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Korbonits M, Blair JC, Boguslawska A, Ayuk J, Davies JH, Druce MR, Evanson J, Flanagan D, Glynn N, Higham CE, Jacques TS, Sinha S, Simmons I, Thorp N, Swords FM, Storr HL, Spoudeas HA. Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 2, specific diseases. Nat Rev Endocrinol 2024; 20:290-309. [PMID: 38336898 DOI: 10.1038/s41574-023-00949-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
Pituitary adenomas are rare in children and young people under the age of 19 (hereafter referred to as CYP) but they pose some different diagnostic and management challenges in this age group than in adults. These rare neoplasms can disrupt maturational, visual, intellectual and developmental processes and, in CYP, they tend to have more occult presentation, aggressive behaviour and are more likely to have a genetic basis than in adults. Through standardized AGREE II methodology, literature review and Delphi consensus, a multidisciplinary expert group developed 74 pragmatic management recommendations aimed at optimizing care for CYP in the first-ever comprehensive consensus guideline to cover the care of CYP with pituitary adenoma. Part 2 of this consensus guideline details 57 recommendations for paediatric patients with prolactinomas, Cushing disease, growth hormone excess causing gigantism and acromegaly, clinically non-functioning adenomas, and the rare TSHomas. Compared with adult patients with pituitary adenomas, we highlight that, in the CYP group, there is a greater proportion of functioning tumours, including macroprolactinomas, greater likelihood of underlying genetic disease, more corticotrophinomas in boys aged under 10 years than in girls and difficulty of peri-pubertal diagnosis of growth hormone excess. Collaboration with pituitary specialists caring for adult patients, as part of commissioned and centralized multidisciplinary teams, is key for optimizing management, transition and lifelong care and facilitates the collection of health-related quality of survival outcomes of novel medical, surgical and radiotherapeutic treatments, which are currently largely missing.
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Affiliation(s)
- Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | | | - Anna Boguslawska
- Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Justin H Davies
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Maralyn R Druce
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Evanson
- Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Nigel Glynn
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Thomas S Jacques
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Saurabh Sinha
- Sheffield Children's and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Simmons
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicky Thorp
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen A Spoudeas
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
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2
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Maia R, Miranda A, Geraldo AF, Sampaio L, Ramaglia A, Tortora D, Severino M, Rossi A. Neuroimaging of pediatric tumors of the sellar region-A review in light of the 2021 WHO classification of tumors of the central nervous system. Front Pediatr 2023; 11:1162654. [PMID: 37416813 PMCID: PMC10320298 DOI: 10.3389/fped.2023.1162654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/07/2023] [Indexed: 07/08/2023] Open
Abstract
Sellar/suprasellar tumors comprise about 10% of all pediatric Central Nervous System (CNS) tumors and include a wide variety of entities, with different cellular origins and distinctive histological and radiological findings, demanding customized neuroimaging protocols for appropriate diagnosis and management. The 5th edition of the World Health Organization (WHO) classification of CNS tumors unprecedently incorporated both histologic and molecular alterations into a common diagnostic framework, with a great impact in tumor classification and grading. Based on the current understanding of the clinical, molecular, and morphological features of CNS neoplasms, there have been additions of new tumor types and modifications of existing ones in the latest WHO tumor classification. In the specific case of sellar/suprasellar tumors, changes include for example separation of adamantinomatous and papillary craniopharyngiomas, now classified as distinct tumor types. Nevertheless, although the current molecular landscape is the fundamental driving force to the new WHO CNS tumor classification, the imaging profile of sellar/suprasellar tumors remains largely unexplored, particularly in the pediatric population. In this review, we aim to provide an essential pathological update to better understand the way sellar/suprasellar tumors are currently classified, with a focus on the pediatric population. Furthermore, we intend to present the neuroimaging features that may assist in the differential diagnosis, surgical planning, adjuvant/neoadjuvant therapy, and follow-up of this group of tumors in children.
