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Auer MK, Büyükerzurmulu D, Lottspeich C, Bidlingmaier M, Rieger E, Nowotny H, Tschaidse L, Auchus RJ, Reisch N. Prevalence of adrenal rest tumors and course of gonadal dysfunction in a clinical sample of men with congenital adrenal hyperplasia: a longitudinal analysis over 10 years. Eur J Endocrinol 2024; 191:370-380. [PMID: 39308408 DOI: 10.1093/ejendo/lvae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 07/19/2024] [Accepted: 09/10/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Subfertility is prevalent in men with classic 21-hydroxylase deficiency (21OHD). We sought to characterize the long-term evolution of their gonadal function. METHODS Retrospective longitudinal single-center study in 27 men (11 with testicular adrenal rest tissue [TART]), median observation period 12 years, testosterone (T), 11-oxygenated androgens, gonadotropins, and inhibin B measurement at each time point. RESULTS T concentrations were below the normal range (n.s.) in 43.2% (no TART) and 54.6% (TART) per patient. After accounting for body mass index, sex hormone-binding globulin, and age, men with TART exhibited higher T (14.0 ± 0.80 nmol/L) than those without (11.9 ± 0.71 nmol/L). During the observation period, T levels rose in both groups but more in men with TART (from 10.1 ± 1.1 to 17.3 ± 1.9 nmol/L vs 10.3 ± 1.0 to 12.8 ± 1.9 nmol/L); this was accompanied by rising luteinizing hormone and diminishing hydrocortisone equivalent dosages (TART: from 38.1 ± 3.2 to 35.1 ± 1.8 mg/d; vs no TART: 28.8 ± 2.7 to 28.1 ± 1.6 mg/d) without correlation with any markers of adrenal androgen control. Inhibin B declined in men with large TART over time while TART status remained stable. CONCLUSION T levels below the normal range are frequent in men with 21OHD, regardless of TART, but change little over time. Besides adrenal androgen control gonadal axis suppression from supraphysiological glucocorticoid dosages needs to be considered. While our results do not endorse regular screening for alterations in TART status among adults, Sertoli cell function should be monitored in men with large TART.
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Affiliation(s)
- Matthias K Auer
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, 80336 Munich, Germany
| | - Duygu Büyükerzurmulu
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, 80336 Munich, Germany
| | - Christian Lottspeich
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, 80336 Munich, Germany
| | - Martin Bidlingmaier
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, 80336 Munich, Germany
| | - Eva Rieger
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, 80336 Munich, Germany
| | - Hanna Nowotny
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, 80336 Munich, Germany
| | - Lea Tschaidse
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, 80336 Munich, Germany
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, United States
- Division of Metabolism, Endocrinology and Diabetes, Department Pharmacology, University of Michigan, Ann Arbor, MI 48109, United States
| | - Nicole Reisch
- Medizinische Klinik and Poliklinik IV, Klinikum der Universität München, LMU München, 80336 Munich, Germany
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Wang Z, Wang R, Wang X, Zheng S, Li M, Yu Y, Liu Z, Sun S, Zhan W. Infertility risk assessment with ultrasound in congenital adrenal hyperplasia male patients. Sci Rep 2024; 14:12058. [PMID: 38802468 PMCID: PMC11130187 DOI: 10.1038/s41598-024-62954-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024] Open
Abstract
Testicular adrenal rest tumor (TART) is a prevalent complication associated with congenital adrenal hyperplasia (CAH), culminating in gonadal dysfunction and infertility. Early hormonal intervention is preventive, but excessive glucocorticoid poses risks. Developing reliable methods for early TART diagnosis and monitoring is crucial. The present study aims to formulate a scoring system to identify high-risk infertility through analysis of TART ultrasound features. Grayscale and power Doppler ultrasound were employed in this retrospective study to evaluate testicular lesions in male CAH patients. Lesion assessment encompassed parameters such as range, echogenicity, and blood flow, and these were subsequently correlated with semen parameters. Results of 49 semen analyzes from 35 patients demonstrated a notable inverse correlation between lesion scores and both sperm concentration (rs = - 0.83, P < 0.001) and progressive motility (rs = - 0.56, P < 0.001). The ROC curve areas for evaluating oligospermia and asthenozoospermia were calculated as 0.94 and 0.72, respectively. Establishing a lesion score threshold of 6 revealed a sensitivity of 75.00% and specificity of 93.94% for oligospermia and a sensitivity of 53.85% and specificity of 100.00% for asthenozoospermia. These findings underscore the potential utility of incorporating ultrasound into routine CAH patient management, facilitating timely interventions to preserve male fertility.
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Affiliation(s)
- Zhiqian Wang
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
- Department of Ultrasound, Ruijin-Hainan Hospital Shanghai Jiao Tong University School of Medicine Hainan Boao Research Hospital, Hainan, 571437, People's Republic of China
| | - Ronghui Wang
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Xing Wang
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Sichang Zheng
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Min Li
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Yifei Yu
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Zhenhua Liu
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China
| | - Shouyue Sun
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China.
| | - Weiwei Zhan
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 2nd Ruijin Road 197, Shanghai, 200025, People's Republic of China.
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DeSanto M, Deem S. A unique case of large cell calcifying type sertoli tumor. Urol Case Rep 2024; 54:102725. [PMID: 38601086 PMCID: PMC11004691 DOI: 10.1016/j.eucr.2024.102725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/12/2024] Open
Abstract
Sertoli cells tumors are a rare testicular malignancy, with prevalence estimated to be less than 1% of testicular cancers. Furthermore, testicular cancer only accounts for approximately 0.5% of all diagnosed cancers. This is a unique case of a 19-year-old male where physical exam and ultrasonography findings revealed an intratesticular mass that, after pathologic analysis, demonstrated T1 large cell calcifying type Sertoli cell tumor which is infrequently documented in the literature.
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Affiliation(s)
| | - Samuel Deem
- Charleston Area Medical Center, Charleston, WV, USA
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Eyer de Jesus L, Paz de Oliveira AP, Porto LC, Dekermacher S. Testicular adrenal rest tumors - Epidemiology, diagnosis and treatment. J Pediatr Urol 2024; 20:77-87. [PMID: 37845103 DOI: 10.1016/j.jpurol.2023.10.005] [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: 03/12/2023] [Revised: 08/08/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Testicular adrenal rest tumors (TART) are common in males suffering from congenital adrenal hyperplasia (CAH). Correct and timely diagnosis is important for differential diagnosis with malignant testis tumors, related infertility and as TART may worsen in time, especially in the absence of adequate and continuous hormonal control. The rarity of the disease, predominance of small cohorts and case reports and research heterogeneity (concerning type of CAH, patients' age and specific focus of the paper) complicate the understanding of this condition. OBJECTIVES To review epidemiological and clinical aspects of TART, including treatment and prognosis. METHODS Non-systematic review of CAH-related TART research. RESULTS TART's prevalence grows progressively over time, predominating after puberty, affecting a mean of 20-40 % of CAH males. There is no proof of more frequent proportional affection of specific CAH phenotypes or types of enzyme deficiency, but cases of TART among non-classic CAH patients have been rarely reported. Chronic undertreated are more frequently affected and present larger tumors. Systematic ultrasound screening of CAH males is the state-of-the art for diagnosis, but TART are still often diagnosed in CAH adults seeking infertility treatment. TART are usually asymptomatic and present normal testicular volume. Biopsies are not recommended, except when the differential diagnosis between TART and testicular tumors cannot be guaranteed. Abnormal semen analysis is common. Leydig cell tumors are the main differential diagnosis, due to histological similarities to TART. Misdiagnosis may lead to unnecessary orchiectomies. Preservation of gonadal functions is inversely proportional to the total tumor volume. Tumors tend to regress under adequate adrenal suppression with steroids. Surgery in not indicated to treat TART. DISCUSSION The reported prevalence of TART depends on age, usage of systematic follow-up ultrasound, and adequate CAH control. Timely detection of the disease is important to avoid irreversible gonadal dysfunction (not clinically apparent, due to high serum levels of androgen) and infertility. The relationship between TART and specific CAH phenotypes/genotypes has not been proved, and some cases do not present abnormal serum ACTH levels. Knowledge about TART should be disseminated among non-experts, to avoid unnecessary orchiectomies and false diagnosis of malignant testis tumors. Infertility is frequent, but has not been not satisfactorily addressed by physicians, even among experts. Sperm cryopreservation should be early offered to CAH adult males, but there are offer problems related to high cost.
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Affiliation(s)
- Lisieux Eyer de Jesus
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil.
| | - Ana Paula Paz de Oliveira
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil
| | - Luiza Coutinho Porto
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil
| | - Samuel Dekermacher
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil
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Finkielstain GP, Rey RA. Challenges in managing disorders of sex development associated with adrenal dysfunction. Expert Rev Endocrinol Metab 2023; 18:427-439. [PMID: 37694439 DOI: 10.1080/17446651.2023.2256393] [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: 07/02/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Disorders of Sex Development (DSD) associated with adrenal dysfunction occur due to different defects in the proteins involved in gonadal and adrenal steroidogenesis. AREAS COVERED The deficiencies in 21-hydroxylase and 11β-hydroxylase lead to DSD in 46,XX patients, defects in StAR, P450scc, 17α-hydroxylase and 17,20-lyase lead to 46,XY DSD, and 3β-HSD2 and POR deficiencies cause both 46,XX and 46,XY DSD. Challenges in diagnosis arise from the low prevalence and the variability in serum steroid profiles. Replacement therapy with hydrocortisone and fludrocortisone helps to minimize life-threatening adrenal crises; however, availability is still an unresolved problem in many countries. Adverse health outcomes, due to the disease or its treatment, are common and include adult short stature, hypertension, osteoporosis, obesity, cardiometabolic risk, and reproductive health issues. Potential biomarkers to improve monitoring and novel treatment options that have been developed with the primary aim to decrease adrenal androgen production are promising tools to help improve the health and quality of life of these patients. EXPERT OPINION Steroid profiling by mass spectrometry and next-generation sequencing technologies represent useful tools for establishing an etiologic diagnosis and drive personalized management. Nonetheless, access to health care still remains an issue requiring urgent solutions in many resource-limited settings.
