Clinical Genetics 1976: 9: 61-70
Chromosome studies in ovarian hypoplasia J. L~szLO,MAGDA G A ~ LAND , P. BBSZE
Cytogenetic Laboratory of the Department of Gynaecology and Obstetrics, Postgraduate Medical School and Department of Pathology, Institute for Medicine of Physical Education and Sports, Budapest, Hungary Six phenotypic female patients characterized by an average stature, infantile body constitution, underdeveloped external and internal reproductive organs and secondary sex characteristics and amenorrhoea are described. In each of them laparotomy and histological study disclosed ovarian hypoplasia. The karyotype was 46,XX in all patients except one. However, the metaphase analysis extending over a greater than usual number of cells revealed an autosomal ring (15) in 5 to 26 % of cells. The patients also showed phenotype signs of D chromosome anomalies. The authors agree with the previously suggested autosoma1 gene effect in sex differentiation. Received 21 March, accepted for publicaiion 2 May 1975
The different forms of female hypogonadism have been variously defined in the past. Recently they have been classified into two main groups, namely Turner’s syndrome and pure gonadal dysgenesis, or Swyer’s syndrome. Certain authors, Polani (1969) and Hamerton (1971) among others, classified the cases associated with a hypoplasia or incomplete dysgenesis of the ovary into the second group although these differ from pure gonadal dysgenesis in many respects. On the basis of literary data (e.g. MBlkova et al. 1974) and our own experience, we regard gonadal hypoplasia as an independent disease entity. Ovarian hypoplasia is very similar in appearance to pure gonadal dysgenesis but differs from it in clinical course, hormone excretion (low estrogen and high gonadotrophin excretion) and above all, in respect of the constitution of the gonads proper. While streak gonads without primordial follicles are a funda-
mental criterion of pure gonadal dysgenesis, ovarian hypoplasia is characterized by smaller than normal ovaries containing remnants of the follicular apparatus. The basic clinical characteristics of the syndrome are a n average or tall stature, underdeveloped secondary sex characteristics, a hypoplasia of the external and internal genital organs and primary amenorrhoea o r raromenorrhoea. Estrogen excretion is very low, and the vaginal smear is atrophic, chiefly basal and parabasal cells being found. An important difference from primary pituitary disease is that the output of urinary gonadotrophins is usually elevated. The patients are chromatin-positive, and have a normal 46,XX chromosome pattern. Christakos et al. (1969) and Nielsen & Friedrich (1971) demonstrated autosomal anomalies in pure gonadal dysgenesis and have pointed out that autosomal aberrations
uterine hypopl.
rudimentary uterus, vaginal aplasia
Genital organs
+ primary
-
+
primary
-
Ovarian hypoplasia verified by laparotomy and histology
Amenorrhoea
Pregnancy
uterine and vaginal hyPoPl.
hypoplastic sella
kyphoscoliosis kyphoscoliosis herniation of nucleus pu Iposus osteoporosis
Bones
-
raromenorrhoea
t
mamma hypopl.
54 infantile shield chest cubitus valg. genu valgum hypotrichosis mamma hypopl. high-arched palate min. webbing of the neck
17 166 44
Case 3 V.M.
53
27 156
Case 2 K.F.
infantile shield chest cubitus valg. genu valgum hypotrichosis mamma hypopl. blue sclera
37 164
Case 1 A.J.
Phenotype and secondary sex characteristics
Age (years) Height (cm) Weight (kg)
Clinical data 23 157
19 164 75
virile
16 162 38
infantile
primary
secondary
+
uterine hypopl.
uterine hypopl.
+
hypoplastic sella spina bifida occulta
acromegaloid
hairlessness hypertrichosis mamma hypopl. mamma hypopl. on nape of neck obesity min. webbing of neck
primary
+
uterine and vaginal hypopl., infantile vulva
hypoplastic sella short middle phalanx of 5th finger delayed ossification
infantile shield chest cubitus valg. genu valgum hairlessness mamma hypopl. short neck
68
Case 6 M.E.
B.J.
Case 4
Case 5 V.K.
Clinical and cytogenetic data
Table 1
63
OVARIAN HYPOPLASIA
might also be held responsible for the disease. This is in good accordance with the opinion of Hamerton (1971) and others that autosomal modifiers may play a part in sexual development. In view of the above considerations it seemed worthwhile to analyse the karyotype of six patients with a 46,XX chromosome constellation and ovarian hypoplasia.
