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Zimmer J, Mueller L, Frank-Herrmann P, Rehnitz J, Dietrich JE, Bettendorf M, Strowitzki T, Krivega M. Low androgen signaling rescues genome integrity with innate immune response by reducing fertility in humans. Cell Death Dis 2024; 15:30. [PMID: 38212646 PMCID: PMC10784536 DOI: 10.1038/s41419-023-06397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024]
Abstract
Development of the gonads under complex androgen regulation is critical for germ cells specification. In this work we addressed the relationship between androgens and genomic integrity determining human fertility. We used different study groups: individuals with Differences of Sex Development (DSD), including Complete Androgen Insensitivity Syndrome (CAIS) due to mutated androgen receptor (AR), and men with idiopathic nonobstructive azoospermia. Both showed genome integrity status influenced by androgen signaling via innate immune response activation in blood and gonads. Whole proteome analysis connected low AR to interleukin-specific gene expression, while compromised genome stability and tumorigenesis were also supported by interferons. AR expression was associated with predominant DNA damage phenotype, that eliminated AR-positive Sertoli cells as the degeneration of gonads increased. Low AR contributed to resistance from the inhibition of DNA repair in primary leukocytes. Downregulation of androgen promoted apoptosis and specific innate immune response with higher susceptibility in cells carrying genomic instability.
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Affiliation(s)
- J Zimmer
- Research Group of Gonadal Differentiation and Embryonic Development, Department of Gynecological Endocrinology & Fertility Disorders, Women Hospital, University of Heidelberg, 69120, Heidelberg, Germany
| | - L Mueller
- Research Group of Gonadal Differentiation and Embryonic Development, Department of Gynecological Endocrinology & Fertility Disorders, Women Hospital, University of Heidelberg, 69120, Heidelberg, Germany
| | - P Frank-Herrmann
- Department of Gynecological Endocrinology & Fertility Disorders, Women Hospital, University of Heidelberg, 69120, Heidelberg, Germany
| | - J Rehnitz
- Department of Gynecological Endocrinology & Fertility Disorders, Women Hospital, University of Heidelberg, 69120, Heidelberg, Germany
| | - J E Dietrich
- Department of Gynecological Endocrinology & Fertility Disorders, Women Hospital, University of Heidelberg, 69120, Heidelberg, Germany
| | - M Bettendorf
- Division of Pediatric Endocrinology, Children's Hospital, University of Heidelberg, 69120, Heidelberg, Germany
| | - T Strowitzki
- Department of Gynecological Endocrinology & Fertility Disorders, Women Hospital, University of Heidelberg, 69120, Heidelberg, Germany
| | - M Krivega
- Research Group of Gonadal Differentiation and Embryonic Development, Department of Gynecological Endocrinology & Fertility Disorders, Women Hospital, University of Heidelberg, 69120, Heidelberg, Germany.
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Hannema SE, Wolffenbuttel KP, van Bever Y, Brüggenwirth HT, van den Berg SAA, Hersmus R, Oosterhuis JW, Looijenga LHJ. Undetectable anti-Mullerian hormone and inhibin B do not preclude the presence of germ cell tumours in 45,X/46,XY or 46,XY gonadal dysgenesis. Clin Endocrinol (Oxf) 2023; 99:58-63. [PMID: 36905105 DOI: 10.1111/cen.14909] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 03/08/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Individuals with 45,X/46,XY or 46,XY gonadal dysgenesis are at increased risk of germ cell malignancies. Therefore, prophylactic bilateral gonadectomy is advised in girls and considered in boys with atypical genitalia for undescended, macroscopically abnormal gonads. However, severely dysgenetic gonads may not contain germ cells rendering gonadectomy unnecessary. Therefore, we investigate if undetectable preoperative serum anti-Müllerian hormone (AMH) and inhibin B can predict the absence of germ cells, (pre)malignant or otherwise. DESIGN, PATIENTS AND MEASUREMENTS Individuals who had undergone bilateral gonadal biopsy and/or gonadectomy because of suspected gonadal dysgenesis in 1999-2019 were included in this retrospective study if preoperative AMH and/or inhibin B were available. Histological material was reviewed by an experienced pathologist. Haematoxylin and eosin and immunohistochemical stainings for SOX9, OCT4, TSPY and SCF (KITL) were used. RESULTS Thirteen males and 16 females were included, 20 with 46,XY and 9 with 45,X/46,XY DSD. Three females had dysgerminoma alongside gonadoblastoma; two gonadoblastoma, one germ cell neoplasia in situ (GCNIS) and three males had pre-GCNIS and/or pre-gonadoblastoma. Gonadoblastoma and/or dysgerminoma were present in 3/11 individuals with undetectable AMH and inhibin B, one of whom also had non-(pre)malignant germ cells. Of the other 18, in whom AMH and/or inhibin B were detectable, only one had no germ cells. CONCLUSIONS Undetectable serum AMH and inhibin B cannot reliably predict the absence of germ cells and germ cell tumours in individuals with 45,X/46,XY or 46,XY gonadal dysgenesis. This information should help in counselling about prophylactic gonadectomy, taking into account both the germ cell cancer risk and potential for gonadal function.
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Affiliation(s)
- Sabine E Hannema
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pediatric Endocrinology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, location Vrije Universiteit, Amsterdam, the Netherlands
| | - Katja P Wolffenbuttel
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Urology and Pediatric Urology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Yolande van Bever
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Hennie T Brüggenwirth
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Sjoerd A A van den Berg
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, the Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Remko Hersmus
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - J Wolter Oosterhuis
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Leendert H J Looijenga
- Erasmus MC, Sophia Children's Hospital, DSD-Expert Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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3
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Chen Z, Li P, Lyu Y, Wang Y, Gao K, Wang J, Lan F, Chen F. Molecular genetics and general management of androgen insensitivity syndrome. Intractable Rare Dis Res 2023; 12:71-77. [PMID: 37287652 PMCID: PMC10242393 DOI: 10.5582/irdr.2023.01024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/25/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023] Open
Abstract
Androgen insensitivity syndrome (AIS) is a rare genetic disorder that affects the development of the male reproductive system in individuals with a 46,XY karyotype. In addition to physical impacts, patients with AIS may face psychological distress and social challenges related to gender identity and acceptance. The major molecular etiology of AIS results from hormone resistance caused by mutations in the X-linked androgen receptor (AR) gene. Depending on the severity of androgen resistance, the wide spectrum of AIS can be divided into complete AIS (CAIS), partial AIS (PAIS), or mild AIS (MAIS). Open issues in the treatment and management of AIS include decisions about reconstructive surgery, genetic counseling, gender assignment, timing of gonadectomy, fertility and physiological outcomes. Although new genomic approaches have improved understanding of the molecular causes of AIS, identification of individuals with AIS can be challenging, and molecular genetic diagnosis is often not achievable. The relationship between AIS genotype and phenotype is not well established. Therefore, the optimal management remains uncertain. The objective of this review is to outline the recent progress and promote understanding of AIS related to the clinical manifestation, molecular genetics and expert multidisciplinary approach, with an emphasis on genetic etiology.
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Affiliation(s)
- Zhongzhong Chen
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center for Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Urogenital Development Research Center, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yiqing Lyu
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yaping Wang
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Kexin Gao
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jing Wang
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fuying Lan
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fang Chen
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center for Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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4
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Al-Sharkawi M, Calonga-Solís V, Dressler FF, Busch H, Hiort O, Werner R. Persistence of foetal testicular features in patients with defective androgen signalling. Eur J Endocrinol 2023; 188:7017644. [PMID: 36721956 DOI: 10.1093/ejendo/lvad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/09/2023] [Accepted: 01/26/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Congenital defects of androgen synthesis or action in 46,XY individuals can result in impaired virilisation, despite the apparent testicular development. In a recent case, report of a young adult with complete androgen insensitivity syndrome (CAIS), tumourous gonadal tissue was shown to express HSD17B3 in Sertoli cells (SCs) and not in Leydig cells (LCs). This expression pattern differs from the typical adult human testis and resembles a foetal mouse testis, suggesting an underlying testicular development and function defect. Here, we investigate the effect of altered androgen signalling in gonads from five 46,XY individuals with defects in androgen synthesis or action. METHODS Gonadal tissue sections from four patients with CAIS, one with CYP17A1 deficiency, and one control were immunostained for LC developmental and steroidogenic markers. The expression of some of these markers during development was investigated by reanalysing previously published single-cell RNA sequencing (scRNA-seq) data from normal human testicular tissues. RESULTS All gonadal tissues from the patients show an exclusive expression of HSD17B3 in SCs and an expression of the foetal/immature LC marker DLK1 in a subset of LCs, suggesting an androgen-dependent differentiation defect of adult SCs and LCs. Furthermore, reanalysis of scRNA-seq data reveals an expression of HSD17B3 in foetal and neonatal SCs that is downregulated in adult SCs. CONCLUSIONS Androgen signalling may affect the differentiation of adults, but possibly not foetal SCs or LCs, and may induce a shift of testosterone production from the tubular compartment in the foetal phase to the interstitial compartment in the adult phase.
