Cases reported • Gonadal Dysgenesis

1/7. A frame shift mutation in the dna-binding domain of the androgen receptor gene associated with complete androgen insensitivity, persistent mullerian 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 mullerian 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 mullerian 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.

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2/7. Fanconi's anemia, medulloblastoma, Wilms' tumor, horseshoe kidney, and gonadal dysgenesis.

An 18-month-old female infant with clinically and cytogenetically documented Fanconi's anemia was found to have two neoplasms previously unreported in this syndrome to our knowledge: a medulloblastoma and a Wilms' tumor, with the latter arising in a horseshoe kidney. An additional feature was pure gonadal dysgenesis. These unusual associations are discussed in the context of certain syndromes suggestive of an axial predisposition for neoplasia (kidneys-central nervous system and kidneys-gonads).

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3/7. Complete and incomplete Drash syndrome: a clinicopathologic study of five cases of a dysontogenetic-neoplastic complex.

Drash syndrome is a complex disorder characterized by abnormal renal function, abnormal sexual differentiation with predisposition to developing gonadal neoplasms, and nephroblastoma. The authors report five cases with various manifestations of this syndrome. Dysgenetic gonads and abnormal sexual differentiation were present in all patients; two had unilateral and two bilateral gonadoblastomas; in addition, one of the latter had a juvenile granulosa cell tumor. Renal failure was present in all patients. One patient had bilateral Wilms' tumor, and one patient had a metanephric hamartoma. Each element of the triad in this syndrome is analyzed with regard to possible pathogenetic mechanisms and current models of carcinogenesis. Cases with complete forms of the syndrome reported in the literature are reviewed. patients with incomplete forms of the syndrome must be followed carefully because other elements of this complex may become manifest.

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4/7. gonadoblastoma: unusual presentation in a patient lacking persistent mullerian ducts.

We report a patient with a disorder of sexual differentiation who presented with a 46,XY karyotype, absent internal mullerian ducts, a vaginal pouch, hypospadias, and bilateral cryptorchidism with a gonadoblastoma in one testis. A human chorionic gonadotropin stimulation test and tissue 5-alpha-reductase and androgen receptor assays were normal. Except for the absence of internal mullerian ducts, this patient most closely resembles the disorder of dysgenetic male pseudohermaphroditism (DMP). On this basis, we hypothesize that the internal mullerian ducts in DMP may manifest anywhere along a spectrum that extends from normal to complete absence of structures depending on the degree of gonadal dysgenesis. This case also illustrates the importance of testicular biopsy in patients with dysgenetic testes because of the high likelihood of germ cell neoplasms in these gonads.

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5/7. Juvenile granulosa cell tumor--another neoplasm associated with abnormal chromosomes and ambiguous genitalia. A report of three cases.

Three infants, 3 months of age or younger with abnormal karyotypes and ambiguous genitalia, had gonadal juvenile granulosa cell tumors. Two of the patients had mixed gonadal dysgenesis and the third had an intersexual disorder of undetermined type. Two tumors arose in undescended testes, and the third in an undescended gonad of uncertain nature. The occurrence of this uncommon neoplasm in these infants indicates that it is another type of neoplasm that may develop in the gonad of a patient with an abnormal karyotype and ambiguous genitalia.

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6/7. gonadal dysgenesis (46,XY) and gonocytoma.

A case of 46,XY gonadal dysgenesis with a type III Teter's gonocytoma occurred in the left ovary of a 22-year-old woman. Hormonal, genetic and laparoscopic studies were performed before the diagnosis of gonadal dysgenesis was made. Gonadal neoplasm was found after bilateral gonadectomy.

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7/7. Importance of early diagnosis and gonadectomy in 46, XY females.

Gonadal neoplasms developed in three 46, XY females aged 3 yr and 10 mo, 15 yr, and 19 yr. One patient died from metastatic neoplasia. early diagnosis of 46, XY gonadal dysgenesis is essential, and should be considered in female infants and children with any features of Turner's syndrome, ambiguous genitalia, phallic hypertrophy, excessive height, large hands and feet, failure of development of secondary sexual characteristics, primary amenorrhea, abdominal mass, or unexplained hypertension. Any female with gonadal dysgenesis and a y chromosome in her karyotype should have prophylactic gonadectomy as soon as possible. The absence of sertoli cells in these patients, causing lack of androgen binding protein with deficient local concentration of androgens and consequent failure of maturation of spermatogonia, may lead to unregulated proliferation of germ cells, and hence explain the frequency of gonadal neoplasia in the 46, XY female.

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