C
-
m
G; r
2 c
8
L
X
5
Material and Methods
s
x+$-
3
Ovarian hypoplasia was verified by laparotomy and biopsy samples of the gonads were studied histologically. Chromosome analysis was performed on short-term lymphocyte cultures according to the Moorhead technique (Moorhead et al. 1960) as modified by Hungerford (1965). In each case 200 lymphocyte metaphases were examined. The karyotypes were also studied by the fluorescence technique, Giemsa banding and autoradiography. Gonadal specimens were embedded in paraffin and the slides were stained with haematoxylin and eosin, van Gieson and Masson’s trichrome stain. The hormonal state of the patients was checked regularly by vaginal smears. Estrogen and gonadotrophin output was determined in urine.
Y
f
c L
01
2
c
m 0
c 8
a 0
Y
g X
s+$
K
N 0
c h
a
2 c
2
In r L
Case Reports
E i .-
The clinical and cytogenetic data of the six patients are shown in Table 1. Cases 2 and 6 are reviewed here in greater detail.
E
s r
z
..-E -.a
a c 2. a .a
-n n
*
I
Case 2, K.F., aged 27 years has never had a menstrual cycle. There is a negative familial and perinatal history. The patient’s phenotype is infantile, she is 156 cm tall, has a shield chest, cubitus valgus and genu valgum. The breasts are hypoplastic, and pubic and axillary hair is very scanty. X-ray examination revealed a distinct kyphoscoliosis and gynaecological examination a vaginal
64
L A S Z L O , G A A L , A N D BC)SZE
Flg. 1. Photograph of Case 2 showing obvious signs of infantilism and an absence of publc halr. Rlght: characteristic micrognathia, sllght ptosls, broad nasal bridge and facial asymmetry.
Flg. 2. Hypogonadism, obesity and protruding maxillary bone in Case 6.
OVARIAN HYPOPLASIA
hypoplasia and a small uterus. A bundlelike structure is palpable at the site of the ovaries. Laboratory findings are as follows: urinary estrogen: 6.1 pgI24 h; 17 KS value: 6.5 mg/24 h; 17 KGS value: 7.6 mg/24 h; PBI: 8.25 pg %. Vaginal cytological examination showed complete atrophy. The M.I. was lOO/O/O. Anomalies in the phenotype were seen as slight microcephalia, senile facies, distinct micrognathia, facial asymmetry, and ptosis
65
and hyperflexibility of the fingers. The patient is chromatin-positive. The karyotype is 46,XX/46,XX r,JD/- A D ring was found in 20 % of the cells. When laparotomy was performed in 1966, a rudimentary uterus and hypoplastic ovaries were found. Biopsy was made from the left ovary, which consisted of a thicker tunica albuginea and a narrow layer of fibrous ovarian cortical tissue packed with cells and covered with germinal epithelium. Many closely packed
Fig. 3. Characteristic hypoplastic ovary in Case 6. Bottam: closely packed degenerated primordial follicles beneath a dense layer of cortical connective tissue.
66
LASZL6. GAAL. AND BOSZE
primordial follicles embedded in thick fibrous tissue were present in the cortical connective tissue. Neither Graafian follicles, nor any indication of follicle maturation were found. The medulla was broader, apparently at the expense of the cortex. The sharply demarcated mesovarium contained mesonephrogenic remnants and degenerated vessels with thick hyalinized walls. The diagnosis was ovarian hypoplasia and primary amenorrhoea. Case 6, M.E., aged 23 years had a negative familial and perinatal history. Body growth was normal. She had an infantile phenotype with an inclination to obesity. Height was 157 cm, body weight 68 kg. She has never
had a menstrual bleeding. Short neck, shield chest, cubitus valgus, and genu valgum were seen. The breasts were hypoplastic and axillary and pubic hair were absent. X-ray examination revealed a small sella and delayed ossification. The middle phalanx of the fifth finger was shorter than normal. GynaecoIogical examination revealed infantile external genitalia, underdeveloped uterus and vagina. Laboratory findings were as follows: urinary estrogen: 3.7 pg/24 h; 17 KS value: 7.8 mg/24 h; 17 KGS value: 8.3 mg/24 h; PBI: 5.0 yg %. Vaginal cytological examination showed complete atrophy. The M.I. was lOO/O/O. The abnormal phenotype showed moderate microcephaly, micrognathia and epi-
Flg. 4. Case 1. Top: 46,XX karyotype with ring of autosome 15. Bottom: C and D group chromosomes with Giemsa banding technique.