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Affiliation(s)
- Mostafa Al-Sharkawi
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, University of Lübeck, 23562 Lübeck, Germany
- Biochemical Genetics Department, Human Genetics and Genome Research Institute, 12622 Dokki, Cairo, Egypt
| | - Verónica Calonga-Solís
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, University of Lübeck, 23562 Lübeck, Germany
- Medical Systems Biology Division, Lübeck Institute of Experimental Dermatology and Institute for Cardiogenetics, University of Lübeck, 23562 Lübeck, Germany
| | - Franz F Dressler
- Institute of Pathology, University Hospital Schleswig-Holstein, Campus Lübeck, 23562 Lübeck, Germany
- Institute of Pathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117, Berlin, Germany
| | - Hauke Busch
- Medical Systems Biology Division, Lübeck Institute of Experimental Dermatology and Institute for Cardiogenetics, University of Lübeck, 23562 Lübeck, Germany
| | - Olaf Hiort
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, University of Lübeck, 23562 Lübeck, Germany
| | - Ralf Werner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, University of Lübeck, 23562 Lübeck, Germany
- Institute of Molecular Medicine, University of Lübeck, 23562 Lübeck, Germany
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Goodman M, Yacoub R, Getahun D, McCracken CE, Vupputuri S, Lash TL, Roblin D, Contreras R, Cromwell L, Gardner MD, Hoffman T, Hu H, Im TM, Prakash Asrani R, Robinson B, Xie F, Nash R, Zhang Q, Bhai SA, Venkatakrishnan K, Stoller B, Liu Y, Gullickson C, Ahmed M, Rink D, Voss A, Jung HL, Kim J, Lee PA, Sandberg DE. Cohort profile: pathways to care among people with disorders of sex development (DSD). BMJ Open 2022; 12:e063409. [PMID: 36130763 PMCID: PMC9494584 DOI: 10.1136/bmjopen-2022-063409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The 'DSD Pathways' study was initiated to assess health status and patterns of care among people enrolled in large integrated healthcare systems and diagnosed with conditions comprising the broad category of disorders (differences) of sex development (DSD). The objectives of this communication are to describe methods of cohort ascertainment for two specific DSD conditions-classic congenital adrenal hyperplasia with 46,XX karyotype (46,XX CAH) and complete androgen insensitivity syndrome (CAIS). PARTICIPANTS Using electronic health records we developed an algorithm that combined diagnostic codes, clinical notes, laboratory data and pharmacy records to assign each cohort candidate a 'strength-of-evidence' score supporting the diagnosis of interest. A sample of cohort candidates underwent a review of the full medical record to determine the score cutoffs for final cohort validation. FINDINGS TO DATE Among 5404 classic 46,XX CAH cohort candidates the strength-of-evidence scores ranged between 0 and 10. Based on sample validation, the eligibility cut-off for full review was set at the strength-of-evidence score of ≥7 among children under the age of 8 years and ≥8 among older cohort candidates. The final validation of all cohort candidates who met the cut-off criteria identified 115 persons with classic 46,XX CAH. The strength-of-evidence scores among 648 CAIS cohort candidates ranged from 2 to 10. There were no confirmed CAIS cases among cohort candidates with scores <6. The in-depth medical record review for candidates with scores ≥6 identified 61 confirmed cases of CAIS. FUTURE PLANS As the first cohort of this type, the DSD Pathways study is well-positioned to fill existing knowledge gaps related to management and outcomes in this heterogeneous population. Analyses will examine diagnostic and referral patterns, adherence to care recommendations and physical and mental health morbidities examined through comparisons of DSD and reference populations and analyses of health status across DSD categories.
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Affiliation(s)
- Michael Goodman
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Rami Yacoub
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Darios Getahun
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California, USA
| | - Courtney E McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Suma Vupputuri
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Timothy L Lash
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
- Aarhus Universitet, Aarhus, Midtjylland, Denmark
| | - Douglas Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Richard Contreras
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lee Cromwell
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Melissa D Gardner
- Susan B Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Trenton Hoffman
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Haihong Hu
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Theresa M Im
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Brandi Robinson
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia, USA
| | - Fagen Xie
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Rebecca Nash
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Qi Zhang
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sadaf A Bhai
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Bethany Stoller
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Yijun Liu
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Maaz Ahmed
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - David Rink
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Ava Voss
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Hye-Lee Jung
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jin Kim
- Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Peter A Lee
- Division of Endocrinology, Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - David E Sandberg
- Susan B Meister Child Health and Evaluation Research Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Mild androgen insensitivity syndrome: the current landscape. Endocr Pract 2022; 28:911-917. [PMID: 35660466 DOI: 10.1016/j.eprac.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Mild Androgen Insensitivity (MAIS) belongs to the Androgen Insensitivity Syndrome (AIS) spectrum, an X-linked genetic disease that is the most common cause of differences in sex development (DSD). Unfortunately, AIS studies mainly focus on the partial and the complete phenotype, and the mild phenotype (MAIS) has been barely reported. Our purpose is to explore the MAIS facets, clinical features, and molecular aspects. METHODS We collected all reported MAIS cases in the medical literature and presented them based on the phenotype and the molecular diagnosis. RESULTS We identified 49 different AR mutations in 69 individuals in the literature. We compared the AR mutations presented in MAIS individuals with AR mutations previously reported in other AIS phenotypes (CAIS and PAIS) regarding the type, location, genotype-phenotype correlation, and functional studies. CONCLUSION This review provides a landscape of the mild phenotype of AIS. Most MAIS patients present with male infertility. Therefore, AR gene sequencing should be considered during male infertility investigation, even in males with typically male external genitalia. In addition, MAIS can be part of other medical conditions, such as X-linked spinal and bulbar muscular atrophy (Kennedy's disease).
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7
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Marino L, Messina A, S Acierno J, Phan-Hug F, J Niederländer N, Santoni F, La Rosa S, Pitteloud N. Testosterone-induced increase in libido in a patient with a loss-of-function mutation in the AR gene. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM21-0031. [PMID: 34152287 PMCID: PMC8240814 DOI: 10.1530/edm-21-0031] [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: 04/20/2021] [Accepted: 05/13/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Complete androgen-insensitivity syndrome (CAIS), a disorder of sex development (46,XY DSD), is caused primarily by mutations in the androgen receptor (AR). Gonadectomy is recommended due to the increased risk of gonadoblastoma, however, surgical intervention is often followed by loss of libido. We present a 26-year-old patient with CAIS who underwent gonadectomy followed by a significant decrease in libido, which was improved with testosterone treatment but not with estradiol. Genetic testing was performed and followed by molecular characterization. We found that this patient carried a previously unidentified start loss mutation in the androgen receptor. This variant resulted in an N-terminal truncated protein with an intact DNA binding domain and was confirmed to be loss-of-function in vitro. This unique CAIS case and detailed functional studies raise intriguing questions regarding the relative roles of testosterone and estrogen in libido, and in particular, the potential non-genomic actions of androgens. LEARNING POINTS N-terminal truncation of androgen receptor can cause androgen-insensitivity syndrome. Surgical removal of testosterone-producing gonads can result in loss of libido. Libido may be improved with testosterone treatment but not with estradiol in some forms of CAIS. A previously unreported AR mutation - p.Glu2_Met190del (c.2T>C) - is found in a CAIS patient and results in blunted AR transcriptional activity under testosterone treatment.
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Affiliation(s)
- Laura Marino
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Andrea Messina
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - James S Acierno
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Franziska Phan-Hug
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Nicolas J Niederländer
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Federico Santoni
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Stefano La Rosa
- Department of Laboratory Medicine and Pathology, Centre Hospitalier Universitaire Vaudois, Lausanne, Vaud, Switzerland
| | - Nelly Pitteloud
- Department of Service of Endocrinology, Diabetes, and Metabolism, Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Vaud, Switzerland
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8
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Oosterhuis JW, Looijenga LH. Mediastinal germ cell tumors: many questions and perhaps an answer. J Clin Invest 2020; 130:6238-6241. [PMID: 33196463 PMCID: PMC7685715 DOI: 10.1172/jci143884] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Some germ cell tumors (GCTs) in men develop into hematologic malignancies; however, the clonal origins of such malignancies remain unknown. In this issue of the JCI, Taylor, Donoghue, et al. unravel the clonal relationship between primary mediastinal nonseminomas (PMNs) and hematologic somatic-type malignancies (HSTMs). Whole-exome sequencing was used to construct phylogenetic trees of the PMNs and the ensuing HSTM clones. HSTMs were derived from multiple distinct clones not detected within the PMNs. Clones from PMNs and HSTMs shared a common precursor, arguably an embryonal carcinoma cell resulting from a reprogrammed primordial germ cell from the thymus. Mutational and copy number variation analysis of a large cohort of patients with PMNs also demonstrated a high prevalence of TP53 mutations not found in testicular nonseminomas. These data likely explain why patients with PMNs are frequently resistant to platinum-based chemotherapy and provide TP53 mutations as potential targets.
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9
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Slowikowska-Hilczer J, Szarras-Czapnik M, Duranteau L, Rapp M, Walczak-Jedrzejowska R, Marchlewska K, Oszukowska E, Nordenstrom A. Risk of gonadal neoplasia in patients with disorders/differences of sex development. Cancer Epidemiol 2020; 69:101800. [PMID: 32905884 DOI: 10.1016/j.canep.2020.101800] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with disorders/differences of sex development (DSD), especially those possessing the Y chromosome, have a higher risk of gonadal germ-cell tumours (GCTs). We aimed to examine the incidence of different types of gonadal neoplasia and associated risk factors. METHODS A total of 1040 DSD patients aged ≥16 years participated in a cross-sectional multicentre European study (dsd-LIFE). Data on medical history were gathered from the patients' archival medical documents. A web-based questionnaire was filled out individually by the participants. A physical examination was performed in all, while ultrasonography of gonads was carried out in 214 and semen analysis was performed for 53 patients. RESULTS Germ-cell neoplasia was present in 12 % of patients with DSD and in 14 % of those with XY DSD. The highest risk (36 %) was observed in 46,XY patients with gonadal dysgenesis (GD): complete GD (33 %) and partial GD (23 %), but also in mixed GD (8 %) and complete androgen insensitivity syndrome (AIS) (6%). It was not reported in partial AIS, XX male, 46,XX DSD and congenital adrenal hyperplasia, Turner and Klinefelter syndromes, or in androgen biosynthesis defects. Benign sex cord-stromal tumours (Sertoli- and Leydig-cell tumours) were noted only in patients with complete AIS (3.1 %) and Klinefelter syndrome (14.3 %). A relationship between risk factors for GCT and gonadal neoplasia appearance, other than the Y chromosome, was not found. CONCLUSION Adult patients with GD and the Y chromosome have the highest risk of GCT and should be kept under thorough medical control and receive special medical follow-up to prevent the development of gonadal tumours.
