1
|
Di Iorgi N, Morana G, Cappa M, D’Incerti L, Garrè ML, Grossi A, Iughetti L, Matarazzo P, Parpagnoli M, Pozzobon G, Salerno M, Sardi I, Wasniewska MG, Zucchini S, Rossi A, Maghnie M. Expert Opinion on the Management of Growth Hormone Deficiency in Brain Tumor Survivors: Results From an Italian Survey. Front Endocrinol (Lausanne) 2022; 13:920482. [PMID: 35909559 PMCID: PMC9331278 DOI: 10.3389/fendo.2022.920482] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Growth hormone deficiency (GHD) is the first and most common endocrine complication in pediatric brain tumor survivors (BTS). GHD can occur due to the presence of the tumor itself, surgery, or cranial radiotherapy (CRT). AIMS This study aimed to evaluate management and adherence to current guidelines of the Italian centers engaged in the diagnosis and follow-up of GHD patients with BTS. METHODS A multidisciplinary scientific board of pediatric endocrinologists, oncologists and radiologists with neuroimaging expertise discussed and reviewed the main issues relating to the management of GHD in pediatric BTS and developed a survey. The survey included questions relating to organizational aspects, risk factors, diagnosis, definition of stable disease, and treatment. The online survey was sent to an expanded panel of specialists dedicated to the care of pediatric BTS, distributed among the three specialty areas and throughout the country (23 Italian cities and 37 Centers). RESULTS The online questionnaire was completed by 86.5% (32 out of 37) of the Centers involved. Most had experience in treating these patients, reporting that they follow more than 50 BTS patients per year. Responses were analyzed descriptively and aggregated by physician specialty. Overall, the results of the survey showed some important controversies in real life adherence to the current guidelines, with discrepancies between endocrinologists and oncologists in the definition of risk factors, diagnostic work-up, decision-making processes and safety. Furthermore, there was no agreement on the neuroimaging definition of stable oncological disease and how to manage growth hormone therapy in patients with residual tumor and GHD. CONCLUSIONS The results of the first Italian national survey on the management of GHD in BTS highlighted the difference in management on some important issues. The time to start and stop rhGH treatment represent areas of major uncertainty. The definition of stable disease remains critical and represents a gap in knowledge that must be addressed within the international guidelines in order to increase height and to improve metabolic and quality of life outcomes in cancer survivors with GHD.
Collapse
Affiliation(s)
- Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Endo-European Reference Networks (ERN) Center for Rare Endocrine Conditions, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Genoa, Italy
- *Correspondence: Natascia Di Iorgi,
| | - Giovanni Morana
- Department of Neurosciences, Neuroradiology Unit, University of Turin, Turin, Italy
| | - Marco Cappa
- Unit of Endocrinology, Bambino Gesù Children’s Hospital, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Ludovico D’Incerti
- Department of Pediatric Radiology, Meyer Children’s Hospital, Florence, Italy
| | | | - Armando Grossi
- Unit of Endocrine Pathology of Post-Tumoral and Chronic Diseases, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences of the Mother, Children and Adults. University of Modena and Reggio Emilia, Modena, Italy
| | - Patrizia Matarazzo
- Department of Pediatric Endocrinology, Regina Margherita Children’s Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Maria Parpagnoli
- Health Sciences Department, Children With Clinical Complex Needs Meyer Children’s Hospital, Florence, Italy
| | - Gabriella Pozzobon
- Pediatric Unit, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Endo-European Reference Networks (ERN) Center for Rare Endocrine Conditions, Milan, Italy
| | - Mariacarolina Salerno
- Pediatric Unit, Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Iacopo Sardi
- Neuro-Oncology Unit, Department of Pediatric Oncology, Meyer Children’s Hospital, Florence, Italy
| | | | - Stefano Zucchini
- Pediatric Endocrine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Endo-European Reference Networks (ERN) Center for Rare Endocrine Conditions, Bologna, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Endo-European Reference Networks (ERN) Center for Rare Endocrine Conditions, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Genoa, Italy
| |
Collapse
|