OVARIAN HYPOPLASIA
canthic folds, prominent nose and maxilla, large ears, and hypertelorism. Marked hyperflexibility of the fingers was noted. The Barr body is positive. The patient’s karyotype is 46,XX/46,XX r/D/. A ring chromosome was found in 5 % of the cells. Laparotomy, performed in 1970, revealed an underdeveloped uterus and small hypoplastic ovaries. Biopsy was made from the right ovary. Pathohistological findings: the narrow ovarian cortex was covered with germinal epithelium and contained many closely packed and in part, degenerated primordial follicles. There were no signs of follicle ripening. The thicker widened medulla was sharply separated from the cortex and contained a few follicular cysts and some atretic follicles. Both the medulla and mesovarium were richly vascularized. The arterial walls showed definite hyaline degeneration. The diagnosis was ovarian hypoplasia and primary amenorrhoea. Discussion
The above described six patients (all of female phenotype) had an average stature,
Fig. 5. D chromosomes of Case 3 with normal Giemsa and quinacrine staining technique.
67
Fig. 6. D ring of autosome 15 of Case 4.
an infantile constitution, underdeveloped secondary sex characteristics, a short neck, cubitus valgus and genu valgum, hypotrichosis, underdeveloped external and internal genital organs, amenorrhoea or raromenorrhoea. Histological examination of the abnormally small ovaries showed a narrow cortex with many partly degenerated, primordial follicles embedded in dense cortical fibrous tissue. The broader medulla was sharply separated from the narrower cortex and contained follicular cysts in its loose, richly vascularized tissue. There were some atretic follicles, but neither corpus luteum nor corpora albicantia were present. Five patients had a modal chromosome number of 46,XX while one had a mosaic 47,XXX karyotype including an X fragment verified by autoradiography. In these six cases of ovarian hypoplasia 5 to 26 % of the carefully studied 200 metaphase cells contained a D ring, most likely belonging
Fig. 7. Case 5. D ring occurring in 8 % of cells.
68
LASZL6, GAAL, AND BdSZE
to autosome 15 according to the fluorescent and Giemsa banding techniques, a consistent finding except for Case 6 who, on the other hand, displayed a D monosomy in about 10 % of cells. In the case of ring formation there is of course no means to identify the affected part of the chromosome or to give an estimate of the loss in genetic substance. Thus any attempt to create a standard phenotypic pattern is obviously difficult. The anomalies include as a rule changes that are related to the deletion of both the long and the short arm, or even ones that are due to a duplication of certain parts in the abnormal chromosome, though the latter changes show considerable variation (Gilgenkrantz et al. 1971, Hecht & Vlietnick 1973). The ring may be completely missing from one cell line, while it appears in a duplicate form in the other, thus giving rise to myxoploidy and variability of the phenotype. The signs associated with the ring of a D group chromosome are very similar to those of the Dq- syndrome. In most cases they are associated with mental retardation and congenital malformations, such as microcephaly, hypertelorism, protruding nasal bridge, anomalous development of the eyes,
large and malformed external ears, epicanthic folds, four-finger crease, and several other anomalies, such as brain, heart and kidney malformations (Lejeune et al. 1968, Gilgenkrantz et al. 1971). Allerdice et al. (1969) regard the presence of a prominent maxilla, facial asymmetry and dental anomalies as additional signs (Table 2). Gonadal agenesis or hypoplasia was first considered by Toews & Jones (1968) to be the result of an aberration of the D chromosome (D-trisomy). Reviewing the literature they found that an anomalous development of the uterus, Fallopian tubes and external genital organs was reported in 80 % of the D-trisomy cases. In a majority of the cases the ovaries also revealed both gross and microscopic lesions characteristic of hypoplasia. On the basis of the above mentioned data Toews & Jones (1968) suggested that autosomal gene effects might have a role in the development of the genital organs and that these developmental anomalies might be a result of autosomal mutations. This theory agrees with those of Christakos et al. (1969) Nielsen & Friedrich (1971), and others, who feel that small autosoma1 deletions may have an important role in the pathogenesis of gonadal hypoplasia.
Table 2 Phenotype signs of D ring Case 1 A.J.
D ring per 100 cells Microcephaly Senile face Facial asymmetry Microphthalmia Epicanthic folds Ptosis Protruding nose and maxilla Anomaly of the ears Hypertelorism Harelip, cleft palate Micrognathia Hyperflexibility of fingers
Case 2 K.F. 20
+ + +
-
++ +
Case 3 V.M.
Case 4 B.J.
Case 5 V.K.
Case 6 M.E.