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Affiliation(s)
- Jolanta Slowikowska-Hilczer
- Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland.
| | - Maria Szarras-Czapnik
- Department of Endocrinology and Diabetology, Children's Memorial Health Institute, Aleja Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Lise Duranteau
- Adolescent and Young Adult Gynaecology Unit and DSD Reference Centre, Bicêtre Hospital, AP.HP Université Paris Saclay, France
| | - Marion Rapp
- Clinic for Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23538 Lubeck, Germany
| | - Renata Walczak-Jedrzejowska
- Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Katarzyna Marchlewska
- Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Elzbieta Oszukowska
- II Clinic of Urology, Medical University of Lodz, Pabianicka 62, 93-513 Lodz, Poland
| | - Anna Nordenstrom
- Department of Paediatric Endocrinology, Astrid Lindgren Children Hospital, Karolinska University Hospital, Stockholm, Sweden
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Vogt PH, Besikoglu B, Bettendorf M, Frank-Herrmann P, Zimmer J, Bender U, Knauer-Fischer S, Choukair D, Sinn P, Lau YFC, Heidemann PH, Strowitzki T. Gonadoblastoma Y locus genes expressed in germ cells of individuals with dysgenetic gonads and a Y chromosome in their karyotypes include DDX3Y and TSPY. Hum Reprod 2020; 34:770-779. [PMID: 30753444 DOI: 10.1093/humrep/dez004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/17/2018] [Accepted: 01/10/2019] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Which Y genes mapped to the 'Gonadoblastoma Y (GBY)' locus on human Y chromosome are expressed in germ cells of individuals with some Differences of Sexual Development (DSD) and a Y chromosome in their karyotype (DSD-XY groups)? SUMMARY ANSWER The GBY candidate genes DDX3Y and TSPY are expressed in the germ cells of DSD-XY patients from distinct etiologies: patients with mixed gonadal dysgenesis (MGD) and sex chromosome mosaics (45,X0/46,XY; 46,XX/46,XY); patients with complete androgen insensitivity (CAIS), patients with complete gonadal dysgenesis (CGD; e.g. Swyer syndrome). WHAT IS KNOWN ALREADY A GBY locus was proposed to be present on the human Y chromosome because only DSD patients with a Y chromosome in their karyotype have a high-although variable-risk (up to 55%) for germ cell tumour development. GBY was mapped to the proximal part of the short and long Y arm. TSPY located in the proximal part of the short Y arm (Yp11.1) was found to be a strong GBY candidate gene. It is expressed in the germ cells of DSD-XY patients with distinct etiologies but also in foetal and pre-meiotic male spermatogonia. However, the GBY region extends to proximal Yq11 and therefore includes probably more than one candidate gene. STUDY DESIGN, SIZE, DURATION Protein expression of the putative GBY candidate gene in proximal Yq11, DDX3Y, is compared with that of TSPY in serial gonadal tissue sections of 40 DSD-XY individuals from the three DSD patient groups (MGD, Complete Androgen Insensitivity Syndrome [CAIS], CGD) with and without displaying malignancy. Expression of OCT3/4 in the same tissue samples marks the rate of pluripotent germ cells. PARTICIPANTS/MATERIALS, SETTING, METHOD A total of 145 DSD individuals were analysed for the Y chromosome to select the DSD-XY subgroup. PCR multiplex assays with Y gene specific marker set score for putative microdeletions in GBY Locus. Immunohistochemical experiments with specific antisera mark expression of the GBY candidate proteins, DDX3Y, TSPY, in serial sections of the gonadal tissue samples; OCT3/4 expression analyses in parallel reveal the pluripotent germ cell fraction. MAIN RESULTS AND THE ROLE OF CHANCE Similar DDX3Y and TSPY protein expression patterns were found in the germ cells of DSD-XY patients from each subgroup, independent of age. In CAIS patients OCT3/4 expression was often found only in a fraction of these germ cells. This suggest that GBY candidate proteins are also expressed in the non-malignant germ cells of DSD-XY individuals like in male spermatogonia. LIMITATIONS, REASONS FOR CAUTION Variation of the expression profiles of GBY candidate genes in the germ cells of some DSD-XY individuals suggests distinct transcriptional and translational control mechanisms which are functioning during expression of these Y genes in the DSD-XY germ cells. Their proposed GBY tumour susceptibility function to transform these germ cells to pre-malignant GB/Germ Cell Neoplasia in Situ (GB/GCNIS) cells seems therefore to be limited and depending on their state of pluripotency. WIDER IMPLICATIONS OF THE FINDINGS These experimental findings are of general importance for each individual identified in the clinic with DSD and a Y chromosome in the karyotype. To judge their risk of germ cell tumour development, OCT3/4 expression analyses on their gonadal tissue section is mandatory to reveal the fraction of germ cells still being pluripotent. Comparative expression analysis of the GBY candidate genes can be helpful to reveal the fraction of germ cells with genetically still activated Y chromosomes contributing to further development of malignancy if at high expression level. STUDY FUNDING/COMPETING INTEREST(S) This research project was supported by a grant (01GM0627) from the BMBF (Bundesministerium für Bildung und Forschung), Germany to P.H.V. and B.B. The authors have no competing interests.
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Affiliation(s)
- P H Vogt
- Division of Reproduction Genetics, Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
| | - B Besikoglu
- Division of Reproduction Genetics, Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany.,Novum, Center for Reproductive Medicine, Akazienallee 8, Essen, Germany
| | - M Bettendorf
- Division of Paediatric Endocrinology and Diabetes, Children Hospital, University of Heidelberg, Heidelberg, Germany
| | - P Frank-Herrmann
- Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
| | - J Zimmer
- Division of Reproduction Genetics, Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
| | - U Bender
- Division of Reproduction Genetics, Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
| | - S Knauer-Fischer
- Division of Paediatric Endocrinology and Diabetes, Children Hospital, University of Heidelberg, Heidelberg, Germany
| | - D Choukair
- Division of Paediatric Endocrinology and Diabetes, Children Hospital, University of Heidelberg, Heidelberg, Germany
| | - P Sinn
- Division of Gynaecopathology, Department of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, Heidelberg, Germany
| | - Y-F C Lau
- Division of Cell & Developmental Genetics, Department of Medicine, VAMC 111C5, San Francisco, CA, USA
| | - P H Heidemann
- Children Hospital Augsburg I, Academic Hospital of University of Munich, Stenglinstraβe 2, Augsburg, Germany
| | - T Strowitzki
- Department of Gynaecol. Endocrinology & Infertility Disorders, Women Hospital, University of Heidelberg, Heidelberg, Germany
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11
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Jiang X, Teng Y, Chen X, Liang N, Li Z, Liang D, Wu L. Six novel Mutation analysis of the androgen receptor gene in 17 Chinese patients with androgen insensitivity syndrome. Clin Chim Acta 2020; 506:180-186. [PMID: 32229106 DOI: 10.1016/j.cca.2020.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Androgen insensitivity syndrome (AIS) is the most common type of 46, XY disorders of sex development (DSD), with a wide range of clinical heterogeneity, from male infertility, hypospadias to completely normal female external genitalia. Mutation of the androgen receptor (AR) gene on the X chromosome (Xq11.2q12) is the main cause of AIS. METHODS By phenotype evaluation, hormone test, ultrasound scan and G-banding karyotype, 17 unrelated Chinese patients were clinical diagnosed with AIS. Sanger sequencing of the AR was performed in these 17 patients. Functional studies were carried out for the novel mutations. RESULTS We identified 16 mutations in all patients, including six novel mutations (Q59*, F171Sfs*4, E204*, G209E, I870T, *921R). It is the first time that a stop codon mutation (*921R) in AR has been identified. Expression and nuclear localization analysis showed the *921R mutation caused an elongated abnormal polypeptide chain of the AR protein, and the abnormal protein could not be transported to the nucleus to stimulate the expression of downstream genes after androgenic treatment. Expression analysis showed the protein level of G209E mutation was obviously decreased. CONCLUSION Our study expands the spectrum of AR mutations and could provide evidence for the genetic and reproductive counseling of families with AIS. All of these findings broadened the mutation spectrum of AR, which were significantly valuable for patient gender assignment, genetic counseling and the clinical and psychological management.
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Affiliation(s)
- Xuanyu Jiang
- Center for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan 410078, China
| | - Yanling Teng
- Hunan Jiahui Genetics Hospital, Changsha, Hunan 410078, China
| | - Xin Chen
- Center for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan 410078, China
| | - Nana Liang
- Center for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan 410078, China
| | - Zhuo Li
- Center for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan 410078, China
| | - Desheng Liang
- Center for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan 410078, China; Hunan Jiahui Genetics Hospital, Changsha, Hunan 410078, China.
| | - Lingqian Wu
- Center for Medical Genetics & Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan 410078, China; Hunan Jiahui Genetics Hospital, Changsha, Hunan 410078, China.
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12
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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13
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A Management Protocol for Gonad Preservation in Patients with Androgen Insensitivity Syndrome. J Pediatr Adolesc Gynecol 2019; 32:605-611. [PMID: 31233832 PMCID: PMC6917890 DOI: 10.1016/j.jpag.2019.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 12/14/2022]
Abstract
Historically, individuals with androgen insensitivity syndrome (AIS) were managed with removal of gonadal tissue at various ages to avert the risk of gonadal malignancy. Recently, clinical practice changed, with gonadectomy being postponed until late adolescence. Adolescents and adults with complete AIS have questioned this approach. Additionally, testicular germ cell tumors are increasingly believed to be quite rare with rates as low as 0% in molecularly confirmed individuals with AIS. Gonadectomy deprives patients of the benefits of their endogenous hormones and potential fertility. Furthermore, human rights organizations advocate for deferring irreversible surgery in conditions known as differences of sex development, which includes AIS, to allow patient autonomy in decision-making. Recent literature supports an approach that uses risk stratification to manage gonads in AIS. Herein we review what is known about malignancy risk in the different subtypes of AIS and propose a management protocol for gonad retention.
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14
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Fénichel P, Chevalier N. Is Testicular Germ Cell Cancer Estrogen Dependent? The Role of Endocrine Disrupting Chemicals. Endocrinology 2019; 160:2981-2989. [PMID: 31617897 DOI: 10.1210/en.2019-00486] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/11/2019] [Indexed: 11/19/2022]
Abstract
Testicular germ cell cancer (TGCC) is the most frequent cancer of the young male, with an increasing incidence worldwide. The pathogenesis and reasons for this increase remain unknown. However, epidemiological and experimental data have suggested that, similar to genital malformations and sperm impairment, it could result from the interaction of genetic and environmental factors including fetal exposure to endocrine-disrupting chemicals (EDCs) with estrogenic effects. In this review, we analyze the expression of classic and nonclassic estrogen receptors by TGCC cells, the way they may influence germ cell proliferation induced by EDCs, and discuss how this estrogen dependency supports the developmental and environmental hypothesis.