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Affiliation(s)
- Rúben Maia
- Department of Neuroradiology, Centro Hospitalar Universitário São João, Porto, Portugal
| | - André Miranda
- Diagnostic Neuroradiology Unit, Imaging Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
| | - Ana Filipa Geraldo
- Diagnostic Neuroradiology Unit, Imaging Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Luísa Sampaio
- Department of Neuroradiology, Centro Hospitalar Universitário São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Antonia Ramaglia
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Giraldi E, Allen JW, Ioachimescu AG. Pituitary Incidentalomas: Best Practices and Looking Ahead. Endocr Pract 2023; 29:60-68. [PMID: 36270609 DOI: 10.1016/j.eprac.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/30/2022] [Accepted: 10/11/2022] [Indexed: 01/11/2023]
Abstract
Pituitary Incidentalomas (PI) are pituitary lesions serendipitously identified on imaging. PIs have become common in clinical practice because of increased use of imaging and radiologic advances. The most frequently incidentally detected lesions in adults are pituitary adenomas, followed by cystic lesions, and rarely other types of tumors and infiltrative and inflammatory disorders. Biochemical screening for hyperprolactinemia and acromegaly is needed in all patients with PI, whereas testing for hyposecretion is recommended for lesions larger than 6.0 mm. Most PIs are small nonfunctioning adenomas or cysts, which can be conservatively managed. For larger lesions, a multidisciplinary approach including endocrinology, neurosurgery, and neuro-ophthalmology is required. For incidentally detected lactotroph, somatotroph, and corticotroph adenomas, disease-specific management guidelines apply. Prospective studies are needed to enhance our understanding of the long-term course and response to treatment.
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Affiliation(s)
- Erica Giraldi
- Department of Medicine (Endocrinology), Emory University School of Medicine, Atlanta, Georgia; Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jason W Allen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Adriana G Ioachimescu
- Department of Medicine (Endocrinology), Emory University School of Medicine, Atlanta, Georgia; Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.
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Borghammar C, Tamaddon A, Erfurth EM, Sundgren PC, Siesjö P, Elfving M, Nilsson M. Non-functioning pituitary microadenoma in children and adolescents: Is follow-up with diagnostic imaging necessary? Endocrine 2023; 79:152-160. [PMID: 36251115 PMCID: PMC9813011 DOI: 10.1007/s12020-022-03212-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 09/27/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE No consensus exists regarding follow-up recommendations for suspected pituitary microadenoma in children. To address this knowledge gap, we investigated the growth potential of pituitary solid and cystic lesions <10 mm in children and evaluated the accuracy of magnetic resonance imaging (MRI) measurements. METHODS The children included were <18 years at first pituitary MRI and radiologically diagnosed with a non-functioning microadenoma or cyst <10 mm. Lesion size at first and latest MRI as well as all individual MRI examinations were re-evaluated. RESULTS In total, 74 children, median age 12 years (range 3-17), had a non-functioning microadenoma, probable microadenoma, or cyst. Of these, 55 underwent repeated MRI (median 3, range 2-7) with a median follow-up of 37 months (range 4-189). None of the pituitary lesions without hormonal disturbances increased significantly during follow-up. Two radiologists agreed that no lesion could be identified in 38/269 (14%) MRI examinations, and in 51/231 (22%) they disagreed about lesion location. In 34/460 (7%) MRI measurements size differed >2 mm, which had been considered significant progression. CONCLUSION Non-functioning pituitary microadenoma in children has small size variations, often below the spatial resolution of the scanners. We suggest lesions <4 mm only for clinical follow-up, lesions 4-6 mm for MRI after 2 years and ≥7 mm MRI after 1 and 3 years, with clinical follow-up in between. If no progression, further MRI should only be performed after new clinical symptoms or hormonal disturbances.
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Affiliation(s)
- Camilla Borghammar
- Skåne University Hospital, Department of Clinical Sciences, Pediatrics, Pediatric Endocrinology, Lund University, Lund, Sweden.
