Ovarian gonadoblastoma with dysgerminoma in a girl with 46,XX karyotype 17a-hydroxylase/17, 20-lyase deficiency: A case report and literature review

17α-hydroxylase/17,20-lyase deficiency (17-OHD), caused by mutations in the gene of the cytochrome P450 family 17 subfamily A member 1 (CYP17A1), is a rare type of congenital adrenal hyperplasia (CAH), usually characterized by cortisol and sex steroid deficiency combined with excessive mineralocorticoid. Gonadoblastoma is a relatively rare ovarian tumor that is frequently seen among patients with 46,XY gonadal dysgenesis. Rarely have they been reported in female patients with normal 46,XX karyotype. Here, we report an interesting case of an 11-year-old Chinese girl who presented acute abdominal pain that was later attributed to tumor rupture of right ovarian gonadoblastoma with dysgerminoma. Further evaluations revealed hypertension and hypokalemia. Hormonal findings showed increased progesterone, hypergonadotropic hypogonadism, and low cortisol levels. Her chromosome karyotype was 46,XX without Y chromosome material detected. Genetic analysis revealed that the patient had a homozygous pathogenic variant c.985_987delTACinsAA (p.Y329Kfs*90) in exon 6 of the CYP17A1 gene and that her parents were all heterozygous carriers of this pathogenic variant. Due to the variable clinical manifestations of 17-OHD, meticulous assessment including genetic analysis is necessary. Further study is warranted to unravel the mechanism of gonadoblastoma in a patient with normal karyotypes.

An aggressive systemic mastocytosis preceded by ovarian dysgerminoma

BACKGROUND

Aggressive systemic mastocytosis (ASM) is a rare malignant disease characterized by disordered mast cell accumulation in various organs. We here describe a female ASM patient with a previous history of ovarian dysgerminoma.

METHODS

Molecular cytogenomic analyses were performed to elucidate an etiological link between the ASM and dysgerminoma of the patient.

RESULTS

This patient was affected by ovarian dysgerminoma which was treated by chemotherapy and surgical resection. Having subsequently been in complete remission for 2 years, she developed symptoms of ASM. A somatic D816A mutation in the KIT gene was detected in her bone marrow, which facilitated the diagnosis of ASM. Unexpectedly, this KIT D816A variant was also detected in the prior ovarian dysgerminoma sample. Whole-exome sequencing allowed us to identify a somatic nonsense mutation of the TP53 gene in the bone marrow, but not in the dysgerminoma. Microarray analysis of the patient's bone marrow revealed a copy-number-neutral loss of heterozygosity at the TP53 locus, suggestive of the homozygous nonsense mutation in the TP53 gene. In addition, the loss of heterozygosity at the TP53 locus was also detected in the dysgerminoma.

CONCLUSIONS

These results indicated that either the mast cells causing the ASM in this case had originated from the preceding ovarian dysgerminoma as a clonal evolution of a residual tumor cell, which acquired the TP53 mutation, or that both tumors developed from a common cancer stem cell carrying the KIT D816A variation.

True hermaphroditism with dysgerminoma: A case report

INTRODUCTION

True hermaphroditism is a rare and usually sporadic disorder. It is defined by the presence of both ovarian and testicular tissues together as ovotestis.

PATIENT CONCERNS

In this study, we reported a rare true hermaphroditism case with dysgerminoma. A 49-year-old woman developed masses in both inguinal regions for 30 years. Recently 3 months, the patient found that the size of mass in her left inguinal region was significantly increased.

DIAGNOSIS

After surgical resection, the results of immunohistochemical examination in left mass revealed a dysgerminoma with positive expression of placental alkaline phosphatase and octamer-binding transcription factor 3/4, and right mass was a cryptorchidism. Chromosomal analysis revealed the karyotype 46, XY. Combined immunohistochemical and karyotype analysis, a diagnosis of true hermaphroditism with dysgerminoma was made.

INTERVENTIONS

Radiotherapy combined with chemotherapy after tumor resection was used to improve her prognosis. Hormone replacement therapy with conjugated estrogen and medroxyprogesterone acetate were used to maintain her female characteristics.

OUTCOMES

The patient underwent hormonal replacement and has been well for 6 months.

CONCLUSION

The positive expression of placental alkaline phosphatase and octamer-binding transcription factor 3/4 could be 2 diagnosis markers of dysgerminoma. Surgery combined with radiotherapy and chemotherapy could improve the prognosis of dysgerminoma. Moreover, hormone replacement therapy with conjugated estrogen and medroxyprogesterone acetate was very helpful to maintain the female characteristic of patients with true hermaphroditism.

Canine ovarian gonadoblastoma with dysgerminoma overgrowth: a case study and literature review

BACKGROUND

Gonadoblastoma (GB) is a rare mixed germ cell-sex cord-stromal tumour, first described in humans, commonly found in dysgenetic gonads of intersex patients that have a Y chromosome. However, this entity in not recognized in the WHO classification of tumours of genital system of domestic animals. Herein, we describe a case of ovarian gonadoblastoma with proliferation of dysgerminoma and sex cord-stromal tumour components, in a phenotypically and cytogenetically normal bitch.