2
|
Influence of biochemical diagnosis of growth hormone deficiency on replacement therapy response and retesting results at adult height. Sci Rep 2021; 11:14553. [PMID: 34267285 PMCID: PMC8282600 DOI: 10.1038/s41598-021-93963-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Isolated growth hormone deficiency (IGHD) is the most frequent endocrinological disorder in children with short stature, however the diagnosis is still controversial due to the scarcity of reliable diagnostic criteria and pre-treatment predictive factors of long term-response. To evaluate recombinant growth hormone (rGH) long-term response and retesting results in three different groups of children divided in accordance with the biochemical criteria of initial diagnosis. Height gain (∆HT) at adult height (AH) and retesting results were evaluated in 57 rGH treated children (M = 34, 59.6%) divided into 3 groups according to initial diagnosis: Group A (n = 25) with max GH peak at stimulation test < 8 µg/L, Group B (n = 19) between 8 and 10 µg/L and Group C (n = 13) with mean overnight GH < 3 µg/L (neurosecretory dysfunction, NSD). Retesting was carried out in all patients after at least one month off therapy upon reaching the AH. 40/57 (70.2%) patients were pre-pubertal at diagnosis and showed ∆HT of 1.37 ± 1.00 SDS, with no significant differences between groups (P = 0.08). Nonetheless, 46% patients in Group B showed ∆HT < 1SDS (vs 13% and 12% in Group A and C, respectively) and 25% children failed to reach mid-parental height (vs 6% and 0% in Group A and C, respectively). At AH attainment, IGHD was reconfirmed in 28% (7/25) and 10% (2/19) in Group A and B, respectively. A reduction of diagnostic cut-off at GH stimulation tests could better discriminate between "good" and "poor responders" and predict the persistence of IGHD through transition. Group C response and the predictive value of baseline IGF-I SDS bring back to light NSD: should we consider an underlying hypothalamic derangement when the clinical presentation is strongly consistent with IGHD but pharmacological stimulation test is normal?
Collapse
|
3
|
Collett-Solberg PF, Ambler G, Backeljauw PF, Bidlingmaier M, Biller BM, Boguszewski MC, Cheung PT, Choong CSY, Cohen LE, Cohen P, Dauber A, Deal CL, Gong C, Hasegawa Y, Hoffman AR, Hofman PL, Horikawa R, Jorge AA, Juul A, Kamenický P, Khadilkar V, Kopchick JJ, Kriström B, Lopes MDLA, Luo X, Miller BS, Misra M, Netchine I, Radovick S, Ranke MB, Rogol AD, Rosenfeld RG, Saenger P, Wit JM, Woelfle J. Diagnosis, Genetics, and Therapy of Short Stature in Children: A Growth Hormone Research Society International Perspective. Horm Res Paediatr 2019; 92:1-14. [PMID: 31514194 PMCID: PMC6979443 DOI: 10.1159/000502231] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/18/2019] [Indexed: 12/28/2022] Open
Abstract
The Growth Hormone Research Society (GRS) convened a Workshop in March 2019 to evaluate the diagnosis and therapy of short stature in children. Forty-six international experts participated at the invitation of GRS including clinicians, basic scientists, and representatives from regulatory agencies and the pharmaceutical industry. Following plenary presentations addressing the current diagnosis and therapy of short stature in children, breakout groups discussed questions produced in advance by the planning committee and reconvened to share the group reports. A writing team assembled one document that was subsequently discussed and revised by participants. Participants from regulatory agencies and pharmaceutical companies were not part of the writing process. Short stature is the most common reason for referral to the pediatric endocrinologist. History, physical examination, and auxology remain the most important methods for understanding the reasons for the short stature. While some long-standing topics of controversy continue to generate debate, including in whom, and how, to perform and interpret growth hormone stimulation tests, new research areas are changing the clinical landscape, such as the genetics of short stature, selection of patients for genetic testing, and interpretation of genetic tests in the clinical setting. What dose of growth hormone to start, how to adjust the dose, and how to identify and manage a suboptimal response are still topics to debate. Additional areas that are expected to transform the growth field include the development of long-acting growth hormone preparations and other new therapeutics and diagnostics that may increase adult height or aid in the diagnosis of growth hormone deficiency.