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Affiliation(s)
- Patrick Fénichel
- Université Côte d'Azur, CHU de Nice, Service d'Endocrinologie, Diabétologie et Médecine de la Reproduction, Hôpital de l'Archet, France
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, INSERM U1065/UNS, Centre Méditerranéen de Médecine Moléculaire, Equipe, France
| | - Nicolas Chevalier
- Université Côte d'Azur, CHU de Nice, Service d'Endocrinologie, Diabétologie et Médecine de la Reproduction, Hôpital de l'Archet, France
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, INSERM U1065/UNS, Centre Méditerranéen de Médecine Moléculaire, Equipe, France
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15
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Islam R, Lane S, Williams SA, Becker CM, Conway GS, Creighton SM. Establishing reproductive potential and advances in fertility preservation techniques for XY individuals with differences in sex development. Clin Endocrinol (Oxf) 2019; 91:237-244. [PMID: 31004515 DOI: 10.1111/cen.13994] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/07/2019] [Accepted: 04/15/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Discordance between gonadal type and gender identity has often led to an assumption of infertility in patients with differences in sex development (DSD). However, there is now greater recognition of fertility being an important issue for this group of patients. Currently, gonadal tissue that may have fertility potential is not being stored for individuals with DSD and, where gonadectomy forms part of management, is often discarded. The area of fertility preservation has been predominantly driven by oncofertility which is a field dedicated to preserving the fertility of patients undergoing gonadotoxic cancer treatment. The use of fertility preservation techniques could be expanded to include individuals with DSD where functioning gonads are present. METHODS This is a systematic literature review evaluating original research articles and relevant reviews between 1974 and 2018 addressing DSD and fertility, in vitro maturation of sperm, and histological/ultrastructural assessment of gonadal tissue in complete and partial androgen insensitivity syndrome, 17β-hydroxysteroid dehydrogenase type 3 and 5α-reductase deficiency. CONCLUSION Successful clinical outcomes of ovarian tissue cryopreservation are paving the way for similar research being conducted using testicular tissue and sperm. There have been promising results from both animal and human studies leading to cryopreservation of testicular tissue now being offered to boys prior to cancer treatment. Although data are limited, there is evidence to suggest the presence of reproductive potential in the gonads of some individuals with DSD. Larger, more detailed studies are required, but if these continue to be encouraging, individuals with DSD should be given the same information, opportunities and access to fertility preservation as other patient groups.
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Affiliation(s)
- Rumana Islam
- Department of Reproductive Medicine, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Sheila Lane
- Department of Paediatric Oncology and Haematology, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Suzannah A Williams
- Nuffield Department of Women's and Reproductive Health, Women's Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Christian M Becker
- Nuffield Department of Women's and Reproductive Health, Oxford Endometriosis CaRe Centre, Women's Centre, John Radcliffe Hospital University of Oxford, Oxford, UK
| | - Gerard S Conway
- Department of Endocrinology, University College London Hospitals, London, UK
| | - Sarah M Creighton
- Elizabeth Garrett Anderson UCL Institute of Women's Health, University College London Hospitals, London, UK
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16
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Kosti K, Athanasiadis L, Goulis DG. Long-term consequences of androgen insensitivity syndrome. Maturitas 2019; 127:51-54. [PMID: 31351520 DOI: 10.1016/j.maturitas.2019.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 11/18/2022]
Abstract
Androgen insensitivity syndrome (AIS) is one of the most common sexual developmental disorders. According to the grade of the remaining androgen receptor (AR) function, AIS is classified as complete (CAIS), partial (PAIS) or mild (MAIS). In CAIS, the prevalence of germ cell tumours is increased compared with the general population. Although patients with CAIS used to undergo gonadectomy before puberty, nowadays a gonadectomy is recommended after spontaneous puberty, and up to 15% of patients retain their gonads. Nevertheless, the risk of germ cell tumour increases gradually after puberty. Annual follow-up with ultrasound or magnetic resonance imaging (MRI) is recommended. Unfortunately, these imaging methods are not sensitive enough for the diagnosis of an in situ germ cell tumour. In PAIS, the risk of germ cell tumour is higher than in CAIS; therefore, an early gonadectomy or an orchidopexy is indicated. Optimal hormone replacement therapy (HRT) is necessary for long-term health. The risks of osteopenia and of regimen osteoporosis are higher, ESPECIALLY in patients with early gonadectomy. Infertility is the rule in CAIS and PAIS. A few mutations do not affect fertility detrimentally, and these are responsible for MAIS. In PAIS leading to a predominantly male phenotype or ambiguous genitalia, multiple surgical procedures for gynaecomastia and/or hypospadias are required. Some small studies have found a higher risk of obesity, hyperlipidaemia and impaired insulin sensitivity. Psychological support is essential, as the prevalence of psychiatric disorders is increased. In conclusion, the diagnosis of AIS has long-term consequences for which shared decision-making (physicians, patients, parents) is appropriate.
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Affiliation(s)
- Konstantia Kosti
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Greece.
| | - Loukas Athanasiadis
- Third Department of Psychiatry, Medical School, Aristotle University of Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Greece
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17
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Lanciotti L, Cofini M, Leonardi A, Bertozzi M, Penta L, Esposito S. Different Clinical Presentations and Management in Complete Androgen Insensitivity Syndrome (CAIS). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16071268. [PMID: 30970592 PMCID: PMC6480640 DOI: 10.3390/ijerph16071268] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 01/08/2023]
Abstract
Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive genetic disorder resulting from maternally inherited or de novo mutations involving the androgen receptor gene, situated in the Xq11-q12 region. The diagnosis is based on the presence of female external genitalia in a 46, XY human individual, with normally developed but undescended testes and complete unresponsiveness of target tissues to androgens. Subsequently, pelvic ultrasound or magnetic resonance imaging (MRI) could be helpful in confirming the absence of Mullerian structures, revealing the presence of a blind-ending vagina and identifying testes. CAIS management still represents a unique challenge throughout childhood and adolescence, particularly regarding timing of gonadectomy, type of hormonal therapy, and psychological concerns. Indeed this condition is associated with an increased risk of testicular germ cell tumour (TGCT), although TGCT results less frequently than in other disorders of sex development (DSD). Furthermore, the majority of detected tumoral lesions are non-invasive and with a low probability of progression into aggressive forms. Therefore, histological, epidemiological, and prognostic features of testicular cancer in CAIS allow postponing of the gonadectomy until after pubertal age in order to guarantee the initial spontaneous pubertal development and avoid the necessity of hormonal replacement therapy (HRT) induction. However, HRT is necessary after gonadectomy in order to prevent symptoms of hypoestrogenism and to maintain secondary sexual features. This article presents differential clinical presentations and management in patients with CAIS to emphasize the continued importance of standardizing the clinical and surgical approach to this disorder.
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Affiliation(s)
- Lucia Lanciotti
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Marta Cofini
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Alberto Leonardi
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Mirko Bertozzi
- Pediatric Surgery, Azienda Ospedaliera Santa Maria della Misericordia, 20122 Perugia, Italy.
| | - Laura Penta
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
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18
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Miyai K, Ito K, Nakanishi K, Tsuda H. Cell-to-cell variation of chromosomal number in the adult testicular germ cell tumors: a comparison of chromosomal instability among histological components and its putative role in tumor progression. Virchows Arch 2019; 474:711-720. [PMID: 30877382 DOI: 10.1007/s00428-019-02560-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/27/2019] [Accepted: 03/05/2019] [Indexed: 01/31/2023]
Abstract
By allelotyping analysis, we previously reported a putative progression pathway from germ cell neoplasia in situ (GCNIS) to seminoma, then to embryonal carcinoma in mixed-type testicular germ cell tumors (TGCTs), and detected that loss of heterozygosity events in seminoma components in mixed tumors were more frequent than those in pure seminomas. To elucidate a role of chromosomal instability in the progression of non-seminomatous germ cell tumor (NSGCT), we performed fluorescence in situ hybridization with centromeric probes for chromosomes 1, 7, 8, 12, 17, and X on a cohort of 52 TGCT cases with 103 histologically distinct components: 39 GCNIS lesions (16 and 23 in tumors with and without NSGCT components, respectively), 39 seminomas (27 as pure seminomas and 12 in mixed tumors), and 25 embryonal carcinomas. On a total component basis, both the mean copy number per tumor cell nucleus and the deviations from the modal number of all chromosomes examined significantly increased from GCNIS to seminoma, then to embryonal carcinoma with few exceptions. Seminoma components in mixed tumors showed a significantly greater extent of chromosomal instability in chromosomes 8 and 12 than pure seminomas, whereas no statistically significant difference was observed between GCNIS lesions with and without NSGCT components. These results suggest that not only aneuploidy, but also the cell-to-cell variation of chromosomal number is a sensitive indicator of chromosomal instability and would be implicated in the progression of NSGCT.
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Affiliation(s)
- Kosuke Miyai
- Department of Basic Pathology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan. .,Department of Laboratory Medicine, National Defense Medical College, Tokorozawa, Saitama, 359-8513, Japan.
| | - Keiichi Ito
- Department of Urology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Kuniaki Nakanishi
- Department of Laboratory Medicine, National Defense Medical College, Tokorozawa, Saitama, 359-8513, Japan
| | - Hitoshi Tsuda
- Department of Basic Pathology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
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19
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Tack LJW, Maris E, Looijenga LHJ, Hannema SE, Audi L, Köhler B, Holterhus PM, Riedl S, Wisniewski A, Flück CE, Davies JH, T'Sjoen G, Lucas-Herald AK, Evliyaoglu O, Krone N, Iotova V, Marginean O, Balsamo A, Verkauskas G, Weintrob N, Ellaithi M, Nordenström A, Verrijn Stuart A, Kluivers KB, Wolffenbuttel KP, Ahmed SF, Cools M. Management of Gonads in Adults with Androgen Insensitivity: An International Survey. Horm Res Paediatr 2018; 90:236-246. [PMID: 30336477 DOI: 10.1159/000493645] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Complete and partial androgen insensitivity syndrome (CAIS, PAIS) are associated with an increased risk of gonadal germ cell cancer (GGCC). Recent guidelines recommend gonadectomy in women with CAIS in late adolescence. Nevertheless, many adult women prefer to retain their gonads. AIMS This study aims to explore attitudes towards gonadectomy in AIS in centres around the world, estimate the proportion of adults with retained gonads and/or who developed GGCC, and explore reasons for declining gonadectomy. METHODS A survey was performed among health care professionals who use the International DSD Registry (I-DSD). RESULTS Data were provided from 22 centres in 16 countries on 166 women (CAIS) and 26 men (PAIS). In CAIS, gonadectomy was recommended in early adulthood in 67% of centres; 19/166 (11.4%) women refused gonadectomy. Among 142 women who had gonadectomy, evidence of germ cell neoplasm in situ (GCNIS), the precursor of GGCC, was reported in 2 (1.4%) out of 8 from whom pathology results were formally provided. Nine out of 26 men with PAIS (34.6%) had retained gonads; 11% of centres recommended routine gonadectomy in PAIS. CONCLUSION Although development of GGCC seems rare, gonadectomy after puberty is broadly recommended in CAIS; in PAIS this is more variable. Overall, our data reflect the need for evidence-based guidelines regarding prophylactic gonadectomy in AIS.
