Franklin C. Behrle, M.D., Frank A. Mantz, Jr., M.D., Robert L. Olson, M.D.,
and James C. Trombold, M.D.
The Departments of Pediatrics and Pathology, University of Kansas Medical Center,
Kansas City, Kansas
(Submitted July 5, 1962; accepted for publication February 23, 1963.)
PRESENT ADDRESS: (F.C.B.) Department of Pediatrics, Seton Hall College of Medicine and Dentistry, Jersey City, New Jersey.
265
PEDIATRICS, August 1963
K
NOWLEDGE concerning specific causesof precocious vinilization in children
has expanded in recent years, and the
body of literature pertaining to
differen-tial diagnosis of the condition is
substan-tial. However, very little mention has been
made to date of the association between
hepatoblastoma and vinilization. This
en-tity deserves greater recognition not only
because it is usually overlooked but
be-cause it poses some intriguing
endocnino-logic questions.
The authors of this report have had the
opportunity to observe a case of
viniliza-tion occurring in a 3-year-old boy who
ul-timately died from an hepatoblastoma. In
reviewing the literature it became
appar-ent that the documented cases of this
dis-ease bore a striking resemblance to one
another, with features sufficiently
distinc-tive to allow ready separation of this group
from other vinilizing diseases. Thus it
ap-pears possible to fashion a prototype for
this disease which should aid materially in
bringing future cases to light. In addition,
we believe the unusual findings in the
pi-tuitary gland of this child deserve special comment.
CASE REPORT
A 3-year-old vhite male was first
ad-milled to the University of Kansas Medical
Center on May 13, 1960, because of
pro-gressive vinilization . Development had
been normal until 9 months prior to
ad-mission, whell it was noted that the child’s
voice was deepening in timbre, the penis
was enlarging, and pubic hair was
begin-ning to develop. These features showed a
gradual progression, along with a rapid
increase in height. Increasing pallor was
also noted shortly before admission.
There were no significant previous
ill-nesses. The maternal great-grandmother
died of carcinoma of the colon, and there
was a strong family history of polyposis of
the colon.
Physical examination revealed a large,
muscular-appearing, pale, white male child
who appeared both acutely and chronically
ill (Fig. 1). His temperature was 103#{176}F
(39.4#{176}C),pulse 140 per minute, blood
pres-sure 130/85 mm Hg, height 44 in. (112
cm), and weight 42 lb (19.1 kg). His voice
was deep and adult in character. the head
circumference was 49 cm, and the head
appeared grossly normal. His eyes and
optic fundi were normal. Sinus tachycardia
was present, and a Grade I systolic
mur-mur was heard at the left sternal border.
Abdominal examination revealed a large.
hard, nodular mass occupying the left
hypochondrium, extending across to the
right nipple line and 8 cm below the left
costal margin. Another mass, softer in
na-tune, was palpated in the right
hypochon-drium and night flank, extending from the
costal margin to the iliac crest. No fluid
wave was present. There was a marked
amount of pubic hair and a large penis.
The testicles were equal in size, measuring
1.5 cm in diameter. They were smooth and
contained no masses. Neurological
exami-nation was normal.
The leukocyte count, blood glucose level,
and blood urea nitrogen were normal. The
hemoglobin concentration was 5.8 gm/100
di-148,000, and the peripheral smear was
con-sistent vith microcytic, hypochromic
ane-mia.
FIG. 1. Patient with hepatoblastoma. Shaded area on abdomen represents liver mass. Pubic hair
shaved prior to surgery.
rect, 0.9 mg/100 ml). The alkaline
p1105-phatase was 4.0 mm units, and the direct
Coombs was negative. The 24-hour urinary
sterOi(1 values (method of Silber and Porter)
were as follows:
Date 17 KS 17 OH
(1960) (mg) (mg)
May 14 1.4 0.7
May 15 1.1 0.8
May 16 1.9 1.1
The sodium in serum was 128 meq/1.