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Affiliation(s)
- Gabriela P Finkielstain
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Rodolfo A Rey
- Centro de Investigaciones Endocrinológicas "Dr. César Bergadá" (CEDIE), CONICET - FEI - División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
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Nebesio TD, Kim MS, Szymanski KM, Kokorowski PJ, Geffner ME, Eugster EA. Patient and Parent Perspectives on Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia. Horm Res Paediatr 2023; 96:518-522. [PMID: 36652933 DOI: 10.1159/000529211] [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: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Testicular adrenal rest tumors (TARTs) increase the risk of infertility in males with classic congenital adrenal hyperplasia (CAH). There is no consensus regarding at what age screening testicular ultrasounds should begin and how often they should be repeated. Furthermore, it is unknown whether patients and parents are aware of the significance of TARTs. OBJECTIVE The objective of the study was to investigate awareness, concern, and screening rates for TARTs in males with classic CAH. METHODS Males with CAH and parents completed an online questionnaire from 2019 to 2020. Responses to questions about TARTs were analyzed. Fisher's exact test was used to determine statistical significance. RESULTS Of 123 responders, 14 were males with CAH (range 16-54 years) and 109 were parents of males with CAH (son's age range infancy to 37 years). Of all responders, 74% were concerned about the possibility of TARTs, 48% had discussions about TARTs with their endocrinologist, and 42% were aware of possible infertility in males with CAH. There was no difference between responses provided by affected males and parents for these topics (p ≥ 0.08). Among male responders with CAH, 93% had at least one testicular ultrasound, and 77% had undergone more than one. Among parent responders, 30% of their sons had at least one testicular ultrasound, and 61% had more than one. The frequency, total number, and age when the first testicular ultrasound was obtained were inconsistent in both groups. Fifty percent of male responders with CAH and 11% of sons were referred to a urologist for evaluation. CONCLUSIONS Although most responders were concerned about TARTs, less than half recalled discussing this issue with their endocrinologist, and less than half were aware of the possibility of infertility. Although TARTs are most often treated medically, several responders were referred to a urologist. Standardized patient education and consensus guidelines are needed for the surveillance and management of TARTs in males with classic CAH.
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Affiliation(s)
- Todd D Nebesio
- Division of Pediatric Endocrinology, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Mimi S Kim
- The Saban Research Institute, Keck School of Medicine of University of Southern California, Children's Hospital Los Angeles, Center for Endocrinology, Diabetes, Metabolism, Los Angeles, California, USA
| | - Konrad M Szymanski
- Department of Urology, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Paul J Kokorowski
- Division of Urology, Department of Surgery and Pediatrics, Cedars Sinai Academic Practice, Los Angeles, California, USA
| | - Mitchell E Geffner
- The Saban Research Institute, Keck School of Medicine of University of Southern California, Children's Hospital Los Angeles, Center for Endocrinology, Diabetes, Metabolism, Los Angeles, California, USA
| | - Erica A Eugster
- Division of Pediatric Endocrinology, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
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Huneif MA, Al Mutairi M, AlHazmy ZH, AlOsaimi FK, AlShoomi AM, AlGhofely MA, AlSaheel A. Screening for testicular adrenal rest tumors among children with congenital adrenal hyperplasia at King Fahad Medical City, Saudi Arabia. J Pediatr Endocrinol Metab 2022; 35:49-54. [PMID: 34757702 DOI: 10.1515/jpem-2021-0291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/04/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess the incidence of testicular adrenal rest tumors (TARTs) among male children with congenital adrenal hyperplasia (CAH) in tertiary care centers. METHODS All male children aged 1-14 years diagnosed with CAH due to 21-hydroxylase deficiency (21 HOD), 11β-hydroxylase deficiency, and 3β-hydroxysteroid dehydrogenase deficiency, confirmed by biochemical and/or genetic testing, underwent scrotal ultrasound examination to identify TARTs. After receiving the diagnosed patients' data, patients' electronic medical records were accessed to collect demographic data and scrotal ultrasound results, along with growth parameters and specific biochemical test results within 2 months of the ultrasound. RESULTS TARTs were observed in 5 (10.9%) of 46 male children with CAH. Four patients with positive findings had 21 HOD classical CAH with salt loss and one had 21 HOD simple virilizing classical CAH. All patients had poor compliance and stage 2 bilateral TARTs. Three TART-positive patients (60.0%) had high ACTH levels, 5 patients (100%) had elevated 17-OHP levels, and 5 patients (100%) had advanced bone age. The youngest patient with positive findings was 4 years old. CONCLUSIONS The prevalence of TARTs increases with age and can be present in young males with classical CAH with 21 HOD. It is associated with elevated 17-hydroxyprogesterone (17-OHP) and advanced bone age SDS. TARTs are less likely to be associated with nonclassical CAH with 21 HOD or other less common CAHs due to 11β-hydroxylase deficiencies and 3β-hydroxysteroid dehydrogenase deficiencies in children. Our study recommends early and routine screening of TARTs in children with CAH.
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Affiliation(s)
- Mohammed Ayed Huneif
- Pediatric Endocrinologist at at Department of Pediatrics, College of Medicine, Najran University Hospital, Najran University, Najran Saudi Arabia
| | - Majed Al Mutairi
- Pediatric Radiologist at the Pediatric Radiology Department, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Fatima Khalid AlOsaimi
- Senior Ultrasound Sonographer in the Pediatric Radiology Department, Children's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Anas M AlShoomi
- Pediatric Endocrinologist in the Pediatric Endocrine Department, Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed A AlGhofely
- Pediatric Endocrinologist in the Pediatric Endocrine Department, Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulhameed AlSaheel
- Pediatric Endocrinologist in the Pediatric Endocrine Department, Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
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Abstract
INTRODUCTION Sertoli cells play central roles in the development of testis formation in fetuses and the initiation and maintenance of spermatogenesis in puberty and adulthood, and disorders of Sertoli cell proliferation and/or functional maturation can cause male reproductive disorders at various life stages. It's well documented that various genes are either overexpressed or absent in Sertoli cells during the conversion of an immature, proliferating Sertoli cell to a mature, non-proliferating Sertoli cell, which are considered as Sertoli cell stage-specific markers. Thus, it is paramount to choose an appropriate Sertoli cell marker that will be used not only to identify the developmental, proliferative, and maturation of Sertoli cell status in the testis during the fetal period, prepuberty, puberty, or in the adult, but also to diagnose the mechanisms underlying spermatogenic dysfunction. AREAS COVERED In this review, we principally enumerated 5 categories of testicular Sertoli cell markers - including immature Sertoli cell markers, mature Sertoli cell markers, immature/mature Sertoli cell markers, Sertoli cell functional markers, and others. EXPERT OPINION By delineating the characteristics and applications of more than 20 Sertoli cell markers, this review provided novel Sertoli cell markers for the more accurate diagnosis and mechanistic evaluation of male reproductive disorders.
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Affiliation(s)
- Xu You
- College of Medicine, China Three Gorges University, Yichang, China.,Third-Grade Pharmacological Laboratory on Traditional Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang China
| | - Qian Chen
- College of Medicine, China Three Gorges University, Yichang, China.,Third-Grade Pharmacological Laboratory on Traditional Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang China.,The Second People's Hospital of Yichang, China Three Gorges University, Yichang China
| | - Ding Yuan
- College of Medicine, China Three Gorges University, Yichang, China
| | - Changcheng Zhang
- College of Medicine, China Three Gorges University, Yichang, China.,Third-Grade Pharmacological Laboratory on Traditional Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang China
| | - Haixia Zhao
- College of Medicine, China Three Gorges University, Yichang, China.,Third-Grade Pharmacological Laboratory on Traditional Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, China Three Gorges University, Yichang China
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San Martín P, Eugenio Russmann ML, Mendeluk G, Fierro MF, Marino R, Pardes E. Classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21-OHD) in adult males: Clinical presentation, hormone function and the detection of adrenal and testicular adrenal rest tumors (TARTs). ENDOCRINOL DIAB NUTR 2021; 68:227-235. [DOI: 10.1016/j.endinu.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
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San Martín P, Eugenio Russmann ML, Mendeluk G, Fierro MF, Marino R, Pardes E. Classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency (21-OHD) in adult males: Clinical presentation, hormone function and the detection of adrenal and testicular adrenal rest tumors (TARTs). ENDOCRINOL DIAB NUTR 2021; 68:227-235. [PMID: 34266634 DOI: 10.1016/j.endien.2020.07.003] [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: 02/29/2020] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION 21-hydroxylase deficiency (21-OHD) is the most common form of congenital adrenal hyperplasia (CAH). In adulthood, most studies are reported in females. By contrast, data on adult males are scarce. OBJECTIVE To describe a series of adult males with classic 21-OHD and to assess the presence of adrenal masses and testicular adrenal rest tumors (TARTs). MATERIAL AND METHODS Eight males (21-42 years) were included. We evaluated clinical presentation, 17-Hydroxyprogesterone (17-OHP), Testosterone (T), Δ4Androstenedione (Δ4A) ACTH, LH, FSH and plasma renin activitiy (PRA) levels at consultation. Molecular studies of the CYP21A2 gene, testicular ultrasound (US), semen analysis and adrenal computed tomography (CT) scan were performed. Treatment and compliance were assessed. RESULTS Basal 17-OHP levels were >20ng/ml in all patients. At consultation, median 17OH-P was 11.5 (2.3-81) ng/ml, FSH: 3 (0.3-4) mUI/ml, LH: 1.1 (0.1-6) mUI/ml, T: 4.3 (1.7-8) ng/ml, Δ4A: 5.7 (1.4-16) ng/ml, ACTH: 86.4 (76-334) pg/ml, PRA: 9.5 (1.3-23.6) ng/ml/h. Semen analysis was performed in 5/8 patients, showing azoospermia in two. Molecular genetic analysis was performed in 4/8 patients. TARTs were found in 5/6, being bilateral in four. Adrenal masses were found in 4/6. In the 7 patients diagnosed in childhood, their follow-up was referred to as irregular, both in their attendance at consultations and in compliance with the indicated treatment. CONCLUSIONS To our knowledge, this is the first series on adult males with classic 21-OHD which concomitantly assesses clinical presentation, molecular biology, adrenal and testicular imaging studies, semen analysis and compliance to treatment. A high prevalence of adrenal masses and TARTs was observed, possibly associated with poor treatment compliance leading to elevated ACTH and increased proliferation. Our findings on TARTs agree with reports in international publications of CAH in males, with adrenal imaging being added in our group. Although we are aware that further studies with a larger sample size and more data are needed, we consider that our findings contribute to the clinical management of classical 21-OHD in the male population.
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Affiliation(s)
- Patricia San Martín
- Department of Endocrinology, Hospital JM Ramos Mejía, Urquiza 609, Zip Code 1221, Buenos Aires, Argentina.
| | | | - Gabriela Mendeluk
- Unit of Clinical Cytology, Hospital JM Ramos Mejía, Urquiza 609, Zip Code 1221, Buenos Aires, Argentina
| | - María Fabiana Fierro
- Department of Endocrinology, Hospital JM Ramos Mejía, Urquiza 609, Zip Code 1221, Buenos Aires, Argentina
| | - Roxana Marino
- Department of Endocrinology, Hospital de Pediatría JP Garrahan, Pichincha 1890, Zip Code 1245, Buenos Aires, Argentina
| | - Ester Pardes
- Department of Endocrinology, Hospital JM Ramos Mejía, Urquiza 609, Zip Code 1221, Buenos Aires, Argentina
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Lim SG, Lee YA, Jang HN, Kong SH, Ahn CH, Kim SW, Shin CH, Kim JH. Long-Term Health Outcomes of Korean Adults With Classic Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. Front Endocrinol (Lausanne) 2021; 12:761258. [PMID: 34712205 PMCID: PMC8547732 DOI: 10.3389/fendo.2021.761258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/27/2021] [Indexed: 01/14/2023] Open
Abstract
There is a lack of studies regarding the long-term outcomes of Asian adults with classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. We hypothesized that adults with CAH are at higher metabolic risk than their age-, and sex-matched controls. We further investigated the long-term health outcome-related factors in adults with CAH. We compared metabolic risk between adults with CAH (71 men, 93 women) and age-, and sex-matched controls (190 men, 261 women) from the Korean National Health and Nutrition Examination Survey data. The presence of obesity, testicular adrenal rest tumors (TARTs), and menstrual irregularity was assessed. Hormone status and treatment regimens were compared according to the presence of adverse outcomes. The median age was 27.0 y and 28.0 y for men and women, respectively. Adults with CAH had a higher waist circumference (88.0 vs. 82.3 cm in men, and 83.5 vs. 72.3 cm in women), and blood pressure (125.0 vs. 113.0 mmHg in men, and 120.0 vs. 104.0 mmHg in women) than age- and sex-matched controls (P<0.05 for all). The 2.7-fold increased risk for hypertension (men) and 2.0-fold increased risk for obesity (women) was significant in patients with CAH (P<0.05 for both). Obese adults with CAH showed significantly higher adrenal limb thicknesses (men) and 17-hydroxyprogesterone and dehydroepiandrosterone sulfate levels (women) (P<0.05 for both). TARTs occurred in 58.1% of men and did not differ by hormone or treatment regimen. Irregular menstruation was observed in 57.1% of women, with higher dehydroepiandrosterone sulfate levels in those with irregular periods. Adults with CAH had a higher metabolic risk than the general population. Poor disease control may increase their risk of metabolic morbidity and menstrual irregularity.
