help button home button Endocrine Society JCEM
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Journal of Clinical Endocrinology & Metabolism , doi:10.1210/jc.2007-0383
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Submit a related Letter to the Editor
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Reprints, Permissions and Rights
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Martinez-Aguayo, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Martinez-Aguayo, A.
Related Collections
Right arrow Adrenal and Hypertension
Right arrow Pediatric Endocrinology
Right arrow Male Endocrinology
The Journal of Clinical Endocrinology & Metabolism Vol. 92, No. 12 4583-4589
Copyright © 2007 by The Endocrine Society

Testicular Adrenal Rest Tumors and Leydig and Sertoli Cell Function in Boys with Classical Congenital Adrenal Hyperplasia

A. Martinez-Aguayo, A. Rocha, N. Rojas, C. García, R. Parra, M. Lagos, L. Valdivia, H. Poggi, A. Cattani the Chilean Collaborative Testicular Adrenal Rest Tumor Study Group

Endocrinology Unit, Department of Pediatrics (A.M.-A., A.R., A.C.); Department of Radiology and Pediatrics (C.G., R.P.); and Molecular Biology Laboratory (M.L., L.V., H.P.), School of Medicine (N.R.), Pontificia Universidad Católica de Chile, 833-0074, Santiago, Chile

Address all correspondence and requests for reprints to: Alejandro Martinez-Aguayo, M.D., Pontificia Universidad Catolica de Chile, 833-0074, Santiago, Chile. E-mail: alemarti{at}med.puc.cl.


   Abstract
Top
 Abstract
Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
Context: Infertility observed in adult males with congenital adrenal hyperplasia (CAH) has been associated with testicular adrenal rest tumors (TART) that may originate during childhood.

Objective: Our objective was to describe the prevalence of TART and Sertoli and Leydig cell function in a group of boys aged 2–10 yr with CAH and to compare prevalence with that of a control group.

Design: From August 2005 to January 2007, 19 patients with classical CAH (CAH group) were referred from seven endocrinology centers.

Methods: We studied 19 subjects in the CAH group and, as a control group, 13 boys from the community that did not have testicular diseases. A complete physical exam was performed. High-resolution ultrasound was used to determine TART prevalence. Inhibin B and anti-Müllerian hormone were used as Sertoli cell markers. The ratio between basal testosterone levels and testosterone levels 72 h after β-human chorionic gonadotropin (5000 U/m2) treatment [(T72– T0)/T0] was used to evaluate Leydig cell response.

Results: CAH and control groups were comparable in chronological age (5.9 vs. 5.6 yr; P = 0.67) and bone age/chronological age ratio (1.09 vs. 1.03; P = 0.09). TART prevalence was four of 19 (21%) in the CAH group. Lower values for inhibin B (49.2. vs. 65.2 pg/ml; P = 0.018), anti-Müllerian hormone (70.1 vs. 94.2 ng/ml; P = 0.002), and (T72– T0)/T0 (5.6 vs. 13.6; P < 0.01) were observed in the CAH group.

Conclusion: TART in prepubertal males with classic CAH could be found during childhood. We also report differences in markers of gonadal function in a subgroup of patients, especially in those with inadequate control.


   Introduction
Top
 Abstract
 Introduction
Subjects and Methods
 Results
 Discussion
 References
 
FERTILITY RATES OF males with congenital adrenal hyperplasia (CAH) are reduced compared with the normal population (1). Available data suggest that the most frequent cause of infertility in CAH patients is associated with testicular adrenal rest tumors (TART) (2). TART have been hypothesized to be adrenal in origin. Development of the primitive adrenal cortex occurs close to the gonads, and TART is considered to be an aberrant adrenal tissue that has descended with the testes (3). In some animal models, both LH and ACTH can regulate testicular steroidogenesis in fetal Leydig cells (4). Recently, Val et al. (5) found that adrenal-like cells that migrate into the testis respond to ACTH and express Cyp11b1 and Cyp21. Pretumor development and growth of these cells is assumed to be ACTH dependent, and under-treatment may play an important role in tumor development. TART have also been reported in other conditions that exhibit high levels of ACTH, such as Addison’s (6) and Nelson’s (7) syndromes.

In CAH patients, not only have anatomical lesions been found, but impaired function of the testes and hypogonadotropic hypogonadism due to chronic suppression of gonadotropin secretion, both caused by overproduction of adrenal androgens, have also been observed (8). Most fertility problems in CAH could have originated during childhood. Otten et al. (9) suggested that prevention of subfertility should be implemented as a treatment goal in pediatric endocrinology at early puberty.

To optimize the fertility of adults with CAH, it is necessary to improve knowledge of the natural history of TART and testicular function during childhood. In this article, we describe the prevalence of TART and Leydig and Sertoli cell function in a group of 19 prepubertal boys with classical CAH.