OVARIAN HYPOPLASIA
Cohen et al. (1967) discovered a pericentric inversion of a D chromosome in a case of primary amenorrhoea and gonadal dysgenesis, further confirming this hypothesis. Witschi (1951), Jones et al. (1963), Ford (1970), Boczkowski & Mikkelsen (1973) and others attribute an important role to the genes of the X chromosomes in gonadal differentiation, but d o not debate the significance of an autosomal control influence. They emphasize, however, that in the preservation of primordial follicles germ cells are as actively involved as the somatic elements of the ovary. In our cases of ovarian hypoplasia the presence of primordial follicles was in accordance with the normal sex chromosome complement of the patients, but the ripening of the primordial follicles grouping in the ovarian cortex seemed to be hindered. The microscopic picture of the gonad is similar to one of an infantile ovary. In the cases studied cytogenetically we could find a low but consistent occurrence of D chromosome aberration. Some of the phenotypic alterations characteristic of a D chromosome abnormality were also found in all these patients. There is a possibility that the histologically demonstrable degeneration of the gonads may be connected with autosomal anomalies. The present study appears to lend further support to the assumption forwarded by other authors that, in addition to the relevant role of sex chromosomes, autosomal gene effects are also involved in controlling sexual differentiation. It is as yet too early to draw definite conclusions, but the necessity of a large scale and careful analysis of karyotypes, as well as of autosomes, in every case where the sex chromosome pattern is insufficient for an adequate explanation of gonadal hypoplasia and phenotype anomalies should be emphasized.
69 References
Allerdice, P. W., J. G. Davis, 0. J. Miller, H. P. Klinger, D. Warburton, D. A. Miller, F. H. Allen, C. A. L. Abrams & E. McGilvray (1969). The 13q- deletion syndrome. Amer. J . hum. Genet. 21, 499-512.
Boczkowski, K. & M. Mikkelsen (1973). Fluorescence and autoradiographic studies in patients with Turner's syndrome and 46,XXpand 46,XXq- karyotypes. J . med. Genet. 10, 350-355.
Christakos, A. C., J. L. Simpson, J. B. Younger & C. D. Christian (1969). Gonadal dysgenesis as an autosomal recessive condition. Amer. J . Ohstet. Gynec. 104, 1027-1039.
Cohen, M. M., V. J. Capraro & N. Takagi (1967). Pericentric inversion in a group D chromosome (13-15) associated with amenorrhoea and gonadal dysgenesis. Ann. hum. Genet. 30, 313-323. Ford, C. E. (1970). Cytogenetics and sex determination in man and mammals. J . biosoc. Sci. Suppl. 2, 7-30.
Gilgenkrantz, S., C. Gabrol, C. Lausecker, M. E. Hartleyb & B. Bohe (1971). Le syndrome Dr. Etude d'un nouveau cas (46,XX, 14r). Ann. GknCt. 14, 23-31.
Hamerton, J. L. (1971). Human Cytogenetics. New York, London, Academic Press. Hecht, F. & R. F. Vlietnick (1973). Autosomal ring and variable phenotypes. Humangenetik 18, 99-100.
Hungerford, D. A. (1965). Leukocytes cultured from small inocula of whole blood and the preparation of metaphase chromosomes by treatment with hypotonic KCL. Stain Technol. 40, 333-338.
Jones, H. W. Jr., M. A. Ferguson-Smith & R. H. Heller (1963). The pathology and cytogenetics of gonadal agenesis. Amer. J. Obstet. Gynec. 87, 578-600.
Lejeune, J., J. Lafourcade, R. Berger, J. Cuveiller, M. 0. Rethor6, B. Dutrillaux, D. Abonyi & H. Jerom (1968). Le phtnotyp Dr. Etude de trois cas de chromosomes D en anneau. Ann. Ge'ne't. 11, 79-87.
MBlkova, J., R. Chrz, K. Motlik, L. Starka, J. KobilkovA & E. SilinkovB-Malkovh (1974). 46,XX gonadal dysgenesis and ovarian hypoplasia. Humangenetik 23, 205-211. Moorhead, P. S., P. C. Nowell, W. J. Mellman, D. M. Battips & D. A. Hungerford (1960). Chromosome preparation of leukocytes cultured from human peripheral blood. Exp. Cell Res. 20, 613-616.
70
LASZL6, GAAL, AND BOSZE
Nielsen, J. & U. Friedrich (1971). Pure gonadal dysgenesis. Clin. Genet. 3, 52-58. Polnni, P. E. (1969). Turner phenotype with normal sex chromosomes. Birth Defects: Original Article Series V . Toews, H. A. & H. W. Jones (1968). Cyclopia in association with D trisomy and gonadal agenesis. Amer. J . Obstet. Gynec. 102, 53-56. Witschi, E. (1951). Embryogenesis of the adrenal and the reproductive glands. Recent Progr. Hormone Res. 6, 1-27.
