Sls Drop

Stem cell factor as a novel diagnostic marker for early malignant germ cells

Carcinoma in situ (CIS) of the testis is the pre‐invasive stage of type II testicular germ cell tumours (TGCTs) of adolescents and adults. These tumours are the most frequently diagnosed cancer in Caucasian adolescents and young adults. In dysgenetic gonads, the precursor of type II GCTs can be either CIS or a lesion known as gonadoblastoma (GB). CIS/GB originates from a primordial germ cell (PGC)/gonocyte, ie an embryonic cell. CIS can be cured by local low‐dose irradiation, with limited side effects on hormonal function. Therefore, strategies for early diagnosis of CIS are essential. Various markers are informative to diagnose CIS in adult testis by immunohistochemistry, including c‐KIT, PLAP, AP‐2γ, NANOG, and POU5F1 (OCT3/4). OCT3/4 is the most informative and consistent in presence and expression level, resulting in intense nuclear staining. In the case of maturational delay of germ cells, frequently present in gonads of individuals at risk for type II (T)GCTs, use of these markers can result in overdiagnosis of malignant germ cells. This demonstrates the need for a more specific diagnostic marker to distinguish malignant germ cells from germ cells showing maturation delay. Here we report the novel finding that immunohistochemical detection of stem cell factor (SCF), the c‐KIT ligand, is informative in this context. This was demonstrated in over 400 cases of normal (fetal, neonatal, infantile, and adult) and pathological gonads, as well as TGCT‐derived cell lines, specifically in cases of CIS and GB. Both membrane‐bound and soluble SCF were expressed, suggestive of an autocrine loop. SCF immunohistochemistry can be a valuable diagnostic tool, in addition to OCT3/4, to screen for precursor lesions of TGCTs, especially in patients with germ cell maturation delay. Copyright

FOXL2 and SOX9 as parameters of female and male gonadal differentiation in patients with various forms of disorders of sex development (DSD)

The transcription factors SOX9 and FOXL2 are required for male and female mammalian gonadal development. We have used specific antibodies to investigate the role of these key proteins in disorders of sex development (DSD), specifically inter‐sex states. In normal gonads, SOX9 was found to be restricted to the presence of (pre‐)Sertoli cells, while FOXL2 was found in granulosa cells, and in stromal cells interpreted as early ovarian stroma. Both proteins were found within a single patient, when testicular and ovarian development was present; and within the same gonad, when both differentiation lineages were identified, as in ovotesticular DSD (ie hermaphrodite). Especially SOX9 was informative to support the presence of early testicular development (ie seminiferous tubules), expected based on morphological criteria only. In a limited number of DSD cases, FOXL2 was found within reasonably well‐developed seminiferous tubules, but double staining demonstrated that it was never strongly co‐expressed with SOX9 in the same cell. All seminiferous tubules containing carcinoma in situ (CIS), the malignant counterpart of a primordial germ cell, ie the precursor of type II germ cell tumours of the testis, seminomas and non‐seminomas, showed the presence of SOX9 and not FOXL2. In contrast, gonadoblastomas (GBs), the precursor of the same type of cancer, in a dysgenetic gonad, showed expression of FOXL2 and no, or only very low, SOX9 expression. These findings indicate that gonadal differentiation, ie testicular or ovarian, determines the morphology of the precursor of type II germ cell tumours, CIS or GB, respectively. We show that in DSD patients, the formation of either ovarian or/and testicular development can be visualized using FOXL2 and SOX9 expression, respectively. In addition, it initiates a novel way to study the role of the supportive cells in the development of either CIS or GB. Copyright

Gonadal development and tumor formation at the crossroads of male and female sex determination

Malignant germ cell tumor (GCT) formation is a well-known complication in the management of patients with a disorder of sex development (DSD). DSDs are defined as congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical. DSD patients in whom the karyotype – at least at the gonadal level – contains (a part of) the Y chromosome are at increased risk for neoplastic transformation of germ cells, leading to the development of the so-called ‘type II germ cell tumors’. However, tumor risk in the various forms of DSD varies considerably between the different diagnostic groups. This contribution integrates our actual knowledge on the pathophysiology of tumor development in DSDs, recent findings on gonadal (mal)development in DSD patients, and possible correlations between the patient’s phenotype and his/her risk for germ cell tumor development.