CASE PRESENTATION

A 17-year-old cross-breed bitch had a firm, grey-white multinodular mass in the left ovary. The tumour was submitted to histopathological examination and Y chromosome detected through karyotype analysis and PCR studies. Microscopically, the ovary was almost replaced by an irregular neoplasm composed of three distinct, intermixed elements: dysgerminoma, mixed germ cell-sex cord-stromal tumour resembling human GB and a proliferative sex cord-stromal tumour component. The germ cells of gonadoblastoma and dysgerminoma components were immunoreactive for c-KIT. Sex cord-stromal cells of gonadoblastoma were immunoreactive for α-inhibin. The sex cord-stromal tumour was immunoreactive for AE1/AE3, occasionally for α-inhibin and negative for epithelial membrane antigen (EMA). The karyotype was 78, XX and PCR analysis confirmed the absence of the Y chromosome.

CONCLUSION

Based on these findings, a diagnosis of gonadoblastoma with proliferation of dysgerminoma and sex cord-stromal tumour was made. This is the first case of ovarian gonadoblastoma in a female dog.

Unexpected diagnosis of stage IIA dysgerminoma in streak gonad in a patient with Swyer syndrome: a case report

Patients with Swyer syndrome, which is also known as 46,XY pure gonadal dysgenesis, are at an increased risk of gonadoblastoma and germ cell tumor. Prophylactic gonadectomy is recommended for these patients. We report a case of stage IIA dysgerminoma arising in a streak gonad in a patient with Swyer syndrome, which was not diagnosable preoperatively and intraoperatively. The patient was primarily amenorrheic and identified as female phenotypically. She underwent gonadectomy at 27 years of age. Preoperative image analysis showed a relatively small uterus without adnexal masses. Laparoscopic findings showed bilateral streak gonads. Postoperatively, histopathological examination revealed that the patient had dysgerminoma in her left streak gonad. Preoperative and intraoperative diagnosis of dysgerminoma in normal size ovaries is thought to be difficult. Although it is rare, considering the occurrence of dysgerminoma in streak gonad with extension to the mesosalpinx, prompt prophylactic gonadectomy is strongly recommended for these patients regardless of the size of the ovaries.

A Report of the Histological Features in 12 Cases of Gonadoblastoma

This report deals with 12 cases of gonadoblastoma submitted to the Ovarian Tumour Panel of the Royal College of Obstetricians and Gynaecologists. These tumours are found in children and young adults. Children may present with obvious genital malformation, retarded growth or precocious puberty. In adults the main complaint is amenorrhoea but sometimes there is associated masculinization. Histologically the gonadoblastoma has a distinctive structure, easily recognized in most instances. The most important feature is the instability of the germ cells in these tumours. Nine of these cases showed an associated dysgerminoma, bilateral in 4. In any cases of suspected gonadal dysgenesis presumptive evidence of diagnosis is suggested by the presence of a Y chromosome, raised gonadotrophin output and pelvic calcification on X-ray examination. At operation, streak tissue on both sides must be removed since these tumours are frequently microscopic in size. For the same reason the tissue removed should be serially sectioned.

The Importance of Gonadotropin Assays in the Clinical follow up Patients with Germinal Tumors of the Testis

Clinical-hormone studies were done on 34 patients with germinal tumors of the testis. The gonadotropin titres varied from normal to highly elevated values. Only in 4 cases (11.77%), however, were the gonadotropin titres above 10,000 mouse units/24 hours. These 4 were among the 9 cases (26.47%) with positive pregnancy tests. Gynaecomastia was present in 4 patients (11.77%). Total estrogens were assayed in these 4 cases and were found to be high. Gynaecomastia is attributed to excess estrogens. Elevated gonadotropin titres were found predominantly in cases of embryonal carcinoma, teratocarcinoma and choriocarcinoma, as well as in the most advanced clinical stages. As regards the correlation between gonadotropin titres and course of the tumor, it was found that the higher the titre the worse the prognosis. The results suggest that hormonal assays are of value in the clinical follow-up of testicular germinal tumors and should therefore be carried out in association with other clinical parameters.

Ovarian dysgerminoma in an adolescent: a case report

INTRODUCTION

Ovarian cancer is the second most frequent gynaecological cancer in Nigeria ranking next after carcinoma of the cervix. It has the highest case-fatality rate worldwide because of insidious onset, lack of effective screening methods and late presentation. This case of a sixteen-year old girl with a three-week history of abdominal pain which was later accompanied by abdominal swelling is a classic example of how dysgerminomas present.

METHOD

The presumptive diagnosis of an ovarian tumour was made after physical examination and this was later confirmed by ultrasound scan. Urgent laparotomy was carried out based on a suspicion of torsion of the pedicle of the cyst.

RESULT

At laparotomy, torsion of the pedicle with an intact capsule and imminent gangrene were found. The histology report revealed a malignant germ cell neoplasm (Dysgerminoma) with focal areas of necrosis without infiltration of the attached omentum.

CONCLUSION

She had conservative surgery (left oophorectomy) done. She, however, defaulted from further follow-up.

XY gonadal dysgenesis--development of a germ cell tumor: case report

Gonadal dysgenesis (GD) is a rare congenital malformation that affects about one in 3,000 births. The authors present a case of a 17-year-old woman with primary amenorrhea and poor breast development. They conducted a laparoscopic surgery and bilaterally removed hypoplastic streak gonads. Histopathology of the ovaries revealed bilateral streak gonads with gonadoblastomas and a right-sided dysgerminoma.

[Features of pubescence in patients with pure gonadal dysgenesis in the course of a hormonally active tumor--case report]

Germ cell tumors are the most frequent ovarian neoplasms among girls and young women under the age of 25. Female patients with gonadal dysgenesis are at higher risk of germ cell tumors. Two cases of women with pure gonadal dysgenesis were described. A hormonally active tumor secreting estrogens, caused the development of sexual features and genital tract bleeding what imitated premature puberty. It needs to be emphasized that the presence of sexual features does not exclude dysgenesis - a pathology that is connected with an increased risk of gonadal tumors--and that the ultrasound evaluation, during which the presence of follicles in gonads is evaluated, is essential.