   Subjects and Methods
Top
 Abstract
 Introduction
 Subjects and Methods
Results
 Discussion
 References
 
Subject group (CAH)

From August 2005 to January 2007, 19 patients from seven endocrinology centers with classical CAH were invited to participate. All male patients were 2–10 yr old and were nonconsanguineous. Three patients had prenatal diagnoses of CAH. In 15 patients, the diagnosis was suspected during hypovolemic shock associated with hyponatremia and hyperkalemia where 17-hydroxyprogesterone (17-OHP) was more than 2000 ng/ml at the median age of 21 d (range, 11–57 d); in one patient (no. 7), CAH was diagnosed at the age of 2 yr because of signs of androgen excess and cyclic vomiting syndrome.

Eighteen patients had the classic salt-wasting form of CAH, characterized by both glucocorticoid and mineralocorticoid deficiency. Patient 7 presumably had a classic simple virilizing form of CAH; however, he had persistently elevated plasma renin activity, suggesting the need for extra salt and mineralocorticoid therapy. For this reason, all patients were treated with a median cortisol dose of 12.6 mg/m2·d (range, 7.8–17) and a median 9-fluorohydrocortisone acetate dose of 0.1 mg (range, 0.05–0.2). Patient 19 did not receive mineralocorticoid treatment during the 6 months before this study for financial reasons.

None of the patients had been previously evaluated for TART.

Control group

The control group included boys from the community; many of them were classmates or neighbors of patients in the subject group. The exclusion criteria were consanguinity with the patients, testicular or inguinal pathology, or treatment with cortisol or any drugs that could interfere with steroidogenesis.

Study protocol

The boys were evaluated at the Pediatrics Endocrinology Office at the Pontificia Universidad Catolica de Chile, with a complete physical exam performed by a pediatric endocrinologist. Height was measured using a wall-mounted stadiometer. Weight was measured using a manual scale with a 10-g gradation (Seca). Height and body mass index (BMI) were converted into SD scores (SDS) to adjust for chronological age (CA) using National Center for Health Statistics growth reference charts (10), which are applicable to the Chilean population (11). The height SDS (HSDS) was corrected for target height SDS (THSDS): HSDS – THSDS. Pubarche was assessed using the method of Tanner (12). Testicular volume was calculated with a Prader orchidometer and testicular palpation. Penis length (cm) was measured from the pubic ramus to the tip of the glans penis by placing the end of a straight edge ruler against the pubic ramus.

At baseline, a hand radiograph was obtained to determine bone age (BA) using the method of Greulich and Pyle (13). Color Doppler ultrasonography (US) was performed by two experienced pediatric radiologists (C.G. and R.P.) using a high-resolution 12-mHz transducer. Measurements of testicular size were made from frozen images. Testicular and tumor volumes were calculated by US using the ellipse formula: V = L x W x D x 0.52, where V is the volume (ml), L is the maximal length (cm), W is the maximal width (cm), and D is the maximal depth (cm). This reading was performed by two observers who were blind to the patient’s status (C.G. and R.P.).

The tests began between 0800 and 0900 h. A basal blood sample was taken for analysis of 17-OHP, androstenedione (A2), dehydroepiandrosterone sulfate (DHEA-S), FSH, LH, testosterone (T), plasma renin activity (PRA), inhibin B (Inh-B), and anti-Müllerian hormone (AMH).

Serum Inh-B and AMH were used as markers of Sertoli cell function. Interstitial Leydig cell function was evaluated by measuring serum T under basal conditions (T0) and 72 h (T72) after im administration of 5000 IU/m2 β-human chorionic gonadotropin (β-hCG) (Pregnyl; Organon, Roseland, NJ), as previously described (14). The T level at 72 h after Pregnyl (T72) treatment was determined in part by the basal level of T (T0); a high basal level may indicate inadequate control and give a smaller response to β-hCG and lower ratio (T72– T0)/T0. For this reason, we presented both the maximal values and the ratio (T72– T0)/T0 to evaluate how many times the testicular steroidogenic response increased over the basal level. Blood samples were separated immediately after collection, and the plasma was stored at –70 C until analysis.

Hormone assays

Serum Inh-B was assayed using an ELISA kit (DLS-10-84100; Diagnostic Systems Laboratories, Webster, TX). This assay has a sensitivity limit of 7 pg/ml, and the interassay and intraassay coefficients of variation (CV) were 6.7 and 4.6%, respectively. Serum AMH was assayed using the AMH/MIS ELISA kit (DLS-10-14400; Diagnostic Systems), and this assay has a sensitivity limit of 0.006 ng/ml. The interassay and intraassay CV were 6.5 and 3.4%, respectively. FSH and LH were measured by immunoradiometric assays (ACS-Centaro; Bayer, Tarrytown, NY). The detection limits were 0.6 and 0.8 mIU/ml, respectively. The interassay CV were 5.54% for FSH and 7.6% for LH. The serum 17-OHP level was determined by RIA (Diagnostic Products Corp., Los Angeles, CA). The detection limit was 0.1 ng/ml. The interassay CV was 8%. The serum DHEA-S level was determined by a competitive chemiluminescence immunoassay (Immulite 2002; Diagnostic Products). The detection limit was 0.3 µg/ml, and the interassay CV was 8.56%. Serum A2 was determined by RIA (Diagnostic Systems). The detection limit of the RIA was 0.1 ng/ml, whereas the interassay CV was 7.6%. Serum T was determined by an electrochemiluminescent immunoassay (Modular Analytics E 170; Roche, Indianapolis, IN), which had a detection limit of 10 ng/dl and an interassay CV of 3.4%. PRA was determined by RIA (DiaSorin, Stillwater, MN). The detection limit of the PRA was 0.2 ng/ml·h, whereas the interassay CV was 6.7%.

