Brief Report
Peripheral precocious puberty: 46,XY complete gonadal dysgenesis
Pubertad precoz periférica: disgenesia gonadal completa 46 XY
M. Santalhaa,
, B. Amaralb, J. Pereirac, L. Ribeirob, M. João Oliveirab, S. Figueiredob, H. Cardosob, C. Peixotod, T. Borgesb, J.A. Cidade-Rodriguesc
Corresponding author
a Departamento de Pediatría, Centro Hospitalar do Alto Ave, Guimarães, Portugal
b Unidad de Endocrinología Pediátrica, Centro Hospitalar do Porto, Porto, Portugal
c Departamento de Cirugía Pediátrica, Centro Hospitalar do Porto, Porto, Portugal
d Departamento de Patología, Centro Hospitalar do Porto, Porto, Portugal
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"apellidos" => "Borges" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 9 => array:3 [ "nombre" => "J.A." "apellidos" => "Cidade-Rodrigues" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Pediatría, Centro Hospitalar do Alto Ave, Guimarães, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Endocrinología Pediátrica, Centro Hospitalar do Porto, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Cirugía Pediátrica, Centro Hospitalar do Porto, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Patología, Centro Hospitalar do Porto, Porto, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pubertad precoz periférica: disgenesia gonadal completa 46 XY" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 680 "Ancho" => 851 "Tamanyo" => 198342 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Anatomohistopathological analysis of surgery showing gonadoblastoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Precocious puberty (PP) is defined as the development of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The aetiology of PP is diverse, ranging from variations of normal development, such as isolated premature thelarche, to diseases with significant comorbidity and mortality, such as germ cell tumours.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Addressing PP involves classifying it into two subtypes: central precocious puberty (CPP), which is gonadotropin-dependent (caused by early maturation of the hypothalamic–pituitary–gonadal [HPG] axis) and peripheral precocious puberty (PPP), which is gonadotropin-independent (due to excess secretion of sex hormones, androgens or oestrogens, from the adrenal glands, the gonads or exogenous sources).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">PPP may be of genetic origin (testotoxicosis; congenital adrenal hyperplasia; <span class="elsevierStyleItalic">DAX1</span> gene mutation; McCune–Albright syndrome) or acquired (ovarian cyst; ovarian, testicular or adrenal tumours that produce the β subunit of human chorionic gonadotropin [β-hCG]); exogenous sex steroids).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Acquired PPP occurs secondary to an increase in exogenous or endogenous sex steroids.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnostic assessment includes an anamnesis and a detailed physical examination and additional tests, such as determination of basal and LHRH-stimulated gonadotropin levels (essential for differential diagnosis between CPP and PPP), hormone tests (testosterone, 17-β-oestradiol, dehydroepiandrosterone sulphate [DHEA-S], androstenedione and 17-hydroxyprogesterone [17-OH-progesterone], β-HCG, free thyroxine [free T4] and thyroid-stimulating hormone [TSH]) and imaging tests (hand-wrist radiograph to determine bone age, pelvic or testicular and abdominal ultrasound and cranial MRI). Finally, in the presence of strong clinical suspicion, genetic testing should be performed.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case history</span><p id="par0035" class="elsevierStylePara elsevierViewall">Girl referred to paediatric endocrinology consultation at the age of 4 years 2 months with suspected precocious puberty.</p><p id="par0040" class="elsevierStylePara elsevierViewall">She had been born to term with adequate somatometry for her gestational age and no important family, perinatal or pathological history.</p><p id="par0045" class="elsevierStylePara elsevierViewall">She presented with appropriate psychomotor development for her age and her height and weight development. Her weight was above the 95th percentile with upward centile crossing, having ranged from the 25th to the 50th percentile up to age 2 and then crossed to values above the 95th percentile by the age of 4 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Development of secondary sexual characteristics was observed at age 4, with the appearance of pubic hair and breast budding. In her first hospital assessment her weight was 22<span class="elsevierStyleHsp" style=""></span>kg (>95th percentile), height 115.5<span class="elsevierStyleHsp" style=""></span>cm (standard deviation score [SDS] 3.10), growth velocity 14.81<span class="elsevierStyleHsp" style=""></span>cm/year (SDS 7.13), target height 159<span class="elsevierStyleHsp" style=""></span>cm (SDS −0.50) and external female genitalia with Tanner stage A1-B2-P2.