Swyer syndrome: a case report with literature review

Gonadoblastomas are known to develop in dysgenetic gonads, especially so, if Y chromosome material is present. A 20-years-old girl who noticed breast development since the age of 12 years presented with primary amenorhoea, distension of lower abdomen and intermittent pain for two months. She had breakthrough bleeding with six months of estrogen replacement. Tanner breast stage was five and pubic hair stage was also five. Examination revealed a mass in the lower abdomen extending into hypogastrium, umbilical and lumbar regions. Her gonadotropin levels were grossly elevated. Karyotyping showed 46XY. CT scan of abdomen showed a 17X11 cm mass in the pelvis without visible gonads. Surgical excision of the mass along with bilateral salpingophorectomy was performed. Histopathology revealed the mass to be a dysgerminoma, while the right gonad lodged gonadoblastoma. She was diagnosed as a rare case of Swyer syndrome.

Swyer syndrome, 46,XY gonadal dysgenesis, a sex reversal disorder with dysgerminoma: a case report and literature review

BACKGROUND

Swyer syndrome, 46,XY gonadal dysgenesis, is a sex reversal disorder with a female phenotype. Germ cell tumors, including dysgerminoma, may arise in streak gonads of patients with gonadal dysgenesis.

CASE

A 22-year-old female patient with a 46,XY karyotype was admitted to hospital for primary amenorrhea and a pelvic mass. Laparotomy exploration revealed a hypoplastic uterus and a 80 x 70 x 60 mm mass in the right gonad with extension to the pelvic peritoneum. Histologic finding in frozen section was dysgerminoma. Debulking surgery with pelvic lymphadenectomy was subsequently performed and the patient was given four cycles of chemotherapy (bleomycin, etoposide, and cisplatin) post-operation.

CONCLUSION

The presence of Y chromosome in patients with 46,XY gonadal dysgenesis may increase the risk of gonadal tumors. A prophylactic bilateral salpingo-gonadenectomy should be advised to those patients.

[Hypercalcemia in malignancies of the female genital tract]

Hypercalcemia is the most common paraneoplastic syndrome in adult malignancies (10%-30%) and rare in pediatric cancers (0.5%-1.3%). Hypercalcemia in malignancies is categorized into two groups: 1) Humoral hypercalcemia of malignancy (HHM)-caused by substances that are produced by the tumor cells and secreted into the blood circulation such as parathyroid hormone-related protein (PTH-rP), parathyroid hormone-intact (PTH-i), the enzyme 1-alpha-hydroxylase that catalyzes the synthesis of the active form of vitamin D (1,25-dihydroxyvitamin D3), and other substances; 2) Hypercalcemia due to bone destruction by metastases. Hypercalcemia occurs in less than 5% of female genital tract malignancies and virtually in all cases (95%) it is HHM. Female genital tract malignancy-associated HHM is caused most often (80%) by PTH-rP. Ovarian cancer is the most common female genital tract malignancy that is associated with HHM. Although HHM occurs in only 5% of ovarian cancers, it occurs in a relatively high percentage in the following rare ovarian tumors: a). Small cell carcinoma of the ovary - a rare tumor that accounts for only 1% of all ovarian cancers and is associated with HHM in 66% of the cases; b). Clear cell carcinoma of the ovary - an uncommon tumor that accounts for 5% of all ovarian cancers and is associated with HHM in 5%-10% of the cases. Since dysgerminoma is the most common malignant ovarian tumor in children, in girls it is the second most common ovarian neoplasm, after ovarian small cell carcinoma, to be associated with HHM.

Dysgerminoma in three patients with Swyer syndrome

Background

Dysgerminoma is the most common malignant germ cell tumor of the ovary. This malignancy can be associated with pure gonadal dysgenesis or Swyer syndrome, mixed gonadal dysgenesis and partial gonadal dysgenesis.

Case presentation

Dysgerminoma developed in 3 phenotypic female patients with 46 XY pure gonadal dysgenesis. All patients presented first with abdominopelvic mass. Laparatomy was done. 46 XY karyotype was made by lymphocyte culture. Then these patients underwent gonadectomy that histopathology results were streak ovaries without evidence for malignancy. Two patients received postoperative adjuvant therapy.

Conclusion

In Patients with Swyer syndrome the risk of dysgerminoma is high and gonadectomy is recommended. Also 5% of dysgerminomas are discovered in phenotypic female and 46 XY karyotype, thus in adolescent with dysgerminoimas and amenorrhea, karyotype should be done.

Severe malignancy-associated hypercalcemia in dysgerminoma

Hypercalcemia is a rare complication of pediatric malignant germ cell tumors. The problem may be missed because of unawareness among pediatric oncologists. We describe a 16-year-old girl with an ovarian dysgerminoma associated with severe hypercalcemia, a metabolic abnormality infrequently reported with this disease. We review some of the potential causes of malignancy-associated hypercalcemia and current treatment strategies. It is our recommendation that calcium levels should be monitored in all children with solid ovarian masses. Hypercalcemia seen in these situations may not improve until the tumor is removed.