X-nays of the chest revealed elevation of
the right side of the diaphragm and large
masses in both hypochondria. Intravenous
pyelograms and barium enema studies
were normal. X-ray of the night wrist
ne-vealed a bone age of 7 years. Skull x-rays
were normal. Bone marrow examination
showed erythroid hyperpiasia and
reac-tive marrow changes. Platelets were
A lapanotomy was performed on tile
tenth hospital day, and a massive tumor
was found to involve both the right and
left lobes of the liver. No other masses
were noted in the colon or retropenitoneal
area. Tile adrenals appeared normal. A
liver biopsy was performed and the
ab-domen closed. The microscopic diagnosis
was hepatoblastoma.
Post-operatively, the patient received
3,000 R of cobalt-60 therapy, with some
regression of the mass on the night. Two
days after operation, gonadotropin assay
revealed 13 mouse units/24-houn volume.
On the sixth post-operative day, 24-hour
urine determination showed 1
1-hydnoxyan-drosterone as 1.2 mg conjugated and 0.85
mg unconjugated; eticholanolone, 1.1 mg
conjugated and 0.36 mg unconjugated;
androsterone, 0.35 mg conjugated and 0.60
unconjugated. The patient was discharged
on the forty-first hospital day.
The child was admitted on three
sub-sequent occasions during the last 6 months
of life. He returned with neurological
symptoms of paraplegia and incontinence.
An epidural metastatic lesion of the
tho-racic spine was removed surgically and
found to be compatible histologically with
hepatoblastoma. His terminal course was
that of progressive back pain, abdominal
distention with ascites, jaundice, and
para-plegia. He died approximately 8 months
following his first admission.
Additional Laboratory Studies
Dr. Claude
J.
Migeon of The JohnsHop-kins Hospital conducted further studies of
plasma androgens in this patient. His
ne-sults are as follows:
Free Fraction: Androsterone-small
amount; unable to determine
quantita-tively; usually undetectable in blood.
S ulfate Fraction :
Dehydroisoandroster-one-none; predominant 17 KS in adults;
probably of adrenal origin.
FIG. 2. Gross specimen of liver.
usually not detectable in young children.
Sulfate Fraction: Etiocholanolone-lO
mcg/100 ml; usually undetectable in adults
or children; thought to be a metabolite of
adrenal and testicular androgens.
Giticuronide Fraction: No detectable 17 KS.
Pathological Findings
The liver was massively enlarged (Fig.
2) and distorted, weighing 1,700 gm. It
was occupied by angular masses of
neo-plastic tissue almost completely replacing
the night lobe, and scattered as rounded
nodules throughout the left lobe. These
were separated by fibrous tnabeculae and
corded strands of residual hepatic
paren-chyma. Invasion of the hepatic vein had
occurred vith intravascular extension of a
solid mass of tumor tissue into the right
atrium of the heart through the ascending
vena cava.
Metastatic tumor flooded all lobes of
both lungs in tile form of minute nodules.
The bodies of the vertebrae from T-1 to
T-5 were variably replaced by tumor
tis-sue and extension into the epidural space
had resulted in compression atrophy of
the spinal cord in this region.
The neoplasm within the liver and at
various metastatic sites presented the
clas-sic histologic appearance of a mixed-type
hepatoblastoma. At no sites were there
evidences of teratoid structure, and no
evidence of pre-existing hepatic disease
was discovered. The cells of tile neoplasm
were preponderantly well differentiated
and closely resembled those of parent
tis-sue. Nucleoli were occasionally seen, and
there was slight to moderate mitotic
ac-tivity. The cellular arrangement was that of
double-cell plates and cords separated by
endothelial-lined sinusoids. The formation
of acinar structures was scattered
through-out (Fig. 3).
At its metastatic sites the tumor cells
occasionally assumed a more
undifferen-tiated sarcomatoid appearance. At all sites
there was the elaboration of a pigment
varying from orange-green to green which
yielded the staining reaction ascribed to
bile when treated with Fouchet’s reagent
after tile technique described by Hall.’
The bile was deposited in the acinar spaces
or within canalicular structures within the
neoplastic cell plates.