Molecular methods

Genomic DNA was isolated from peripheral blood leukocytes of CAH patients by standard procedures. The mutations Pro30Leu, I2 splice, G110{Delta}8nt, Ile172Asn, Cluster E6, Val281Leu, Leu306 + 1nt, Gln318stop, Arg356Trp, and Pro453Ser were genotyped by allele-specific PCR, as previously described; in Chilean patients with classical CAH, about 80% of the mutated alleles are identified with this method (15).

Ethics

The protocol for this study was approved by the Ethical Committee of the Pontificia Universidad Catolica de Chile. Parents of all children participating in the study gave signed informed consent.

Statistical analysis

Results are expressed as medians and ranges. Statistical analyses were performed using SPSS 10.0 for Windows (SPSS Inc., Chicago, IL). Differences between CAH and control groups were assessed by nonparametric tests (Mann-Whitney U tests) for variables that were not normally distributed. Spearman’s rho was used to determine the associations among Leydig cell function, 17-OHP, Inh-B, and AMH. P values < 0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
Discussion
 References
 
Thirty-two boys were examined, 19 of whom were patients with CAH. Clinical characteristics and DNA analyses of the patients in the CAH group at the beginning of the study are shown in Table 1Go.


View this table:
[in this window]
[in a new window]

  		TABLE 1. Phenotype, CA, BA, HSDS, results of DNA analysis, and glucocorticoid and mineralocorticoid therapy at the time of investigation in 19 male patients with CAH

 
Anthropometrics and physical examinations

At recruitment, the CA (in years) and heights (SDS) were not different between the two groups. In the CAH group, the BMI (SDS) and penis length were greater than those in the control group. No tumors were detected by palpation. Three patients with CAH had pubarche (patient 7, Tanner II; patient 9, Tanner III; patient 18, Tanner II) (Table 2Go).


View this table:
[in this window]
[in a new window]

  		TABLE 2. Anthropometrics and data from physical examinations at recruitment

 
Testicular US

The median testicular volume was 0.6 ml (with a range of 0.27–1.29 ml) and 0.78 ml (with a range of 0.35–1.29 ml; P = 0.065) in the CAH and control groups, respectively. In the CAH group, ultrasound found seven lesions in four of the 19 patients (bilateral lesions in three subjects). The prevalence of TART in CAH was 21%. No masses were found in the control group. The maximal diameter of lesions varied from 0.5–1.0 cm. They were all located adjacent to the mediastinum testis and were all hypoechoic and had ill-defined margins (Fig. 1Go). Patient 6 had right and left testicular volumes of 0.96 and 0.42 ml, respectively; TART were identified in the right testis, with a maximal diameter (and volume) of 0.7 x 0.2 x 0.1 cm (0.007 ml). Patient 7 had right and left testicular volumes of 0.75 and 0.7 ml, respectively; TART were identified in both testes with a maximal diameter (and volume) of 1.0 x 0.3 x 0.4 cm (0.06 ml) and 0.8 x 0.3 x 0.3 cm (0.04 ml), respectively. Patient 9 had right and left testicular volumes of 1.38 and 1.2 ml, respectively; TART were identified in both testes with a maximal diameter (and volume) of 0.6 x 0.3 x 0.4 cm (0.04 ml) and 0.5 x 0.3 x 0.3 cm (0.02 ml), respectively. Patient 18 had right and left testicular volumes of 0.7 and 0.9 ml, respectively; TART were identified in both testes with a maximal diameter (and volume) of 0.6 x 0.8 x 0.4 cm (0.1 ml) and 0.8 x 0.8 x 0.4 cm (0.13 ml), respectively.


Figure 1
View larger version (106K):
[in this window]
[in a new window]

  		FIG. 1. Patient 18. Sagittal (A) and transverse (B) US of the right testicle show an intratesticular, hypoechoic, and ill-defined lesion, measuring 0.8 x 0.6 x 0.4 cm, that is located around the mediastinum testis (arrows).

 
Hormone profile

17-OHP was higher in the CAH group [6.6 (range, 0.1–556) ng/ml)] compared with the control group [0.8 (0.2–1.1) ng/ml; P = 0.007; Fig. 2AGo]. No significant differences were found in basal T (however, all the individuals in the control group had basal T < 10 ng/dl) [10 (10–163) vs. <10 ng/dl; P = 0.32; Fig. 2BGo], A2 [0.2 (0.1–15.8) vs. 0.3 (0.1–0.4) ng/ml; P = 0.97], DHEA-S [<0.3 vs. 0.3 (0.3–0.97) µg/ml; P = 0.28], FSH [0.6 (0.6–2.2) vs. 0.6 (0.6–2.9) mIU/ml; P = 0.97], LH [<0.8 vs. <0.8 mIU/ml; P = 1.0], or PRA [1.5 (0.2–75) vs. 2.9 (1.3–11) ng/ml·h; P = 0.108] between the CAH and control groups.