Intra-abdominal mass aspirate from an alopecic dog

An 11-year-old female Yorkshire terrier was presented to the University of Minnesota Veterinary Medical Center for evaluation of a palpable intra-abdominal mass and alopecia. Abdominal ultrasonography revealed a large, complex, cavitary mass in the left caudal region of the abdomen. A fine needle aspirate of the mass was collected. A population of markedly pleomorphic, large, round to polygonal cells were found singly and in small noncohesive aggregates. The cells contained scant, clear to blue-gray cytoplasm, large, round to oval nuclei, and distinctly stippled to reticular chromatin. Cytologic findings were consistent with a tumor of ovarian origin, with a primary differential diagnosis of germ cell tumor. Hormonal analysis of serum revealed a marked increase in 14-OH-progesterone concentration (2.71 ng/mL, reference interval 0.05-0.69 ng/mL). Ovariohysterectomy was performed, and the mass was found to be in the area of the left ovary. Histologic evaluation of the reproductive tract confirmed a diagnosis of left ovarian dysgerminoma. Based on immunohistochemical stains, the tumor was negative for c-kit (CD117c) and single cells were positive for neuron-specific enolase. A right ovarian cyst and squamous metaplasia of the right uterine horn also were diagnosed. The cyst was presumed to be the source of 14-OH-progesterone, which likely resulted in the squamous metaplasia and dermatopathy. Three months after surgery, the progesterone concentration had returned to normal and the alopecia had nearly resolved. Dysgerminomas in dogs are reported rarely, but have a distinctive, recognizable, cytologic appearance and should be included in the differential diagnosis of an intra-abdominal mass in a reproductively intact female dog.

A large pelvic mass in an adolescent patient with granulomatous nephritis: case report and discussion of treatment challenges

BACKGROUND

An adolescent patient with granulomatous nephritis presents with a large, solid pelvic mass. Pertinent differential diagnosis for this solid ovarian mass as well as discussion regarding treatment challenges for this patient is delineated.

CASE

A 15-year-old female presented to her primary care doctor with fatigue and syncope. Initial laboratory workup revealed a hemoglobin of 7.9 g/dL, an elevated creatinine of 3.5 mmol/L, and an elevated ionized calcium of 13.1 mg/dL. Renal biopsy revealed diffuse non-caseating granulomatous nephritis with rare acid-fast bacilli. Renal ultrasound first noted a pelvic mass. Pelvic ultrasound revealed a 15.0 x 8.4 x 12.2 cm mass, characterized as mostly solid with diffuse spaces, in the location of the right ovary. CA-125 and the lactate dehydrogenase (LDH) tumor markers were elevated. The patient underwent a left salpingo-oophorectomy and pelvic staging. Intra-operative frozen section revealed a dysgerminoma. Final pathology report revealed extensive non-caseating granulomatous inflammation within the ovarian tumor. Special stains showed no evidence of acid-fast organisms.

CONCLUSION

Dysgerminoma is the most likely solid ovarian tumor in a patient of this age. In light of her initial renal biopsy with acid-fast bacilli, pelvic tuberculosis needs to be considered. Due to its extreme rarity, sarcoidosis of her genital tract should be lower on the differential, yet this patient presented with pathology consistent with non-caseating granulomas suggesting this diagnosis. Once ovarian dysgerminoma was diagnosed, the possibility that this patient's renal findings may represent paraneoplastic syndrome also becomes important for her treatment.

Ovarian dysgerminoma and acute abdomen

BACKGROUND

Ovarian dysgerminoma cases are very rarely presented together with acute abdomen. The purpose of this study is to present dysgerminoma ovarii with abdominal pain in lower right abdominal part after abdominal trauma as an abdominal emergency.

PATIENTS AND METHODS

Our 12-year old female patient was admitted to our hospital after traffic accident with abdominal trauma. On physical examination the abdomen was acute and the mass in lower abdomen was palpated. Ultrasound and CT examinations showed the presence of large, multilobulated and predominantly solid pelvic mass. Fluid was found in the lower part of pelvis. Immediate exploratory laparotomy was performed. It exposed a superficial actively bleeding tumour vessel. We stopped the bleeding and did a biopsy of the tumour because it was too big for surgical treatment.

CONCLUSION

Ovarian dysgerminoma should be part of the differential diagnosis in female children with acute surgical abdomen when a solid mass is detected by ultrasonographic scan (Fig. 4, Ref. 11).

Ovarian dysgerminoma associated with Pseudo-Meigs' syndrome and functioning ovarian stroma: a case report

BACKGROUND

We present the first case of an ovarian dysgerminoma complicated by pseudo-Meigs' syndrome. Furthermore, this is the fourth reported case of ovarian dysgerminoma with functioning ovarian stroma resulting elevated androgen levels preoperatively.

CASE

A 25-year-old white female was referred to our department for abdominal swelling and a rapidly enlarging abdominal mass. Chest X-ray showed massive right pleural effusion. Abdominopelvic CT scan showed a left adnexal solid mass and ascites. Preoperative abnormally elevated hormone levels were as follows: free testosterone 7.7 pg/mL, androstenodione 13.6 ng/mL, and cortisol 29.4 microg/dL. Left salpingo-oophorectomy and wedge resection of the right ovary were performed. Final histopathological investigation of the left ovary was dysgerminoma associated with stromal luteinization.

CONCLUSION

Dysgerminoma should be considered in the differential diagnosis in a young patient with a pelvic mass, ascites, and pleural effusion and preoperative counseling should be directed accordingly. In addition, dysgerminomas may be accompanied by ovarian stromal luteinization and steroid hormone production, which occasionally result in chemical or clinical hyperandrogenism.

