Morning Report. Chief Complaint HPI. What else do you want to know? Additional Patient Info (cont d) Additional Patient Info.

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1 Morning Report Jonathan Marron and Stephanie Siehr Lucille Packard Children s Hospital July 22, 2009 Chief Complaint 2 year old female presents to her pediatrician with fever, cough, and rhinorrhea Mom, an L&D nurse, mentions she noticed breast buds while putting on her daughter s swimsuit several days prior HPI What else do you want to know? Not tender Symmetric Not cystic or fluctuant They re breast buds! I know I m an L&D nurse! No associated pubertal signs (no axillary or pubic hair, no growth spurt, no interest in Justin Timberlake) No nipple discharge No medications or known environmental exposures No family history of precocious puberty or thelarche, gynecomastia,, or other endocrinologic disorders No history of infantile breast augmentation surgery PMH: none Additional Patient Info ROS: negative except for URI sxs,, as above FHx: significant h/o CA (M w/ BCC, PGM w/ breast CA, MGM w/ gastric CA, MGF w/ glioma); M & F w/ nml pubertal course Additional Patient Info (cont d) Physical Exam Vital Signs stable Gen: NAD, well-appearing, appropriate for age HEENT: wnl CV: wnl Chest: CTAB, cm areas of glandular breast tissue, equal bilaterally, no skin lesions, no TTP Abd: : soft, NTND, NABS, no HSM GU: Tanner I, nml ext female genitalia Ext: no axillary hair. WWP, no c/c/e Skin: no lesions, rashes, or petechiae

2 Thelarche So what is the diagnosis? Precocious Puberty Defined as the beginning of breast development Typically begins between 8 and 13 years Average age of onset 10.3 years Earlier in Hispanic and African-American American girls Premature thelarche defined as isolated breast development in girls younger than 8 years of age in Caucasians, 7 years in Hispanics and African- Americans Usually does not progress to precocious puberty Defined as early maturation of the hypothalamic-pituitary pituitary- gonadal axis with development of 2 or more sexual characteristics Premature thelarche 6 mo to 2 yr Breast size fluctuates (80%) No pubic/axillary hair No apocrine odor No menses No growth acceleration Normal bone age Generally benign, self- limited Precocious puberty 5 yr to 8 yr Breast size unchanging + pubic/axillary hair + apocrine odor + menses + growth acceleration Advanced bone age Can lead to short stature Normal sex hormones Neonates Fetus exposed to high estrogens (estradiol( estradiol) DOL 1-21 testosterone secretion in boys and estradiol secretion in girls surges 2/2 neonatal HPG axis activity Nadir ~ 10 days of life, w/ ~ 2 months By 6 months gonadotropin secretion drops to prepubertal levels Minipuberty of early infancy physiologic process that can explain breast tissue in infants Differential diagnosis for isolated premature thelarche in absence of other signs of precocious puberty? Childhood/Adolescence During childhood, sex hormone levels remain low At the onset of puberty, gonadotropins stimulate ovarian estradiol production

3 Differential diagnosis Partial activation of HPG axis (usually 2/2 FSH secretion) or failure of follicular involution Exposure to exogenous estrogen cosmetics, hair products, food (?poultry, soy) Xenoestrogens (chemicals binding to estrogen receptor) McCune-Albright syndrome Classic triad= Gonadotropin-independent independent precocious puberty, café au lait macules, polyostotic fibrous dysplasia Neoplasm (ovarian, pituitary, adrenal, hepatocellular CA) CAH Idiopathic Iatrogenic So what should we do? Algorithm for evaluation of females presenting with early breast development But what DID we do? Diamantopoulos, S. et al. Pediatrics in Review 2007;28:e57-e68 Initial Workup FSH- <0.1 miu/ml (0-2.8) LH- <0.1 miu/ml (0-1.6) Estradiol- elevated at 186 pg/ml (<25 in prepubertal children) But 2 weeks later Pediatrician referred family to Endocrinology clinic for outpatient follow-up

4 New symptoms! Pt returns to clinic w/ 2 day h/o anorexia, 1 day h/o intermittent, colicky abdominal pain w/o N/V. Nml stooling. Notable exam findings Afebrile Breast buds still present +Abdominal distension. ~6x8cm motile, firm, nontender mass in LLQ. No HSM, +BS. So now what?? Initial Imaging Abdominal u/s heterogeneous solid and cystic mass within right adnexa,, 9x9.9x7.9cm. Internal cystic components measuring up to 3-4cm 3 in size. Uterus and L ovary wnl. Admitted to LPCH for inpt w/u & mgmt Differential diagnosis Germ cell tumors (#1 adnexal mass) Teratoma (mature and immature), dysgerminoma, embryonal carcinoma, yolk sac tumor, polyembryona, choriocarcinoma Sex cord stromal tumors Granulosa cell tumor, Sertoli/Leydig cell tumor Sarcoma Lymphoma/Leukemia (#1 childhood tumor) Wilms tumor (#1 abdominal mass) Neuroblastoma/PNET To complete the workup AFP 5 miu/ml (nml <10) β-hcg 1 miu/ml (nml <5) Urine VMA 12 mg (nml( 0-27) Urine HVA 18 mg (nml( 0-42) Inhibin A pg/ml (nml a lot less) Inhibin B pending Putting it all together Patient with premature thelarche,, elevated estradiol and inhibin A (without elevations in AFP, β-hcg or urine HVA/VMA), with a large R adnexal mass MRI abdomen/pelvis large cystic pelvic mass with some solid components, 11 x 8 x 10 cm,, and areas of internal hemorrhaging. Mass likely arising from R ovary

5 Juvenile Granulosa Cell Tumor Tumor References 1. Braunstein GD. Prevention and treatment of gynecomastia. UpTo Date Online. 2007;15.1. Available at: 2. Diamantopoulos S, Bao Y. Gynecomastia and premature thelarche: : A guide for practitioners. Pediatrics in Review. 2007; 28(9): e Herskovitz E, Leiberman E. Gynecomastia: : a review. The Endocrinologist. 2002;12 :