| | - Ashkan Tamaddon
- Skåne University Hospital, Department of Clinical Sciences, Medical Imaging and Physiology, Lund University, Lund, Sweden
| | - Eva-Marie Erfurth
- Skåne University Hospital, Department of Clinical Sciences, Endocrinology, Lund University, Lund, Sweden
| | - Pia C Sundgren
- Skåne University Hospital, Department of Clinical Sciences, Medical Imaging and Physiology, Lund University, Lund, Sweden
- Department of Clinical Sciences, Radiology, Lund University, Lund, Sweden
- Lund Bioimaging Center, Lund University, Lund, Sweden
| | - Peter Siesjö
- Skåne University Hospital, Department of Clinical Sciences, Neurosurgery, Lund University, Lund, Sweden
| | - Maria Elfving
- Skåne University Hospital, Department of Clinical Sciences, Pediatrics, Pediatric Endocrinology, Lund University, Lund, Sweden
| | - Margareta Nilsson
- Skåne University Hospital, Department of Clinical Sciences, Medical Imaging and Physiology, Lund University, Lund, Sweden
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Fava D, Calandrino A, Calevo MG, Allegri AEM, Napoli F, Gastaldi R, Patti G, Casalini E, Bassi M, Accogli A, Alyasin ARAA, Ramaglia A, Rossi A, Maghnie M, Morana G, Di Iorgi N. Clinical, Endocrine and Neuroimaging Findings in Girls With Central Precocious Puberty. J Clin Endocrinol Metab 2022; 107:e4132-e4143. [PMID: 35881919 DOI: 10.1210/clinem/dgac422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT The etiology of central precocious puberty (CPP) includes a spectrum of conditions. Girls younger than age 6 years with CPP should undergo cranial magnetic resonance imaging (MRI), but it remains controversial whether all girls who develop CPP between the ages of 6 and 8 years require neuroimaging examination. OBJECTIVE To investigate the frequency of brain MRI abnormalities in girls diagnosed with CPP and the relationship between maternal factors, their age at presentation, clinical signs and symptoms, hormonal profiles, and neuroimaging findings. METHODS Data were collected between January 2005 and September 2019 from 112 girls who showed clinical pubertal progression before 8 years of age who underwent brain MRI. RESULTS MRI was normal in 47 (42%) idiopathic (I) scans, 54 (48%) patients had hypothalamic-pituitary anomalies (HPA) and/or extra-HP anomalies (EHPA), and 11 (10%) had brain tumors or tumor-like conditions (BT/TL), including 3 with neurological signs. Associated preexisting disorders were documented in 16. Girls with BT/TL had a higher LH peak after GnRH test (P = 0.01) than I, and those older than age 6 years had a higher craniocaudal diameter of the pituitary gland (P = 0.01); their baseline FSH and LH (P = 0.004) and peak FSH (P = 0.01) and LH (P = 0.05) values were higher than I. Logistic regression showed maternal age at menarche (P = 0.02) and peak FSH (P = 0.02) as BT/TL risk factors. CONCLUSIONS MRI provides valuable information in girls with CPP by demonstrating that fewer than half have a normal brain MRI and that few can have significant intracranial lesions after the age of 6, despite the absence of suggestive neurological signs.
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Affiliation(s)
- Daniela Fava
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
| | - Andrea Calandrino
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
| | | | - Flavia Napoli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
| | - Roberto Gastaldi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
| | - Giuseppa Patti
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
| | - Emilio Casalini
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
| | - Marta Bassi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
| | - Andrea Accogli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
- Department of Specialized Medicine, Division of Medical Genetics, McGill University Health Centre, Montreal H4A 3J1, Canada
- Department of Human Genetics, Faculty of Medicine, McGill University, Montreal H3A 1G1, Canada
| | - Abdel Razaq Ahmad A Alyasin
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
| | - Antonia Ramaglia
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa 16142, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
| | - Giovanni Morana
- Department of Neurosciences, Neuroradiology Unit, University of Turin, Turin 10126, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa 16142, Italy
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Paun L, Lavé A, Patet G, Bartoli A. Supratentorial Pediatric Midline Tumors and Tumor-like Lesions: Clinical Spectrum, Natural History and Treatment Options. Children (Basel) 2022; 9:children9040534. [PMID: 35455578 PMCID: PMC9032564 DOI: 10.3390/children9040534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 04/10/2023]
Abstract
Childhood Central Nervous System tumors account for 25% of all pediatric tumors. Large availability and broadening of indications to imaging has made incidental findings more common. Among these, midline lesions have different clinical relevance depending on their intrinsic pattern of behaviour and on their specific location. In this narrative review we describe the natural history and treatment options of midline lesions in children.
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Sheldon BL, O'Brien MW, Adamo MA. Growth hormone replacement therapy: is it safe to use in children with asymptomatic pituitary lesions? J Pediatr Endocrinol Metab 2021; 34:1525-1529. [PMID: 34407327 DOI: 10.1515/jpem-2021-0479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/04/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Small pituitary cysts are commonly discovered on pediatric brain magnetic resonance imagings (MRIs), particularly in patients with growth hormone deficiency (GHD). We examined the need for operative management in children with these masses as well as the effect of growth hormone replacement (GHR) on these lesions. METHODS This was a retrospective review of pituitary protocol MRIs conducted in children 0-19 at a single center between April 2010-November 2020. Sex, indication for initial MRI, volume, and whether surgery was performed was determined. Records were reviewed to determine whether GHD was present and treatment with GHR documented. For patients with subsequent MRIs, volume on most recent scan was calculated. RESULTS Of the 101 children with cysts, 25 had laboratory-confirmed GHD and 76 did not. GHD patients had a higher mean age compared to no growth hormone deficiency (NGHD) cohort (11.2 and 8.4 years, respectively; p=0.02) and a larger proportion of males (p<0.001). The mean cyst volume on initial MRI was not significantly smaller in patients with GHD (0.063 ± 0.012 cm3) vs. those without GHD (0.171 ± 0.039 cm3, p=0.11). Of the 21 GHD patients who received GHR and had follow-up MRIs, 10 had no change in pituitary cyst size, two had cysts that shrank, and seven disappeared. The remaining two cysts enlarged an average of 0.061 ± 0.033 cm3. Zero GHR recipients required surgical intervention. CONCLUSIONS Small sellar cysts discovered incidentally on imaging in children are unlikely to require surgical intervention. GHR does not appear to significantly enlarge these pediatric pituitary lesions and is safe for use.