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Laboratory tests revealed high levels of oestradiol, total testosterone and β-HCG (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The levels of 17-OH-progesterone, DHEA-S, delta-4-androstenedione, free T4, TSH, adrenocorticotropic hormone, cortisol (morning level), prolactin, lactate dehydrogenase (LDH) and alpha-foetoprotein (α-FP) were normal for her age (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Serum FSH was 0.3<span class="elsevierStyleHsp" style=""></span>mU/mL and LH<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.1<span class="elsevierStyleHsp" style=""></span>mU/L, and the LH/RH test showed a prepubertal response (peak LH 1.1<span class="elsevierStyleHsp" style=""></span>mU/mL; peak FSH 2.3<span class="elsevierStyleHsp" style=""></span>mU/mL, LH/FSH ratio <1).</p><p id="par0065" class="elsevierStylePara elsevierViewall">Bone age (BA) was 19 months in advance of chronological age (CA) (BA: 5 years 9 months, CA: 4 years 2 months). The pelvic ultrasound revealed a focal, well-circumscribed hyperechoic mass 25<span class="elsevierStyleHsp" style=""></span>mm in diameter in the left adnexal region. The pelvic computed tomography revealed bilateral solid adnexal lesions, with calcified matrix, measuring 30<span class="elsevierStyleHsp" style=""></span>mm on the right and 25<span class="elsevierStyleHsp" style=""></span>mm on the left.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Histological examination of the biopsy specimen showed patches of tissue occupied by bilateral gonadoblastoma structures, confirmed by immunohistochemistry (CD117 and inhibin-alpha).</p><p id="par0075" class="elsevierStylePara elsevierViewall">A laparoscopic bilateral oophorectomy was performed. Anatomohistopathological analysis confirmed the presence of bilateral gonadoblastoma (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Genetic testing of peripheral blood revealed a 46,XY karyotype with mutation c.89G>T (p.Arg30Ile) in exon 1 of the <span class="elsevierStyleItalic">SRY</span> gene (sex-determining region of the Y chromosome), which confirmed the diagnosis of complete XY gonadal dysgenesis due to a mutation in the <span class="elsevierStyleItalic">SRY</span> gene.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Gonadoblastomas are rare benign tumours composed of germ cells mixed with circumscribed nests of sex cord cells, generally with a hyaline basement membrane and with diffuse or focal calcifications.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> They were first described by Scully in 1953.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In 50% of cases there is excessive and abnormal growth of the germ cells, with progression to dysgerminoma, and occasionally other germ tumours, such as embryonic carcinoma and choriocarcinoma.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> These tumours are rarely causes of precocious puberty.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In this case, the onset of thelarche and pubarche at age 4, with a marked acceleration of growth velocity, was indicative of an organic condition as the cause of PP. The laboratory study showed high levels of oestradiol and testosterone, with prepubertal FSH and LH levels. These facts guided the analysis of peripheral causes. The pelvic assessment identified the presence of ovarian masses which, in conjunction with the high β-HCG level, suggested a tumoural condition as the diagnosis.</p><p id="par0100" class="elsevierStylePara elsevierViewall">β-HCG is a glycoprotein hormone, which, as well as being associated with pregnancy, is considered a tumour marker for gynaecological cancer, and also, more rarely, for non-gynaecological cancer.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The tumours are hormonally active, with the ability to produce β-HCG.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Other possible germ cell tumour markers, such as LDH and α-FP, were within normal values. Capito et al., in a study carried out with 11 patients with 46,XY pure gonadal dysgenesis, also described the presence of gonadoblastoma and dysgerminoma with normal α-FP levels in a 17-year-old patient with incomplete pubertal development for her age.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In the case presented here, the biopsy confirmed a tumoural condition, which was identified as bilateral gonadoblastoma.</p><p id="par0115" class="elsevierStylePara elsevierViewall">These tumours occur almost exclusively in patients with gonadal dysgenesis associated with the presence of a Y chromosome, the most frequent karyotypes in these situations being 46,XY and 45,X/46,XY mosaicism.