Figure 2
View larger version (21K):
[in this window]
[in a new window]

  		FIG. 2. 17-OHP and basal and post-β-hCG treatment levels of T in the CAH and control groups. Data are represented as individual values of 17-OHP on a scatter dot plot graphic. The solid lines are at the median (A). Basal T and post-β-hCG treatment levels of T are presented as symbols and lines in the graphic: •, CAH group; {circ}, control group. Lines are at the median (B). P values are from the Mann-Whitney U test. Patients 6, 7, 9, and 18 had TART.

 
In the CAH group, four patients were currently under control as characterized by basal elevated T (in pubertal range) and high levels of 17-OHP (patients 2, 6, 9, and 13), two of them had TART (patients 6 and 9). The other two subjects with TART (patients 7 and 18) had a basal T less than 10 ng/dl with a 17-OHP of 2.7 and 62.5 ng/ml, respectively. The accelerated BA in patient 18 (Table 1Go) suggests that he was probably under control for a long time.

Leydig cell function

After 72 h of β-hCG treatment, the maximal T level was lower in the CAH group than in the control group [78 (33–403) vs. 143 (60–413) ng/dl; P = 0.02; Fig. 2BGo]. Moreover, the ratio between (T72– T0)/T0 was lower in the CAH group [5.6 (–0.26–39.3)] compared with the control group [13.3 (5.0–40); P < 0.01; Fig. 3AGo].


Figure 3
View larger version (12K):
[in this window]
[in a new window]

  		FIG. 3. Leydig and Sertoli cell function in the CAH and control groups. Data are shown as a scatter dot plot graphic. Individual values of the ratio between (T72– T0)/T0 (A), Inh-B (B), and AMH (C) are shown. •, CAH group; {circ}, control group. Lines indicate the median value. P values are from the Mann-Whitney U test. Patients 6, 7, 9, and 18 had TART.

 
Serum levels of Inh-B and AMH

Serum Inh-B was significantly lower in the CAH group [49.2 (17.7–89.9) pg/ml] compared with the control group [65.2 (27.2–122) pg/ml; P = 0.018; Fig. 3BGo]. Also, AMH was lower in the CAH group [70.1 (2.1–140) ng/ml] than in the control group [94.2 (47.5–307.7) ng/ml; P = 0.002; Fig. 3CGo]. In the CAH group, Inh-B and AMH were directly associated (rho = 0.556; P = 0.013).

Correlations between Inh-B and AMH with Leydig cell function

The associations between Leydig cell function and Inh-B (rho = 0.490; P = 0.004) and AMH (rho = 0.485; P = 0.005), as defined by the ratio (T72– T0)/T0, were directly proportional in all groups (CAH and control; Fig. 4Go). Lower values of Inh-B and AMH were associated with lower Leydig cell function, especially in the CAH group, particularly the ones with TART. In the CAH group, a significant inverse correlation was found between Leydig cell function and 17-OHP (rho = –0.622; P = 0.004) but not with Inh-B (rho = –0.047; P = 0.85) and AMH (rho = –0.204; P = 0.401).


Figure 4
View larger version (17K):
[in this window]
[in a new window]

  		FIG. 4. Correlations between Leydig cell function and Inh-B (A) and AMH (B) in all groups. •, CAH group; {circ}, control group.

 
Clinical and hormonal status in the CAH group with and without TART

In the CAH group, the boys with TART were older than the boys without TART [7.8 (7.7–9.6) vs. 4.7 (2.7–6.7) yr old; P = 0.002] and had higher plasma levels of 17-OHP [105.7 (2.7–556) vs. 4.1 (0.1–201) ng/ml; P = 0.049]. Of the four patients with TART, three (patients 6, 9, and 18) had extremely high plasma levels of 17-OHP (148, 556, and 62 ng/ml, respectively; Fig. 2AGo). The BA/CA ratio [1.3 (1.1–1.9) vs. 1.1 (0.8–1.7); P = 0.08] and HSDS – THSDS [1.6 (0.8–3.7) vs. 0.7 (–0.7–3.3) SDS; P = 0.079] were similar in both subgroups.

There were no differences in the ratio (T72– T0)/T0 [2.4 (–0.26–8.8) vs. 5.7 (0.9–39.3); P = 0.185] or serum Inh-B [41.9 (37.9–58.5) vs. 52.6 (17.7–89.9) pg/ml; P = 0.721] between the CAH group with TART compared with the CAH group without TART. AMH was significantly lower in the CAH group with TART compared with the CAH group without TART [40.7 (2.1–45.6) vs. 73.6 (34–140) ng/ml; P = 0.009]. Patient 9 had the lowest AMH (2 ng/ml) and the highest basal T level (163 ng/dl) in the whole group; this subject had bilateral TART and poor adherence to treatment.