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Affiliation(s)
| | | | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA.,Department of Pediatrics, Albany Medical Center, Albany, NY, USA
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Abstract
Pituitary incidentalomas are discovered in approximately 10% to 40% of brain images. A complete patient history, physical examination, and dedicated pituitary function testing are needed, and subsequent results should lead to appropriate patient management. However, most lesions are asymptomatic pituitary adenomas or Rathke cleft cysts with a benign course. Many lesions can be clinically significant, including prolactinomas or other pituitary adenomas that warrant specific pituitary disease treatment. In other cases, mass effect causing visual compromise or refractory headache indicates a need for surgery. Here, various facets of a complex evaluation and treatment algorithm for pituitary incidentalomas are reviewed.
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Affiliation(s)
- Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Maria Fleseriu
- Departments of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition), and Neurological Surgery, and Pituitary Center, Oregon Health & Science University, CH8N 3303 South Bond Avenue, Portland, OR, USA.
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Abstract
Pituitary incidentalomas (PI) are lesions of the pituitary region discovered fortuitously by imaging for reasons unrelated to pituitary disease. They range from small cysts to large invasive adenomas. All over the world, improvements in the quality and availability of radiological examinations are leading to an increase in the discovery of PI. In the last four decades, significant advances have been made in the understanding of PI. Autopsy studies have shown that about 10% of deceased individuals harbour a PI, most often a non-functioning microadenoma. In contrast, modern patient series showed that among PIs that come to endocrinological attention, a significant proportion are macroadenomas, and many patients suffer from asymptomatic or pauci-symptomatic endocrine or ophthalmologic disturbances. Other than adenomas, empty sella, Rathke's cleft cyst, craniopharyngioma and meningioma are the most frequent types of PIs. About 10% of micro-incidentalomas and 25% of macro-incidentalomas grow over time. Most cases can be managed conservatively by mere surveillance. Follow-up is necessary in all patients with macroadenoma, but uncertainty remains for microadenomas as to the extent of endocrinological work-up as well as the necessity and duration of follow-up. Visual and endocrine anomalies constitute the most common indications for surgery. When needed, surgery yields better outcome in PIs than in symptomatic pituitary lesions.
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Michali-Stolarska M, Tukiendorf A, Zacharzewska-Gondek A, Jacków-Nowicka J, Chrzanowska J, Trybek G, Bladowska J. MRI Protocol for Pituitary Assessment in Children with Growth or Puberty Disorders-Is Gadolinium Contrast Administration Actually Needed? J Clin Med 2021; 10:jcm10194598. [PMID: 34640616 PMCID: PMC8509364 DOI: 10.3390/jcm10194598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to assess the diagnostic value of non-contrast pituitary MRI in children with growth or puberty disorders (GPDs) and to determine the criteria indicating the necessity to perform post-contrast examination. A retrospective study included re-analysis of 567 contrast-enhanced pituitary MRIs of children treated in a tertiary reference center. Two sets of sequences were created from each MRI examination: Set 1, including common sequences without contrast administration, and Set 2, which included common pre- and post-contrast sequences (conventional MRI examination). The differences in the visibility of pituitary lesions between pairs of sets were statistically analyzed. The overall frequency of Rathke’s cleft cysts was 11.6%, ectopic posterior pituitary 3.5%, and microadenomas 0.9%. Lesions visible without contrast administration accounted for 85% of cases. Lesions not visible before and diagnosed only after contrast injection accounted for only 0.18% of all patients. Statistical analysis showed the advantage of the antero-posterior (AP) pituitary dimension over the other criteria in determining the appropriateness of using contrast in pituitary MRIs. The AP dimension was the most significant factor in logistic regression analysis: OR = 2.23, 95% CI, 1.35–3.71, p-value = 0.002, and in ROC analysis: AUC: 72.9% with a cut-off value of 7.5 mm, with sensitivity/specificity rates of 69.2%/73.5%. In most cases, the use of gadolinium-based contrast agent (GBCA) in pituitary MRI in children with GPD is unnecessary. The advantages of GBCA omission include shortening the time of MRI examination and of general anesthesia; saving time for other examinations, thus increasing the availability of MRI for waiting children; and acceleration in their further clinical management.