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Affiliation(s)
- Lloyd J W Tack
- Division of Paediatric Endocrinology, Department of Paediatrics, Ghent University Hospital, Department of Internal Medicine and Paediatrics, Ghent University, Ghent,
| | - Ellen Maris
- Division of Paediatric Endocrinology, Department of Paediatrics, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Leendert H J Looijenga
- Laboratory for Experimental Patho-Oncology, Department of Pathology, Josephine Nefkens Building, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Laura Audi
- Growth and Development Research Unit, Vall d'Hebron Research Institute (VHIR), Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Birgit Köhler
- Klinik für Pädiatrische Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Paul-Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital of Schleswig-Holstein, UKSH, Campus Kiel, Kiel, Germany
| | - Stefan Riedl
- Department of Pediatric Pulmology, Allergology and Endocrinology, Medical University of Vienna, Vienna, Austria
- Department of Pediatrics, St. Anna Children´s Hospital, Medical University of Vienna, Vienna, Austria
| | - Amy Wisniewski
- Department of Urology, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Christa E Flück
- Paediatric Endocrinology, Diabetology and Metabolism, Department of Paediatrics and Department of BioMedical Research, Bern University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Justin H Davies
- Department of Endocrinology, University Hospital Southampton, Southampton, United Kingdom
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Angela K Lucas-Herald
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, United Kingdom
| | - Olcay Evliyaoglu
- Department of Paediatric Endocrinology, Faculty of Medicine, İstanbul University Cerrahpaşa, İstanbul, Turkey
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Violeta Iotova
- Department of Paediatrics, Medical University Varna, Varna, Bulgaria
| | - Otilia Marginean
- First Paediatric Clinic, University of Medicine and Pharmacy Victor Babes, Timisoara, Romania
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Paediatric Endocrinology Unit, Centre for Rare Endocrine Conditions, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Gilvydas Verkauskas
- Centre of Paediatric Surgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Naomi Weintrob
- Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Department of Paediatrics, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Mona Ellaithi
- Faculty of Medical Laboratory Sciences, Al-Neelain University, Khartoum, Sudan
| | - Anna Nordenström
- Department of Women's and Children's Health, Paediatric Endocrinology Q2: 04, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Annemarie Verrijn Stuart
- Department of Paediatrics, Children's Hospital, University Medical Center, Utrecht, The Netherlands
| | - Kirsten B Kluivers
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Katja P Wolffenbuttel
- Department of Urology and Paediatric Urology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Royal Hospital for Children, Glasgow, United Kingdom
| | - Martine Cools
- Division of Paediatric Endocrinology, Department of Paediatrics, Ghent University Hospital, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
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20
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Cools M, Wolffenbuttel KP, Hersmus R, Mendonca BB, Kaprová J, Drop SLS, Stoop H, Gillis AJM, Oosterhuis JW, Costa EMF, Domenice S, Nishi MY, Wunsch L, Quigley CA, T'Sjoen G, Looijenga LHJ. Malignant testicular germ cell tumors in postpubertal individuals with androgen insensitivity: prevalence, pathology and relevance of single nucleotide polymorphism-based susceptibility profiling. Hum Reprod 2018; 32:2561-2573. [PMID: 29121256 DOI: 10.1093/humrep/dex300] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 09/14/2017] [Indexed: 01/29/2023] Open
Abstract
STUDY QUESTION What is the prevalence of malignant testicular germ cell tumors (TGCT) and its precursors, (pre-) germ cell neoplasia in situ (GCNIS), in late teenagers and adults who have androgen insensitivity syndrome (AIS) and the impact of an individual's genetic susceptibility to development of TGCT? SUMMARY ANSWER No GCNIS or TGCT was diagnosed, but pre-GCNIS was identified in 14 and 10% of complete and partial AIS patients, respectively, and was associated with a higher genetic susceptibility score (GSS), with special attention for KITLG (rs995030) and ATFZIP (rs2900333). WHAT IS KNOWN ALREADY Many adult women with AIS decline prophylactic gonadectomy, while data regarding the incidence, pathophysiology and outcomes of TGCT in postpubertal individuals with AIS are lacking. The relevance of genetic factors, such as single nucleotide polymorphisms (SNPs), in predisposing AIS individuals to TGCT is unknown. STUDY DESIGN, SIZE, DURATION This multicenter collaborative study on prophylactically removed gonadal tissue was conducted in a pathology lab specialized in germ cell tumor biology. PARTICIPANTS/MATERIALS, SETTING, METHODS Material from 52 postpubertal individuals with molecularly confirmed AIS (97 gonadal samples) was included; the median age at surgery was 17.5 (14-54) years. Immunohistochemical studies and high-throughput profiling of 14 TGCT-associated SNPs were performed. The main outcome measures were the prevalence of pre-GCNIS, GCNIS and TGCT, and its correlation with a GSS, developed based on the results of recent genome-wide association studies. MAIN RESULTS AND ROLE OF CHANCE The earliest recognizable change preceding GCNIS, referred to as pre-GCNIS, was present in 14% of individuals with complete and 10% of those with partial AIS at a median age of 16 years. No GCNIS or invasive TGCT were found. The median GSS was significantly greater for those with, compared to those without, pre-GCNIS (P = 0.01), with an overlap between groups. Our data suggest important roles for risk alleles G at KITLG (rs995030) and C at ATFZIP (rs2900333), among the 14 studied TGCT-associated SNPs. LARGE SCALE DATA N/A. LIMITATIONS REASONS FOR CAUTION A limited number of cases were included. WIDER IMPLICATIONS OF THE FINDINGS Our data suggest that the prevalence of pre-GCNIS in individuals with AIS beyond puberty is around 15%. Genetic susceptibility likely contributes to pre-GCNIS development in AIS but factors related to malignant progression remain unclear. Although data in older patients remain scarce, malignant progression appears to be a rare event, although the natural history of the premalignant lesion remains unknown. Therefore, the practice of routine prophylactic gonadectomy in adults with AIS appears questionable and the patient's preference, after having been fully informed, should be decisive in this matter. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by research grants from the Research Foundation Flanders (FWO) (to M.C.), the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq G0D6713N) (to B.B.M. and M.C.) and the European Society for Pediatric Endocrinology (ESPE), granted by Novo Nordisk AB (to J.K.). There are no competing interests.
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Affiliation(s)
- M Cools
- Pediatrics and Genetics, Ghent University and Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - K P Wolffenbuttel
- Department of Pediatric Urology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - R Hersmus
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - B B Mendonca
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - J Kaprová
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Pediatrics, Charles University, 2nd Faculty of Medicine and University Hospital Motol, Prague, Czech Republic
| | - S L S Drop
- Department of Pediatric Endocrinology, Sophia Children's Hospital and Erasmus Medical Center, Rotterdam, The Netherlands
| | - H Stoop
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - A J M Gillis
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - J W Oosterhuis
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
| | - E M F Costa
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - S Domenice
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - M Y Nishi
- Department of Endocrinology, Hormone and Molecular Genetics Laboratory, LIM/42 Clinicas Hospital; University of Sao Paulo, Sao Paulo, Brazil
| | - L Wunsch
- Department of Pediatric Urology, Universitätsklinikum Schleswig-Holstein and Universität zu Lübeck, Lübeck, Germany
| | - C A Quigley
- Pediatric Endocrinology, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - G T'Sjoen
- Internal Medicine, Ghent University and Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - L H J Looijenga
- Laboratory for Experimental Patho-Oncology, Josephine Nefkens Institute and Erasmus Medical Center, Rotterdam, The Netherlands
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21
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Cools M, Nordenström A, Robeva R, Hall J, Westerveld P, Flück C, Köhler B, Berra M, Springer A, Schweizer K, Pasterski V. Caring for individuals with a difference of sex development (DSD): a Consensus Statement. Nat Rev Endocrinol 2018; 14:415-429. [PMID: 29769693 PMCID: PMC7136158 DOI: 10.1038/s41574-018-0010-8] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The term differences of sex development (DSDs; also known as disorders of sex development) refers to a heterogeneous group of congenital conditions affecting human sex determination and differentiation. Several reports highlighting suboptimal physical and psychosexual outcomes in individuals who have a DSD led to a radical revision of nomenclature and management a decade ago. Whereas the resulting recommendations for holistic, multidisciplinary care seem to have been implemented rapidly in specialized paediatric services around the world, adolescents often experience difficulties in finding access to expert adult care and gradually or abruptly cease medical follow-up. Many adults with a DSD have health-related questions that remain unanswered owing to a lack of evidence pertaining to the natural evolution of the various conditions in later life stages. This Consensus Statement, developed by a European multidisciplinary group of experts, including patient representatives, summarizes evidence-based and experience-based recommendations for lifelong care and data collection in individuals with a DSD across ages and highlights clinical research priorities. By doing so, we hope to contribute to improving understanding and management of these conditions by involved medical professionals. In addition, we hope to give impetus to multicentre studies that will shed light on outcomes and comorbidities of DSD conditions across the lifespan.
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Affiliation(s)
- Martine Cools
- Department of Paediatric Endocrinology, Ghent University Hospital, University of Ghent, Ghent, Belgium.
| | - Anna Nordenström
- Department of Women's and Children's Health, Paediatric Endocrinology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ralitsa Robeva
- Clinical Center of Endocrinology and Gerontology, Medical University-Sofia, Medical Faculty, Sofia, Bulgaria
| | | | | | - Christa Flück
- Paediatric Endocrinology and Diabetology, Department of Paediatrics and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Birgit Köhler
- Department of Paediatric Endocrinology, Charité University Medicine, Humboldt University Berlin, Berlin, Germany
| | - Marta Berra
- Department of Obstetrics and Gynaecology, Ramazzini Hospital, AUSL Modena, Modena, Italy
| | - Alexander Springer
- Department of Paediatric Surgery, Medical University Vienna, Vienna, Austria
| | - Katinka Schweizer
- Institute for Sex Research and Forensic Psychiatry, University Clinic Hamburg-Eppendorf, Hamburg, Germany
| | - Vickie Pasterski
- Department of Psychology, University of Cambridge, Cambridge, UK
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22
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Ulbright TM. Recently Described and Clinically Important Entities in Testis Tumors: A Selective Review of Changes Incorporated Into the 2016 Classification of the World Health Organization. Arch Pathol Lab Med 2018; 143:711-721. [DOI: 10.5858/arpa.2017-0478-ra] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
In 2016 the World Health Organization published a revised classification of testicular neoplasms based upon advances in understanding their pathogenesis and molecular biology. The rationale for this revision and additional clinically relevant observations were the topics of a talk given to the Houston Society of Clinical Pathologists in April 2017. This paper summarizes that talk.