Address: J . LLiszl6 Cytogenetic Laboratory of the Depurtmcnt of Gynaecology and Obstetrics Postgraduate Medical School 1389 Budapest Szaholcs v . 35 Hungary
Chromosome studies in ovarian hypoplasia J. L~szLO,MAGDA G A ~ LAND , P. BBSZE
Cytogenetic Laboratory of the Department of Gynaecology and Obstetrics, Postgraduate Medical School and Department of Pathology, Institute for Medicine of Physical Education and Sports, Budapest, Hungary Six phenotypic female patients characterized by an average stature, infantile body constitution, underdeveloped external and internal reproductive organs and secondary sex characteristics and amenorrhoea are described. In each of them laparotomy and histological study disclosed ovarian hypoplasia. The karyotype was 46,XX in all patients except one. However, the metaphase analysis extending over a greater than usual number of cells revealed an autosomal ring (15) in 5 to 26 % of cells. The patients also showed phenotype signs of D chromosome anomalies. The authors agree with the previously suggested autosoma1 gene effect in sex differentiation. Received 21 March, accepted for publicaiion 2 May 1975
The different forms of female hypogonadism have been variously defined in the past. Recently they have been classified into two main groups, namely Turner’s syndrome and pure gonadal dysgenesis, or Swyer’s syndrome. Certain authors, Polani (1969) and Hamerton (1971) among others, classified the cases associated with a hypoplasia or incomplete dysgenesis of the ovary into the second group although these differ from pure gonadal dysgenesis in many respects. On the basis of literary data (e.g. MBlkova et al. 1974) and our own experience, we regard gonadal hypoplasia as an independent disease entity. Ovarian hypoplasia is very similar in appearance to pure gonadal dysgenesis but differs from it in clinical course, hormone excretion (low estrogen and high gonadotrophin excretion) and above all, in respect of the constitution of the gonads proper. While streak gonads without primordial follicles are a funda-
mental criterion of pure gonadal dysgenesis, ovarian hypoplasia is characterized by smaller than normal ovaries containing remnants of the follicular apparatus. The basic clinical characteristics of the syndrome are a n average or tall stature, underdeveloped secondary sex characteristics, a hypoplasia of the external and internal genital organs and primary amenorrhoea o r raromenorrhoea. Estrogen excretion is very low, and the vaginal smear is atrophic, chiefly basal and parabasal cells being found. An important difference from primary pituitary disease is that the output of urinary gonadotrophins is usually elevated. The patients are chromatin-positive, and have a normal 46,XX chromosome pattern. Christakos et al. (1969) and Nielsen & Friedrich (1971) demonstrated autosomal anomalies in pure gonadal dysgenesis and have pointed out that autosomal aberrations
uterine hypopl.
rudimentary uterus, vaginal aplasia
Genital organs
+ primary
-
+
primary
-
Ovarian hypoplasia verified by laparotomy and histology
Amenorrhoea
Pregnancy
uterine and vaginal hyPoPl.
hypoplastic sella
kyphoscoliosis kyphoscoliosis herniation of nucleus pu Iposus osteoporosis
Bones
-
raromenorrhoea
t
mamma hypopl.
54 infantile shield chest cubitus valg. genu valgum hypotrichosis mamma hypopl. high-arched palate min. webbing of the neck
17 166 44
Case 3 V.M.
53
27 156
Case 2 K.F.
infantile shield chest cubitus valg. genu valgum hypotrichosis mamma hypopl. blue sclera
37 164
Case 1 A.J.
Phenotype and secondary sex characteristics
Age (years) Height (cm) Weight (kg)
Clinical data 23 157
19 164 75
virile
16 162 38
infantile
primary
secondary
+
uterine hypopl.
uterine hypopl.
+
hypoplastic sella spina bifida occulta
acromegaloid
hairlessness hypertrichosis mamma hypopl. mamma hypopl. on nape of neck obesity min. webbing of neck
primary
+
uterine and vaginal hypopl., infantile vulva
hypoplastic sella short middle phalanx of 5th finger delayed ossification
infantile shield chest cubitus valg. genu valgum hairlessness mamma hypopl. short neck
68
Case 6 M.E.
B.J.
Case 4
Case 5 V.K.
Clinical and cytogenetic data
Table 1
63
OVARIAN HYPOPLASIA
might also be held responsible for the disease. This is in good accordance with the opinion of Hamerton (1971) and others that autosomal modifiers may play a part in sexual development. In view of the above considerations it seemed worthwhile to analyse the karyotype of six patients with a 46,XX chromosome constellation and ovarian hypoplasia.