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Affiliation(s)
- Marta Michali-Stolarska
- Department of General and Interventional Radiology and Neuroradiology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.M.-S.); (J.J.-N.); (J.B.)
| | - Andrzej Tukiendorf
- Department of Public Health, Wroclaw Medical University, 50-367 Wroclaw, Poland;
| | - Anna Zacharzewska-Gondek
- Department of General and Interventional Radiology and Neuroradiology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.M.-S.); (J.J.-N.); (J.B.)
- Correspondence: ; Tel.: +48-(71)-733-1668; Fax: +48-(71)-734-1669
| | - Jagoda Jacków-Nowicka
- Department of General and Interventional Radiology and Neuroradiology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.M.-S.); (J.J.-N.); (J.B.)
| | - Joanna Chrzanowska
- Department of Developmental Endocrinology and Diabetology, Wroclaw Medical University, 50-367 Wroclaw, Poland;
| | - Grzegorz Trybek
- Department of Oral Surgery, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland;
| | - Joanna Bladowska
- Department of General and Interventional Radiology and Neuroradiology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.M.-S.); (J.J.-N.); (J.B.)
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Baird K, McCroskey J, Arynchyna A, Abdullatif H, Ashraf AP, Simpson L, Rocque BG. Incidental Pituitary Cysts in Children: Does Growth Hormone Treatment Affect Cyst Size? Endocr Pract 2021; 27:1128-1132. [PMID: 33965583 DOI: 10.1016/j.eprac.2021.04.887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To evaluate the response of incidentally discovered pituitary cysts to growth hormone (GH) treatment. METHODS A retrospective chart review was performed of children with pituitary cysts on magnetic resonance imaging (MRI) over a 5-year period. Records and images were reviewed, and the results were analyzed using descriptive statistics. Children with pituitary cysts who received GH treatment were compared with those without. RESULTS We identified 109 children with pituitary cysts, 24 were treated with GH therapy. The average age was 8.5 ± 5.1 years. Children whose initial MRI scan was to evaluate growth hormone deficiency were more commonly male and non-Hispanic White compared with those with scans for other indications (male, 18 of 24 vs 35 of 85, P = .003; White, 23 of 24 vs 58 of 85, P = .004). Among patients who received GH treatment, 12 had follow-up MRI. Six had no change in cyst size and 6 had a decrease in cyst size. We observed no difference in the likelihood of cyst growth between those who received GH and those who did not (0 of 12 cysts with GH vs 1 of 15 cysts without GH showed growth at follow-up). No patient had neurologic deficits attributable to the pituitary cyst at any time. CONCLUSION In a single-institution, retrospective study, we find no evidence of growth in pituitary cysts in response to GH therapy.
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Affiliation(s)
- Katelin Baird
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | | | - Lauren Simpson
- University of Alabama at Birmingham, Birmingham, Alabama
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12
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Abstract
According to the WHO classification 2017 of Pituitary Tumors adenomas are classified not only by structure and immunostaining for pituitary hormones but also by expression of the pituitary transcription factors Pit-1, T-pit and SF-1. By these factors, three cell lineages can be identified: Pit-1 for the GH-, Prolactin- and TSH-cell lineage, T-pit for the ACTH-cell lineage, and SF-1 for the gonadotrophic cell lineage. By this principle, all GH and/or Prolactin producing and all TSH producing adenomas must be positive for Pit-1, all corticotrophic adenomas for T-pit, and all gonadotrophic for SF-1. In adenomas without expression of pituitary hormones immunostainings for the transcription factors have to be examined. If these are also negative the criteria for an endocrine inactive null cell adenoma are fulfilled. If one transcription factor is positive the corresponding cell lineage indicates a potential hormonal activity of the adenoma. So Pit-1 expressing hormone-negative adenomas can account for acromegaly, hyperprolactinemia, or TSH hyperfunction. T-pit positive hormone negative adenomas can induce Cushing's disease, and SF-1 positive hormone negative tumors indicate gonadotrophic adenomas. Instead of the deleted atypical adenoma of the WHO classification of 2004 now (WHO classification 2017) criteria exist for the identification of aggressive adenomas with a conceivably worse prognosis. Some adenoma subtypes are described as aggressive "per se" without necessity of increased morphological signs of proliferation. All other adenoma subtypes must also be designated as aggressive if they show signs of increased proliferation (mitoses, Ki-67 index>3-5%, clinically rapid tumor growth) and invasion. By these criteria about one third of pituitary adenoma belong to the group of aggressive adenomas with potentially worse prognosis. The very rare pituitary carcinoma (0.1 % of pituitary tumors) is defined only by metastases. Many of them develop after several recurrences of Prolactin or ACTH secreting adenomas. The correlation of clinical findings and histological classification of pituitary adenomas is very important since every discrepancy has to be discussed between clinicians and pathologists. Based on data of the German Registry of Pituitary Tumors a table for examinations of correlations is shown in this review.
