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Gonadoblastoma Workup

  • Author: Joseph L Lasky, III, MD; Chief Editor: Max J Coppes, MD, PhD, MBA  more...
 
Updated: Jun 05, 2014
 

Laboratory Studies

See the list below:

  • Chromosome analysis
    • Chromosome analysis is the most important laboratory study in the diagnosis of gonadoblastoma.
    • The karyotype at birth is used as a screening test in neonates with abnormal genitalia.
    • The karyotype may also be used at a later age to detect patients who have androgen insensitivity/male pseudohermaphroditism (46,XY) and who present with primary amenorrhea.
    • The karyotype confirms the diagnosis of Turner syndrome and can differentiate the many other chromosomal abnormalities that have been described.
    • The presence of a Y chromosome has clearly been linked to the risk of developing gonadoblastoma in the intersex population. However, because the karyotype is not able to detect the molecular presence of a Y chromosome in patients with Turner syndrome, the absence of a Y chromosome does not exclude the patient from developing gonadoblastoma.
    • In patients with Turner syndrome (45,XO), the karyotype analysis lacks the sensitivity to detect the molecular presence of a Y chromosome, which has been confirmed and well documented with the use of the PCR and fluorescence in situ hybridization (FISH).
  • Serum electrolyte panel
    • In newborns with clitoromegaly, obtain a serum electrolyte panel to exclude life-threatening electrolyte disturbances.
    • Elevated serum potassium and low serum sodium are observed in patients with 21-hydroxylase deficiency, and other abnormalities of androgen synthesis are observed in patients with congenital adrenal hyperplasia.
  • Endocrinologic evaluation: Concomitant endocrine abnormalities should be delineated, including measurement of luteinizing hormone (LH), follicle-stimulating hormone (FSH), adrenocorticotropic hormone (ACTH), testosterone/dihydrotestosterone (after gonadotrophin chorionic hormone [GCH] stimulation), 17-OH progesterone, and cortisol.
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Imaging Studies

See the list below:

  • Imaging studies are useful in diagnosing features of intersexuality in newborns but have a limited role in the diagnosis gonadoblastoma. All of these studies help to identify patients at risk of developing gonadoblastoma in addition to characterizing the specific intersex disorder of the individual.
    • Most patients with ambiguous genitalia usually undergo retrograde genitography to delineate the urogenital anatomy. Often, the bladder, vagina, and any communication between the 2 structures can be identified.
    • If a diagnostic surgical procedure is planned, cystourethroscopy and vaginoscopy can be performed to better visualize the anatomy.
  • In patients that present later in life, localization studies such as ultrasonography, CT scanning, and MRI may be useful.
    • Ultrasonographic evaluation of the gonads and other pelvic organs is frequently used to identify and characterize any persistence of müllerian duct structures.
    • Particularly in patients with mixed gonadal dysgenesis, ultrasonography can be helpful in visualizing the uterus, vagina, fallopian tubes, ovary, and a contralateral testicle.
  • A flat abdominal radiograph can sometimes reveal gonadal calcification, which is a classic pathologic finding in gonadoblastoma.
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Procedures

The role of exploratory laparotomy and gonadal biopsy is not well defined. More often in the past, it has been used for diagnostic purposes to help identify and characterize the anatomy of patients with mixed intersex disorders. Currently, the diagnosis can be made with the use of karyotype identification and molecular techniques, minimizing the need for a diagnostic biopsy. Today, an exploratory laparotomy is reserved for patients who undergo predominately a therapeutic and not a diagnostic gonadectomy.