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Clinical presentation is variable, ranging from the absence of symptoms to different degrees of virilisation or feminisation and the presence of abdominal mass.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Presentation with signs of precocious puberty seems to be related to autonomous sex steroid secretion, which occurs in 15% of cases, being conditioned by tumour components derived from sex cord cells. Androgen secretion induces virilisation, or isosexual pseudopuberty, if oestrogen secretion dominates.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In this case, this strong association of gonadoblastomas with disorders of sexual differentiation led us to carry out a genetic study, which confirmed the diagnosis of 46,XY complete gonadal dysgenesis with the identification of mutation c.89G>T (p.Arg30Ile) in exon 1 of the <span class="elsevierStyleItalic">SRY</span> gene. This mutation was first described as a cause of gonadal dysgenesis by Assumpção et al. in 2002.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Complete gonadal dysgenesis is characterised by gonadal streaks, normal development of the Müller ducts and external female genitalia.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,13</span></a> This disruption of sexual differentiation is the result of a failure of foetal testicular development, secondary to mutations in certain genes, such as <span class="elsevierStyleItalic">SRY</span>, <span class="elsevierStyleItalic">SOX9</span>, <span class="elsevierStyleItalic">SF1</span>, <span class="elsevierStyleItalic">DAX1</span> and <span class="elsevierStyleItalic">WT1</span>.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,14</span></a> Mutations of the <span class="elsevierStyleItalic">SRY</span> gene represent only 10–20% of 46,XY disorders of sexual differentiation, which is due in the remaining cases to mutations in other genes among those mentioned.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Oophorectomy remains the treatment of choice due to the high risk of malignant transformation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">As well as oophorectomy, the treatment includes hormone therapy and fertility induction, because of the infertility of all these patients.</p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion, we wish to emphasise how important it is for health care professionals to be familiar with the physiology of normal puberty, so as to be able to recognise anomalies in pubertal development, whose aetiology may entail high morbidity and mortality, as in the case of ovarian tumours.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres375154" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec354296" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres375155" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec354297" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case history" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-05-27" "fechaAceptado" => "2013-09-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec354296" "palabras" => array:3 [ 0 => "Gonadal dysgenesis" 1 => "Gonadoblastoma" 2 => "Precocious puberty" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec354297" "palabras" => array:3 [ 0 => "Disgenesia gonadal" 1 => "Gonadoblastoma" 2 => "Pubertad precoz" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite standard clinical definitions and availability of diagnostic tests for precocious puberty, an intensive and structured investigation is needed in order to diagnose the aetiology in particular cases.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A 4-year-old, phenotypically female child was referred to paediatric endocrinology consultation for premature pubarche and thelarche. There was an acceleration of growth velocity with high levels of oestradiol and testosterone, and prepubertal FSH and LH measurements. Investigation showed bilateral gonadoblastoma as the cause of the peripheral precocious puberty.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Genetic studies revealed 46,XY karyotype with mutation c.89G>T (p.Arg30Ile) in exon 1 of the SRY gene, confirming the diagnosis of complete gonadal dysgenesis. Disorders of sexual differentiation must be considered in the approach and investigation of peripheral precocious puberty, especially in the presence of ovarian tumours, such as gonadoblastoma and dysgerminoma.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La pubertad precoz, a pesar de las definiciones clínicas estandarizadas y pruebas de diagnóstico disponibles, requiere, en ciertas situaciones una investigación exhaustiva y estructurada con el fin de conocer la causa.