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Affiliation(s)
- Wolfgang Saeger
- Institute of Pathology and Neuropathology of the University of Hamburg, UKE, Hamburg, Germany
| | - Arend Koch
- Institute of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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13
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Shareef M, Nasrallah MP, AlArab N, Atweh LA, Zadeh C, Hourani R. Pituitary incidentalomas in paediatric population: Incidence and characteristics. Clin Endocrinol (Oxf) 2021; 94:269-276. [PMID: 33098093 DOI: 10.1111/cen.14353] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/17/2020] [Accepted: 10/12/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the incidence of pituitary incidentalomas in the paediatric population and among its different age subgroups as well as to identify the characteristics of these lesions. Additionally, we aim to give a perspective on the management and follow-up of these patients. DESIGN AND PATIENTS We retrospectively studied MRI of children aged 18 years or below who underwent MRI with sellar region within their field of view between January 2010 and December 2018. MEASUREMENTS Pituitary lesions were considered incidental according to the definition by the Endocrine Society. We reported the size, location and signal characteristics of each lesion. Medical charts of the subjects were reviewed for age, sex, the MRI indication and the hormonal assays levels. RESULTS We identified 40 pituitary lesions of which 31 were incidental lesions. The incidence of pituitary incidentaloma in our cohort was 22 per 1000 patients with female predisposition ( 64.5%) and a mean age of 11 ± 6 years. Rathke's cleft cyst was the most prevalent lesion, accounting for 67.7% followed by cystic pituitary lesions and microadenomas. The most common indications for imaging were growth disturbance (12.9%) followed by headache (9.7%). Abnormal laboratory workup was present in 13% of the subjects. Incidental lesions were more common in the older age groups compared to young children. CONCLUSION Incidental pituitary lesions in the paediatric population are relatively infrequent and increases with age. Rathke's cleft cyst is the most common incidentally encountered pituitary lesion followed by cystic pituitary lesions and microadenomas.
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Affiliation(s)
- Muhammed Shareef
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mona P Nasrallah
- Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Natally AlArab
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lamya A Atweh
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Catherina Zadeh
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Roula Hourani
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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14
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Baldo F, Marin M, Murru FM, Barbi E, Tornese G. Dealing With Brain MRI Findings in Pediatric Patients With Endocrinological Conditions: Less Is More? Front Endocrinol (Lausanne) 2021; 12:780763. [PMID: 35095759 PMCID: PMC8791386 DOI: 10.3389/fendo.2021.780763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/20/2021] [Indexed: 12/22/2022] Open
Abstract
Neuroimaging is a key tool in the diagnostic process of various clinical conditions, especially in pediatric endocrinology. Thanks to continuous and remarkable technological developments, magnetic resonance imaging can precisely characterize numerous structural brain anomalies, including the pituitary gland and hypothalamus. Sometimes the use of radiological exams might become excessive and even disproportionate to the patients' medical needs, especially regarding the incidental findings, the so-called "incidentalomas". This unclarity is due to the absence of well-defined pediatric guidelines for managing and following these radiological findings. We review and summarize some indications on how to, and even if to, monitor these anomalies over time to avoid unnecessary, expensive, and time-consuming investigations and to encourage a more appropriate follow-up of brain MRI anomalies in the pediatric population with endocrinological conditions.