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Affiliation(s)
- Seung Gyun Lim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Jung Hee Kim, ; ; Young Ah Lee,
| | - Han Na Jang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sung Hye Kong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Jung Hee Kim, ; ; Young Ah Lee,
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Engels M, Span PN, van Herwaarden AE, Sweep FCGJ, Stikkelbroeck NMML, Claahsen-van der Grinten HL. Testicular Adrenal Rest Tumors: Current Insights on Prevalence, Characteristics, Origin, and Treatment. Endocr Rev 2019; 40:973-987. [PMID: 30882882 DOI: 10.1210/er.2018-00258] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/23/2019] [Indexed: 11/19/2022]
Abstract
This review provides the reader with current insights on testicular adrenal rest tumors (TARTs), a complication in male patients with congenital adrenal hyperplasia (CAH). In recent studies, an overall TART prevalence of 40% (range, 14% to 89%) in classic patients with CAH is found. Reported differences are mainly caused by the method of detection and the selected patient population. Biochemically, histologically, and molecularly, TARTs exhibit particular adrenal characteristics and were therefore thought to originate from aberrant adrenal cells. More recently, TARTs have been found to also exhibit testicular characteristics. This has led to the hypothesis of pluripotent cells as the origin of TARTs. High concentrations of ACTH could cause hyperplasia of these pluripotent cells, as TARTs appear to be associated with poor hormonal control with concomitant elevated ACTH. Unfortunately, as yet there are no methods to prevent the development of TARTs, nor are there guidelines to treat patients with TARTs. Intensified glucocorticoid treatment could improve fertility status in some cases, although studies report contradicting results. TARTs can also lead to irreversible testicular damage, and therefore semen cryopreservation could be offered to patients with TARTs. Further research should focus on the etiology and pharmacological treatment to prevent TART development or to treat TARTs and improve the fertility status of patients with TARTs.
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Affiliation(s)
- Manon Engels
- Department of Pediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paul N Span
- Department of Radiation Oncology, Radiotherapy and OncoImmunology Laboratory, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Antonius E van Herwaarden
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fred C G J Sweep
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Piskinpasa H, Ciftci Dogansen S, Kusku Cabuk F, Guzey D, Sahbaz NA, Akdeniz YS, Mert M. BILATERAL ADRENAL AND TESTICULAR MASS IN A PATIENT WITH CONGENITAL ADRENAL HYPERPLASIA. ACTA ENDOCRINOLOGICA-BUCHAREST 2019; -5:113-117. [PMID: 31149069 DOI: 10.4183/aeb.2019.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction Congenital adrenal hyperplasia (CAH) autosomal recessive disorders characterized by impaired adrenal steroid hormone synthesis. The most common form is 21-hydroxylase deficiency (21OHD). Testicular adrenal rest tumors (TARTs) are benign intratesticular masses that occur in male patients with CAH. TARTs are quite common in patients with 21OHD who were diagnosed late. Case report A 41-year-old male patient with CAH secondary to 21OHD. The patient was referred to our endocrinology department from the andrology clinic for bilateral adrenal masses. Bilateral orchiectomy had been performed due to bilateral testicular masses and azoospermia two years ago. The pathology was reported as Leydig cell tumor. In hormonal assessment, baseline cortisol levels were low, 17-hydroxyprogesterone levels with baseline and after cosyntropin stimulation test were high. As a result of clinic and laboratory assessment, the patient was diagnosed with simple virilising CAH due to 21OHD and adrenal insufficiency. Then, prednisolone replacement was initiated. Bilateral orchiectomy tissue blocks of the patient were re-assessed and were considered TART. Magnetic resonance imaging revealed bilateral adrenal masses with 88x55 mm on the right and 41x22 mm on the left. Laparoscopic right adrenalectomy was applied and pathology was reported as myelolipoma. Follow-up of the mass on the left adrenal gland is ongoing. The patient is monitored under prednisolone and testosterone replacement therapy. Early diagnosis of CAH is very important because of the complications it causes. It should be considered especially for bilateral testicular and/or adrenal masses. Both fertility and adrenal glands can be protected with an early diagnosis and an early glucocorticoid replacement.
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Affiliation(s)
- H Piskinpasa
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
| | - S Ciftci Dogansen
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
| | - F Kusku Cabuk
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Pathology, Istanbul, Turkey
| | - D Guzey
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of General Surgery, Istanbul, Turkey
| | - N A Sahbaz
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of General Surgery, Istanbul, Turkey
| | - Y S Akdeniz
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
| | - M Mert
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital - Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
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Werneck G, Rodrigues EMR, Mantovani RM, Lane JSS, Silva IN. Testicular adrenal rest tumors in patients with congenital adrenal hyperplasia: 6 years of follow-up. J Pediatr Endocrinol Metab 2019; 32:519-526. [PMID: 31075083 DOI: 10.1515/jpem-2018-0512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/14/2019] [Indexed: 11/15/2022]
Abstract
Background Testicular adrenal rest tumors (TARTs) leading to primary gonadal failure are the main etiology of infertility in congenital adrenal hyperplasia (CAH). We aimed at identifying the evolution of TART and related findings in young CAH patients. Methods Twelve male patients (3-23 years old) with 21-hydroxilase deficiency (11 with classic salt-wasting form) were included. Testicular ultrasonography (US) was performed in two moments, by a single blinded specialist in pediatric diagnostic imaging. Tumor progression was classified according to the Response Evaluation Criteria in Solid Tumors (RECIST). The clinical and laboratory data were retrieved from medical records. Serum 17-OH-progesterone (17OHP) and androstenedione concentrations were evaluated during the whole period of follow-up, from the CAH diagnosis. A logistic regression model with repeated measures was developed for the analysis. Results The prevalence of TART was 41.6% (n = 5) in the initial US evaluation and 66.6% (n = 8) after 6 years of follow-up. Tumor progression was detected in 4 of the 5 patients, and 1 presented with a stable tumor. Three patients presented with new tumors in the second evaluation. Most of the patients (n = 11) were pubertal, including a 7-year-old child with TART who presented with central precocious puberty. At regression analysis, it was observed that an inadequate hormonal control led to a 16 times greater chance of a patient to present with TART (OR = 16.08; confidence interval [CI] 95% = 2.38-108.81; p = 0.004). Conclusions We found a high prevalence of progressive TART in young pubertal subjects. US testicular screening should help in improving therapeutic optimization in CAH patients to reduce future impairment in fertility.
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Affiliation(s)
- Gabriela Werneck
- Divisão de Endocrinologia Infantil e do Adolescente - Departamento de Pediatria, Faculdade de Medicina/Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Alfredo Balena 190, s/267, 30130-100, Belo Horizonte, MG,Brazil
| | - Enda M R Rodrigues
- Faculdade de Medicina, Division of Pediatric Endocrinology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Rafael M Mantovani
- Faculdade de Medicina, Division of Pediatric Endocrinology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Jovita S S Lane
- Faculdade de Medicina/Hospital das Clínicas, Departamento de Radiologia e Imagem, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ivani N Silva
- Faculdade de Medicina, Division of Pediatric Endocrinology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Breil T, Yakovenko V, Inta I, Choukair D, Klose D, Mittnacht J, Schulze E, Alrajab A, Grulich-Henn J, Bettendorf M. Typical characteristics of children with congenital adrenal hyperplasia due to 11β-hydroxylase deficiency: a single-centre experience and review of the literature. J Pediatr Endocrinol Metab 2019; 32:259-267. [PMID: 30817301 DOI: 10.1515/jpem-2018-0298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/30/2018] [Indexed: 11/15/2022]
Abstract
Background 11β-hydroxylase deficiency (11βOHD) is a rare disease representing the second most common cause of congenital adrenal hyperplasia (CAH) (5-8%) with an incidence of about 1:100,000. In contrast to 21-hydroxylase deficiency (21OHD), 11βOHD is not included in neonatal screening programmes. The objective of this study was to demonstrate the typical features of male patients with 11βOHD. Methods Clinical, biochemical and radiological data of patients with 11βOHD were analysed in this retrospective single-centre analysis. Results Six male patients of four unrelated families with 11βOHD were identified (0.1-13.5 years of chronological age [CA] at diagnosis). The predominant symptoms were arterial hypertension, tall stature and precocious pseudopuberty. Bone ages (BAs) were remarkably advanced at diagnosis in four index patients (median difference BA-CA: 5.5 years, range 1.5-9.2 years). Homozygous mutations were identified in exon 7 (c.1179_1180dupGA [p.Asn394Argfs*37]) and exon 8 (c.1398+2T>C) of the CYP11B1 gene leading both to a complete loss of function. The latter mutation has not yet been described in databases. 11βOHD was identified by the measurement of 11-deoxycortisol in a newborn screening card of one patient retrospectively. Testicular adrenal rest tumours (TARTs) were detected in three patients at 3.7 years, 11 years and 14.4 years. Conclusion The diagnosis of CAH due to 11βOHD is delayed and should be suspected in children with arterial hypertension, tall stature and precocious pseudopuberty. Patients may develop TARTs as early as infancy. 11βOHD should be included in newborn screening programmes, at least in newborns of index families, to allow early diagnosis and the start of treatment to reduce morbidity.