The effect of treatment with an LH-RH agonist (Buserelin) on gonadal activity growth and bone maturation in children with central precocious puberty

Twenty-five children (23 girls and 2 boys) with central precocious puberty were treated with the LH-RH agonistd-Ser (TBU)6-LHRH (1–9) EA (HOE) 766, Buserelin) by daily subcutaneous injection for a period of 11–18 months. Eight girls and 2 boys previously treated with cyproterone acetate (CPA, 100–150 mg/m2 body surface per day) and the first seven newly diagnosed patients received 2×10 μg Buserelin/kg bodyweight per day for 1 week, followed by a maintenance therapy of 1×10 μg/kg per day. After an initial marked increase, oestrogen (E2) serum levels in girls and testosterone (T) values in boys decreased. After a treatment period of 6–20 weeks the patients received 2×20 μg Buserelin/kg per day for 1 week and thereafter a maintenance dosage of 20 μg/kg per day to obtain full suppression (i.e. E2<50 pmol/l; T<1 nmol/l). The remaining eight patients started directly on 2×20 μg Buserelin/kg per day followed by 1×20 μg/kg per day.All eight girls with menarche before therapy had no further menses. In all girls there was a reduction of palpable breast tissue. Decrease of pubic hair development was observed in 3 girls, an increase was seen in 5 girls, whereas in the remaining 15 girls no change was observed. Both boys had a reduction of testicular volume and of pubic hair. The basal growth rate during the half year preceding Buserelin treatment was elevated in the newly diagnosed patients as compared to the growth rate of the patients previously treated with CPA and to the median growth rate of healthy children.During the first 6 months of treatment the mean growth rate decreased slightly in the patients who had received no previous treatment and increased in the patients previously treated with CPA. During the subsequent year a marked fall of the mean growth rate was observed. Paired comparison of the mean SDS (height/chronological age and height/bone age) and of the mean final height prediction (according to Bayley and Pinneau) of 15 children treated for 18 months revealed no significant change.We conclude that during an observation period of 18 months the daily subcutaneous administration of the LH-RH agonist Buserelin has been a safe and effective method of selectively inhibiting gonadal activity in children with central precocious puberty. With prolonged treatment an improvement of the final height prediction is expected.

Pituitary-dependent Cushing disease and primary adrenocortical nodular dysplasia in childhood

Four patients with Cushing syndrome were followed for 1.5–12 years. The main clinical symptoms were marked growth retardation and truncal obesity. Two patients had pituitary-dependent Cushing disease, while the other two had primary adrenocortical nodular dysplasia.The treatment of choice of pituitary-dependent Cushing disease is transsphenoidal resection of the microadenoma while in primary adrenocortical nodular dysplasia bilateral adrenalectomy with subsequent steroid replacement is recommended. In our pre-or early pubertal patients catch-up growth occurred following surgical therapy and in all cases pubertal development proceeded normally.

A new model to predict final height in constitutionally tall children

In order to develop new height prediction models for children with constitutionally tall stature, 55 such boys and 88 girls were recalled for measurement of adult final height (FH). Data on height (H), age (CA), and target height (TH) were collected from the hospital charts and radiographs of the left hand and wrist were retrieved and used for bone age (BA) determination [BA according to the methods of Greulich and Pyle (BAGP) and Tanner and Whitehouse (BARUs)]‐ Standard multiple regression techniques were used to develop prediction equations for FH. In addition, to test the validity of the new equations, FH was measured in a second group of constitutionally tall children (n = 32) and compared with the predicted FH according to our models. In addition, a comparison was made with other prediction methods. Mean (SD) FH was 196.0 (4.9) cm in boys and 180.5 (3.8) cm in girls. The ultimate regression equation was FH (cm) = 216.07 + 0.75 × H + 0.25 × TH ‐ 11.09 × CA ‐ 14.02 × BAOP+ 0.74 × (CA × BAGP) for boys and FH = 161.42 + 0.73 × H + 0.15 × TH ‐ 8.41 × CA ‐ 8.83 × BARUS ‐ 2.45 × M + 0.55 × (CA × BARUS) for girls. The models showed satisfying accuracy: the mean (SD) errors were −1.4 (3.2) cm for boys and −0.5 (3.1) cm for girls with corresponding mean (SD) absolute errors of 2.7 (2.2) cm and 2.0 (2.4) cm, respectively. Compared with the current prediction methods, the new models were quite promising. Their clinical validity has to be ascertained in larger groups of tall children.