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Affiliation(s)
| | - Maura Marin
- University of Trieste, Trieste, Italy
- *Correspondence: Maura Marin,
| | - Flora Maria Murru
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Egidio Barbi
- University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Gianluca Tornese
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
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Brener A, Kozyrev DA, Shiran SI, Azoulay E, Pratt LT, Precel R, Ben-Sira L, Eyal O, Constantini S, Roth J, Lebenthal Y. Incidental Findings on Brain Magnetic Resonance Imaging (MRI) in Pediatric Endocrine Patients. Endocr Pract 2020; 26:1105-1114. [PMID: 33471712 DOI: 10.4158/ep-2020-0208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/10/2020] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To explore incidental findings on brain magnetic resonance imaging (MRI) studies of pediatric patients referred due to endocrine disorders. METHODS A retrospective, observational study conducted in a tertiary referral center. The neuroimaging database of 17,445 brain MRI studies of 11,011 pediatric patients were searched for cases with endocrine referrals and without medical history of malignancy, genetic syndromes, and/or neurologic comorbidities. This database was linked to the pediatric neurosurgical database. Clinical data were retrieved from medical files. RESULTS In total, 524 patients (50.2% males, mean age 8.5±3.5 years) were referred to brain MRI due to growth disturbances (n = 313), pubertal disorders (n = 183), prolactin hypersecretion (n = 18), central diabetes insipidus (n = 8), and obesity (n = 1). Incidental findings were found in 128 (24.4%) cases. Chiari type 1 malformation was more prevalent in patients with growth disturbances (P<.001). Small pituitary cysts were observed in 20 (3.8%) patients, and pineal cysts in 25 (4.8%) patients, mostly girls (68%, P<.001). White matter lesions were diagnosed in 30 (5.7%) patients, none with clinical evidence of neurologic disease. Brain asymmetry without clinical significance and developmental venous anomalies were observed in 14 (2.7%) and 8 (1.5%) patients, respectively. Twelve patients were diagnosed with intracranial tumors, and 5 required surgical intervention for a histopathologic diagnosis of juvenile pilocytic astrocytoma (n = 3), choroid plexus papilloma (n = 1), or inconclusive (n = 1). The rest were managed conservatively. CONCLUSION Incidental findings on brain MRIs of pediatric patients referred by endocrinologists are common and raise dilemmas. The spectrum ranges from structural disruptions to tumors. Decision-making is individualized and patient-centered.
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Affiliation(s)
- Avivit Brener
- From the Pediatric Endocrinology and Diabetes Unit, Tel-Aviv, Israel.
| | | | - Shelly I Shiran
- the Pediatric Radiology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Erez Azoulay
- From the Pediatric Endocrinology and Diabetes Unit, Tel-Aviv, Israel
| | - Li-Tal Pratt
- the Pediatric Radiology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ronit Precel
- the Pediatric Radiology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Liat Ben-Sira
- the Pediatric Radiology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ori Eyal
- From the Pediatric Endocrinology and Diabetes Unit, Tel-Aviv, Israel
| | | | - Jonathan Roth
- the Department of Pediatric Neurosurgery, Tel-Aviv, Israel
| | - Yael Lebenthal
- From the Pediatric Endocrinology and Diabetes Unit, Tel-Aviv, Israel
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Chiu CF, Wang CJ, Chen YP, Lo FS. Pathological and Incidental Findings in 403 Taiwanese Girls With Central Precocious Puberty at Initial Diagnosis. Front Endocrinol (Lausanne) 2020; 11:256. [PMID: 32431668 PMCID: PMC7214687 DOI: 10.3389/fendo.2020.00256] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/06/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Whether girls with central precocious puberty (CPP) should undergo routine brain magnetic resonance imaging (MRI) to identify potential intracranial pathologies is controversial. Aims: To evaluate the brain MRI results of girls with CPP and identify the clinical and endocrine predictors of brain abnormalities. Methods: This retrospective study obtained data from pediatric endocrine clinics at Chang Gung Children's Hospital. From 1997 and 2017, 403 girls were consecutively diagnosed with CPP. After the exclusion of patients with a history of central nervous system (CNS) insults or associated neuropsychiatric symptom or signs, we studied the prevalence of brain abnormalities in 251 girls with CPP who received detailed MRI examinations of the hypothalamus and pituitary area. We also recorded the demographic data of the participants, including the onset of puberty; initial pubertal status; height; weight; uterus and ovary sizes; and basal luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol levels, and the response to GnRH stimulation test. Results: Among the 251 girls with CPP, we observed no brain alterations in 190 (75.70%), abnormalities in the hypothalamic-pituitary (H-P) area in 54 (21.51%), and abnormalities in the non-H-P area in 7 (2.79%). Among the 54 patients that had H-P lesions, we noted pathological findings related to CPP (hypothalamic hamartoma) in only one (0.4%) girl aged below 6 years old. We also identified incidental findings in the other girls with H-P lesions, including non-functioning pituitary microadenomas (12.35%), pituitary pars intermedia cysts (4.38%), Rathke's pouch cysts (1.99%), pituitary hypoplasia (1.59%), and pineal gland cysts (0.8%). The patients that had non-H-P lesions were found to have arachnoid cysts (1.59%), Chiari I malformation (0.4%), prepontine nodule (0.4%), and choroidal fissure cyst (0.4%). Of all the patients with brain lesions, 45 (73.77%) underwent regular MRI follow-up. While none of the H-P and non-H-P lesions showed progression, 19.67% of these regressed during the follow-up. None of the participants exhibited other hormonal abnormalities or underwent surgery. Conclusion: The prevalence of true pathological brain lesions related to CPP in girls without prior symptoms or signs of CNS lesions was low (0.4%). None of the girls with intracranial lesions required further intervention besides the GnRH agonist treatment. These data question the routine use of brain MRI in all girls with CPP, especially in those who are healthy without neurologic symptoms.