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Affiliation(s)
- Thomas Breil
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Vira Yakovenko
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Ioana Inta
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniela Choukair
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniela Klose
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Janna Mittnacht
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Egbert Schulze
- Molecular Laboratory, Prof. F. Raue, Heidelberg, Germany
| | - Abdul Alrajab
- Division of Paediatric Radiology, Department of Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jürgen Grulich-Henn
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Bettendorf
- Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, University Hospital Heidelberg, Heidelberg, Germany
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Mendes-Dos-Santos CT, Martins DL, Guerra-Júnior G, Baptista MTM, de-Mello MP, de Oliveira LC, Morcillo AM, Lemos-Marini SHV. Prevalence of Testicular Adrenal Rest Tumor and Factors Associated with Its Development in Congenital Adrenal Hyperplasia. Horm Res Paediatr 2019; 90:161-168. [PMID: 30149373 DOI: 10.1159/000492082] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/09/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Testicular adrenal rest tumors (TART) can cause infertility in congenital adrenal hyperplasia (CAH) males. AIMS To determine TART prevalence in patients with CAH due to 21-hydroxylase deficiency (21-OHD) and evaluate possible factors associated with its development. METHODS This is a descriptive and analytical cross-sectional study evaluating males with the classical form of 21-OHD through testicular ultrasonography and serum inhibin B dosages. Data on prescribed glucocorticoid dose and serum levels of 17- hydroxyprogesterone (17-OHP), androstenedione (Andro), ACTH, renin, and LH were obtained from medical records. RESULTS Thirty-eight males were evaluated. The mean age on ultrasonography was 15.2 ± 6.7 (3-27) years. Nine patients (23.7%) had TART, 4 of them were prepubertal and the youngest was 5 years old. No association was found between TART and 21-OHD phenotype, glucocorticoid dose, or 17-OHP, ACTH, LH, renin, and inhibin B levels measured in the 6 preceding years. However, 50% of the patients who presented increased Andro 2 years prior to the evaluation had TART (p = 0.018, OR = 8.00 [95% CI: 1.42-44.92]), whereas in the normal Andro group only 16.7% had tumors. CONCLUSION This study showed that TART can occur in prepubertal patients and that disease control could be a factor associated with its development. Therefore, we suggest investigating TART development early in childhood, mainly in poorly controlled 21-OHD patients.
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Affiliation(s)
| | | | - Gil Guerra-Júnior
- Pediatric Endocrinology Unit, Department of Pediatrics/CIPED, University of Campinas, UNICAMP, Campinas, Brazil
| | | | - Maricilda Palandi de-Mello
- Center of Molecular Biology and Genetic Engineering (CBMEG), University of Campinas, UNICAMP, Campinas, Brazil
| | | | - André Moreno Morcillo
- Pediatric Endocrinology Unit, Department of Pediatrics/CIPED, University of Campinas, UNICAMP, Campinas, Brazil
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17
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 564] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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18
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Li X, Xu Z, Wang X. Computed tomography findings of testicular adrenal rest tumors resulted from 21-hydroxylase deficiency. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2018; 26:341-346. [PMID: 29562581 DOI: 10.3233/xst-17388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
21-hydroxylase deficiency is a rare kind of autosomal recessive disorders, which can result in congenital adrenal hyperplasia and/or testicular adrenal rest tumors. 21-hydroxylase deficiency with TARTs is prone to be misdiagnosed as Leydig cell tumors. Although the sonographic characteristics of TARTs have been summarized in previous reports, its features in computed tomography images were rarely reported. In this study, we presented and summarized the clinical and imaging data of a special case suffering this disease, aiming to improve the imaging diagnosis performance.
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Affiliation(s)
- Xiao Li
- Shandong University, Shandong Medical Imaging Research Institute, Jinan, Shandong, PR China
| | - Zhuodong Xu
- Shandong University, Shandong Medical Imaging Research Institute, Jinan, Shandong, PR China
| | - Ximing Wang
- Shandong University, Shandong Medical Imaging Research Institute, Jinan, Shandong, PR China
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19
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El-Maouche D, Arlt W, Merke DP. Congenital adrenal hyperplasia. Lancet 2017; 390:2194-2210. [PMID: 28576284 DOI: 10.1016/s0140-6736(17)31431-9] [Citation(s) in RCA: 306] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/28/2017] [Accepted: 04/10/2017] [Indexed: 12/13/2022]
Abstract
Congenital adrenal hyperplasia is a group of autosomal recessive disorders encompassing enzyme deficiencies in the adrenal steroidogenesis pathway that lead to impaired cortisol biosynthesis. Depending on the type and severity of steroid block, patients can have various alterations in glucocorticoid, mineralocorticoid, and sex steroid production that require hormone replacement therapy. Presentations vary from neonatal salt wasting and atypical genitalia, to adult presentation of hirsutism and irregular menses. Screening of neonates with elevated 17-hydroxyprogesterone concentrations for classic (severe) 21-hydroxylase deficiency, the most common type of congenital adrenal hyperplasia, is in place in many countries, however cosyntropin stimulation testing might be needed to confirm the diagnosis or establish non-classic (milder) subtypes. Challenges in the treatment of congenital adrenal hyperplasia include avoidance of glucocorticoid overtreatment and control of sex hormone imbalances. Long-term complications include abnormal growth and development, adverse effects on bone and the cardiovascular system, and infertility. Novel treatments aim to reduce glucocorticoid exposure, improve excess hormone control, and mimic physiological hormone patterns.
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Affiliation(s)
- Diala El-Maouche
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham & Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
| | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA; The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
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20
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Dumic M, Duspara V, Grubic Z, Oguic SK, Skrabic V, Kusec V. Testicular adrenal rest tumors in congenital adrenal hyperplasia-cross-sectional study of 51 Croatian male patients. Eur J Pediatr 2017; 176:1393-1404. [PMID: 28879515 DOI: 10.1007/s00431-017-3008-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 08/24/2017] [Accepted: 08/27/2017] [Indexed: 11/26/2022]
Abstract
UNLABELLED Testicular adrenal rest tumors (TARTs) are common cause of infertility in males with congenital adrenal hyperplasia (CAH). We studied the role of genotype and disease regulation on TART development, their impact on gonadal function, and frequency in 47 21-hydroxylase deficiency (21-OHD) and four 11-hydroxylase deficiency (11-OHD) male patients. Testicular ultrasound (TU), genotype, hormonal measurement in 51, and spermiogram in five patients were performed. TARTs were detected in 14 SW21-OHD and one 11-OHD patient: 1/8 patients aged <7 years (1.8 years old is the youngest), 1/8 patients aged <12 years, 5/17 patients aged <18 years, and in 8/18 adults. All 21-OHD TART patients had exclusively severe mutations of CYP21A2 gene. Poor hormonal control in 8/15 patients with and 12/36 patients without TART indicates correlation of tumor development with poor disease control. None of the TART patients fathered a child. Low inhibin-B was found in 7/15 TART patients. Azoospermia was found in four and oligoasthenozoospermia in one patient. CONCLUSION TART was detected exclusively in patients with severe CYP21A2 mutations. Disease regulation plays a role in development of TART that impairs testicular function and increases the risk of infertility. Screening for TART by TU is indicated from early childhood. What is Known: • Due to improved diagnostic and therapeutic possibilities, majority of the male patients with congenital adrenal hyperplasia nowadays reach adulthood and screening for long-term complications is becoming more important. • Testicular adrenal rest tumors (TARTs) are common cause of infertility and impaired gonadal function in males with CAH. What is New: • A 1.8-year-old boy described in this paper is the youngest reported patient with TART. • Screening for TART by testicular ultrasound from early childhood, especially in patients with severe CYP21A mutations, is recommended.
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Affiliation(s)
- Miroslav Dumic
- Department of Pediatrics, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Vlatko Duspara
- Clinical Department of Diagnostic and Interventional Radiology, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Zorana Grubic
- Tissue Typing Centre, Department of Transfusion Medicine and Transplantation Biology, Department of Laboratory Medicine, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Sasa Kralik Oguic
- Endocrinological Laboratory, Department of Laboratory Medicine, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Veselin Skrabic
- Department of Pediatrics, Clinical Hospital Centre Split, University of Split Medical School, Split, Croatia
| | - Vesna Kusec
- Endocrinological Laboratory, Department of Laboratory Medicine, Clinical Hospital Centre Zagreb, University of Zagreb Medical School, Zagreb, Croatia
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21
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Mooij CF, Webb EA, Claahsen van der Grinten HL, Krone N. Cardiovascular health, growth and gonadal function in children and adolescents with congenital adrenal hyperplasia. Arch Dis Child 2017; 102:578-584. [PMID: 27974295 DOI: 10.1136/archdischild-2016-311910] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/21/2016] [Indexed: 11/04/2022]
Abstract
After the introduction of replacement therapy with glucocorticoids and mineralocorticoids in the 1950s, congenital adrenal hyperplasia (CAH) is no longer a life-limiting condition. However, due to the successful introduction of medical steroid hormone replacement, CAH has become a chronic condition, with associated comorbidities and long-term health implications. The aim of treatment is the replacement of mineralocorticoids and glucocorticoids and the normalisation of elevated androgen concentrations. Long-term consequences of the condition and current treatment regimens include unfavourable changes in the cardiovascular risk profile, impaired growth, testicular adrenal rest tumours (TART) in male and subfertility in both male and female patients with CAH. Optimising replacement therapy in patients with CAH remains challenging. On one hand, treatment with supraphysiological doses of glucocorticoids might be required to normalise androgen concentrations and decrease size or presence of TARTs. On the other hand, treatment with supraphysiological doses of glucocorticoids is associated with an increased prevalence of unfavourable cardiovascular and metabolic risk profiles as well as impaired longitudinal growth and gonadal function. Therefore, treatment of children and adults with CAH requires an individualised approach. Careful monitoring for early signs of complications is already warranted during paediatric healthcare provision to prevent and reduce the impact of comorbidities in later life.
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Affiliation(s)
- Christiaan F Mooij
- Institute of Metabolism and Systems Research, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK.,Department of Paediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Emma A Webb
- Institute of Metabolism and Systems Research, Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK
| | - Hedi L Claahsen van der Grinten
- Department of Paediatric Endocrinology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nils Krone
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Sheffield Children's Hospital, Sheffield, UK
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Bulsari K, Falhammar H. Clinical perspectives in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. Endocrine 2017; 55:19-36. [PMID: 27928728 DOI: 10.1007/s12020-016-1189-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
Congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency is a rare autosomal recessive genetic disorder. It is caused by reduced or absent activity of 11β-hydroxylase (CYP11B1) enzyme and the resultant defects in adrenal steroidogenesis. The most common clinical features of 11 beta-hydroxylase deficiency are ambiguous genitalia, accelerated skeletal maturation and resultant short stature, peripheral precocious puberty and hyporeninemic hypokalemic hypertension. The biochemical diagnosis is based on raised serum 11-deoxycortisol and 11-deoxycorticosterone levels together with increased adrenal androgens. More than 100 mutations in CYP11B1 gene have been reported to date. The level of in-vivo activity of CYP11B1 relates to the degree of severity of 11 beta-hydroxylase deficiency. Clinical management of 11 beta-hydroxylase deficiency can pose a challenge to maintain adequate glucocorticoid dosing to suppress adrenal androgen excess while avoiding glucocorticoid-induced side effects. The long-term outcomes of clinical and surgical management are not well studied. This review article aims to collate the current available data about 11 beta-hydroxylase deficiency and its management.