The pituitary gland was grossly
unre-markable, but its microscopic appearance
was of extreme interest. Hematoxylin and
eosin sections showed changes somewhat
suggestive of the pituitary of pregnancy,
with marked prominence of
basophils-many of which were enlarged and
some-what vacuolated (Fig. 4). Crooke’s changes
were specifically absent. When stained
dif-fenentially by means of peniodic-acid-Schiff
Witll orange G, a more specific idea as to
the nature of the cytologic alteration was
obtained by counting a total of 2,352 cells
in two separate sections by the Rasmussen
method.2 This revealed a distribution of
basophils 21%, sparsely granulated
baso-phils 7%, amphophils 9%, acidophils 24%,
and chromophobes 39%, indicating a
marked increase in cells of the basophilic
type at the apparent expense of both acido..
philic
and chromophobic elements.Of the remaining endocrine organs only
the testes displayed noteworthy alterations.
They were somewhat enlarged, each
sys-FIG. 3. Microscopic section of liver.
Fic. 5. Microscopic section of testis, demonstrating Leydig cell hyperplasia.
tem appeared unaltered, showing no
evi-dence of cellular deveolpment or
spermato-genesis. The intertubular spaces, however,
were crowded with Leydig cells of
some-what fusiform outline. Pigment and
crys-talloids were absent within but lipid
stor-age was abundant (Fig. 5).
The prostate showed slight hyperplasia
of ducts in lobular pattern and
differentia-lion of their lining cells into tall columnar
mucus-secreting types.
Detailed examination of the adrenals,
thyroids, pineal, and brain showed no
ab-normalities. Step-sectioning of the
hypo-thalamus also revealed no lesions.
COMMENT
The salient features of the documented
cases of this disease are listed in Table I.
The uniformity of physical and laboratory
findings among patients is apparent. In
addition to the signs of early
masculiniza-tion, all of the children have had
pro-nounced liver enlargement, with readily
palpable nodules or tumors noted in two
instances. This latter finding is particularly
important to the differential diagnosis, as
noted below. Urinary 17-ketosteroids have
been either normal or only moderately
elevated with respect to age. Urinary
go-nadotropins were elevted in tile three
in-stances in which they were determined.
Leydig cell hyperplasia and absence of
spermatogenesis were tile characteristic
histologic findings in the testes.
This combination of features is
practi-cally unique among the various disorders
causing iso-sexual precocity in the male
child. The increased urinary
gonadotro-pins, relatively low 17-ketosteroid output,
and Leydig cell hyperplasia readily
differ-entiate this condition from virilization
caused by adrenal hyperplasia on tumor,
as well as testicular tumor. Gross liver
enlargement is the essential item which
distinguishes this from “constitutional”
precocity of the incomplete type, and
van-ious diseases which cause virilization
through encroachment upon the
hypothal-amic-pituitary region.*
* Wilkins and Ravitch (PEDIATRICS, 9:671, 1952)
reported a case of virilization caused by an
en-capsulated adrenal cortical tumor within the liver. Presumably such a case could be differentiated
from hepatoblastoma on the basis of laboratory
A uthor.s Presenting Sign.s trinary (i’onado-tro pins Bone Age (yr) Testes Pituitary MacNab’ et al. Not stated Liver enlargement; “precocious secondary
sexual changes” ; testes not enlarged
0.4
I .0
. . . .
.. Ley(lig cell
byperplasia; no spermato-genesis . Reeves4 et at.
8 Palpable liver; pubic hair; deep voice; muscular development;
penile enlargement ;
acne; slightly enlarged testes
14 .I
8 .4
.. ..
96 mu.
‘384 m.u.