Of the four patients with TART, three of them had poor response to β-hCG treatment (under the minimum range of the control group; Fig. 3AGo), which was associated with a high level of 17-OHP (patients 6, 9, and 18), and two subjects had elevated basal T levels (patients 6 and 9; Fig. 2BGo). Patient 7 had a basal T less than 10 ng/dl with a 17-OHP of 2.7 ng/ml with a (T72– T0)/T0 that was comparable with the control group.


   Discussion
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
References
 
Our results show that TART can be detected from childhood in boys with classical CAH and appear to be associated with inadequate control of CAH. The differences in markers of gonadal function occurring in children with CAH suggest a possible dysfunction in a subgroup of these patients, especially among boys with high basal androgen levels.

In 1940, Wilkins et al. (16) reported the presence of testicular masses in male patients with CAH due to 21-hydroxylase deficiency, so-called TART. Histologically, by electron microscopy, TART resemble Leydig cell tumors with features that are consistent with steroid-secreting cells. However, unlike Leydig cell tumors, they never contain Reinke crystalloids. The most likely pathological diagnosis is Leydig cell tumor. The associated clinical and laboratory features, including a high frequency of bilaterality and a decrease in the size of the tumor with corticosteroid therapy, are important in the diagnosis of TART (17).

Rutgers et al. (17) proposed that these masses could originate from hilar pluripotent cells, which proliferate as a result of elevated levels of ACTH. Recently, an interesting study identified and characterized a novel population of adrenal-like cells that appear in mouse testes during embryonic development and are found in adulthood. This experiment provides evidence that these cells exhibit mixed adrenal and Leydig cell properties; they express the adrenal markers Cyp11b1, Cyp21, and Cyp17 and respond to ACTH and hCG stimulation, but they do not express the Leydig cell-specific marker insulin-like factor 3. This indicates that they are a population of steroidogenic cells distinct from Leydig cells that migrate from the gonad/mesonephros border during development and that they are likely equivalent to precursors of the adrenal rest tumors found in patients with CAH (5).

Depending on the detection method (palpation vs. US), the prevalence of TART varied from 0–95% (8). US is considered the method of choice for the study of TART, because it is as sensitive as magnetic resonance imaging but is more accessible (18).

This study of 19 male patients with CAH showed TART in four patients. The TART incidence in children is less then that reported for adolescents and adults (8), which, according to their lower age, is expected. In our study, boys with CAH and TART were older and had higher levels of 17-OHP than boys with CAH without TART. It is possible that there is a higher prevalence in adolescents because adults and poor control patients are more likely to have hyperplastic cells due to LH- and ACTH-mediated stimulation.

Stikkelbroeck et al. (19) described that all TART in their patients were located adjacent to the mediastinum testis and that small TART (<2 cm) were hypoechoic; the same characteristics were found in our CAH group with TART.

Many authors have suggested that infertility in patients with CAH could originate during the prenatal stages or during childhood (8, 20, 21). Studying testicular activity during the prepubertal period is difficult because it has classically been considered a quiescent phase. However, the combined analysis of Sertoli cell markers and T in basal and hCG-stimulated conditions enhances our ability to diagnose the underlying endocrine defect, as in our study (22).

Different mechanisms have been proposed to explain infertility in males with CAH. The location of TART near the testicular mediastinum can lead to the obstruction of seminiferous tubules. The steroids produced by the tumors may reach the circulation and interfere with the secretion of FSH and LH by the pituitary, or there could be a steroidogenic enzyme defect due to paracrine toxicity. However, some of these theories are supported only by case reports (23, 24).

The response of T to β-hCG has long been used to successfully evaluate the presence or absence of testicular tissue and to elucidate defects of T biosynthesis or function (25, 26, 27). Work by Combes-Moukhovsky et al. (24) showed no response to β-hCG in a prepubertal boy with TART and postulated that, in this case, the normal testicular tissue was either nonfunctional or was destroyed. In adolescents and adults with CAH, Leydig cell dysfunction has also been reported (8). In our study, we show that some patients with CAH have a lower testicular response to β-hCG stimulation, which was inversely proportional to the basal level of 17-OHP. Lower LH receptor responses to β-hCG could be associated with Leydig cell dysfunction in a subgroup of patients with CAH or with suppression of the gonadostat by endogenous adrenal steroids and may not necessarily indicate testicular damage per se.

Inh-B is accepted as a marker of Sertoli cell function in children (28, 29, 30) and adults (31, 32, 33). Measurements of AMH have been used to determine testicular status in prepubertal children with nonpalpable gonads, thus differentiating anorchia from undescended testes in boys with bilateral cryptorchidism, and serve as a measure of testicular integrity in children with intersexual anomalies (34). These new markers may contribute to a better understanding of the regulation of hypothalamic-pituitary-gonadal axis function and the physiopathology of the mechanisms involved in sexual differentiation and/or fertility disorders (35).