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Affiliation(s)
- Krupali Bulsari
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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Ohana Marques Coelho de Carvalho L, Miguel Garcia Lora R, Renata Rezende Penna C, Calland Ricarte Beserra I. Testicular Adrenal Rests Tumors and Testicular Microlithiasis in a Brazilian Case Series with Classic Congenital Adrenal Hyperplasia. Int J Endocrinol Metab 2017; 15:e40611. [PMID: 28835760 PMCID: PMC5554608 DOI: 10.5812/ijem.40611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/28/2016] [Accepted: 12/10/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Testicular adrenal rest tumors are a benign condition characterized by the presence of remnants of adrenal tissue within the testes that can lead to infertility. Testicular microlithiasis are calculus deposits within the seminiferous tubules. Both are described in congenital adrenal hyperplasia. OBJECTIVES Describe the frequency of testicular adrenal rest tumors and testicular microlithiasis in a Brazilian case series of patients with classic congenital adrenal hyperplasia and to also relate these changes to disease control and hypothalamic-pituitary-gonadal axis disorders. METHODS Case series study. An ultrasound examination of the scrotum was performed on 12 patients between the ages of 5.33 to 22 (14.72 ± 5.26) years. Testicular adrenal rest tumors were classified according to the degree of testicular infiltration in stages by adapting the Grinten's classification, ranging from the absence of testicular adrenal rests visible by ultrasound (stage ≤ 1) to chronic obstruction of the testicular parenchyma with irreversible damage of the testicle (stage 5). RESULTS Six patients (5 salt wasting and 1 simple virilizing) with an average age of 17.27 ± 3.09 years and have gone through puberty showed testicular adrenal rest tumors (Grinten stage ≥ 3). In 2 of the patients there was a coincidence with testicular microlithiasis. The frequency of testicular adrenal rest tumors did not relate with the levels of serum 17-hydroxyprogesterone and androstenedione. In 3 patients with testicular adrenal rest tumors, gonadotropin levels were suggestive of hypergonadotropic hypogonadism and one of hypogonadotropic hypogonadism. CONCLUSIONS Testicular adrenal rest tumors were found in greater frequency during puberty and was not related to hormonal control in this group. Some of them happened with testicular microlithiasis.
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Affiliation(s)
| | | | - Claudia Renata Rezende Penna
- Head of Radiology Unit, Instituto de Puericultura e Pediatria Martagao Gesteira, Federal University of Rio de Janeiro, Brazil
| | - Izabel Calland Ricarte Beserra
- Head of Endocrinology Unit, Instituto de Puericultura e Pediatria Martagao Gesteira, Federal University of Rio de Janeiro and Professor of Pediatric Endocrinology, Federal University of Rio de Janeiro, Brazil
- Corresponding author: Izabel Calland Ricarte Beserra, Praca Tele Santana 45 ap, 302, bloco 2, Barra da Tijuca, CEP: 22793.298, Rio de Janeiro, Brazil. Tel: +55-213938-4811, Fax: +55-212590-4891, E-mail:
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Parsa AA, New MI. Steroid 21-hydroxylase deficiency in congenital adrenal hyperplasia. J Steroid Biochem Mol Biol 2017; 165:2-11. [PMID: 27380651 DOI: 10.1016/j.jsbmb.2016.06.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 02/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) refers to a group of inherited genetic disorders involving deficiencies in enzymes that convert cholesterol to cortisol within the adrenal cortex. There are five key enzymes involved in the production of cortisol. Of these key enzymes, deficiency of 21-hydroxylase is the most commonly defective enzyme leading to CAH representing more than 90% of cases. The low adrenal cortisol levels associated with CAH affects the hypothalamic-pituitary-adrenal negative feedback system leading to increased pituitary adrenocorticotropic hormone (ACTH) production, which overstimulates the adrenal cortex in an attempt to increase cortisol production resulting in a hyperplastic adrenal cortex. The deficiency of enzyme 21-hydroxylase results from mutations or deletions in the CYP21A2 gene found on chromosome 6p. The disorder is transmitted as an autosomal recessive pattern and specific mutations may be correlated to enzymatic compromise of varying degrees, leading to the clinical manifestation of 21-hydroxylase deficiency (21-OHD) CAH.
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Affiliation(s)
- Alan A Parsa
- Department of Medicine, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii, United States.
| | - Maria I New
- Adrenal Steroid Disorders Program, Icahn School of Medicine at Mount Sinai, Manhattan, NY, United States
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25
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Testicular Adrenal Rest Tumors in Boys and Young Adults with Congenital Adrenal Hyperplasia. J Urol 2016; 197:931-936. [PMID: 27840017 DOI: 10.1016/j.juro.2016.09.072] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE Testicular adrenal rest tumors are a well-known complication in males who have congenital adrenal hyperplasia with potential infertility in adulthood. We assessed the prevalence of testicular adrenal rest tumors in infants to young men presenting to a congenital adrenal hyperplasia Comprehensive Care Center. MATERIALS AND METHODS A total of 35 males with congenital adrenal hyperplasia due to 21-hydroxylase deficiency underwent scrotal ultrasonography, including 7 younger than 5 years, 9 who were 5 to 12 years old and 19 who were older than 12 years. Three and 35 patients had classic and nonclassic congenital adrenal hyperplasia, respectively. Bone age x-ray or advanced bone age x-ray history, glucocorticoid dose, fludrocortisone dose, and serum 17-hydroxyprogesterone, testosterone and androstenedione levels within 3 months of ultrasound were also recorded. RESULTS Testicular adrenal rest tumors were detected in 5 of 35 patients (14%), including 1 of 9 (11%) who were 5 to 12 years old and 4 of 19 (21%) who were older than 12 years. The tumors were not detected in any patients younger than 5 years, including 1 infant with poor hormonal control. The youngest patient with positive findings was 6.6 years old. All patients with positive findings had bilateral disease and only 1 had suspicious physical findings. The glucocorticoid dose and 17-hydroxyprogesterone did not differ between patients with vs without a testicular adrenal rest tumor. Those with a tumor were more likely to have advanced bone age x-ray results (100% vs 42%, p = 0.04) and higher fludrocortisone dose (p <0.01). All males with nonclassic congenital adrenal hyperplasia had negative tumor findings. CONCLUSIONS Testicular adrenal rest tumors were present in young males with classic congenital adrenal hyperplasia but not in infants or toddlers. These tumors were associated with higher fludrocortisone requirements and a history of advanced bone age x-ray results. However, the tumors did not develop in all poorly controlled males. Longitudinal studies are needed to understand the individual predisposition to testicular adrenal rest tumors and the age at which to begin screening patients with congenital adrenal hyperplasia.
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Sha YK, Sha YW, Ding L, Liu WW, Song YQ, Lin J, He XM, Qiu PP, Zhang L, Li P. A Case of Bilateral Testicular Tumors Subsequently Diagnosed as Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2016; 9:574-80. [PMID: 26985347 PMCID: PMC4793180 DOI: 10.22074/ijfs.2015.4618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 09/16/2014] [Indexed: 11/28/2022]
Abstract
21-hydroxylase deficiency (21-OHD) caused congenital adrenal hyperplasia (CAH) is a
group of autosomal recessive genetic disorders resulting from mutations in genes involved
with cortisol (CO) synthesis in the adrenal glands. Testicular adrenal rest tumors (TARTs)
are rarely the presenting symptoms of CAH. Here, we describe a case of simple virilizing
CAH with TARTs, in a 15-year-old boy. The patient showed physical signs of precocious
puberty. The levels of blood adrenocorticotropic hormone (ACTH), urinary 17-ketone
steroids (17-KS), dehydroepiandrosterone sulfate (DHEA-S), and serum progesterone
(PRGE) were elevated, whereas those of follicle-stimulating hormone (FSH), luteinizing
hormone (LH), and CO were reduced. Computed tomography (CT) of the adrenal glands
and magnetic resonance imaging (MRI) of the testes showed a soft tissue density (more
pronounced on the right side) and an irregularly swollen mass (more pronounced on the
left side), respectively. Pathological examination of a specimen of the mass indicated
polygonal/circular eosinophilic cytoplasm, cord-like arrangement of interstitial cells, and
lipid pigment in the cytoplasm. Immunohistochemistry results precluded a diagnosis of
Leydig cell tumors. DNA sequencing revealed a hackneyed homozygous mutation, I2g,
on intron 2 of the CYP21A2 gene. The patient’s symptoms improved after a three-month
of dexamethasone therapy. Recent radiographic data showed reduced hyperplastic adrenal nodules and testicular tumors. A diagnosis of TART should be considered and prioritized in CAH patients with testicular tumors. Replacement therapy using a sufficient
amount of dexamethasone in this case helps combat TART.
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Affiliation(s)
- Yan-Kun Sha
- Department of Nephrology, First Affiliated Hospital of Liaoning Medical University, Jinzhou City 121000, Liaoning Province, China
| | - Yan-Wei Sha
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Lu Ding
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Wei-Wu Liu
- Department of Radiation, The Second Hospital of Jilin University, Changchun City 130041, Jilin Province, China
| | - Yue-Qiang Song
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Jin Lin
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Xue-Mei He
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Ping-Ping Qiu
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Ling Zhang
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
| | - Ping Li
- Reproductive Medicine Center, Maternal and Child Health Hospital of Xiamen City 361005, Xiamen City, Fujian Province, China
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Kavoussi PK, Summers-Colquitt RB, Odenwald KC, Kressin M, Kavoussi KM, Pool TB, Kavoussi SK. Sperm retrieval and concomitant tumor resection in azoospermic men with congenital adrenal hyperplasia and bilateral testicular adrenal rest tumors: a case report. J Assist Reprod Genet 2016; 33:545-8. [PMID: 26861965 PMCID: PMC4818631 DOI: 10.1007/s10815-016-0665-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 01/20/2016] [Indexed: 11/06/2022] Open
Abstract
Purpose The objective of this study was to offer a new treatment approach for sperm retrieval simultaneously with tumor resection in azoospermic men with congenital adrenal hyperplasia (CAH), orchialgia, and bilateral testicular adrenal rest tumors (TARTs) who fail to respond to medical treatment. Methods This is a retrospective chart review from a couple’s fertility center. Results Between May 2013 and May 2015, two azoospermic men with CAH and bilateral TARTs, with orchialgia, and desire to conceive underwent bilateral TART resection in the same surgical setting as sperm retrieval after remaining azoospermic with normalization of gonadotropins with treatment with human chorionic gonadotropin (hCG). Both men had adequate sperm retrieved for in vitro fertilization/intracytoplasmic sperm retrieval (IVF/ICSI) at the time of bilateral TART resections. They had complete TART resections with resolution of orchialgia. The wife of one patient had a successful pregnancy with use of retrieved sperm resulting in a live birth, and the sperm from the other man is cryopreserved for future use. Conclusions It is feasible to perform successful sperm retrieval simultaneously with TART resection in azoospermic men with CAH after medical treatments with persistent azoospermia, rather than subjecting these men to multiple invasive procedures.