.. Abun(laflt
Leydig cell tissue; no spermato-genesis l)ecreased acidophils Increased amphophuls Case Report Mass. (;e,ieral hospital5
2l Palpable liver; pubic hair; deep voice; penile enlargement;
acne; muscular
development ;testes not enlarged
0.4 1.5 1 1 rat u. 3-3 Leydig cell
hyperplasia; no spermato-genesis . Present Case
S Palpable liver; pubic hair; deep voice; penile enlargement; muscular development; increased skeletal growth; testes mod.
enlarged
1 .4 I .1
1 .9 0.7 0 .8 1 . 1
13 mu. 7 Leydig cell hyperplasia; no spermato-genesis Increased basophils and amphophils 270
The laboratory studies clearly implicate
a gonadotnopin as the factor responsible
for Leydig cell hyperplasia and consequent
testosterone production in these cases.
This interpretation is in keeping with the
plasma steroid determinations in our
pa-tient. The elevated plasma androgen level,
in the absence of dehydroisoandrosterone
(
DHA), suggests the testes as the sourceof androgen, since DHA is thought to be
of adrenal origin. Likewise, as
androster-one and etiocholanolone are metabolites of
both adrenal and testicular androgens, it
seems reasonable to attribute the increase
in these substances to the testes rather
than the adrenals. The fact that relatively
little testosterone is needed to vinilize a
very young child could account for the
observed changes in the face of low
out-put of 17-ketosteroids in the urine of three
of the children.
Whereas the foregoing offers a
plausi-ble explanation for the virilization, present
knowledge of the exact nature of the
gonadotropin involved is incomplete. Two
of the known substances capable of
pro-ducing this effect are pituitary luteinizing
hormone (LH) and human chorinic
gonad-otropin (HCG). To date, attempts to
cate-gonize the gonadotropin in this disease
have tended to incriminate a substance
analogous to HCG. Albert recovered
HCG-like material from tumor tissue of the
case reported by Reeves.4 McArthur,5 in a
detailed study of the urine in the case
from the Massachusetts General Hospital,
TABLE I
Age at
On.set
(yr)
REPORTED CASEM OF VIRILIZATION WIT)! HEPATOMA
24-hour
Urinary
Steroids
17-KS 17-011
also isolated a substance which was
indis-tinguishable from HCG by biologic tests.
Nevertheless, it should be borne in mind
that none of the gonadotropic effects in
assay animals is specific for either HCG or
LH, and chemical tests capable of making
this distinction are as yet unsatisfactony. In
view of this, and the fact that unusual
changes were noted in the pituitary glands
of two of these cases, we are prompted
to urge caution in interpreting previous
studies.
The interesting pituitary changes seen
in our patient appear to have been present
also in Reeve’s case, and consisted of a
relative decrease in the number of
acido-phils
and chromophobes, with acon-siderable increase in basophils and
ampho-phils. These findings are pertinent in that
the elaboration of pituitary gonadotropin
is generally ascribed to the basophilic
ele-ments. With this in mind, an attempt was
made to ascertain the secretory status of
this gland, using the method of
and 10 These authors postulated
that cells which lose the capacity of
stain-ability with peniodic-acid-Schiff reagent
following pretreatment with performic
acid represent gonadotrophs. Application
of this test disclosed nearly complete loss
of staining of the abundant basophils,
sug-gesting an elevated content of gonadotropin
within the gland.
The significance of the latter observation
is not readily apparent, but it is difficult
to reconcile it with the concept of the
hepatic neoplasm as the primary source
of gonadotropin in this disease. Resolution
of
this conflict awaits either more refinedmethods for differentiating LH from HCG,
or a clearer
understanding
of reciprocal
hormonal relationships than currently
exists.
SUMMARY
A case of hepatoblastoma associated
with vinilization in a 3-year-old boy is
pre-sented. Three additional cases culled from
the literature are discussed to point out
the striking similarities in this group. Their
distinctive character allows differentiation
of this disease from other causes of
iso-sexual precocity in the male child.
Inter-esting findings in the pituitary glands of
two of the children raise questions as to
the nature of the gonadotropin involved in
the vinilization process.
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1. Flail, M. J.: A staining reaction for bilirubin in
sections of tissue. Amer. J. Clin. Path., 34:
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Sus-sex: Sumfield and Day, Ltd., 1952, p. 168.
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