Familial dysgerminoma associated with 46, XX pure gonadal dysgenesis

Although the occurrence of pure gonadal dysgenesis PGD is usually sporadic and nonfamilial, here we present 3 sisters with 46, XX PGD, who are born from a first cousin marriage. Review of their family pedigree is compatible with autosomal recessive inheritance. Surprisingly, 2 of these sisters developed ovarian tumors. Both showed the pathological result of dysgerminoma with syncytiotrophoblastic giant cells. These 2 cases are examples of tumorigenesis in PGD without an identifiable Y chromosome. Therefore, malignant degeneration of the streak gonads should be considered in the patients with 46, XX PGD.

Internal hemorrhage caused by a twisted malignant ovarian dysgerminoma: ultrasonographic findings of a rare case and review of the literature

PURPOSE

Ovarian cancer presents as an acute abdomen very rarely. The purpose of the study is the description of a right ovarian malignant dysgerminoma presenting as an abdominal emergency.

CASE

A 16-year-old white female presented with acute abdominal pain in the right iliac fossa. On physical examination the abdomen was acute and a mass in the right lower abdomen was palpated. The patient was sexually active and bimanual gynecological examination revealed the presence of a large lobulated solid tumor in the position of the right adnexa. Ultrasound examination showed the presence of a large, multilobulated, heterogeneous, predominantly solid pelvic mass. Color flow imaging showed intratumoral flow signals. The uterus and the left ovary had normal size and echo-texture. Fluid was found in the cul-de-sac and in Morisson's space. An immediate exploratory laparotomy exposed the presence of a twisted right ovarian mass and intraperitoneal hemorrhage. A superficial tumoral vessel actively bleeding was seen. Peritoneal fluid was obtained for cytology. The intra-abdominal hemorrhage ceased when the ovarian pedicle was clamped. The patient underwent right salpingo-oophorectomy and biopsy of the omentum. Pathologic analysis revealed a malignant dysgerminoma of the right ovary, expanding to the mesosalpinx. Cytology was positive for malignancy. Postoperative CT scan of the upper and lower abdomen was negative. The patient was assigned to FIGO Stage IIC and referred for platinum-based chemotherapy.

CONCLUSION

Ovarian malignant dysgerminoma may present as an acute abdomen because of torsion, passive blood congestion, rupture of superficial tumoral vessels and subsequent intra-abdominal hemorrhage. Ovarian dysgerminoma should be part of the differential diagnosis in a young woman with acute surgical abdomen and a solid heterogeneous pelvic mass detected by ultrasonographic scan.

Management of ovarian dysgerminoma during a pregnancy complicated by preeclampsia; a case report

A case of a 25-year-old primigravid woman at 31 weeks' gestation with the diagnosis of preeclampsia, malignant pelvic mass, fetal growth restriction and postpartum pulmonary thromboembolism is reported. Fertility preserving surgery for ovarian carcinoma following cesarean delivery was carried out. Final histopathology revealed Stage IC dysgerminoma. After eight months of initial surgery she became pregnant spontaneously. After two years of initial surgery she is still alive without any evidence of disease.

Y chromosome sequences in Turner's syndrome: association with virilization and gonadoblastoma

The presence of Y chromosome fragments in patients with Turner's syndrome is known to increase the risk of gonadoblastoma and virilization. Y chromosome material is detected in up to 6% of patients with Turner's syndrome by karyotype. By DNA analysis, Y chromosome sequences have been reported in 0-60% of patients. The putative gonadoblastoma gene has been mapped to the pericentromeric region of the Y chromosome increasing the interest in studying these sequences.

AIMS

1. To determine the frequency of occult Y chromosome sequences in patients with Turner's syndrome. 2. To analyze the clinical implications of Y sequences detected by karyotype and occult Y sequences.

STUDY DESIGN

Cross-sectional study of 58 patients with Turner's syndrome (30 45,X; two with structural anomalies; 26 mosaic [two of whom were 45,X/46,XY]). SRY, TSPY and DYZ3 sequences were amplified by PCR using genomic DNA from peripheral blood.

RESULTS

All three Y chromosome sequences were found in one out of 56 patients whose karyotype was not suggestive of having Y chromosome material and in one patient with 45,X/46,Xr(X) karyotype. The patients with the ring chromosome and 45,X/46,XY karyotype underwent surgery and were found to have a gonadoblastoma and dysgerminoma. The four patients with Y chromosome material had non-virilized female genitalia.

CONCLUSIONS

Analysis by PCR was more sensitive in detecting Y chromosome sequences than conventional karyotype. The presence of Y material was not associated with virilization. We confirmed the association of Y fragments and gonadoblastoma at an early age.

Peripheral neuropathy in association with an ovarian dysgerminoma

BACKGROUND

Peripheral neuropathy among women with ovarian dysgerminoma has not been so far reported in the literature.

CASE

We report a case of an 18-year-old woman with an association of an abdominal relapse of an ovarian dysgerminoma and a polyradiculoneuritis. The normality of neurologic investigations and the disappearance of all sensitive and muscular alterations after tumor ablation and one cycle of chemotherapy are in favor of a paraneoplastic syndrome. After 5 years this young woman is still in complete remission without any neurologic symptoms.

CONCLUSION

We describe the first case of a polyradiculoneuritis associated with an ovarian dysgerminoma. The evolution of the paraneoplastic syndrome was favorable after treatment of the tumor.