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Affiliation(s)
- Parviz K Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA.
| | - Roxanne B Summers-Colquitt
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Kate C Odenwald
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Megan Kressin
- Department of Pathology, St. David's South Austin Medical Center, 901 W. Ben White Blvd, Austin, TX, 78704, USA
| | - Keikhosrow M Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Thomas B Pool
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
| | - Shahryar K Kavoussi
- Austin Fertility & Reproductive Medicine/Westlake IVF, 300 Beardsley Lane, Building B, Suite 200, Austin, TX, 78746, USA
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Lekarev O, Lin-Su K, Vogiatzi MG. Infertility and Reproductive Function in Patients with Congenital Adrenal Hyperplasia: Pathophysiology, Advances in Management, and Recent Outcomes. Endocrinol Metab Clin North Am 2015; 44:705-22. [PMID: 26568487 DOI: 10.1016/j.ecl.2015.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Individuals with congenital adrenal hyperplasia have reduced fertility. However, reproductive outcomes have improved over the years. This review provides an update on the multiple pathologic processes that contribute to reduced fertility in both sexes, from alterations of the hypothalamic-pituitary-gonadal axis to the direct effect on gonadal function by elevated circulating adrenal androgens. In addition, elevated serum progesterone concentrations may hinder ovulation and embryo implantation in women, whereas in men testicular adrenal rest tumors can be a major cause of infertility. Suppression of adrenal androgen secretion represents the first line of therapy toward spontaneous conception in both sexes.
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Affiliation(s)
- Oksana Lekarev
- Pediatric Endocrinology, Weill Cornell Medical College, New York, NY, USA
| | - Karen Lin-Su
- Pediatric Endocrinology, Weill Cornell Medical College, New York, NY, USA
| | - Maria G Vogiatzi
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA.
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Yu MK, Jung MK, Kim KE, Kwon AR, Chae HW, Kim DH, Kim HS. Clinical manifestations of testicular adrenal rest tumor in males with congenital adrenal hyperplasia. Ann Pediatr Endocrinol Metab 2015; 20:155-61. [PMID: 26512352 PMCID: PMC4623344 DOI: 10.6065/apem.2015.20.3.155] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/19/2015] [Accepted: 09/21/2015] [Indexed: 11/20/2022] Open
Abstract
PURPOSE In male patients with congenital adrenal hyperplasia (CAH), the presence of testicular adrenal rest tumors (TARTs) have been reported, however their prevalence and clinical manifestations are not well known. Untreated TARTs may lead to testicular structural damage and infertility. This study was conducted to investigate the prevalence of TARTs in male patients with CAH, and characterize the manifestations to identify contributing factors to TART. METHODS Among 102 CAH patients aged 0-30 years, 24 male patients have been regularly followed up in our outpatient clinic at Severance Children's Hospital from January 2000 to December 2014. In order to reveiw the characteristics of TART patients, we calculated the mean levels of hormones during the 5 years before the time of investigation. Five patients underwent follow-up scrotal ultrasonography (US) after adjusting the dosage of glucocorticoids. RESULTS TARTs were detected in 8 of the 13 patients (61.5%). The median age of TARTs diagnosis was 20.2 years with the youngest case being 15.5 years old. The mean serum level of adrenocorticotropic hormone (ACTH) was higher in the TARTs patient group compared to the non-TARTs group (P<0.05). The tumor size decreased in 3 cases, slightly increased in 1 case, and had no change in another case. CONCLUSION The serum ACTH level might be associated with the growth promoting factor for TARTs, but the exact mechanism has not been clearly identified. Screening for TARTs using US is important in male patients with CAH for early-detection and prevention of ongoing complications, such as infertility.
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Affiliation(s)
- Min Kyung Yu
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Mo Kyung Jung
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Eun Kim
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ah Reum Kwon
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hee Kim
- Department of Pediatrics, Sohwa Children's Hospital, Seoul, Korea
| | - Ho-Seong Kim
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Falhammar H, Nordenström A. Nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency: clinical presentation, diagnosis, treatment, and outcome. Endocrine 2015; 50:32-50. [PMID: 26082286 DOI: 10.1007/s12020-015-0656-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/03/2015] [Indexed: 01/14/2023]
Abstract
Nonclassic congenital adrenal hyperplasia (NCAH) is one of the most frequent autosomal recessive disorders in man with a prevalence ranging from 0.1 % in Caucasians up to a few percent in certain ethnic groups. Most cases are never diagnosed due to very mild symptoms, misdiagnosing as polycystic ovary syndrome, or ignorance. In contrast to classic CAH, patients with NCAH present with mild partial cortisol insufficiency and hyperandrogenism and will survive without any treatment. Undiagnosed NCAH may result in infertility, miscarriages, oligomenorrhea, hirsutism, acne, premature pubarche, testicular adrenal rest tumors, adrenal tumors, and voice problems among other symptoms. A baseline measurement of 17-hydroxyprogesterone can be used for diagnosis, but the ACTH stimulation test with measurement of 17-hydroxyprogesterone is regarded as the golden standard. The diagnosis can be verified by CYP21A2 mutation analysis. Treatment is symptomatic and usually with glucocorticoids alone. The lowest possible glucocorticoid dose should be used. Long-term treatment with glucocorticoids will improve the symptoms but will also result in iatrogenic cortisol insufficiency and may also lead to long-term complications such as obesity, insulin resistance, hypertension, osteoporosis, and fractures. Although the complications seen in NCAH patients have been assumed to be related to the glucocorticoid treatment, some may, in fact, be associated with prolonged hyperandrogenism. Different risk factors and negative consequences should be monitored regularly in an attempt to improve the clinical outcome. More research is needed in this relatively common disorder.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, D2:04, Karolinska University Hospital, 171 76, Stockholm, Sweden,
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31
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Claahsen-van der Grinten HL, Dehzad F, Kamphuis-van Ulzen K, de Korte CL. Increased prevalence of testicular adrenal rest tumours during adolescence in congenital adrenal hyperplasia. Horm Res Paediatr 2015; 82:238-44. [PMID: 25195868 DOI: 10.1159/000365570] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 06/18/2014] [Indexed: 12/20/2022] Open
Abstract
UNLABELLED Testicular adrenal rest tumours (TART) are one of the most important causes of infertility in adult male patients with congenital adrenal hyperplasia (CAH). These benign tumours are already detected in children, but screening of TART is not routinely performed. OBJECTIVE To define retrospectively the prevalence of TART in 41 paediatric male CAH patients aged 0-19 years regularly followed by high-frequency (Fcentral 12-MHz) ultrasound techniques. RESULTS Above the age of 10 years, there was a clear increase in the prevalence of TART: 10-12 years, 28% (2 of 7 patients), 13-14 years, 50% (4/8), and 15-16 years, 75% (3/4). Above the age of 16 years, TART were detected in 100% of the patients (7/7). The tumours were not detectable by palpation. CONCLUSION TART is already present in childhood with an increasing prevalence after onset of puberty. We recommend regular ultrasound from the onset of puberty in all boys with classic CAH.
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Abstract
Adrenal steroidogenesis is a dynamic process, reliant on de novo synthesis from cholesterol, under the stimulation of ACTH and other regulators. The syntheses of mineralocorticoids (primarily aldosterone), glucocorticoids (primarily cortisol), and adrenal androgens (primarily dehydroepiandrosterone and its sulfate) occur in separate adrenal cortical zones, each expressing specific enzymes. Congenital adrenal hyperplasia (CAH) encompasses a group of autosomal-recessive enzymatic defects in cortisol biosynthesis. 21-Hydroxylase (21OHD) deficiency accounts for more than 90% of CAH cases and, when milder or nonclassic forms are included, 21OHD is one of the most common genetic diseases.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; Department of Pharmacology, University of Michigan, Room 5560A MSRBII, 1150 West Medical Center Drive, Ann Arbor, MI 48109, USA.
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Pina C, Khattab A, Katzman P, Bruckner L, Andolina J, New M, Yau M. Ovarian carcinoma in a 14-year-old with classical salt-wasting congenital adrenal hyperplasia and bilateral adrenalectomy. J Pediatr Endocrinol Metab 2015; 28:663-7. [PMID: 25427061 DOI: 10.1515/jpem-2014-0299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/26/2014] [Indexed: 11/15/2022]
Abstract
A 14-year-old female with classical congenital adrenal hyperplasia because of 21-hydroxylase deficiency underwent bilateral adrenalectomy at 6 years of age as a result of poor hormonal control. Because the patient was adrenalectomized, extra adrenal androgen production was suspected. Imaging studies including pelvic ultrasound and pelvic magnetic resonance imaging (MRI) were obtained to evaluate for adrenal rest tumors of the ovaries. Abdominal MRI was obtained to evaluate for residual adrenal tissue. A cystic lesion arising from her right ovary suspicious for ovarian neoplasm was noted on pelvic MRI. Right salpingo-oophorectomy was performed and histopathological examination revealed ovarian serous adenocarcinoma, low-grade, and well-differentiated. Tumor marker CA-125 was elevated and additional ovarian cancer staging workup confirmed stage IIIC due to one lymph node positive for carcinoma. The patient then developed a large left ovarian cyst, which led to a complete total abdominal hysterectomy and removal of the left ovary and fallopian tube. Pathology confirmed ovarian serous adenocarcinoma with microscopic focus of carcinoma in the left ovary. After numerous complications, the patient responded well to chemotherapy, CA-125 levels fell and no evidence of carcinoma was observed on subsequent imaging. To our knowledge, this is the first reported case of an ovarian serous adenocarcinoma in a patient with CAH. Although rare, we propose that the ovaries were the origin of androgen production and not residual adrenal tissue. The relationship between CAH and ovarian carcinomas has yet to be established, but further evaluation is needed given the poor survival rate of high-grade serous ovarian carcinoma.
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Chihaoui M, Kanoun F, Chaker F, Yazidi M, Bouchrit K, Mizouni H, Feki M, Kharrat M, Slimane H. Testicular adrenal rest tumours in young adult males with congenital adrenal hyperplasia: prevalence and impact on testicular function. Andrologia 2015; 48:45-50. [PMID: 25880899 DOI: 10.1111/and.12416] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2015] [Indexed: 11/30/2022] Open
Abstract
Testicular adrenal rest tumours (TARTs) have been described in patients with congenital adrenal hyperplasia (CAH). The aim of the study was to determine the prevalence of TARTs in patients with CAH, the associated factors and their impact on gonadal function. It is a prospective study concerning six young adult men with CAH, four cases with 21-hydroxylase deficiency and two cases with 11-hydroxylase deficiency. All patients were under glucocorticoid therapy. The mean age was 25 years (range: 20-31). All patients underwent a physical examination with testicular palpation, scrotal ultrasonography, a blood sample for serum testosterone, FSH, LH, inhibin B, ∆4-androstenedione and 17-OH-progesterone measurements and a semen analysis. Ultrasound revealed TARTs in four patients; three were bilateral. The mean tumour size was 6.3 ml (range: 0.02-14.1). The tumours were palpable in two cases. 17-OH-progesterone was <10 ng/ml in all cases. Decreased testosterone level was found in one case. The semen analysis revealed azoospermia in one case and poor semen quality in four patients. TARTs were common and associated with impaired spermatogenesis.
