Letter to the Editor

Abstract

We have read with interest the article concerning a neuroendocrine tumor of the pancreas resulting in precocious puberty by Schutte and Knight [ [1] Schutte W.P. Knight P.J. Precocious puberty because of a pancreatic neuroectodermal tumor. J Pediatr Surg. 2006; 41: 1916-1918 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar ] that was recently published in your journal. Although their patient is of interest, we have a few comments regarding the diagnostic process. In the initial evaluation of the patient 4 months previously, they mentioned several signs of puberty precox (ie, pubic hair, breast bud development, and vaginal bleeding), increased estradiol level (165 pg/mL), and advanced bone age. These signs show probability of peripheral precocious puberty in the patient. In such cases, a more extensive investigation including gonadotropin-releasing hormone testing is recommended to rule out a discrete lesion affecting some part of the hormonal axis controlling puberty [ 2 Rodriguez H. Pescovitz O.H. Precocious puberty: clinical management. in: Radovick S. MacGillivray M.H. Pediatric endocrinology: a practical clinical guide. Humana Pres Inc, New Jersey2004: 399-428 Google Scholar , 3 Lee P.A. Kerrigan J.R. Precocious puberty. in: Pescovitz O.H. Eugster E.A. Pediatric endocrinology: mechanisms, manifestations, and management. Lippincott Williams and Wilkins, Philadelphia2004: 316-333 Google Scholar , 4 Rosenfield R.L. Puberty in the female and its disorders. in: Sperling M.A. Pediatric endocrinology. Saunders, Philadelphia (Pa)2002: 455-518 Google Scholar ]. Furthermore, an estradiol level at the upper end of the premenarcheal normal range (75 pg/mL) necessitates a prompt workup to distinguish a tumoral lesion [ 4 Rosenfield R.L. Puberty in the female and its disorders. in: Sperling M.A. Pediatric endocrinology. Saunders, Philadelphia (Pa)2002: 455-518 Google Scholar , 5 Wheeler M.D. Styne D.M. Diagnosis and management of precocious puberty. Pediatr Clin North Am. 1990; 37: 1255-1271 PubMed Google Scholar ]. The authors reported that an initial abdominal ultrasonography had been unremarkable for a mass lesion, and they also noted that the pediatric endocrinologist who had first seen the patient thought that a specific hormone-secreting source was not apparent. On the other hand, the mass could have only been disclosed after it was palpated by physical examination after 4 months. Herein, we would like to imply that despite an initial noncontributory ultrasonographic examination, the authors must have performed further abdominal imaging with the above-mentioned clinical and laboratory findings for the patient who most probably has peripheral precocious puberty [ 4 Rosenfield R.L. Puberty in the female and its disorders. in: Sperling M.A. Pediatric endocrinology. Saunders, Philadelphia (Pa)2002: 455-518 Google Scholar , 5 Wheeler M.D. Styne D.M. Diagnosis and management of precocious puberty. Pediatr Clin North Am. 1990; 37: 1255-1271 PubMed Google Scholar ]. Keeping in mind the 33% possibility of ultrasonography not detecting such a lesion, we call this to the attention of clinicians for early diagnosis of relevant tumors [ [6] Rosch T. Lorenz R. Braig C. et al. Endoscopic ultrasound in pancreatic tumor diagnosis. Gastrointest Endosc. 1991; 37: 347-352 Abstract Full Text PDF PubMed Scopus (401) Google Scholar ]. Fortunately, the authors did not uncover any metastatic lesion, but they could have eventually found otherwise after a 4-month delay in the management of a pancreatic malignancy. In this regard, gonadotropin-releasing hormone testing and detailed abdominal imaging seem to be paramount.