Nonseminomatous Germ Cell Tumor Arising in Splenogonadal Fusion

Splenogonadal fusion is a rare congenital malformation in which the spleen is abnormally connected to the gonads or to the mesonephric derivatives. A few more than 150 cases have been described in the world literature. We report an additional case of splenogonadal fusion. A nonseminomatous germ cell tumor was found in the testicle involved in this splenogonadal fusion. To our knowledge, this is the third reported case of a testicular neoplasm associated with splenogonadal fusion and the first reported case of intra-abdominal nonseminomatous germ cell testicular tumor arising in this rare anomaly. The literature pertaining to splenogonadal fusion and the testicular tumor arising in this anomaly is briefly reviewed.

Gonadoblastoma and dysgerminoma associated with XY gonadal dysgenesis in an adolescent with chronic renal failure: a case of Frasier syndrome

STUDY OBJECTIVES

To report a rare reason for primary amenorrhea, a Frasier syndrome, XY gonadal dysgenesis associated with renal failure with eventual development of gonadoblastoma. To study immunohistochemical analysis of gonadoblastoma and dysgerminoma. To analyze the possibility of androgen receptor mutation in this rare syndrome.

METHODS

We report a case of a 16-yr-old female with this syndrome. She underwent a laparoscopic bilateral gonadectomy and salpingectomy. A histopathological examination revealed gonadoblastoma with focal malignant dysgerminoma in the left dysgenetic gonad and an immunohistochemical of these fairly rare, malignant tumors. An androgen receptor was coded. Analysis was done.

RESULTS

Immunohistochemical analysis showed that inhibin was strongly positive in gonadoblastoma but negative in dysgerminoma. No mutations of the androgen receptor gene were found.

CONCLUSIONS

Inhibin positivity in gonadal stroma and in gonadoblastoma may indicate hormonal activity causing advanced puberty in patients with XY gonadal dysgenesis.

Dysgerminoma associated with hypercalcemia: A case report

Hypercalcemia is an extremely rare paraneoplastic manifestation of malignancy in children. The authors report a case of dysgerminoma in a 14-year-old girl associated with severe hypercalcemia that only resolved after excision of the tumor. There are only 6 previously reported cases of dysgerminoma associated with hypercalcemia. Serum calcium levels should be checked in all children with solid ovarian tumors. Hypercalcemia in such circumstances may be resistant to medical management, and surgical resection of the tumor results in the normalization of calcium levels.

Histopathology of familial ovarian tumors in women from families with and without germline BRCA1 mutations

Breast cancers from patients with germline BRCA1 mutations show characteristic histopathologic features. However, similar studies of BRCA1-associated ovarian cancers have reported inconsistent findings. Interobserver differences in histopathologic classification are a significant source of variation, and most studies have obtained histopathologic information from pathology reports rather than from review of histopathology slides. We therefore reviewed the histopathology slides and pathology reports to determine histologic type, grade, and stage for cancers of the ovary or peritoneum in 217 women from 126 families enrolled in the Gilda Radner Familial Ovarian Cancer Registry. Peripheral blood DNA from at least 1 affected member of each family was analyzed for BRCA1 mutations, and tumors from BRCA1 mutation-positive families were compared with those from BRCA1-negative families. Of 66 patients from 36 BRCA1-positive families, 64 had ovarian carcinoma, 1 had an ovarian carcinoma in situ, and 1 had a dysgerminoma. Of 151 patients from 90 BRCA1-negative families, 135 had ovarian carcinoma, 10 had ovarian borderline tumors, 3 had ovarian sex cord/stromal tumors, and 3 had primary peritoneal carcinoma. There were fewer grade 1 (P <.001) and stage I (P =.10) cancers in patients from BRCA1-positive families than in patients from BRCA1-negative families. Neither mucinous nor borderline tumors were found in the BRCA1-positive families. Ovarian cancers arising in women from BRCA1-positive families are more likely to be high grade and nonmucinous than cancers arising in women from BRCA1-negative families. The absence of borderline tumors in patients from BRCA1-positive families adds to accumulating evidence that BRCA1 mutations do not play a role in the development of these tumors. HUM PATHOL 31:1420-1424.

Cyclophosphamide and water retention: mechanism revisited

We describe an 8 year-old girl with established diabetes insipidus who developed cyclophosphamide-associated antidiuresis. The patient had received cyclophosphamide as part of a high-dose chemotherapy regimen for recurrent suprasellar dysgerminoma prior to autologous bone marrow transplantation. Urinary output decreased and specific gravity increased shortly after a 1 hour i.v. infusion of 50 mg/kg cyclophosphamide and the effect lasted some 5 hours. No other drug could be implicated. This response, occurring in a patient with no ability to secrete vasopressin, suggests a direct tubular effect of one or more cyclophosphamide metabolites. Administering i.v. cyclophosphamide requires careful monitoring of fluid balance in order to avoid water intoxication. Further research is warranted both into the mechanism of this effect and the metabolite responsible for it.

Trisomy 21 associated with ovarian dysgerminoma

A 13-year-old G(0)P(0) white female with trisomy 21 presented with a complex pelvic mass. She underwent resection of the mass and complete staging for what was found to be a stage IIIC completely resected dysgerminoma. She was treated with three cycles of bleomycin, etoposide, and cisplatin chemotherapy and remains free of disease 1 year later. This association is presented as a rare case that may illustrate the relative increase in germ cell neoplasms in female patients with Down's syndrome. While the association of seminoma with Down's syndrome has been documented in a number of cases in males, the female counterpart of this tumor, dysgerminoma, in trisomy 21 has been reported quite infrequently. The potential for germ cell tumors in both male and female trisomy 21 is therefore illustrated.