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Affiliation(s)
- Chiao-Fan Chiu
- Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medicine Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chao-Jan Wang
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Pin Chen
- Department of Obstetrics and Gynecology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Fu-Sung Lo
- Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- *Correspondence: Fu-Sung Lo
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Abstract
The genetic landscape of pituitary adenomas (PAs) is diverse and many of the identified cases remain of unclear pathogenetic mechanism. Germline genetic defects account for a small percentage of all patients and may present in the context of relevant family history. Defects in AIP (mutated in Familial Isolated Pituitary Adenoma syndrome or FIPA), MEN1 (coding for menin, mutated in Multiple Endocrine Neoplasia type 1 or MEN 1), PRKAR1A (mutated in Carney complex), GPR101 (involved in X-Linked Acrogigantism or X-LAG), and SDHx (mutated in the so called "3 P association" of PAs with pheochromocytomas and paragangliomas or 3PAs) account for the most common familial syndromes associated with PAs. Tumor genetic defects in USP8, GNAS, USP48 and BRAF are some of the commonly encountered tissue-specific changes and may explain a larger percentage of the developed tumors. Somatic (at the tumor level) genomic changes, copy number variations (CNVs), epigenetic modifications, and differential expression of miRNAs, add to the variable genetic background of PAs.
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18
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Thaker VV, Lage AE, Kumari G, Silvera VM, Cohen LE. Clinical Course of Nonfunctional Pituitary Microadenoma in Children: A Single-Center Experience. J Clin Endocrinol Metab 2019; 104:5906-5912. [PMID: 31390015 PMCID: PMC6800531 DOI: 10.1210/jc.2019-01252] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/01/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Pituitary lesions consistent with microadenomas are increasingly discovered by MRI. Sparse data are available on the long-term clinical and imaging course of such lesions in children. OBJECTIVE The aim of this study was to define the clinical and imaging course of pituitary lesions representing or possibly representing nonfunctioning microadenomas in children to guide clinical management. DESIGN Retrospective observational study. METHODS The clinical data warehouse at a tertiary care academic children's hospital was queried with the terms "pituitary" AND "microadenoma" and "pituitary" AND "incidentaloma." The electronic health records of the identified subjects were reviewed to extract data on the clinical and imaging course. RESULTS A total of 78 children had nonfunctioning pituitary lesions incidentally discovered during clinical care, of which 44 (56%) were reported as presumed or possible microadenomas. In the children with microadenoma (median age 15 years, interquartile range 2), a majority (70%) underwent imaging for nonendocrine symptoms, the most common being headache (n = 16, 36%). No significant increase in the size of the microadenoma or cysts or worsening of pituitary function was seen over the average clinical follow-up of 4.5 ± 2.6 years. Four cases of drug-induced hyperprolactinemia resolved with discontinuation of the offending medication. CONCLUSIONS Asymptomatic pituitary lesions representing cysts, microadenomas, or possible microadenomas follow a benign course in children. In the absence of new endocrine or visual symptoms, repeat MRI may not be needed, and if performed, should be done in no less than a year. When possible, it is prudent to discontinue hyperprolactinemia-inducing medications before imaging.
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Affiliation(s)
- Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
- Correspondence and Reprint Requests: Vidhu V. Thaker, MD, Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, 1150 St. Nicholas Avenue, New York, NY 10032. E-mail:
| | | | - Garima Kumari
- Clinical Research Informatics, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Laurie E Cohen
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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