Objective.—
To summarize and explain the most important changes to the classification of testicular neoplasms in the World Health Organization 2016 revision.
Data Sources.—
Peer-reviewed published literature and contributions by individuals with expertise in this area that were also reviewed by genitourinary pathologists.
Conclusions.—
Most changes occurred in the germ cell tumor classification, including replacement of the terms intratubular germ cell neoplasia unclassified and carcinoma in situ by germ cell neoplasia in situ; subdivision of the tumors into 2 main categories, those derived from germ cell neoplasia in situ and those not derived from germ cell neoplasia in situ; distinction of germ cell neoplasia in situ from germ cells with delayed maturation and pre–germ cell neoplasia in situ; expansion of the trophoblastic tumor category to include epithelioid trophoblastic tumor and cystic trophoblastic tumor; and substitution of spermatocytic tumor for spermatocytic seminoma and its placement in the non–germ cell neoplasia in situ group. Other revisions included eliminating sclerosing Sertoli cell tumor as a distinct entity; the recognition of intratubular hyalinizing Sertoli cell tumor; and acceptance of the role of undifferentiated gonadal tissue in the pathogenesis of gonadoblastoma.
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Affiliation(s)
- Thomas M. Ulbright
- From the Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis
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23
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Batista RL, Costa EMF, Rodrigues ADS, Gomes NL, Faria JA, Nishi MY, Arnhold IJP, Domenice S, Mendonca BBD. Androgen insensitivity syndrome: a review. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:227-235. [PMID: 29768628 PMCID: PMC10118986 DOI: 10.20945/2359-3997000000031] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/18/2018] [Indexed: 11/23/2022]
Abstract
Androgenic insensitivity syndrome is the most common cause of disorders of sexual differentiation in 46,XY individuals. It results from alterations in the androgen receptor gene, leading to a frame of hormonal resistance, which may present clinically under 3 phenotypes: complete (CAIS), partial (PAIS) or mild (MAIS). The androgen receptor gene has 8 exons and 3 domains, and allelic variants in this gene occur in all domains and exons, regardless of phenotype, providing a poor genotype - phenotype correlation in this syndrome. Typically, laboratory diagnosis is made through elevated levels of LH and testosterone, with little or no virilization. Treatment depends on the phenotype and social sex of the individual. Open issues in the management of androgen insensitivity syndromes includes decisions on sex assignment, timing of gonadectomy, fertility, physcological outcomes and genetic counseling.
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Affiliation(s)
- Rafael Loch Batista
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Elaine M Frade Costa
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Andresa de Santi Rodrigues
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil.,Laboratório de Sequenciamento em Larga Escala (SELA), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Nathalia Lisboa Gomes
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - José Antonio Faria
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Mirian Y Nishi
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil.,Laboratório de Sequenciamento em Larga Escala (SELA), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Ivo Jorge Prado Arnhold
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Sorahia Domenice
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Berenice Bilharinho de Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Disciplina de Endocrinologia, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil.,Laboratório de Sequenciamento em Larga Escala (SELA), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
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24
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Aliberti P, Perez Garrido N, Marino R, Ramirez P, Solari AJ, Sciurano R, Costanzo M, Guercio G, Warman DM, Bailez M, Baquedano MS, Rivarola MA, Belgorosky A, Berensztein E. Androgen Insensitivity Syndrome at Prepuberty: Marked Loss of Spermatogonial Cells at Early Childhood and Presence of Gonocytes up to Puberty. Sex Dev 2018; 11:225-237. [PMID: 29393262 DOI: 10.1159/000486089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 01/01/2023] Open
Abstract
Androgen insensitivity syndrome (AIS) is a hereditary condition in patients with a 46,XY karyotype in which loss-of-function mutations of the androgen receptor (AR) gene are responsible for defects in virilization. The aim of this study was to investigate the consequences of the lack of AR activity on germ cell survival and the degree of testicular development reached by these patients by analyzing gonadal tissue from patients with AIS prior to Sertoli cell maturation at puberty. Twenty-three gonads from 13 patients with AIS were assessed and compared to 18 testes from 17 subjects without endocrine disorders. The study of the gonadal structure using conventional microscopy and the ultrastructural characteristics of remnant germ cells using electron microscopy, combined with the immunohistochemical analysis of specific germ cell markers (MAGE-A4 for premeiotic germ cells and of OCT3/4 for gonocytes), enabled us to carry out a thorough investigation of germ cell life in an androgen-insensitive microenvironment throughout prepuberty until young adulthood. Here, we show that germ cell degeneration starts very early, with a marked decrease in number after only 2 years of life, and we demonstrate the permanence of gonocytes in AIS testis samples until puberty, describing 2 different populations. Additionally, our results provide further evidence for the importance of AR signaling in peritubular myoid cells during prepuberty to maintain Sertoli and spermatogonial cell health and survival.
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Affiliation(s)
- Paula Aliberti
- Servicio de Endocrinología, Hospital de Pediatría 'Prof. Dr. Juan Pedro Garrahan', Buenos Aires, Argentina
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25
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Konrade I, Zavorikina J, Fridvalde A, Rots D, Kalere I, Strumfa I, Dambrova M, Gailite L. Novel Variant of the Androgen Receptor Gene in a Patient With Complete Androgen Insensitivity Syndrome and Polyorchidism. Front Endocrinol (Lausanne) 2018; 9:795. [PMID: 30705665 PMCID: PMC6345100 DOI: 10.3389/fendo.2018.00795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/18/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: Complete androgen insensitivity (CAIS) in 65-95% cases is caused by pathogenic allelic variants (mutations) in the gene encoding androgen receptor (AR gene) and is characterized by female phenotype development with a male karyotype (46, XY). Patients are usually diagnosed during puberty and undergo gonadectomy due to increased testicular germ cell tumor risk. Only a few outcomes have been reported in older individuals with postponed gonadectomy. Case presentation: A 48-year-old CAIS patient presented with polyorchidism (four testes) without gonadal malignancies. Genetic testing identified a novel allelic variant in the AR gene [c.2141T>G (p.Phe805Cys)] causing the clinical symptoms. Conclusion: We have described a unique patient with CAIS and polyorchidism without malignancies in her late 40's bearing a novel likely pathogenic variant in the AR gene.
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Affiliation(s)
- Ilze Konrade
- Department of Internal Medicine, Riga Stradins University, Riga, Latvia
- Department of Endocrinology, Riga East University Hospital, Riga, Latvia
| | - Julija Zavorikina
- Department of Internal Medicine, Riga Stradins University, Riga, Latvia
| | - Aija Fridvalde
- Department of Internal Medicine, Riga Stradins University, Riga, Latvia
| | - Dmitrijs Rots
- Scientific Laboratory of Molecular Genetics, Riga Stradins University, Riga, Latvia
| | - Ieva Kalere
- Department of Pharmacy, Riga Stradins University, Riga, Latvia
| | - Ilze Strumfa
- Department of Pathology, Riga Stradins University, Riga, Latvia
| | - Maija Dambrova
- Department of Human Physiology and Biochemistry, Riga Stradins University, Riga, Latvia
| | - Linda Gailite
- Scientific Laboratory of Molecular Genetics, Riga Stradins University, Riga, Latvia
- *Correspondence: Linda Gailite
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26
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Chaudhry S, Tadokoro-Cuccaro R, Hannema SE, Acerini CL, Hughes IA. Frequency of gonadal tumours in complete androgen insensitivity syndrome (CAIS): A retrospective case-series analysis. J Pediatr Urol 2017; 13:498.e1-498.e6. [PMID: 28351649 DOI: 10.1016/j.jpurol.2017.02.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive disorder of sex development (DSD) where affected individuals are phenotypically female, but have an XY karyotype and testes. The risk of gonadal tumour development in CAIS may increase with age; incidence rates have been reported to be 0.8-22% in patients who have retained their gonads into adulthood. Consequently, gonadectomy has been recommended either during childhood or after puberty is complete, although there is no consensus on the optimal timing for this procedure. OBJECTIVE AND HYPOTHESES To establish the frequency of histological abnormalities in CAIS in relation to the age at gonadectomy. METHOD Data were collected from the Cambridge DSD database on patients with CAIS (n = 225; age range 3-88 years) who had undergone gonadectomy, and their age of gonadectomy, gonadal histology and immunohistochemistry. RESULTS Evaluable data were obtained from 133 patients. Median age at gonadectomy was 14.0 years (range: 18 days-68 years). Pubertal status was: prepuberty, n = 62; postpuberty, n = 68. Thirteen cases were aged >20 years at gonadectomy. The pattern of histology is summarised in the Summary table. DISCUSSION In this large case series of CAIS patients who had undergone gonadectomy, while the combined malignant and premalignant gonadal histology prevalence was 6.0%, the findings confirm the low occurrence of gonadal malignancy in CAIS, with a frequency of 1.5%. The two cases of malignancy were postpubertal. Germ cell neoplasia in situ (GCNIS) was observed in six cases, of which one occurred prepuberty and five postpuberty. The study highlighted difficulties in diagnosis of GCNIS and the need for histological analysis in expert centres. CONCLUSION The results support the current recommendation that gonads in CAIS can be retained until early adulthood. The small number of individuals with gonadectomy after age 20 years do not allow firm conclusion regarding later adulthood. Therefore, it is recommended that the option of gonadectomy be discussed in adulthood. Some form of regular surveillance of the gonads is then recommended, although none of the available options are ideal.