C
-
m
G; r
2 c
8
L
X
5
Material and Methods
s
x+$-
3
Ovarian hypoplasia was verified by laparotomy and biopsy samples of the gonads were studied histologically. Chromosome analysis was performed on short-term lymphocyte cultures according to the Moorhead technique (Moorhead et al. 1960) as modified by Hungerford (1965). In each case 200 lymphocyte metaphases were examined. The karyotypes were also studied by the fluorescence technique, Giemsa banding and autoradiography. Gonadal specimens were embedded in paraffin and the slides were stained with haematoxylin and eosin, van Gieson and Masson’s trichrome stain. The hormonal state of the patients was checked regularly by vaginal smears. Estrogen and gonadotrophin output was determined in urine.
Y
f
c L
01
2
c
m 0
c 8
a 0
Y
g X
s+$
K
N 0
c h
a
2 c
2
In r L
Case Reports
E i .-
The clinical and cytogenetic data of the six patients are shown in Table 1. Cases 2 and 6 are reviewed here in greater detail.
E
s r
z
..-E -.a
a c 2. a .a
-n n
*
I
Case 2, K.F., aged 27 years has never had a menstrual cycle. There is a negative familial and perinatal history. The patient’s phenotype is infantile, she is 156 cm tall, has a shield chest, cubitus valgus and genu valgum. The breasts are hypoplastic, and pubic and axillary hair is very scanty. X-ray examination revealed a distinct kyphoscoliosis and gynaecological examination a vaginal
64
L A S Z L O , G A A L , A N D BC)SZE
Flg. 1. Photograph of Case 2 showing obvious signs of infantilism and an absence of publc halr. Rlght: characteristic micrognathia, sllght ptosls, broad nasal bridge and facial asymmetry.
Flg. 2. Hypogonadism, obesity and protruding maxillary bone in Case 6.
OVARIAN HYPOPLASIA
hypoplasia and a small uterus. A bundlelike structure is palpable at the site of the ovaries. Laboratory findings are as follows: urinary estrogen: 6.1 pgI24 h; 17 KS value: 6.5 mg/24 h; 17 KGS value: 7.6 mg/24 h; PBI: 8.25 pg %. Vaginal cytological examination showed complete atrophy. The M.I. was lOO/O/O. Anomalies in the phenotype were seen as slight microcephalia, senile facies, distinct micrognathia, facial asymmetry, and ptosis
65
and hyperflexibility of the fingers. The patient is chromatin-positive. The karyotype is 46,XX/46,XX r,JD/- A D ring was found in 20 % of the cells. When laparotomy was performed in 1966, a rudimentary uterus and hypoplastic ovaries were found. Biopsy was made from the left ovary, which consisted of a thicker tunica albuginea and a narrow layer of fibrous ovarian cortical tissue packed with cells and covered with germinal epithelium. Many closely packed
Fig. 3. Characteristic hypoplastic ovary in Case 6. Bottam: closely packed degenerated primordial follicles beneath a dense layer of cortical connective tissue.
66
LASZL6. GAAL. AND BOSZE
primordial follicles embedded in thick fibrous tissue were present in the cortical connective tissue. Neither Graafian follicles, nor any indication of follicle maturation were found. The medulla was broader, apparently at the expense of the cortex. The sharply demarcated mesovarium contained mesonephrogenic remnants and degenerated vessels with thick hyalinized walls. The diagnosis was ovarian hypoplasia and primary amenorrhoea. Case 6, M.E., aged 23 years had a negative familial and perinatal history. Body growth was normal. She had an infantile phenotype with an inclination to obesity. Height was 157 cm, body weight 68 kg. She has never
had a menstrual bleeding. Short neck, shield chest, cubitus valgus, and genu valgum were seen. The breasts were hypoplastic and axillary and pubic hair were absent. X-ray examination revealed a small sella and delayed ossification. The middle phalanx of the fifth finger was shorter than normal. GynaecoIogical examination revealed infantile external genitalia, underdeveloped uterus and vagina. Laboratory findings were as follows: urinary estrogen: 3.7 pg/24 h; 17 KS value: 7.8 mg/24 h; 17 KGS value: 8.3 mg/24 h; PBI: 5.0 yg %. Vaginal cytological examination showed complete atrophy. The M.I. was lOO/O/O. The abnormal phenotype showed moderate microcephaly, micrognathia and epi-
Flg. 4. Case 1. Top: 46,XX karyotype with ring of autosome 15. Bottom: C and D group chromosomes with Giemsa banding technique.