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Histologic Findings

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  • Gross evaluation of gonadoblastoma usually reveals a small, slightly lobulated, 1-cm to 8-cm, soft to firm, gray-tan to brown, slightly lobulated tumor. The consistency has been described as gritty on cut sections because of the presence of multifocal calcification.[18]
  • Histologically, the following 2 distinct cell types characterize these tumors: (1) large germ cells (similar to dysgerminoma and seminoma) and (2) small cells, which resemble immature Sertoli or granulosa cells. Additionally, a third type of cell can frequently be observed in the stroma of the tumor and is nearly identical to Leydig cells, with the exception of having visible Reinke crystals, and are thought to be responsible for frequent virilizing features in these patients.[18] Although gonadoblastoma has normal germinal and stromal characteristics, some of the germ cells are large and have numerous mitotic figures that resemble classic testicular seminoma. In fact, as these cells overgrow the surrounding stroma, the tumor gains the characteristics of a more aggressive lesion and acquires the potential for metastatic spread.
  • The 2 main cell types form discrete solid aggregates that often contain calcifications. If the germ cells invade the margins of these discrete aggregates, the lesion is no longer considered benign and is termed a dysgerminoma/seminoma. With advanced local growth, the dysgerminoma/seminoma nearly obliterates the architecture that characterizes the benign histologic features of the gonadoblastoma. Approximately 17% of germinomas arising in gonadoblastomas are bilateral.
  • The pathologic diagnosis of gonadoblastoma can be challenging. Gonadoblastoma is often misdiagnosed as a nonseminomatous germ cell tumor. Only a few cases of nonseminomatous germ cell tumors (eg, yolk sac, embryonal cell carcinoma, teratoma, mucinous adenoma) have been reported in patients with gonadoblastoma.
  • Immunohistochemical stain results for OCT3/4, TSPY, and SCF are generally positive.[19]
  • In patients with Turner syndrome, the gonads are streaks, made up of fibrous stroma arranged in whorls similar to those in ovarian stroma but lacking primordial follicles.
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Staging

Gonadoblastoma is not staged because it is not a malignant tumor. However, not removed early, at least 30% of these lesions develop into a higher grade malignancy, usually dysgerminoma or seminoma. These, of course, need to be appropriately staged depending on their histology.

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Contributor Information and Disclosures
Author

Joseph L Lasky, III, MD Clinical Associate Professor of Pediatrics and Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pediatric Hematology/Oncology, Harbor-UCLA Medical Center

Joseph L Lasky, III, MD is a member of the following medical societies: American Association for Cancer Research, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, Society for Neuro-Oncology, American Society of Clinical Oncology

Disclosure: Received grant/research funds from Novo-Nordisk for site pi; Received grant/research funds from Emmaus for site pi; Received consulting fee from Octapharma for consulting; Received consulting fee from CSL Behring for consulting; Received grant/research funds from Novartis for site pi.

Coauthor(s)

Kathleen M Sakamoto, MD, PhD Shelagh Galligan Professor, Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine

Kathleen M Sakamoto, MD, PhD is a member of the following medical societies: International Society for Experimental Hematology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Society for Pediatric Research

Disclosure: Nothing to disclose.

Nejd F Alsikafi, MD Clinical Assistant Professor, Department of Urology, Loyola University, Chicago Stritch School of Medicine

Nejd F Alsikafi, MD is a member of the following medical societies: American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Timothy P Cripe, MD, PhD, FAAP Chief, Division of Hematology/Oncology/BMT, Gordon Teter Endowed Chair in Pediatric Cancer, Nationwide Children's Hospital; Professor of Pediatrics, Ohio State University College of Medicine

Timothy P Cripe, MD, PhD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Association for Cancer Research, American Pediatric Society, American Society of Gene and Cell Therapy, American Society of Pediatric Hematology/Oncology, Connective Tissue Oncology Society, Society for Pediatric Research, Children's Oncology Group

Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA Executive Vice President, Chief Medical and Academic Officer, Renown Heath

Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American College of Healthcare Executives, American Society of Pediatric Hematology/Oncology, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Stephan A Grupp, MD, PhD Director, Stem Cell Biology Program, Department of Pediatrics, Division of Oncology, Children's Hospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania School of Medicine

Stephan A Grupp, MD, PhD is a member of the following medical societies: American Association for Cancer Research, Society for Pediatric Research, American Society for Blood and Marrow Transplantation, American Society of Hematology, American Society of Pediatric Hematology/Oncology

Disclosure: Nothing to disclose.

Acknowledgements

William J Cromie, MD, MBA President and Chief Executive Officer, Health Care, Capital District Physicians' Health Plan

William J Cromie, MD, MBA is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, Medical Society of the State of New York, Société Internationale d'Urologie (International Society of Urology), Society for Pediatric Urology, Society of University Urologists, and Society of Uroradiology

Disclosure: Nothing to disclose.

Dimitri Kuznetsov, MD Staff Physician, Department of Surgery, Section of Urology, University of Chicago

Dimitri Kuznetsov, MD is a member of the following medical societies: American Urological Association and Endourological Society

Disclosure: Nothing to disclose.

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