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Affiliation(s)
- S Chaudhry
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - R Tadokoro-Cuccaro
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
| | - S E Hannema
- Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands; Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - C L Acerini
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - I A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Abstract
CONTEXT - Precursor lesions of urologic malignancies are established histopathologic entities, which are important not only to recognize for clinical purposes, but also to further investigate at the molecular level in order to gain a better understanding of the pathogenesis of these malignancies. OBJECTIVE - To provide a brief overview of precursor lesions to the most common malignancies that develop within the genitourinary tract with a focus on their clinical implications, histologic features, and molecular characteristics. DATA SOURCES - Literature review from PubMed, urologic pathology textbooks, and the 4th edition of the World Health Organization Classification of Tumours of the Urinary System and Male Genital Organs. All photomicrographs were taken from cases seen at Weill Cornell Medicine or from the authors' personal slide collections. CONCLUSIONS - The clinical importance and histologic criteria are well established for the known precursor lesions of the most common malignancies throughout the genitourinary tract, but further investigation is warranted at the molecular level to better understand the pathogenesis of these lesions. Such investigation may lead to better risk stratification of patients and potentially novel treatments.
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28
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Abstract
Disorders (differences) of sexual development encompass a variety of conditions with atypical development of chromosomal, gonadal, or anatomic sex. Three of the most common differences of sex development conditions include congenital adrenal hyperplasia, complete androgen insensitivity, and Turner syndrome. Obstetrician-gynecologists who care for affected individuals in their practice must be familiar with the genetic, endocrine, and anatomic considerations of the most common conditions to provide optimal care. As women with these conditions transition to adult care, the gynecologist needs to assess the patient's understanding and educate her regarding her diagnosis and ongoing medical care. All of these conditions may affect self-perception, mental health, fertility, sexual function, and bone and cardiovascular health. Women with congenital adrenal hyperplasia need lifelong endocrine management and require genetic counseling before pregnancy. Women with androgen insensitivity syndrome require counseling regarding gonadectomy and hormone replacement therapy and may require vaginal elongation for intercourse. Most women with Turner syndrome experience premature ovarian insufficiency and require long-term estrogen replacement. Women with Turner syndrome often have congenital anomalies and autoimmune disorders, which require regular monitoring and care during adulthood. The purpose of this review is to provide the obstetrician-gynecologist who cares for adult women with the most common disorders (differences) of sexual development conditions an outline of the current recommendations for screening and ongoing health care with particular emphasis on the underlying genetics, management of subfertility, infertility and sexual concerns, approach to hypogonadism, and understanding of associated comorbidities.
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29
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Presence of Germ Cells in Disorders of Sex Development: Implications for Fertility Potential and Preservation. J Urol 2016; 197:937-943. [PMID: 27840018 DOI: 10.1016/j.juro.2016.08.108] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE We sought to determine the presence of germ cells in the gonads of patients with disorders of sex development to establish whether preservation of germ cells for future fertility potential is possible. We hypothesized that germ cells are present but vary by age and diagnosis. MATERIALS AND METHODS We reviewed histology from patients with disorders of sex development who underwent gonadectomy/biopsy from 2002 to 2014 at a single institution for pathological classification of the gonad, composition of gonadal stroma and germ cell presence. RESULTS A total of 44 patients were identified and germ cells were present in 68%. The presence and average number of germ cells per mm2 were analyzed by gonad type and diagnosis. By gonad type all ovotestes, most testes, ovaries and dysgenetic testes, and 15% of streak gonads had germ cells present. By diagnosis germ cells were present in all patients with complete androgen insensitivity syndrome, Denys-Drash syndrome, SRY mutation, mixed gonadal dysgenesis, ovotesticular conditions and StAR (steroid acute regulatory protein) deficiency, in some patients with persistent müllerian duct syndrome, XO/XY Turner syndrome and disorders of sex development not otherwise specified, and in none with complete or partial gonadal dysgenesis. Germ cells were present in the gonads of 88% of patients 0 to 3 years old, 50% of those 4 to 11 years old and 43% of those older than 12 years. CONCLUSIONS Germ cells were present in the majority of our cohort and the presence decreased with age. This novel, fertility driven evaluation of germ cell quantity in a variety of disorders of sex development suggests that fertility potential may be greater than previously thought. Further studies must be done to evaluate a larger population and examine germ cell quality to determine the viability of these germ cells.
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Lepais L, Morel Y, Mouriquand P, Gorduza D, Plotton I, Collardeau-Frachon S, Dijoud F. A novel morphological approach to gonads in disorders of sex development. Mod Pathol 2016; 29:1399-1414. [PMID: 27469328 DOI: 10.1038/modpathol.2016.123] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/09/2016] [Accepted: 06/10/2016] [Indexed: 01/10/2023]
Abstract
Disorders of sex development are defined as congenital conditions with discordance between the phenotype, the genotype, the karyotype, and the hormonal profile. The disorders of sex development consensus classification established in 2005 are mainly based on chromosomal and biological data. However, histological anomalies are not considered. The aims of this study were to define the specific pathological features of gonads in various groups of disorders of sex development in order to clarify the nosology of histological findings and to evaluate the tumor risk in case of a conservative approach. One hundred and seventy-five samples from 86 patients with disorders of sex development were analyzed following a strict histological reading protocol. The term 'gonadal dysgenesis' for the histological analysis was found confusing and therefore excluded. The concept of 'dysplasia' was subsequently introduced in order to describe the architectural disorganization of the gonad (various degrees of irregular seminiferous tubules, thin albuginea, fibrous interstitium). Five histological types were identified: normal gonad, hypoplastic testis, dysplastic testis, streak gonad, and ovotestis. The analysis showed an association between undifferentiated gonadal tissue, a potential precursor of gonadoblastoma, and dysplasia. Dysplasia and undifferentiated gonadal tissue were only encountered in cases of genetic or chromosomal abnormality ('dysgenesis' groups in the disorders of sex development consensus classification). 'Dysgenetic testes', related to an embryonic malformation of the gonad, have variable histological presentations, from normal to streak. Conversely, gonads associated with hormonal deficiencies always display a normal architecture. A loss of expression of AMH and α-inhibin was identified in dysplastic areas. Foci of abnormal expression of the CD117 and OCT4 immature germ cells markers in dysplasia and undifferentiated gonadal tissue were associated with an increased risk of neoplasia. This morphological analysis aims at clarifying the histological classification and gives an indication of tumor risk of gonads in disorders of sex development.
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Affiliation(s)
- Laureline Lepais
- Service d'Anatomie Pathologique, Centre de Biologie et de Pathologie Est, Bron, France.,Université Lyon 1, Lyon, France
| | - Yves Morel
- Université Lyon 1, Lyon, France.,Service d'Endocrinologie Moléculaire et Maladies Rares, Centre de Biologie et de Pathologie Est, Bron, France
| | - Pierre Mouriquand
- Université Lyon 1, Lyon, France.,Service de Chirurgie Urologique Pédiatrique, Hôpital Femme Mère Enfant, Bron, France
| | - Daniela Gorduza
- Service de Chirurgie Urologique Pédiatrique, Hôpital Femme Mère Enfant, Bron, France
| | - Ingrid Plotton
- Université Lyon 1, Lyon, France.,Service d'Endocrinologie Moléculaire et Maladies Rares, Centre de Biologie et de Pathologie Est, Bron, France
| | - Sophie Collardeau-Frachon
- Service d'Anatomie Pathologique, Centre de Biologie et de Pathologie Est, Bron, France.,Université Lyon 1, Lyon, France
| | - Frédérique Dijoud
- Service d'Anatomie Pathologique, Centre de Biologie et de Pathologie Est, Bron, France.,Université Lyon 1, Lyon, France
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Moch H, Cubilla AL, Humphrey PA, Reuter VE, Ulbright TM. The 2016 WHO Classification of Tumours of the Urinary System and Male Genital Organs-Part A: Renal, Penile, and Testicular Tumours. Eur Urol 2016; 70:93-105. [PMID: 26935559 DOI: 10.1016/j.eururo.2016.02.029] [Citation(s) in RCA: 1895] [Impact Index Per Article: 236.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/04/2016] [Indexed: 02/07/2023]
Abstract
UNLABELLED The fourth edition of the World Health Organization (WHO) classification of urogenital tumours (WHO "blue book"), published in 2016, contains significant revisions. These revisions were performed after consideration by a large international group of pathologists with special expertise in this area. A subgroup of these persons met at the WHO Consensus Conference in Zurich, Switzerland, in 2015 to finalize the revisions. This review summarizes the most significant differences between the newly published classification and the prior version for renal, penile, and testicular tumours. Newly recognized epithelial renal tumours are hereditary leiomyomatosis and renal cell carcinoma (RCC) syndrome-associated RCC, succinate dehydrogenase-deficient RCC, tubulocystic RCC, acquired cystic disease-associated RCC, and clear cell papillary RCC. The WHO/International Society of Urological Pathology renal tumour grading system was recommended, and the definition of renal papillary adenoma was modified. The new WHO classification of penile squamous cell carcinomas is based on the presence of human papillomavirus and defines histologic subtypes accordingly. Germ cell neoplasia in situ (GCNIS) of the testis is the WHO-recommended term for precursor lesions of invasive germ cell tumours, and testicular germ cell tumours are now separated into two fundamentally different groups: those derived from GCNIS and those unrelated to GCNIS. Spermatocytic seminoma has been designated as a spermatocytic tumour and placed within the group of non-GCNIS-related tumours in the 2016 WHO classification. PATIENT SUMMARY The 2016 World Health Organization (WHO) classification contains new renal tumour entities. The classification of penile squamous cell carcinomas is based on the presence of human papillomavirus. Germ cell neoplasia in situ of the testis is the WHO-recommended term for precursor lesions of invasive germ cell tumours.