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Niña de 4 años de edad, fenotípicamente de sexo femenino, enviada a la consulta de endocrinología pediátrica por pubarquia y telarquia. Se observó aceleración en la tasa de crecimiento con niveles altos de estradiol y testosterona, con determinaciones prepúberes de la hormona luteinizante y foliculoestimulante. El resto del estudio de pubertad precoz periférica mostró la presencia de gonadoblastoma bilateral. El estudio genético reveló cariotipo 46 XY con mutación c.89G> T (p.Arg30Ile) en el exón 1 del gen SRY, confirmando el diagnóstico de disgenesia gonadal completa.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Los trastornos de la diferenciación sexual deben ser considerados en el abordaje y la investigación de las causas de la pubertad precoz periférica, especialmente en presencia de tumores de ovario, como gonadoblastoma y disgerminomas.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Santalha M, Amaral B, Pereira J, Ribeiro L, João Oliveira M, Figueiredo S, et al. Pubertad precoz periférica: disgenesia gonadal completa 46 XY. An Pediatr (Barc). 2014;81:246–250.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3175 "Ancho" => 2403 "Tamanyo" => 360076 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Height development with upward height percentile crossing.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 955 "Ancho" => 1625 "Tamanyo" => 152735 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Gross examination of surgical specimens.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 680 "Ancho" => 851 "Tamanyo" => 198342 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Anatomohistopathological analysis of surgery showing gonadoblastoma.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">β-HCG: beta subunit of the human chorionic gonadotropin hormone; FSH: follicle-stimulating hormone; IGF1: insulin-like growth factor 1; LH: luteinising hormone.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Result \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Reference value \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17-Hydroxyprogesterone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90<span class="elsevierStyleHsp" style=""></span>ng/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4–115<span class="elsevierStyleHsp" style=""></span>ng/dL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dehydroepiandrosterone sulphate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.1<span class="elsevierStyleHsp" style=""></span>μg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5–35<span class="elsevierStyleHsp" style=""></span>μg/dL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Delta-4-androstenedione \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.357<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.85–2.75<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Free thyroxine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.5<span class="elsevierStyleHsp" style=""></span>μg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.3–15<span class="elsevierStyleHsp" style=""></span>μg/dL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroid-stimulating hormone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5<span class="elsevierStyleHsp" style=""></span>μU/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6–6.3<span class="elsevierStyleHsp" style=""></span>μU/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IGF1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">297<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16–396<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adrenocorticotropic hormone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.5<span class="elsevierStyleHsp" style=""></span>pg/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–28<span class="elsevierStyleHsp" style=""></span>pg/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cortisol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7<span class="elsevierStyleHsp" style=""></span>μg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3–20<span class="elsevierStyleHsp" style=""></span>μg/dL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prolactin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.5<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6–18<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lactate dehydrogenase \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">257<span class="elsevierStyleHsp" style=""></span>U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110–295<span class="elsevierStyleHsp" style=""></span>U/L \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alpha-foetoprotein \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.6<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0–15<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">β-HCG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.3<span