, Arlt W, Ross RJ. Treatment and health outcomes in adults with congenital adrenal hyperplasia. Nat Rev Endocrinol 2014; 10:115-24. [PMID: 24342885 DOI: 10.1038/nrendo.2013.239] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a genetic disorder caused by defective steroidogenesis that results in glucocorticoid deficiency; the most common underlying mutation is in the gene that encodes 21-hydroxylase. Life-saving glucocorticoid treatment was introduced in the 1950s, and the number of adult patients is now growing; however, no consensus has been reached on the management of CAH beyond childhood. Adult patients are prescribed a variety of glucocorticoids, including hydrocortisone, prednisone, prednisolone, dexamethasone and combinations of these drugs taken in either a circadian or reverse circadian regimen. Despite these personalized treatments, biochemical control of CAH is only achieved in approximately one-third of patients. Some patients have a poor health status, with an increased incidence of obesity and osteoporosis, and impaired fertility and quality of life. The majority of poor health outcomes seem to relate to inadequate treatment rather than the genotype of the patient. Patients receiving high doses of glucocorticoids and the more potent synthetic long-acting glucocorticoids are at an increased risk of obesity, insulin resistance and a reduced quality of life. Further research is required to optimize the treatment of adult patients with CAH and improve health outcomes.
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Affiliation(s)
- Thang S Han
- Department of Diabetes and Endocrinology, St Peter's NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK
| | - Brian R Walker
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Wiebke Arlt
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical & Experimental Medicine, University of Birmingham, Birmingham B15 2TT, UK
| | - Richard J Ross
- Academic Unit of Diabetes, Endocrinology & Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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Reichman DE, White PC, New MI, Rosenwaks Z. Fertility in patients with congenital adrenal hyperplasia. Fertil Steril 2014; 101:301-9. [DOI: 10.1016/j.fertnstert.2013.11.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 01/31/2023]
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Abstract
The management of congenital adrenal hyperplasia involves suppression of adrenal androgen production, in addition to treatment of adrenal insufficiency. Management of adolescents with congenital adrenal hyperplasia is especially challenging because changes in the hormonal milieu during puberty can lead to inadequate suppression of adrenal androgens, psychosocial issues often affect adherence to medical therapy, and sexual function plays a major part in adolescence and young adulthood. For these reasons, treatment regimen reassessment is indicated during adolescence. Patients with non-classic congenital adrenal hyperplasia require reassessment regarding the need for glucocorticoid drug treatment. No clinical trials have compared various regimens for classic congenital adrenal hyperplasia in adults, thus therapy is individualised and based on the prevention of adverse outcomes. Extensive patient education is key during transition from paediatric care to adult care and should include education of females with classic congenital adrenal hyperplasia regarding their genital anatomy and surgical history. Common issues for these patients include urinary incontinence, vaginal stenosis, clitoral pain, and cosmetic concerns; for males with classic congenital adrenal hyperplasia, common issues include testicular adrenal rest tumours. Transition from paediatric to adult care is most successful when phased over many years. Education of health-care providers on how to successfully transition patients is greatly needed.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
| | - Dix P Poppas
- the Institute for Pediatric Urology, Comprehensive Center for Congenital Adrenal Hyperplasia, Komansky Center for Children's Health, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
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Ali HH, Samkari A, Arabi H. Testicular adrenal rest "tumor" or Leydig cell tumor? A report of a challenging case with literature review. Avicenna J Med 2013; 3:15-9. [PMID: 23984262 PMCID: PMC3752856 DOI: 10.4103/2231-0770.112789] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) refers to group of inherited diseases resulting from impaired adrenal steroidogenesis, and its most common cause is 21-hydroxylase deficiency. Testicular adrenal rest tumors (TARTs) are an important complication of CAH, which probably develop from ectopic remnants of intra-testicular adrenal tissue stimulated by Adrenocorticotropic hormone (ACTH) hypersecretion. These lesions are typically located within the rete testis and are bilateral, synchronous, nodular and multiple. TART usually, but not always, responses to suppressive medical therapy. TART leads to testicular structural damage, spermatogenesis disorders, infertility and most importantly, mass-forming lesions that could be mistaken for Leydig cell tumor (LCT). The later has a significantly different behavior with up to 10% of being malignant. Nowadays, due to advances in diagnosing and treating CAH, mass-forming TART is rarely encountered. As a result, there is the paucity in the medical literature regarding its features from pathological perspective. We herein present a case of mass-forming TART and we discuss the clinical, radiological, and morphological features as well as the major differential diagnosis of this rare lesion.
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Affiliation(s)
- Hiba Hassan Ali
- Department of Anatomic Pathology, Faculty of Medicine, King Abdul-Aziz University, Jeddah, Saudi Arabia
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Marumudi E, Khadgawat R, Surana V, Shabir I, Joseph A, Ammini AC. Diagnosis and management of classical congenital adrenal hyperplasia. Steroids 2013; 78:741-6. [PMID: 23624029 DOI: 10.1016/j.steroids.2013.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 04/09/2013] [Accepted: 04/09/2013] [Indexed: 11/17/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is among the most common genetic disorders. Deficiency of adrenal steroid 21-hydroxylase deficiency due to mutations in the CYP21A2 gene accounts for about 95% cases of CAH. This disorder manifests with androgen excess with or without salt wasting. It also is a potentially life threatening disorder; neonatal screening with 17-hydroxyprogesterone measurement can diagnose the condition in asymptomatic children. Carefully monitored therapy with glucocorticoid and mineralocorticoid supplementation will ensure optimal growth and development for children with CAH. Genital surgery may be required for girls with CAH. Continued care is required for individuals with CAH as adults to prevent long-term adverse consequences of the disease, including infertility, metabolic syndrome and osteoporosis.
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Affiliation(s)
- Eunice Marumudi
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
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Abstract
The most common form of congenital adrenal hyperplasia is steroid 21-hydroxylase deficiency (21OHD). When the nonclassical (mild) form is included, 21OHD is the most common genetic disease in human beings. With the advent of pharmaceutical preparation of glucocorticoids starting in the 1960s and newborn screening starting in the 1990s, the majority of children with 21OHD are reaching adulthood, which has yielded a cohort of patients with, in essence, a new disease. Only recently have some data emerged from cohorts of adults with 21OHD, and in some centers, experience with the management of these patients is growing. These patients suffer from poor health, infertility, characteristic tumors in the adrenal glands and gonads, and consequences of chronic glucocorticoid therapy. Their care is fragmented and inconsistent, and many stop taking their medications out of frustration. Internal medicine residents and endocrinology fellows receive little training in their care, which further discourages their seeking medical attention. Adults with 21OHD have a different physiology from patients with Addison's disease or other androgen excess states, and their needs are different than those of young children with 21OHD. Consequently, their care requires unorthodox treatment and monitoring strategies foreign to most endocrine practitioners. Our goal for this article is to review their physiology, complications, and needs in order to develop rational and effective treatment and monitoring strategies.
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Affiliation(s)
- Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine and the Program for Disorders of Sexual Development, University of Michigan, Room 5560A, MSRBII, 1150 West Medical Center Drive, Ann Arbor, Michigan 48109, USA.
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