Around the onset of puberty, Sertoli cells undergo a radical change in their morphology and function. There is also an increase in T concentration at puberty, coincident with androgen receptor expression in Sertoli cells. Together, all of these factors induce a change from an immature, proliferative state (which produces AMH) to a mature, nonproliferative state (36). After puberty, AMH becomes low or undetectable due to down-regulation of AMH production by T (37). In patients with either central or gonadotropin-independent precocious puberty, the hormonal regulatory mechanisms of AMH secretion are androgen mediated and are independent of gonadotropins, as we observed in one of our patients (38). We did not perform an LHRH test to evaluate central precocious puberty; however, boys with TART and lower AMH levels also had lower Inh-B, which usually increases with the progression of puberty in boys.

The lower levels of Inh-B and AMH observed in the CAH group could reflect gonadal dysfunction in a subgroup of these children, associated with inadequate control and TART. We could postulate that in patients with uncontrolled CAH, high levels of T could stimulate the androgen receptor and induce premature maturation of immature Sertoli cells, which could result in a decrease in AMH. If premature maturation of Sertoli cells impacts future fertility, it must be investigated.

In this study, the percentage of identified alleles was lower than previously reported in Chilean patients with CAH (15). Other methods are being implemented to further analyze the patients with unidentified alleles, including sequencing of the CYP21 gene and MPLA for detection of deletions and duplications.

We suggest studying TART with testicular ultrasound in all prepubertal patients with inadequately treated classical CAH and in all patients at the onset of puberty, due to its potential impact on future fertility. In those patients with documented TART, glucocorticoid therapy must be optimized. The suggested follow-up should include periodic assessment of testicular volume with ultrasound and testicular function with measurements of serum Inh-B levels. If TART persists accompanied by an increase in the relation between tumor/testicular parenchymal tissue and/or a lack of increase in serum Inh-B, more aggressive glucocorticoid therapy and eventually testis-sparing surgery must be considered.

In conclusion, in our series, we show that TART could be detected since childhood in boys with classical CAH. We also report differences in markers of gonadal function in these boys compared with the control group, which could reflect a gonadal dysfunction in a specific subgroup of patients with CAH. Its physiopathology could be explained by the paracrine regulatory mechanism of local T produced in TART and Leydig and Sertoli cell functions. More studies are necessary to determine the reversibility of this phenomenon and its impact on future fertility.


   Acknowledgments
 
We thank Linus Holmgren and Fernando Cassorla for their critical review of this manuscript and Ms. Rosario Muñoz for her technical support. We are also indebted to our patients and their families.

Members of the Chilean Collaborative Testicular Adrenal Rest Tumor Study Group include M. L. Alcazar and P. Lacourt (Hospital Sótero del Río), F. Cassorla and E. Codner (Instituto de Investigaciones Materno Infantil, Universidad de Chile), E. Escobar (Clínica el Roble), X. Gaete (Hospital Roberto del Río), H. García and R. Silva (Clínica Santa María), V. Giadrosich (Hospital Carlos Van Buren), and C. Godoy and F. Ugarte (Hospital Exequiel González Cortez).


   Footnotes
 
This work was supported by grants from the Chilean Endocrine and Diabetes Society (SOCHED 2005–06) and DIPUC 12PI.

Disclosure Statement: The authors have nothing to disclose.

First Published Online September 25, 2007

Abbreviations: A2, Androstenedione; AMH, anti-Müllerian hormone; BA, bone age; BMI, body mass index; CA, chronological age; CAH, congenital adrenal hyperplasia; CV, coefficients of variation; DHEA-S, dehydroepiandrosterone sulfate; β-hCG, β-human chorionic gonadotropin; HSDS, height SDS; Inh-B, inhibin B; 17-OHP, 17-hydroxyprogesterone; PRA, plasma renin activity; SDS, SD score; T, testosterone; TART, testicular adrenal rest tumors; THSDS, target height SDS; US, ultrasonography.

Received February 21, 2007.

Accepted September 14, 2007.