OVARIAN HYPOPLASIA
canthic folds, prominent nose and maxilla, large ears, and hypertelorism. Marked hyperflexibility of the fingers was noted. The Barr body is positive. The patient’s karyotype is 46,XX/46,XX r/D/. A ring chromosome was found in 5 % of the cells. Laparotomy, performed in 1970, revealed an underdeveloped uterus and small hypoplastic ovaries. Biopsy was made from the right ovary. Pathohistological findings: the narrow ovarian cortex was covered with germinal epithelium and contained many closely packed and in part, degenerated primordial follicles. There were no signs of follicle ripening. The thicker widened medulla was sharply separated from the cortex and contained a few follicular cysts and some atretic follicles. Both the medulla and mesovarium were richly vascularized. The arterial walls showed definite hyaline degeneration. The diagnosis was ovarian hypoplasia and primary amenorrhoea. Discussion
The above described six patients (all of female phenotype) had an average stature,
Fig. 5. D chromosomes of Case 3 with normal Giemsa and quinacrine staining technique.
67
Fig. 6. D ring of autosome 15 of Case 4.
an infantile constitution, underdeveloped secondary sex characteristics, a short neck, cubitus valgus and genu valgum, hypotrichosis, underdeveloped external and internal genital organs, amenorrhoea or raromenorrhoea. Histological examination of the abnormally small ovaries showed a narrow cortex with many partly degenerated, primordial follicles embedded in dense cortical fibrous tissue. The broader medulla was sharply separated from the narrower cortex and contained follicular cysts in its loose, richly vascularized tissue. There were some atretic follicles, but neither corpus luteum nor corpora albicantia were present. Five patients had a modal chromosome number of 46,XX while one had a mosaic 47,XXX karyotype including an X fragment verified by autoradiography. In these six cases of ovarian hypoplasia 5 to 26 % of the carefully studied 200 metaphase cells contained a D ring, most likely belonging
Fig. 7. Case 5. D ring occurring in 8 % of cells.
68
LASZL6, GAAL, AND BdSZE
to autosome 15 according to the fluorescent and Giemsa banding techniques, a consistent finding except for Case 6 who, on the other hand, displayed a D monosomy in about 10 % of cells. In the case of ring formation there is of course no means to identify the affected part of the chromosome or to give an estimate of the loss in genetic substance. Thus any attempt to create a standard phenotypic pattern is obviously difficult. The anomalies include as a rule changes that are related to the deletion of both the long and the short arm, or even ones that are due to a duplication of certain parts in the abnormal chromosome, though the latter changes show considerable variation (Gilgenkrantz et al. 1971, Hecht & Vlietnick 1973). The ring may be completely missing from one cell line, while it appears in a duplicate form in the other, thus giving rise to myxoploidy and variability of the phenotype. The signs associated with the ring of a D group chromosome are very similar to those of the Dq- syndrome. In most cases they are associated with mental retardation and congenital malformations, such as microcephaly, hypertelorism, protruding nasal bridge, anomalous development of the eyes,
large and malformed external ears, epicanthic folds, four-finger crease, and several other anomalies, such as brain, heart and kidney malformations (Lejeune et al. 1968, Gilgenkrantz et al. 1971). Allerdice et al. (1969) regard the presence of a prominent maxilla, facial asymmetry and dental anomalies as additional signs (Table 2). Gonadal agenesis or hypoplasia was first considered by Toews & Jones (1968) to be the result of an aberration of the D chromosome (D-trisomy). Reviewing the literature they found that an anomalous development of the uterus, Fallopian tubes and external genital organs was reported in 80 % of the D-trisomy cases. In a majority of the cases the ovaries also revealed both gross and microscopic lesions characteristic of hypoplasia. On the basis of the above mentioned data Toews & Jones (1968) suggested that autosomal gene effects might have a role in the development of the genital organs and that these developmental anomalies might be a result of autosomal mutations. This theory agrees with those of Christakos et al. (1969) Nielsen & Friedrich (1971), and others, who feel that small autosoma1 deletions may have an important role in the pathogenesis of gonadal hypoplasia.
Table 2 Phenotype signs of D ring Case 1 A.J.
D ring per 100 cells Microcephaly Senile face Facial asymmetry Microphthalmia Epicanthic folds Ptosis Protruding nose and maxilla Anomaly of the ears Hypertelorism Harelip, cleft palate Micrognathia Hyperflexibility of fingers
Case 2 K.F. 20
+ + +
-
++ +
Case 3 V.M.
Case 4 B.J.
Case 5 V.K.
Case 6 M.E.