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Affiliation(s)
- Holger Moch
- Department of Pathology, University Hospital Zurich, Zurich, Switzerland.
| | - Antonio L Cubilla
- Instituto de Patología e Investigación, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Peter A Humphrey
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Victor E Reuter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thomas M Ulbright
- Department of Pathology and Laboratory Medicine, Indiana University Health Partners, Indiana University School of Medicine, Indianapolis, IN, USA
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Frank-Herrmann P, Vogt P, Strowitzki T. Fehlanlage der Gonaden und endokrinologische Ursachen genitaler Fehlbildungen bei Frauen. DER GYNÄKOLOGE 2015. [DOI: 10.1007/s00129-015-3796-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Jørgensen A, Lindhardt Johansen M, Juul A, Skakkebaek NE, Main KM, Rajpert-De Meyts E. Pathogenesis of germ cell neoplasia in testicular dysgenesis and disorders of sex development. Semin Cell Dev Biol 2015; 45:124-37. [PMID: 26410164 DOI: 10.1016/j.semcdb.2015.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/21/2015] [Indexed: 12/29/2022]
Abstract
Development of human gonads is a sex-dimorphic process which evolved to produce sex-specific types of germ cells. The process of gonadal sex differentiation is directed by the action of the somatic cells and ultimately results in germ cells differentiating to become functional gametes through spermatogenesis or oogenesis. This tightly controlled process depends on the proper sequential expression of many genes and signalling pathways. Disturbances of this process can be manifested as a large spectrum of disorders, ranging from severe disorders of sex development (DSD) to - in the genetic male - mild reproductive problems within the testicular dysgenesis syndrome (TDS), with large overlap between the syndromes. These disorders carry an increased but variable risk of germ cell neoplasia. In this review, we discuss the pathogenesis of germ cell neoplasia associated with gonadal dysgenesis, especially in individuals with 46,XY DSD. We summarise knowledge concerning development and sex differentiation of human gonads, with focus on sex-dimorphic steps of germ cell maturation, including meiosis. We also briefly outline the histopathology of germ cell neoplasia in situ (GCNIS) and gonadoblastoma (GDB), which are essentially the same precursor lesion but with different morphological structure dependent upon the masculinisation of the somatic niche. To assess the risk of germ cell neoplasia in different types of DSD, we have performed a PubMed search and provide here a synthesis of the evidence from studies published since 2006. We present a model for pathogenesis of GCNIS/GDB in TDS/DSD, with the risk of malignancy determined by the presence of the testis-inducing Y chromosome and the degree of masculinisation. The associations between phenotype and the risk of neoplasia are likely further modulated in each individual by the constellation of the gene polymorphisms and environmental factors.
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Affiliation(s)
- Anne Jørgensen
- Department of Growth & Reproduction and International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Denmark.
| | - Marie Lindhardt Johansen
- Department of Growth & Reproduction and International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Denmark.
| | - Anders Juul
- Department of Growth & Reproduction and International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Denmark.
| | - Niels E Skakkebaek
- Department of Growth & Reproduction and International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Denmark.
| | - Katharina M Main
- Department of Growth & Reproduction and International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Denmark.
| | - Ewa Rajpert-De Meyts
- Department of Growth & Reproduction and International Center for Research and Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Denmark.
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Rivero-Müller A, Potorac I, Pintiaux A, Daly AF, Thiry A, Rydlewski C, Nisolle M, Parent AS, Huhtaniemi I, Beckers A. A novel inactivating mutation of the LH/chorionic gonadotrophin receptor with impaired membrane trafficking leading to Leydig cell hypoplasia type 1. Eur J Endocrinol 2015; 172:K27-36. [PMID: 25795638 DOI: 10.1530/eje-14-1095] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/20/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The LH/chorionic gonadotrophin receptor (LHCGR) is a G protein-coupled receptor (GPCR) that plays a central role in male sexual differentiation, regulation of ovarian follicular maturation, ovulation and maintenance of corpus luteum and pregnancy, as well as maintenance of testicular testosterone production. Mutations in the LHCGR gene are very rare. The aim of this work was to study the clinical and molecular characteristics of a rare familial LHCGR mutation. METHODS Five affected members of a family, including a phenotypically female, but genotypically male (46,XY), patient with Leydig cell hypoplasia type 1 and four genotypically female siblings with reproductive abnormalities, were studied genetically. Cell trafficking studies as well as signalling studies of mutated receptor were performed. RESULTS The five affected patients were all homozygous for a novel mutation in the LHCGR gene, a deletion of guanine in position 1850 (1850delG). This resulted in a frameshift affecting most of the C-terminal intracellular domain. In vitro studies demonstrated that the 1850delG receptor was completely incapable of transit to the cell membrane, becoming trapped within the endoplasmic reticulum. This could not be rescued by small-molecule agonist treatment or stimulated intracellularly by co-expression of a yoked human chorionic gonadotrophin. CONCLUSIONS This novel LHCGR mutation leads to complete inactivation of the LHCGR receptor due to trafficking and signalling abnormalities, which improves our understanding of the impact of the affected structural domain on receptor trafficking and function.
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Affiliation(s)
- Adolfo Rivero-Müller
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFa
| | - Iulia Potorac
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Axelle Pintiaux
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Adrian F Daly
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Albert Thiry
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Catherine Rydlewski
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Michelle Nisolle
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Anne-Simone Parent
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Ilpo Huhtaniemi
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
| | - Albert Beckers
- Department of PhysiologyInstitute for Biomedicine, University of Turku, Turku, FinlandDepartment of EndocrinologyCentre Hospitalier Universitaire de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumFaculty of Natural Sciences and TechnologyÅbo Akademi University, Turku, FinlandDepartment of Biochemistry and Molecular BiologyMedical University of Lublin, 20-093 Lublin, PolandDepartment of Surgery and CancerImperial College London, Institute of Reproductive and Developmental Biology, Hammersmith Campus, London, UKDepartments of GynecologyAnatomopathologyCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, BelgiumDepartment of Medical GeneticsErasme Hospital, Brussels, BelgiumDepartment of PediatricsCHU de Liège, Université de Liège, Domaine Universitaire du Sart-Tilman, 4000 Liège, Belgium
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Abstract
PURPOSE OF REVIEW Androgen insensitivity syndrome (AIS) can present with a wide range of phenotypes, and its management requires a multidisciplinary approach from diagnosis in infancy to adulthood. This review provides an update on some clinical and genetic aspects in AIS. Additional outcome data on surgical and psychosexual findings are presented, together with a discussion on the risk of development of gonadal tumours in AIS. RECENT FINDINGS This review covers clinical features of AIS, including recent trends in sex of rearing, aspects of androgen receptor gene mutations and longer term outcomes in both complete and partial forms of AIS. SUMMARY More follow-up studies are needed to optimize management in AIS, especially in the partial form. Predicting the risk of gonadal tumours is key to determining the timing of gonadectomy or whether to retain the gonads in the long term.
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Affiliation(s)
- Rieko Tadokoro-Cuccaro
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Oosterhuis JW, Stoop J, Rijlaarsdam MA, Biermann K, Smit V, Hersmus R, Looijenga LHJ. Pediatric germ cell tumors presenting beyond childhood? Andrology 2014; 3:70-7. [DOI: 10.1111/andr.305] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/17/2014] [Accepted: 10/18/2014] [Indexed: 01/22/2023]
Affiliation(s)
- J. W. Oosterhuis
- Department of Pathology; Laboratory for Experimental Patho-Oncology; Erasmus MC Cancer Institute; Erasmus University Medical Center Rotterdam; Rotterdam The Netherlands
| | - J.A. Stoop
- Department of Pathology; Laboratory for Experimental Patho-Oncology; Erasmus MC Cancer Institute; Erasmus University Medical Center Rotterdam; Rotterdam The Netherlands
| | - M. A. Rijlaarsdam
- Department of Pathology; Laboratory for Experimental Patho-Oncology; Erasmus MC Cancer Institute; Erasmus University Medical Center Rotterdam; Rotterdam The Netherlands
| | - K. Biermann
- Department of Pathology; Laboratory for Experimental Patho-Oncology; Erasmus MC Cancer Institute; Erasmus University Medical Center Rotterdam; Rotterdam The Netherlands
| | - V.T.H.B.M. Smit
- Department of Pathology; Leiden University Medical Center; Leiden The Netherlands
| | - R. Hersmus
- Department of Pathology; Laboratory for Experimental Patho-Oncology; Erasmus MC Cancer Institute; Erasmus University Medical Center Rotterdam; Rotterdam The Netherlands
| | - L. H. J. Looijenga
- Department of Pathology; Laboratory for Experimental Patho-Oncology; Erasmus MC Cancer Institute; Erasmus University Medical Center Rotterdam; Rotterdam The Netherlands
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Hiort O, Birnbaum W, Marshall L, Wünsch L, Werner R, Schröder T, Döhnert U, Holterhus PM. Management of disorders of sex development. Nat Rev Endocrinol 2014; 10:520-9. [PMID: 25022812 DOI: 10.1038/nrendo.2014.108] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The medical term disorders of sex development (DSDs) is used to describe individuals with an atypical composition of chromosomal, gonadal and phenotypic sex, which leads to differences in the development of the urogenital tract and reproductive system. A variety of genetic factors have been identified that affect sex development during gonadal differentiation or in specific disorders associated with altered androgen biosynthesis or action. The diagnosis of DSDs in individuals and the subsequent management of patients and their families requires a targeted and structured approach, involving a multidisciplinary team with effective communication between the disciplines. This approach includes distinct clinical, imaging, laboratory and genetic evaluations of patients with DSDs. Although treatment of patients with DSDs can include endocrine and surgical options, many patients have concerns that arise from past incorrect treatments that were founded on the traditional binary concept of the sexes. To dispel these concerns, it is necessary to create centres of expertise for DSDs that include physicians, surgeons, psychologists and specialists in diagnostic procedures to manage patients and their families. Additionally, the inclusion of trained peer support in the multidisciplinary DSD team seems to be integral to the supportive management of patients with DSDs. Most importantly, dealing with DSDs requires acceptance of the fact that deviation from the traditional definitions of gender is not necessarily pathologic.
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Affiliation(s)
- Olaf Hiort
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Wiebke Birnbaum
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Louise Marshall
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Lutz Wünsch
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Ralf Werner
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Tatjana Schröder
- Department of Gynaecology and Obstetrics, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Ulla Döhnert
- Division of Experimental Paediatric Endocrinology and Diabetes, Department of Paediatric and Adolescent Medicine, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Paul-Martin Holterhus
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, Christian-Albrechts-University, Schwanenweg 20, 24105 Kiel, Germany
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Comment on "complete androgen insensitivity syndrome: optimizing diagnosis and management". Case Rep Obstet Gynecol 2014; 2014:285715. [PMID: 24949207 PMCID: PMC4037611 DOI: 10.1155/2014/285715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 04/27/2014] [Indexed: 11/29/2022] Open
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40
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Response to: Comment on “Complete Androgen Insensitivity Syndrome: Optimizing Diagnosis and Management”. Case Rep Obstet Gynecol 2014; 2014:808270. [PMID: 25574409 PMCID: PMC4276687 DOI: 10.1155/2014/808270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 10/30/2014] [Indexed: 11/23/2022] Open
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