   References
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 

  1. Claahsen-van der Grinten HL, Stikkelbroeck NM, Sweep CG, Hermus AR, Otten BJ 2006 Fertility in patients with congenital adrenal hyperplasia. J Pediatr Endocrinol Metab 19:677–685[Medline]
  2. Claahsen-van der Grinten HL, Otten BJ, Takahashi S, Meuleman EJ, Hulsbergen-van de Kaa C, Sweep FC, Hermus AR 2007 Testicular adrenal rest tumors in adult males with congenital adrenal hyperplasia: evaluation of pituitary-gonadal function before and after successful testis-sparing surgery in eight patients. J Clin Endocrinol Metab 92:612–615[Abstract/Free Full Text]
  3. Barwick TD, Malhotra A, Webb JA, Savage MO, Reznek RH 2005 Embryology of the adrenal glands and its relevance to diagnostic imaging. Clin Radiol 60:953–959[CrossRef][Medline]
  4. O’Shaughnessy PJ, Fleming LM, Jackson G, Hochgeschwender U, Reed P, Baker PJ 2003 Adrenocorticotropic hormone directly stimulates testosterone production by the fetal and neonatal mouse testis. Endocrinology 144:3279–3284[Abstract/Free Full Text]
  5. Val P, Jeays-Ward K, Swain A 2006 Identification of a novel population of adrenal-like cells in the mammalian testis. Dev Biol 299:250–256[CrossRef][Medline]
  6. Seidenwurm D, Smathers RL, Kan P, Hoffman A 1985 Intratesticular adrenal rests diagnosed by ultrasound. Radiology 155:479–481[Abstract/Free Full Text]
  7. Johnson RE, Scheithauer B 1982 Massive hyperplasia of testicular adrenal rests in a patient with Nelson’s syndrome. Am J Clin Pathol 77:501–507[Medline]
  8. Stikkelbroeck NM, Otten BJ, Pasic A, Jager GJ, Sweep CG, Noordam K, Hermus AR 2001 High prevalence of testicular adrenal rest tumors, impaired spermatogenesis, and Leydig cell failure in adolescent and adult males with congenital adrenal hyperplasia. J Clin Endocrinol Metab 86):5721–5728
  9. Otten BJ, Stikkelbroeck MM, Claahsen-van der Grinten HL, Hermus AR 2005 Puberty and fertility in congenital adrenal hyperplasia. Endocr Dev 8:54–66[Medline]
  10. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL 2000 CDC growth charts: United States. Adv Data 8:1–27[Medline]
  11. Youlton R, Valenzuela C 1990 Growth patterns in height and weight in children aged 0 to 17 years and cranial circumference in children aged 0 to 2 years from medium-high and high socioeconomic status in Santiago. Comparison with growth in children from medium-low and low status in the Northern area of Santiago. Rev Chil Pediatr 1–22
  12. Tanner JM 1981 Growth and maturation during adolescence. Nutr Rev 39:43–55[Medline]
  13. Greulich WW, Pyle SI 1959 Radiographic atlas of skeletal development of the hand and wrist. 2nd ed. Stanford, CA: Stanford University Press
  14. Knorr D, Beckmann D, Bidlingmaier F, Helmig FJ, Sippell WG 1979 Plasma testosterone in male puberty. II. hCG stimulation test in boys with hypospadia. Acta Endocrinol (Copenh) 90:365–371[Abstract/Free Full Text]
  15. Fardella CE, Poggi H, Pineda P, Soto J, Torrealba I, Cattani A, Oestreicher E, Foradori A 1998 Salt-wasting congenital adrenal hyperplasia: detection of mutations in CYP21B gene in a Chilean population. J Clin Endocrinol Metab 83:3357–3360[Abstract/Free Full Text]
  16. Wilkins L, Fleishmann W, Howard JE 1940 Macrogenitosomia precox associated with hyperplasia of the androgenic tissue of the adrenal and death from corticoadrenal insufficiency. Endocrinology 26:385–395[Abstract/Free Full Text]
  17. Rutgers JL, Young RH, Scully RE 1988 The testicular "tumor" of the adrenogenital syndrome. A report of six cases and review of the literature on testicular masses in patients with adrenocortical disorders. Am J Surg Pathol 12:503–513[Medline]
  18. Avila NA, Premkumar A, Merke DP 1999 Testicular adrenal rest tissue in congenital adrenal hyperplasia: comparison of MR imaging and sonographic findings. AJR Am J Roentgenol 172:1003–1006[Abstract/Free Full Text]
  19. Stikkelbroeck NM, Suliman HM, Otten BJ, Hermus AR, Blickman JG, Jager GJ 2003 Testicular adrenal rest tumors in postpubertal males with congenital adrenal hyperplasia: sonographic and MR features. Eur Radiol 13:1597–1603[CrossRef][Medline]
  20. Bonaccorsi AC, Adler I, Figueiredo JG 1987 Male infertility due to congenital adrenal hyperplasia: testicular biopsy findings, hormonal evaluation, and therapeutic results in three patients. Fertil Steril 47:664–670[Medline]
  21. Murphy H, George C, de Kretser D, Judd S 2001 Successful treatment with ICSI of infertility caused by azoospermia associated with adrenal rests in the testes: case report. Hum Reprod 16:263–267[Abstract/Free Full Text]
  22. Kubini K, Zachmann M, Albers N, Hiort O, Bettendorf M, Wolfle J, Bidlingmaier F, Klingmuller D 2000 Basal inhibin B and the testosterone response to human chorionic gonadotropin correlate in prepubertal boys. J Clin Endocrinol Metab 85:134–138[Abstract/Free Full Text]