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Affiliation(s)
- M Chihaoui
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - F Kanoun
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - F Chaker
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - M Yazidi
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - K Bouchrit
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - H Mizouni
- Department of Radiology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - M Feki
- Department of Biochemistry, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - M Kharrat
- Department of Genetics, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - H Slimane
- Department of Endocrinology, University Hospital La Rabta, Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
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Teixeira SR, Elias PCL, Andrade MTS, Melo AF, Elias Junior J. The role of imaging in congenital adrenal hyperplasia. ACTA ACUST UNITED AC 2014; 58:701-8. [DOI: 10.1590/0004-2730000003371] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 06/17/2014] [Indexed: 01/19/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is an autossomic recessive disorder caused by impaired steroidogenesis. Patients with CAH may present adrenal insufficiency with or without salt-wasting, as well as various degrees of virilization and fertility impairment, carrying a high incidence of testicular adrenal rest tumors and increased incidence of adrenal tumors. The diagnosis of CAH is made based on the adrenocortical profile hormonal evaluation and genotyping, in selected cases. Follow-up is mainly based on hormonal and clinical evaluation. Utility of imaging in this clinical setting may be helpful for the diagnosis, management, and follow-up of the patients, although recommendations according to most guidelines are weak when present. Thus, the authors aimed to conduct a narrative synthesis of how imaging can help in the management of patients with CAH, especially focused on genitography, ultrasonography, computed tomography, and magnetic resonance imaging.
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Han TS, Walker BR, Arlt W, Ross RJ. Treatment and health outcomes in adults with congenital adrenal hyperplasia. Nat Rev Endocrinol 2014; 10:115-24. [PMID: 24342885 DOI: 10.1038/nrendo.2013.239] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a genetic disorder caused by defective steroidogenesis that results in glucocorticoid deficiency; the most common underlying mutation is in the gene that encodes 21-hydroxylase. Life-saving glucocorticoid treatment was introduced in the 1950s, and the number of adult patients is now growing; however, no consensus has been reached on the management of CAH beyond childhood. Adult patients are prescribed a variety of glucocorticoids, including hydrocortisone, prednisone, prednisolone, dexamethasone and combinations of these drugs taken in either a circadian or reverse circadian regimen. Despite these personalized treatments, biochemical control of CAH is only achieved in approximately one-third of patients. Some patients have a poor health status, with an increased incidence of obesity and osteoporosis, and impaired fertility and quality of life. The majority of poor health outcomes seem to relate to inadequate treatment rather than the genotype of the patient. Patients receiving high doses of glucocorticoids and the more potent synthetic long-acting glucocorticoids are at an increased risk of obesity, insulin resistance and a reduced quality of life. Further research is required to optimize the treatment of adult patients with CAH and improve health outcomes.
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Affiliation(s)
- Thang S Han
- Department of Diabetes and Endocrinology, St Peter's NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK
| | - Brian R Walker
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Wiebke Arlt
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical & Experimental Medicine, University of Birmingham, Birmingham B15 2TT, UK
| | - Richard J Ross
- Academic Unit of Diabetes, Endocrinology & Metabolism, The Medical School, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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Reichman DE, White PC, New MI, Rosenwaks Z. Fertility in patients with congenital adrenal hyperplasia. Fertil Steril 2014; 101:301-9. [DOI: 10.1016/j.fertnstert.2013.11.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 01/31/2023]
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Testicular adrenal rest tumors in boys with congenital adrenal hyperplasia: 3D US and elastography--do we get more information for diagnosis and monitoring? J Pediatr Urol 2013; 9:1032-7. [PMID: 23507289 DOI: 10.1016/j.jpurol.2013.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 02/08/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Testicular adrenal rest tumors (TART) are the nodular testicular lesions deriving from the adrenal remnant tissue reported in boys and men with congenital adrenal hyperplasia. Until now, the diagnostics of TART have been based on a combination of clinical features, imaging methods (primarily two dimensional ultrasound--2D US), response of the foci to glycocorticosteroid (GCS) therapy and exclusion of the neoplastic process. Application of 2D US supplies however a limited range of information about the volume, demarcation, structure and vascularization of the lesions. OBJECTIVE To define whether the use of 3D US, power Doppler and elastography changes the algorithm of the diagnostics and monitoring or treatment of TART. MATERIAL AND METHODS In this study, modern ultrasound techniques such as 3D US and elastography were introduced in two boys with TART. RESULTS The 3D power Doppler option gives the opportunity for accurate assessment of the volume of testes and adrenal tissue foci and their vascularization. Sonographic elastography allows the assessment of stiffness of adrenal tissue areas compared to normal testis parenchyma. CONCLUSION The use of these modern techniques enables more adequate and advanced diagnostics, and more precise monitoring of the effects of treatment in patients with TART.
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Pierre P, Despert F, Tranquart F, Coutant R, Tardy V, Kerlan V, Sonnet E, Baron S, Lorcy Y, Emy P, Delavierre D, Monceaux F, Morel Y, Lecomte P. Adrenal rest tissue in gonads of patients with classical congenital adrenal hyperplasia: multicenter study of 45 French male patients. ANNALES D'ENDOCRINOLOGIE 2012; 73:515-22. [PMID: 23131470 DOI: 10.1016/j.ando.2012.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 06/10/2012] [Accepted: 09/10/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Several cases of testicular adrenal rest tumours have been reported in men with congenital adrenal hyperplasia (CAH) due to the classical form of 21-hydroxylase deficiency but the prevalence has not been established. The aims of this report were to evaluate the frequency of testicular adrenal rest tissue in this population in a retrospective multicentre study involving eight endocrinology centres, and to determine whether treatment or genetic background had an impact on the occurrence of adrenal rest tissue. MATERIAL AND METHODS Testicular adrenal rest tissue (TART) was sought clinically and with ultrasound examination in forty-five males with CAH due to the classical form of 21-hydroxylase deficiency. When the diagnosis of testicular adrenal rest tumours was sought, good observance of treatment was judged on biological concentrations of 17-hydroxyprogesterone (17OHP), delta4-androstenedione, active renin and testosterone. The results of affected and non-affected subjects were compared. RESULTS TART was detected in none of the 18 subjects aged 1 to 15years but was detected in 14 of the 27 subjects aged more than 15years. Five patients with an abnormal echography result had no clinical signs. Therapeutic control evaluated at diagnosis of TART seemed less effective when diagnosis was made in patients with adrenal rest tissue compared to TART-free subjects. Various genotypes were observed in patients with or without TART. CONCLUSION Due to the high prevalence of TART in classical CAH and the delayed clinical diagnosis, testicular ultrasonography must be performed before puberty and thereafter regularly during adulthood even if the clinical examination is normal.
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Affiliation(s)
- Peggy Pierre
- Adult Endocrinology Unit, University Hospital of Tours, 2, boulevard Tonnelé, 37044 Tours cedex 9, France.
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Ashby HL, Gama RM, Sur H, Inglis J, Ford C, Gama R. Hypergonadotrophic hypogonadism due to testicular adrenal rest tumours presenting with hypogonadotrophic hypergonadism. Ann Clin Biochem 2012; 49:497-9. [PMID: 22734073 DOI: 10.1258/acb.2011.011236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Primary testicular failure is characterized by low serum testosterone with appropriately high serum gonadotrophins, that is hypergonadotrophic hypogonadism. We report on a 27-year-old man with congenital adrenal hyperplasia (CAH) and infertility due to testicular adrenal rest rumours (TART) resulting in primary testicular failure but presenting with azoospermia, elevated serum testosterone and very low serum gonadotrophins. Hypergonadotrophic hypogonadism was unmasked by increasing glucocorticoid dosage. It is important to recognise the limitations of follicle-stimulating hormone, luteinising hormone and testosterone in assessing testicular function in men with CAH. Abnormal semen analysis may be the best indicator of testicular dysfunction in men with CAH.
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Affiliation(s)
- Helen L Ashby
- Department of Clinical Chemistry, New Cross Hospital, Wolverhampton, West Midlands, WV10 0QP, UK.
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Falhammar H, Thorén M. Clinical outcomes in the management of congenital adrenal hyperplasia. Endocrine 2012; 41:355-73. [PMID: 22228497 DOI: 10.1007/s12020-011-9591-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/20/2011] [Indexed: 01/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of disorders affecting adrenal steroid synthesis. The most common form, 21-hydroxylase deficiency, leads to decreased production of cortisol and aldosterone with increased androgen secretion. In classic CAH glucocorticoid treatment can be life-saving, and provides symptom control, but must be given in an unphysiological manner with the risk of negative long-term outcomes. A late diagnosis or a severe phenotype or genotype has also a negative impact. These factors can result in impaired quality of life (QoL), increased cardiometabolic risk, short stature, osteoporosis and fractures, benign tumors, decreased fertility, and vocal problems. The prognosis has improved during the last decades, thanks to better clinical management and nowadays the most affected patients seem to have a good QoL. Very few patients above the age of 60 years have, however, been studied. Classifying patients according to genotype may give additional useful clinical information. The introduction of neonatal CAH screening may enhance long-term results. Monitoring of different risk factors and negative consequences should be done regularly in an attempt to improve clinical outcomes further.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, D2:04, 17176 Stockholm, Sweden,
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Falhammar H, Nyström HF, Ekström U, Granberg S, Wedell A, Thorén M. Fertility, sexuality and testicular adrenal rest tumors in adult males with congenital adrenal hyperplasia. Eur J Endocrinol 2012; 166:441-9. [PMID: 22157069 PMCID: PMC3290120 DOI: 10.1530/eje-11-0828] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Fertility in males with congenital adrenal hyperplasia (CAH) is reported from normal to severely impaired. Therefore, we investigated fertility/fecundity, social/sexual situation, and pituitary-gonadal function in CAH males. SUBJECTS AND METHODS The patient cohort comprised 30 males, aged 19-67 years, with 21-hydroxylase deficiency. Their fertility was compared with age-matched national population data. For the evaluation of social/sexual factors and hormone status, age-matched controls were recruited (n = 32). Subgroups of different ages (<30 years and older) and CYP21A2 genotypes (null (severe salt-wasting (SW)), I2splice (milder SW), and I172N (simple virilizing)) were also studied. Patients underwent testicular ultrasound examination (n = 21) and semen analysis (n = 14). RESULTS Fertility was impaired in CAH males compared with national data (0.9 ± 1.3 vs 1.8 ± 0.5 children/father, P<0.001). There were no major differences in social and sexual factors between patients and controls apart from more fecundity problems, particularly in the I172N group. The patients had lower testosterone/estradiol (E(2)) ratio and inhibin B, and higher FSH. The semen samples were pathological in 43% (6/14) of patients and sperm concentration correlated with inhibin B and FSH. Testicular adrenal rest tumors (TARTs) were found in 86% (18/21). Functional testicular volume correlated positively with the testosterone/E(2) ratio, sperm concentration, and inhibin B. Patients with pathological semen had increased fat mass and indications of increased cardiometabolic risk. CONCLUSIONS Fertility/fecundity was impaired in CAH males. The frequent occurrence of TARTs resulting in testicular insufficiency appears to be the major cause, but other factors such as elevated fat mass may contribute to a low semen quality.