class="elsevierStyleHsp" style=""></span>U/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤1<span class="elsevierStyleHsp" style=""></span>U/L \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FSH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3<span class="elsevierStyleHsp" style=""></span>mU/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><5<span class="elsevierStyleHsp" style=""></span>mU/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.1<span class="elsevierStyleHsp" style=""></span>mU/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><5<span class="elsevierStyleHsp" style=""></span>mU/L \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oestradiol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.3<span class="elsevierStyleHsp" style=""></span>pg/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><12.5<span class="elsevierStyleHsp" style=""></span>pg/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total testosterone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.21<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.06–0.8<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab569262.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Hormone values and tumour 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 6 | 20 |
| 2024 October | 62 | 43 | 105 |
| 2024 September | 75 | 41 | 116 |
| 2024 August | 92 | 80 | 172 |
| 2024 July | 61 | 45 | 106 |
| 2024 June | 65 | 49 | 114 |
| 2024 May | 79 | 55 | 134 |
| 2024 April | 74 | 44 | 118 |
| 2024 March | 54 | 28 | 82 |
| 2024 February | 57 | 30 | 87 |
| 2024 January | 46 | 27 | 73 |
| 2023 December | 55 | 25 | 80 |
| 2023 November | 54 | 34 | 88 |
| 2023 October | 45 | 31 | 76 |
| 2023 September | 39 | 28 | 67 |
| 2023 August | 48 | 17 | 65 |
| 2023 July | 48 | 27 | 75 |
| 2023 June | 60 | 27 | 87 |
| 2023 May | 51 | 20 | 71 |
| 2023 April | 44 | 22 | 66 |
| 2023 March | 66 | 27 | 93 |
| 2023 February | 48 | 23 | 71 |
| 2023 January | 34 | 30 | 64 |
| 2022 December | 66 | 46 | 112 |
| 2022 November | 64 | 38 | 102 |
| 2022 October | 60 | 41 | 101 |
| 2022 September | 47 | 32 | 79 |
| 2022 August | 51 | 50 | 101 |
| 2022 July | 53 | 40 | 93 |
| 2022 June | 54 | 45 | 99 |
| 2022 May | 66 | 35 | 101 |
| 2022 April | 107 | 34 | 141 |
| 2022 March | 129 | 56 | 185 |
| 2022 February | 125 | 26 | 151 |
| 2022 January | 109 | 29 | 138 |
| 2021 December | 78 | 36 | 114 |
| 2021 November | 85 | 43 | 128 |
| 2021 October | 59 | 49 | 108 |
| 2021 September | 32 | 36 | 68 |
| 2021 August | 35 | 46 | 81 |
| 2021 July | 40 | 41 | 81 |
| 2021 June | 43 | 20 | 63 |
| 2021 May | 54 | 38 | 92 |
| 2021 April | 119 | 70 | 189 |
| 2021 March | 91 | 18 | 109 |
| 2021 February | 60 | 23 | 83 |
| 2021 January | 52 | 17 | 69 |
| 2020 December | 51 | 13 | 64 |
| 2020 November | 44 | 21 | 65 |
| 2020 October | 72 | 24 | 96 |
| 2020 September | 55 | 18 | 73 |
| 2020 August | 21 | 7 | 28 |
| 2020 July | 24 | 19 | 43 |
| 2020 June | 48 | 14 | 62 |
| 2020 May | 37 | 15 | 52 |
| 2020 April | 26 | 12 | 38 |
| 2020 March | 38 | 16 | 54 |
| 2020 February | 34 | 6 | 40 |
| 2020 January | 46 | 11 | 57 |
| 2019 December | 94 | 25 | 119 |
| 2019 November | 52 | 15 | 67 |
| 2019 October | 57 | 14 | 71 |
| 2019 September | 46 | 16 | 62 |
| 2019 August | 87 | 23 | 110 |
| 2019 July | 50 | 31 | 81 |
| 2019 June | 64 | 24 | 88 |
| 2019 May | 116 | 32 | 148 |
| 2019 April | 100 | 31 | 131 |
| 2019 March | 43 | 14 | 57 |
| 2019 February | 46 | 17 | 63 |
| 2019 January | 46 | 17 | 63 |
| 2018 December | 61 | 30 | 91 |
| 2018 November | 81 | 37 | 118 |
| 2018 October | 109 | 16 | 125 |
| 2018 September | 74 | 17 | 91 |
| 2018 August | 3 | 0 | 3 |
| 2018 July | 3 | 0 | 3 |
| 2018 June | 5 | 0 | 5 |
| 2018 May | 8 | 0 | 8 |
| 2018 April | 40 | 0 | 40 |
| 2018 March | 52 | 0 | 52 |
| 2018 February | 14 | 0 | 14 |
| 2018 January | 27 | 0 | 27 |
| 2017 December | 24 | 0 | 24 |
| 2017 November | 30 | 0 | 30 |
| 2017 October | 16 | 0 | 16 |
| 2017 September | 26 | 0 | 26 |
| 2017 August | 25 | 0 | 25 |
| 2017 July | 29 | 0 | 29 |
| 2017 June | 44 | 16 | 60 |
| 2017 May | 52 | 12 | 64 |
| 2017 April | 65 | 37 | 102 |
| 2017 March | 18 | 18 | 36 |
| 2017 February | 51 | 8 | 59 |
| 2017 January | 17 | 2 | 19 |
| 2016 December | 42 | 11 | 53 |
| 2016 November | 46 | 18 | 64 |
| 2016 October | 76 | 10 | 86 |
| 2016 September | 75 | 5 | 80 |
| 2016 August | 34 | 6 | 40 |
| 2016 July | 16 | 3 | 19 |
| 2016 March | 1 | 0 | 1 |
| 2016 February | 2 | 0 | 2 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 2 | 11 | 13 |
| 2015 October | 9 | 13 | 22 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 3 | 22 | 25 |
| 2015 June | 2 | 0 | 2 |
| 2015 May | 2 | 11 | 13 |
| 2015 April | 2 | 9 | 11 |
| 2015 March | 3 | 0 | 3 |
| 2015 February | 7 | 0 | 7 |
| 2015 January | 1 | 0 | 1 |
| 2014 December | 1 | 1 | 2 |
| 2014 November | 4 | 1 | 5 |
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