  23. Clark RV, Albertson BD, Munabi A, Cassorla F, Aguilera G, Warren DW, Sherins RJ, Loriaux DL 1990 Steroidogenic enzyme activities, morphology, and receptor studies of a testicular adrenal rest in a patient with congenital adrenal hyperplasia. J Clin Endocrinol Metab 70:1408–1413[Abstract/Free Full Text]
  24. Combes-Moukhovsky ME, Kottler ML, Valensi P, Boudou P, Sibony M, Attali JR 1994 Gonadal and adrenal catheterization during adrenal suppression and gonadal stimulation in a patient with bilateral testicular tumors and congenital adrenal hyperplasia. J Clin Endocrinol Metab 79:1390–1394[Abstract]
  25. Forest MG 1979 Pattern of the response of testosterone and its precursors to human chorionic gonadotropin stimulation in relation to age in infants and children. J Clin Endocrinol Metab 49:132–137[Abstract/Free Full Text]
  26. Dunkel L, Perheentupa J, Apter D 1985 Kinetics of the steroidogenic response to single versus repeated doses of human chorionic gonadotropin in boys in prepuberty and early puberty. Pediatr Res 19:1–4[Medline]
  27. Davenport M, Brain C, Vandenberg C, Zappala S, Duffy P, Ransley PG, Grant D 1995 The use of the hCG stimulation test in the endocrine evaluation of cryptorchidism. Br J Urol 76:790–794[Medline]
  28. Crofton PM, Thomson AB, Evans AE, Groome NP, Bath LE, Kelnar CJ, Wallace WH 2003 Is inhibin B a potential marker of gonadotoxicity in prepubertal children treated for cancer? Clin Endocrinol (Oxf) 58:296–301[CrossRef][Medline]
  29. Trigo RV, Bergada I, Rey R, Ballerini MG, Bedecarras P, Bergada C, Gottlieb S, Campo S 2004 Altered serum profile of inhibin B, Pro-{alpha}C and anti-Mullerian hormone in prepubertal and pubertal boys with varicocele. Clin Endocrinol (Oxf) 60:758–764[CrossRef][Medline]
  30. Bordallo MA, Guimaraes MM, Pessoa CH, Carrico MK, Dimetz T, Gazolla HM, Dobbin J, Castilho IA 2004 Decreased serum inhibin B/FSH ratio as a marker of Sertoli cell function in male survivors after chemotherapy in childhood and adolescence. J Pediatr Endocrinol Metab 17:879–887[Medline]
  31. Jensen TK, Andersson AM, Hjollund NH, Scheike T, Kolstad H, Giwercman A, Henriksen TB, Ernst E, Bonde JP, Olsen J, McNeilly A, Groome NP, Skakkebaek NE 1997 Inhibin B as a serum marker of spermatogenesis: correlation to differences in sperm concentration and follicle-stimulating hormone levels. A study of 349 Danish men. J Clin Endocrinol Metab 82:4059–4063[Abstract/Free Full Text]
  32. Anawalt BD, Bebb RA, Matsumoto AM, Groome NP, Illingworth PJ, McNeilly AS, Bremner WJ 1999 Serum inhibin B levels reflect Sertoli cell function in normal men and men with testicular dysfunction. J Clin Endocrinol Metab 81:3341–3345[CrossRef]
  33. Andersson AM, Petersen JH, Jorgensen N, Jensen TK, Skakkebaek NE 2004 Serum inhibin B and follicle-stimulating hormone levels as tools in the evaluation of infertile men: significance of adequate reference values from proven fertile men. J Clin Endocrinol Metab 89:2873–2879[Abstract/Free Full Text]
  34. Lee MM, Donahoe PK, Silverman BL, Hasegawa T, Hasegawa Y, Gustafson ML, Chang, YC, MacLaughlin DT 1997 Measurements of serum Mullerian inhibiting substance in the evaluation of children with nonpalpable gonads. N Engl J Med 336:1480–1486[Abstract/Free Full Text]
  35. Bergada I, Bergada C, Campo S 2001 Role of inhibins in childhood and puberty. J Pediatr Endocrinol Metab 14:343–353[Medline]
  36. Sharpe RM, McKinnell C, Kivlin C, Fisher JS 2003 Proliferation and functional maturation of Sertoli cells, and their relevance to disorders of testis function in adulthood. Reproduction 125:769–784[Abstract]
  37. Josso N 1995 Pediatric applications of anti-Mullerian hormone research. 1992 Andrea Prader Lecture. Horm Res 43:243–248[Medline]
  38. Rey R, Lordereau-Richard I, Carel JC, Barbet P, Cate RL, Roger M, Chaussain JL, Josso N 1993 Anti-Mullerian hormone and testosterone serum levels are inversely during normal and precocious pubertal development. J Clin Endocrinol Metab 77:1220–1226[Abstract]



This article has been cited by other articles:


Home page
 J. Clin. Endocrinol. Metab.Home page
N. Reisch, L. Flade, M. Scherr, M. Rottenkolber, F. Pedrosa Gil, M. Bidlingmaier, H. Wolff, H.-P. Schwarz, M. Quinkler, F. Beuschlein, et al.
High Prevalence of Reduced Fecundity in Men with Congenital Adrenal Hyperplasia
J. Clin. Endocrinol. Metab., May 1, 2009; 94(5): 1665 - 1670.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Submit a related Letter to the Editor
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Reprints, Permissions and Rights
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Martinez-Aguayo, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Martinez-Aguayo, A.
Related Collections
Right arrow Adrenal and Hypertension
Right arrow Pediatric Endocrinology
Right arrow Male Endocrinology

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Endocrinology Endocrine Reviews J. Clin. End. & Metab.
Molecular Endocrinology Recent Prog. Horm. Res. All Endocrine Journals