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Affiliation(s)
- Henrik Falhammar
- Departments of Endocrinology, Metabolism and Diabetes, D02:04, Karolinska Institute, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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Delfino M, Elia J, Imbrogno N, Argese N, Mazzilli R, Toscano V, Mazzilli F. Testicular adrenal rest tumors in patients with congenital adrenal hyperplasia: prevalence and sonographic, hormonal, and seminal characteristics. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:383-388. [PMID: 22368128 DOI: 10.7863/jum.2012.31.3.383] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Testicular adrenal rest tumors have been described in patients with congenital adrenal hyperplasia (CAH). The aim of this work was to (1) evaluate the prevalence of testicular adrenal rest tumors in patients with CAH; (2) study the hormonal profile; (3) define the sonographic features; (4) assess the seminal profile; and (5) initiate a longitudinal study on the possible role of corticotropin (ACTH) plasma levels in the induction and persistence of testicular adrenal rest tumors. METHODS Eighteen patients affected by CAH, aged 21 to 41 years, were studied. These were all patients referred to our endocrinology unit for the first time to undergo a clinical evaluation. All of the patients were taking long-term cortisone acetate and fludrocortisone replacement therapy. The study included (1) a physical examination, (2) testis sonography, (3) a hormonal profile, (4) semen analysis. RESULTS Sonography showed testicular adrenal rest tumors in 11 patients (61.1%); of these, 9 cases (50.0%) were bilateral, and 2 (11.1%) were unilateral. The diameter ranged from 4 to 38 mm. In 9 patients, the lesions were hypoechoic, whereas in 2, they were hyperechoic. High plasma ACTH levels were detected in all of the patients with tumors despite long-term therapy. Semen analysis found 2 cases of azoospermia and 6 cases of oligoasthenoteratozoospermia; the 3 remaining patients were normospermic. The preliminary longitudinal study has shown 3 patients with a disappearance or reduction of the tumors after 6 months of modified treatment. CONCLUSIONS This study confirms the high prevalence of testicular adrenal rest tumors in patients with CAH and the major role played in its pathogenesis by high plasma ACTH levels.
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Affiliation(s)
- Michele Delfino
- Department of Medical and Molecular Medicine, Unit of Andrology, Sant’Andrea Hospital, University of Rome Sapienza, Rome, Italy
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Nermoen I, Rørvik J, Holmedal SH, Hykkerud DL, Fougner KJ, Svartberg J, Husebye ES, Løvås K. High frequency of adrenal myelolipomas and testicular adrenal rest tumours in adult Norwegian patients with classical congenital adrenal hyperplasia because of 21-hydroxylase deficiency. Clin Endocrinol (Oxf) 2011; 75:753-9. [PMID: 21689130 DOI: 10.1111/j.1365-2265.2011.04151.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Increased frequencies of adrenal tumours and testicular adrenal rest tumours (TART) have been reported in patients with 21-hydroxylase deficiency (21OHD). OBJECTIVE Patients, methods and design From a cross-sectional population-based study of 101 adult Norwegian patients with 21OHD, sixty-two participated in this study (23 men, 39 women; age range 18-75); thirty-two were salt wasting (SW) and 30 simple virilizing (SV); they were assessed with adrenal computed tomography (CT), testicular ultrasound and hormone measurement in the morning after overnight medication fast. RESULTS Nine adrenal tumours were detected in seven (11%) patients (bilateral in 2); four were myelolipomas and one a phaeochromocytoma. Seventeen (27%) had normal adrenal size, whereas 36 (58%) had persisting hyperplasia, and seven (11%) adrenal hypoplasia. Abnormal adrenals were more common in SW than in SV. TART occurred exclusively in SW and was present in seven (57%) of these men. Testicular volumes were small compared with normative data. Morning ACTH and 17-hydroxyprogesterone levels correlated positively with adrenal dimensions and frequency of TART. CONCLUSION In this unselected population of patients with classical 21OHD, we found high frequencies of adrenal tumours, particularly myelolipomas, and of hyperplasia and hypoplasia, and TART in SW. It is important that physicians are aware that benign adrenal and testicular tumours occur frequently in 21OHD. Furthermore, these findings may reflect inappropriate glucocorticoid therapy, making a case for the advancement of novel physiological treatment modalities.
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Affiliation(s)
- Ingrid Nermoen
- Institute of Clinical Medicine, Akershus University Hospital, University of Oslo, Norway.
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Mitchell D. A Patient With Bilaterally Enlarged Testes. Lab Med 2011. [DOI: 10.1309/lm9rkasm3rzre8rd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Jin HY, Choi JH, Kim GH, Lee CS, Yoo HW. Testicular adrenal rest tumors in a patient with untreated congenital adrenal hyperplasia. KOREAN JOURNAL OF PEDIATRICS 2011; 54:137-40. [PMID: 21738545 PMCID: PMC3121001 DOI: 10.3345/kjp.2011.54.3.137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 10/10/2010] [Accepted: 10/29/2010] [Indexed: 11/27/2022]
Abstract
Testicular adrenal rest tumors (TARTs) are considered to be formed from aberrant adrenal tissue that has become hyperplastic because of elevated adrenocorticotropic hormone (ACTH) in male patients with congenital adrenal hyperplasia (CAH). A 6-year-old boy presented with testicular enlargement and pubic hair. He was diagnosed with CAH complicated by precocious puberty. However, he was not followed-up. At the age of 17, he visited the outpatient clinic because of testicular enlargement and short stature. His right and left testicles were 10×6 cm and 7.5×4.5 cm, respectively. His height was 155.1 cm (standard deviation score [SDS], -2.90). The diagnosis of CAH due to 21 hydroxylase deficiency was confirmed by mutation analysis of CYP21A2. Histological examination of the testes showed large, polygonal, eosinophilic cells with round nuclei and prominent nucleoli, which were suggestive of TARTs. He was treated with dexamethasone for 3 weeks and tumors regressed. Subsequently, dexamethasone was replaced by prednisolone and 9α-fludrocortisone; thereafter, the reduced testis size has been maintained.
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Affiliation(s)
- Hye Young Jin
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Marchini GS, Cocuzza M, Pagani R, Torricelli FC, Hallak J, Srougi M. Testicular adrenal rest tumor in infertile man with congenital adrenal hyperplasia: case report and literature review. SAO PAULO MED J 2011; 129:346-51. [PMID: 22069134 PMCID: PMC10868949 DOI: 10.1590/s1516-31802011000500010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 08/03/2010] [Accepted: 03/16/2011] [Indexed: 11/22/2022] Open
Abstract
CONTEXT Synthesis of cortisol and aldosterone is impaired in patients with congenital adrenal hyperplasia (CAH) because of 21-hydroxylase deficiency. Men with CAH have low fertility rates compared with the normal population, and this is related to testicular adrenal rest tumors. Findings of azoospermia in combination with a testicular tumor on ultrasound are likely to have a mechanical cause, especially when in the testicular mediastinum. The preferred treatment method consists of intensive corticoid therapy. However, when the tumor is unresponsive to steroid therapy, surgical treatment should be considered. CASE REPORT We present the case of a male patient with CAH due to 21-hydroxylase deficiency who presented a testicular tumor and azoospermia. Treatment with low daily corticoid doses had previously been started by an endocrinologist, but after 12 months, no significant change in sperm count was found. Although the adrenocorticotrophic hormone and 17-hydroxyprogesterone levels returned to normal values, the follicle-stimulating hormone (FSH), luteinizing hormone and testosterone levels remained unchanged. Ultrasound examination confirmed that the testicles were small and heterogenous bilaterally, and revealed a mosaic area at the projection of the testis network bilaterally. Magnetic resonance imaging confirmed the finding. Testicular biopsy revealed the presence of preserved spermatogenesis and spermiogenesis in 20% of the seminiferous tubules in the right testicle. The patient underwent testis-sparing tumor resection. After 12 months of follow-up, there was no tumor recurrence but the patient still presented azoospermia and joined an intracytoplasmic sperm injection program.
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Affiliation(s)
- Giovanni Scala Marchini
- Department of Urology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Jin HY, Choi JH, Kim GH, Lee CS, Yoo HW. Testicular adrenal rest tumors in a patient with untreated congenital adrenal hyperplasia. KOREAN JOURNAL OF PEDIATRICS 2011. [DOI: 10.3345/kjp.2011.54.3.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hye Young Jin
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Ho Choi
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Gu Hwan Kim
- Department of Pediatrics, Medical Genetics Clinic and Laboratory, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Chung Sik Lee
- Department of Pathology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Han Wook Yoo
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
- Department of Pediatrics, Medical Genetics Clinic and Laboratory, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Kang MJ, Kim JH, Lee SH, Lee YA, Shin CH, Yang SW. The prevalence of testicular adrenal rest tumors and associated factors in postpubertal patients with congenital adrenal hyperplasia caused by 21-hydroxylase deficiency. Endocr J 2011; 58:501-8. [PMID: 21521928 DOI: 10.1507/endocrj.k11e-034] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Development of a testicular adrenal rest tumor (TART) is common in males with congenital adrenal hyperplasia, and it can be an important cause of infertility. In the present study, we observed the prevalence of TARTs, and analyzed its associated factors in patients with 21-hydroxylase deficiency. Testicular ultrasonography was performed in 48 postpubertal male patients aged 10.6 to 27.1 years. To determine whether patients were undertreated, we analyzed the serum 17-hydroxyprogesterone (17-OHP) levels to the time of ultrasonographic measurement and calculated the percentage of measurements when serum 17-OHP level was >10 ng/mL relative to the total number of measurements during the follow-up period. We divided the 6-year period before ultrasonographic measurement (time 0) into three 2-year intervals and calculated the average concentration of serum 17-OHP in each interval to give a -2(nd) to 0 year-average concentration (-2-0YAC), -4-2YAC and -6-4YAC. A TART was detected by ultrasonography in 31 of 48 patients (64.6%) and the median maximal cross-sectional area of the TARTs was 0.71 (0.03, 4.95) cm(2). The corrected final adult height was lower, and -4-2YAC and body mass index were higher in patients with TART than in those without. After controlling for the type of 21-hydroxylase deficiency, hydrocortisone-equivalent dose, age, and -6-4YAC, the size of TART was associated with a high undertreatment percentage with a marginal statistical significance. These results suggest that strict disease control is mandatory and regular examination with testicular ultrasonography is recommended in male patients, regardless of the type of 21-hydroxylase deficiency.
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Affiliation(s)
- Min Jae Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, 110-769, Korea
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Vajda Z, Borbély G, Jakab Z, Riesz P, Rácz K. [Bilateral testicular tumor in a young man with congenital 11β-hydroxylase deficiency]. Orv Hetil 2010; 151:1863-8. [PMID: 20980225 DOI: 10.1556/oh.2010.28993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Adrenal rest tumor presenting as palpable testicular mass has been well described in boys and adult males with congenital adrenal hyperplasia. It develops most commonly in patients with 21- hydroxylase deficiency, but the entity may also occur in rare forms of congenital adrenal hyperplasia, including 11β-hydroxylase deficiency. Because the management of testicular adrenal rest tumors is substantially different from that applied in benign and malignant testicular tumors, an accurate differentiation between these entities is particularly important. Authors present the history of a young adult male with 11β-hydroxylase deficiency who developed adrenal rest tumors presenting as palpable bilateral testicular masses during treatment with glucocorticoids, then testicular masses showed a rapid regression after an adequate glucocorticoid treatment. Considering lessons obtained from this case, authors review the pathomechanism, symptoms, as well as current diagnostic and treatment modalities of testicular adrenal rest tumors.
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Affiliation(s)
- Zsolt Vajda
- Fovárosi Önkormányzat Heim Pál Kórház Budapest Üllői út 86. 1089.
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