Precocious Puberty as the Presenting Symptom of Adrenal Tumors

We describe 3 children (2 girls, 1 boy) with precocious sexual development resulting from adrenal tumors. One girl presented with isosexual precocious puberty due to a feminizing adrenocortical carcinoma. Plasma levels of estradiol, testosterone, DHEA-S, DOC, 11-deoxyCortisol and 17-OH-progesterone were highly elevated preoperatively and remained within the normal range until the appearance 2Vi and 3 years later of rapidly growing metastases in the brain and breast, each time accompanied by a rise of DOC and 11-deoxy Cortisol. The remaining two patients (1 boy, 1 girl) presented with virilization without hypercortisolism. Serum levels of testosterone and DHEA-S were markedly elevated and remained within the normal range for 3-4 years following surgical removal of the adrenal adenoma. Two patients had a pubertal bone age at the time of adrenalectomy and immediately thereafter developed isosexual central puberty, whereas the third patient with a prepubertal bone age at the time of adrenalectomy did not develop puberty up to 4 years after surgery. This observation supports the hypothesis that maturation as reflected by the bone age is a crucial factor for the activation of puberty. Abdominal sonography and computed tomography were valuable noninvasive tools for diagnosing adrenal tumors and recurrence of tumor growth. In addition, elevated adrenal precursor steroids in serum appeared to be a marker of malignant adrenocortical tumor growth. Reprint address: S.L.S. Drop, M.D., Ph.D. Division of Pediatric Endocrinology Sophia Childrens Hospital PO Box 70029 3000 LL Rotterdam The Netherlands INTRODUCTION Sexual precocity refers to the appearance of sexual characteristics in a girl before the age of 8 years and in a boy before the age of 10 years /1/ . True or central precocious puberty is caused by premature maturation of the hypothalamic pituitary axis, leading to stimulation of the gonads to produce sex-steroids. In girls, up to 60% of the cases of true precocious puberty are idiopathic, whereas in most of the boys a cerebral organic lesion can be found /1 ,14/ . Pseudo-precocious puberty, either isosexual or heterosexual, is characterized by excessive production of sex steroids without activation of the hypothalamic pituitary axis, as in gonadal or adrenal tumors or in the virilizing forms of congenitl adrenal hyperplasia. This report describes 3 patients (2 girls, 1 boy) with precocious pseudopuberty due to adrenal tumors. It puts emphasis on recent advances of noninvasive techniques of diagnosing adrenal tumors. In addition the usefulness of hormonal serum levels in the distinction of central versus pseudo-precocious puberty is discussed.

Genetische basis, terminologie en het risico voor de ontwikkeling van kiemceltumoren bij stoornissen in de geslachtsontwikkeling

SamenvattingDe laatste jaren is significante vooruitgang geboekt in het onderzoek naar genen die betrokken zijn bij de normale geslachtsontwikkeling en hoe mutaties in deze genen leiden tot een stoornis in dit proces. Tevens is inzicht verkregen in het ontstaan van kiemceltumoren, die met een verhoogde frequentie voorkomen bij patiënten met bepaalde vormen van een gestoorde geslachtsontwikkeling. Tegelijk is de gangbare nomenclatuur en classificatie herzien. Dit artikel biedt een overzicht van de geslachtsontwikkeling en een update over de kennis van de genen die betrokken zijn bij, en aanleiding kunnen geven tot, een abnormaal verloop van dit proces. De vernieuwde nomenclatuur en classificatie, gebruikt sinds 2006, worden toegelicht. Ten slotte wordt het risico op de ontwikkeling van kiemceltumoren bij de verschillende vormen van deze aandoeningen besproken en wordt beschreven hoe recent onderzoek erin geslaagd is een risicoanalyse mogelijk te maken.Vanuit psychologisch perspectief wordt de laatste jaren in toenemende mate het belang benadrukt om bij ernstige ondervirilisatie waar mogelijk te kiezen voor de mannelijke genderidentiteit. Patiëntenbelangenverenigingen pleiten voor een meer conservatief beleid met betrekking tot gonadectomie; er lijkt een vernieuwde interesse te groeien bij artsen, wetenschappers en overheidsinstanties voor het opzetten van internationale studies en samenwerkingsverbanden om het beleid bij patiënten met een gestoorde geslachtsontwikkeling te optimaliseren. De verwachting is dan ook dat al deze factoren samen in de komende jaren zullen leiden tot nieuwe richtlijnen met betrekking tot de optimale zorg voor patiënten bij wie de geslachtsontwikkeling abnormaal is verlopen.SummaryIn recent years, considerable progress has been made in the characterization of genes involved in normal sex development, and in how mutations in these genes may lead to abnormalities in this process. Moreover, promising results have been obtained in the research concerning the development of germ cell tumors in these patients. At the same time, the commonly used nomenclature and classification system describing the various forms of disorders of sex development has been revised. This article summarizes our actual knowledge with regard to normal sex development and the various genes that are involved in this process and describes how mutations in these genes may lead to a disturbed process of sex development. The renewed nomenclature and classification system, which are in use since 2006, are explained; finally the risk for the development of germ cell tumors in patients with disorders of sex development is discussed, and it is shown how recent research has offered tools to estimate the risk in the individual patient.Psychological research is increasingly emphasizing the importance to consider male gender identity wherever possible in cases of severe undervirilization. Patient advocacy groups demand a more conservative approach with regard to gonadectomy. Medical doctors, scientists, as well as governmental instances are increasingly interested in the development of international research protocols and collaborations in order to optimize the management of patients with disorders of sex development in the future. As a consequence, it is expected that new guidelines for the optimal care of these patients will be proposed in the coming years.