SRY mutation and tumor formation on the gonads of XP pure gonadal dysgenesis patients

We report three patients with XY pure gonadal dysgenesis. Two of these patients developed gonadoblastoma and associated dysgerminoma. Molecular analyses were undertaken to investigate the relationship between the formation of these tumors and Y chromosome aberrations. Deletion analyses were performed by polymerase chain reaction (PCR) amplification of Y chromosome-specific DNA sequences (PABY, SRY, DYS250, DYS254, and DYZ1). A cryptic deletion of the short arm of the Y chromosome that included the PABY, SRY, DYS250, and DYS254 loci was observed in one of the patients (22-years-old) with an associated tumor. In the other two patients who did not demonstrate such a deletion, the sequence of the SRY open reading frame was determined by the dideoxynucleotide method. Two nucleotide substitutions followed by a seven nucleotide deletion were observed in the 3' end of HMG (high mobility group)-box in the other patient (15-years-old) with an associated tumor. The patient (22-years-old) without an associated tumor did not have the cryptic deletion or mutation of SRY. A Y chromosome specific sequence (DYZ1) was demonstrated by PCR amplification of microdissected tumor tissues from these two patients. These results suggest that SRY may play a role in the formation of gonadal tumors, especially dysgerminoma.

A frame shift mutation in the DNA-binding domain of the androgen receptor gene associated with complete androgen insensitivity, persistent müllerian structures, and germ cell tumors in dysgenetic gonads

OBJECTIVE

To describe the molecular, cytogenetic, immunohistochemical, and endocrinologic characteristics of a young 46,XY female with persistent müllerian structures and germ cell tumors in dysgenetic gonads.

DESIGN

Descriptive case study.

SETTING

Mackay Memorial Hospital and National Yang-Ming University, Taipei, Taiwan.

PATIENT(S)

A 22-year-old 46,XY female with persistent müllerian structures, a low level of serum testosterone, and no apparent adnexal masses.

INTERVENTION(S)

Laparoscopic removal of the dysgenetic gonads.

MAIN OUTCOME MEASURE(S)

Detection of an androgen receptor gene mutation by a semiautomated DNA sequencer, of the chromosomal complement by cytogenetic examination, of placental alkaline phosphatase activity by immunohistochemical analysis, and of neoplasms in dysgenetic gonads by histologic studies.

RESULT(S)

A unilateral gonadoblastoma and a contralateral gonadoblastoma associated with a dysgerminoma were found in the excised gonads. The tumors had a 46,XY complement. Placental alkaline phosphatase was present in the tumor cells. A frameshift mutation in the DNA-binding domain of the androgen receptor gene was detected in the patient's blood and the tumor tissues. A five-nucleotide "AGGAA" deletion at codons 608 and 609 of the androgen receptor gene resulted in a missing arginine and lysine as well as a frameshift that introduced a stop codon 12 amino acid downstream from the mutation.

CONCLUSION(S)

Molecular genetic analysis of the androgen receptor gene aids in the rapid diagnosis of complete androgen insensitivity irrespective of atypical clinical phenotypes and endocrinologic parameters.

Morphology of gonads in pure XY gonadal dysgenesis

The authors gathered 20 patients having Swyer's syndrome and performed a bilateral gonadectomy and carried out a pathohistologic evaluation of the streak gonads. A more frequent occurrence of streak gonad tumors was found together with the possibility of tracing the merge gonadoblastoma into dysgerminoma (the youngest patient was 15 years old). In 95% of the streak gonads checked an ovary-like stroma was found. In 11 of the patients (55%) one of the above mentioned tumors was found. A frequent finding was the presence of Leydig-type cells, calcifications and the remains of Wolffian canals. In three streak gonads, the corpora albicans-like formations were found.

Chylopericardium of neoplastic aetiology

Here we present the case of a 30-year-old man diagnosed with a dysgerminoma with mediastinal involvement, who developed an isolated chylopericardium during treatment. The purpose of this paper is to review the etiology, diagnosis and new approaches to the treatment of chylopericardium.

Dysgerminoma with syncytiotrophoblastic giant cells arising from 46,XX pure gonadal dysgenesis

BACKGROUND

Dysgerminoma with syncytiotrophblastic giant cells is a rare ovarian tumor. Only ten cases of this tumor have been reported, and all tumors developed in normal ovaries. This report presents a case of dysgerminoma with syncytiotrophoblastic giant cells arising in a patient with 46,XX pure gonadal dysgenesis.

CASE

An 18-year-old phenotypic female of normal height without somatic anomalies with nonfunctional ovaries underwent a bilateral gonadectomy for a right ovarian tumor and left streak gonad. The tumor revealed a dysgerminoma containing scattered syncytiotrophoblastic giant cells. Her serum hCG was elevated, and hCG was demonstrated within syncytiotrophoblastic giant cells immunohistochemically. The clinical diagnosis was stage Ia dysgerminoma with syncytiotrophoblastic giant cells. Her karyotype was 46,XX and the sex-determining region Y gene was not detected in tumor DNA by polymerase chain reaction analysis.

CONCLUSION

This rare gonadal tumor may arise from dysgenetic gonads in addition to gonadoblastoma and pure dysgerminoma. It is an example of tumorgenesis in pure gonadal dysgenesis with no identifiable Y chromosome component.

Laparoscopic gonadectomy in male pseudohermaphrodites

OBJECTIVE

To study patients of male pseudohermaphroditism and establish the laparoscopic approach for gonadectomy in these cases.