OVARIAN HYPOPLASIA
Cohen et al. (1967) discovered a pericentric inversion of a D chromosome in a case of primary amenorrhoea and gonadal dysgenesis, further confirming this hypothesis. Witschi (1951), Jones et al. (1963), Ford (1970), Boczkowski & Mikkelsen (1973) and others attribute an important role to the genes of the X chromosomes in gonadal differentiation, but d o not debate the significance of an autosomal control influence. They emphasize, however, that in the preservation of primordial follicles germ cells are as actively involved as the somatic elements of the ovary. In our cases of ovarian hypoplasia the presence of primordial follicles was in accordance with the normal sex chromosome complement of the patients, but the ripening of the primordial follicles grouping in the ovarian cortex seemed to be hindered. The microscopic picture of the gonad is similar to one of an infantile ovary. In the cases studied cytogenetically we could find a low but consistent occurrence of D chromosome aberration. Some of the phenotypic alterations characteristic of a D chromosome abnormality were also found in all these patients. There is a possibility that the histologically demonstrable degeneration of the gonads may be connected with autosomal anomalies. The present study appears to lend further support to the assumption forwarded by other authors that, in addition to the relevant role of sex chromosomes, autosomal gene effects are also involved in controlling sexual differentiation. It is as yet too early to draw definite conclusions, but the necessity of a large scale and careful analysis of karyotypes, as well as of autosomes, in every case where the sex chromosome pattern is insufficient for an adequate explanation of gonadal hypoplasia and phenotype anomalies should be emphasized.
69 References
Allerdice, P. W., J. G. Davis, 0. J. Miller, H. P. Klinger, D. Warburton, D. A. Miller, F. H. Allen, C. A. L. Abrams & E. McGilvray (1969). The 13q- deletion syndrome. Amer. J . hum. Genet. 21, 499-512.
Boczkowski, K. & M. Mikkelsen (1973). Fluorescence and autoradiographic studies in patients with Turner's syndrome and 46,XXpand 46,XXq- karyotypes. J . med. Genet. 10, 350-355.
Christakos, A. C., J. L. Simpson, J. B. Younger & C. D. Christian (1969). Gonadal dysgenesis as an autosomal recessive condition. Amer. J . Ohstet. Gynec. 104, 1027-1039.
Cohen, M. M., V. J. Capraro & N. Takagi (1967). Pericentric inversion in a group D chromosome (13-15) associated with amenorrhoea and gonadal dysgenesis. Ann. hum. Genet. 30, 313-323. Ford, C. E. (1970). Cytogenetics and sex determination in man and mammals. J . biosoc. Sci. Suppl. 2, 7-30.
Gilgenkrantz, S., C. Gabrol, C. Lausecker, M. E. Hartleyb & B. Bohe (1971). Le syndrome Dr. Etude d'un nouveau cas (46,XX, 14r). Ann. GknCt. 14, 23-31.
Hamerton, J. L. (1971). Human Cytogenetics. New York, London, Academic Press. Hecht, F. & R. F. Vlietnick (1973). Autosomal ring and variable phenotypes. Humangenetik 18, 99-100.
Hungerford, D. A. (1965). Leukocytes cultured from small inocula of whole blood and the preparation of metaphase chromosomes by treatment with hypotonic KCL. Stain Technol. 40, 333-338.
Jones, H. W. Jr., M. A. Ferguson-Smith & R. H. Heller (1963). The pathology and cytogenetics of gonadal agenesis. Amer. J. Obstet. Gynec. 87, 578-600.
Lejeune, J., J. Lafourcade, R. Berger, J. Cuveiller, M. 0. Rethor6, B. Dutrillaux, D. Abonyi & H. Jerom (1968). Le phtnotyp Dr. Etude de trois cas de chromosomes D en anneau. Ann. Ge'ne't. 11, 79-87.
MBlkova, J., R. Chrz, K. Motlik, L. Starka, J. KobilkovA & E. SilinkovB-Malkovh (1974). 46,XX gonadal dysgenesis and ovarian hypoplasia. Humangenetik 23, 205-211. Moorhead, P. S., P. C. Nowell, W. J. Mellman, D. M. Battips & D. A. Hungerford (1960). Chromosome preparation of leukocytes cultured from human peripheral blood. Exp. Cell Res. 20, 613-616.
70
LASZL6, GAAL, AND BOSZE
Nielsen, J. & U. Friedrich (1971). Pure gonadal dysgenesis. Clin. Genet. 3, 52-58. Polnni, P. E. (1969). Turner phenotype with normal sex chromosomes. Birth Defects: Original Article Series V . Toews, H. A. & H. W. Jones (1968). Cyclopia in association with D trisomy and gonadal agenesis. Amer. J . Obstet. Gynec. 102, 53-56. Witschi, E. (1951). Embryogenesis of the adrenal and the reproductive glands. Recent Progr. Hormone Res. 6, 1-27.
Address: J . LLiszl6 Cytogenetic Laboratory of the Depurtmcnt of Gynaecology and Obstetrics Postgraduate Medical School 1389 Budapest Szaholcs v . 35 Hungary