STUDY DESIGN

Seven phenotypic females with XY karyotype were evaluated through a diagnostic protocol which included clinical, cytogenetic, hormonal, endoscopic and histologic evaluation. The gonads were then removed by laparoscopic surgery.

RESULTS

The seven patients included three patients of pure gonadal dysgenesis, two patients of testicular feminization and one patient each of mixed gonadal dysgenesis and dysgenetic male pseudohermaphroditism. Two of the seven patients (28.57%) had gonadal neoplasias on histopathology-one dysgerminoma and one occult seminoma. In all of these patients, removal of the gonads was accomplished laparoscopically. No complications occurred during any of the surgeries.

CONCLUSION

Due to the reduced morbidity, shorter hospital stay and safety, laparoscopic gonadectomy can be considered the treatment of choice for the removal of gonads in male pseudohermaphrodites in the hands of experienced laparoscopic surgeons.

Hypercalcemia associated with dysgerminoma: case report and imaging findings

Hypercalcemia associated with malignancy is rare in children. We report a case of hypercalcemia associated with ovarian dysgerminoma in a 13-year-old girl with renal medullary calcinosis and vascular calcifications. To our knowledge this is the first report of the imaging findings in this condition and only the fourth case report of hypercalcemia associated with dysgerminoma.

An unusual case of urinary incontinence, ataxia-telangiectasia, and metastatic dysgerminoma: case report and review of the literature

Ataxia-telangiectasia (A-T) is a rare autosomal recessive disease notable for neurodegeneration, chromosomal instability, and a predisposition to cancer. It presents in childhood with a variable phenotype. We report the first case of an A-T related tumor presenting as urinary incontinence, and the first case of 2-year survival in an A-T patient with metastatic dysgerminoma.

Langerhans' cell histiocytosis: possible association with malignant germ cell tumour

A rare case of adult onset Langerhans' cell histiocytosis associated with dysgerminoma in a 35 year old Chinese woman is reported. The patient had a history of dysgerminoma of left ovary 15 years previously and had undergone surgery followed by radiotherapy and an uneventful recovery. She presented again in March 1994, this time with a left clavicular mass, which was shown histologically to be Langerhans' cell histiocytosis. The report illustrates the probable association between the two lesions, with some discussion on the underlying pathogenesis.

Dysgerminoma of the ovary in a patient with triple-X syndrome

A 24-year-old patient with dysgerminoma of the right ovary and hypoplastic left ovary was screened for chromosomal aberration. Triple-X syndrome was found in the oral epithelium and lymphocyte culture, while chromosomal in situ hybridization of the tumor itself showed a normal XX karyotype. Although trisomy X and dysgerminoma are coincidental findings in our case report, women with malignant germ cell tumors and abnormal genitalia should be checked for chromosomal aberrations to exclude anomalies carrying a Y chromosome.

Dysgerminoma of the ovary with hypercalcemia associated with elevated parathyroid hormone-related protein

The purpose of the present paper is to present a rare case of dysgerminoma of the ovary with hypercalcemia showing elevation of multiple serum tumor markers including parathyroid hormone-related protein (PTH-rP). An 18-year-old unmarried woman, with ovarian dysgerminoma showing hypercalcemia and elevated serum PTH-rP, received six courses of a combination chemotherapy consisting of bleomycin, etoposide and cisplatin after her first surgery, and had no evidence of recurrence approximately 30 months after completing the chemotherapy.

Dysgerminoma and gonadal dysgenesis in a 46,XX female with no evidence of Y chromosomal DNA

The occurrence of dysgerminoma in dysgenetic gonads without Y chromosomal influence is exceptionally rare. We used Southern blot hybridization of Y-DNA probes to genomic DNA to search for any Y-related influence in a patient with a dysgerminoma, dysgenetic gonads, and a 46,XX karyotype. No Y-specific DNA was found at 11 loci representing the short arm, centromere, and long arm. This absence of any Y-DNA leaves open to question the absolute requirement of Y-related influence in the development of dysgerminoma in dysgenetic gonads.

Mixed-lineage acute myeloid leukemia associated with a suprasellar dysgerminoma

An association between primary mediastinal germ cell tumors and hematologic malignancies has been recognized since 1985. We present a patient with a suprasellar germ cell tumor and an associated leukemia. A 20-year-old black female presented in December 1987 with a 6-month history of headaches and weight loss, confusion, polyuria, and polydipsia. Evaluation revealed hypernatremia, normal neurologic examination except poor recall, and an enhancing inhomogeneous suprasellar mass on cranial computed tomography. Biopsy of the mass diagnosed a dysgerminoma, which was treated with craniospinal radiation. In February 1988, the patient developed pancytopenia, which resolved with discontinuation of cimetidine and phenytoin. She did well until June 1988 when she presented with skin lesions over the trunk and extremities. Skin biopsy revealed a leukemic infiltration. She was admitted with a WBC 1,500/microliter (without blasts), Hb 11.6 g/dl, PLT 210,000 microliter. Bone marrow biopsy revealed hypercellularity with 50% blasts, demonstrating mixed-lineage acute myeloblastic leukemia (myelomonocytic-M4; megakaryoblastic-M7). The patient was induced with a standard Ara-C/daunorubicin regimen. Two weeks postinduction, she became septic and expired. An autopsy demonstrated leukemic involvement of the spleen, liver, bone marrow, and skin, without residual dysgerminoma. This represents the first reported case of suprasellar dysgerminoma associated with a mixed-lineage leukemia not related to chemotherapy.