Collapse
Affiliation(s)
- Paulo F. Collett-Solberg
- aDisciplina de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil,*Paulo Ferrez Collett-Solberg, MD, PhD, Pavilhão Reitor Haroldo Lisboa da Cunha, térreo, Rua São Francisco Xavier 524, Maracanã, Rio de Janeiro 20550-013 (Brazil), E-Mail
| | - Geoffrey Ambler
- bInstitute of Endocrinology and Diabetes, The University of Sydney, Sydney, New South Wales, Australia
| | - Philippe F. Backeljauw
- cDivision of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Martin Bidlingmaier
- dEndocrine Laboratory, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Beverly M.K. Biller
- eNeuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Pik To Cheung
- gPaediatric Endocrinology, Genetics, and Metabolism, Virtus Medical Group and The University of Hong Kong, Hong Kong SAR, China
| | - Catherine Seut Yhoke Choong
- hDepartment of Endocrinology, Perth Children's Hospital, Child and Adolescent Health Service, Perth, Washington, Australia,iDivision of Paediatrics, School of Medicine, University of Western Australia, Perth, Washington, Australia,jThe Centre for Child Health Research, Telethon Kids Institute, University of Western Australia, Perth, Washington, Australia
| | - Laurie E. Cohen
- kDivision of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pinchas Cohen
- lLeonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Andrew Dauber
- mDivision of Endocrinology, Children's National Health System, Washington, District of Columbia, USA
| | - Cheri L. Deal
- nEndocrine and Diabetes Service, CHU Sainte-Justine and University of Montreal, Montreal, Québec, Canada
| | - Chunxiu Gong
- oEndocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children's Hospital, Beijing, China
| | - Yukihiro Hasegawa
- pDivision of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Andrew R. Hoffman
- qDepartment of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Paul L. Hofman
- rLiggins Institute, University of Auckland, Auckland, New Zealand
| | - Reiko Horikawa
- sDivision of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Alexander A.L. Jorge
- tUnidade de Endocrinologia Genética (LIM25), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anders Juul
- uDepartment of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter Kamenický
- vService d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Paris, France
| | - Vaman Khadilkar
- wHirabai Cowasji Jehangir Medical Research Institute (HCJMRI), Jehangir Hospital, Pune, India
| | - John J. Kopchick
- xEdison Biotechnology Institute and Department of Biomedical Sciences, HCOM Ohio University Athens, Athens, Ohio, USA
| | - Berit Kriström
- yInstitute of Clinical Science, Pediatrics, Umeå University, Umeå, Sweden
| | - Maria de Lurdes A. Lopes
- zUnidade de Endocrinologia Pediátrica, Area da Mulher, Criança e Adolescente, Centro Hospitalar Universitário de Lisboa Central-Hospital de Dona Estefânia, Lisbon, Portugal
| | - Xiaoping Luo
- ADepartment of Pediatrics, Tongji Hospital, Tongji Medical Colleage, Huazhong University of Science and Technology, Wuhan, China
| | - Bradley S. Miller
- BDivision of Endocrinology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Madhusmita Misra
- CDivision of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Irene Netchine
- DExplorations Fonctionnelles Endocriniennes, AP-HP Hôpital Trousseau, Centre de Recherche Saint Antoine, INSERM, Sorbonne Université, Paris, France
| | - Sally Radovick
- EDepartment of Pediatrics, Robert Wood Johnson Medical School, Child Health Institute of New Jersey-Rutgers University, New Brunswick, New Jersey, USA
| | | | - Alan D. Rogol
- GDepartment of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Jan M. Wit
- JDepartment of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Joachim Woelfle
- KPediatric Endocrinology Division, Children's Hospital, University of Bonn, Bonn, Germany
| |
Collapse
|
4
|
Lawitschka A, Schwarze P, Rovelli A, Badoglio M, Socie G, Tichelli A, Bauer D, Rovo A, Basak G, Schoemans H, Peters C, Salooja N. Management of growth failure and growth hormone deficiency after pediatric allogeneic HSCT: Endocrinologists are of importance for further guidelines and studies. Pediatr Hematol Oncol 2019; 36:494-503. [PMID: 31633441 DOI: 10.1080/08880018.2019.1670764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Growth failure (GF) is a frequent problem after pediatric allogeneic hematopoietic stem cell transplantation (HSCT). Growth hormone deficiency (GHD) occurs in 20 to 85%, but published data on the efficacy of growth hormone treatment (GHT) are conflicting. Currently, there are no recommendations on screening for and treatment of GHD after HSCT. We aimed to describe the management of endocrine follow-up (FU)and details of GHT within European Society for Blood and Marrow Transplantation (EBMT) centers.In a retrospective questionnaire study, all EBMT centers performing pediatric HSCT were invited. Results were evaluated in correlation with the structure of endocrine aftercare (HSCT-clinicians and endocrinologists).The majority of centers (80%) reported endocrine FU by an endocrinologist - either within the HSCT-center or in a separate endocrine clinic. Fifty-four percent reported FU outside of the HSCT-center. As diagnostic tests the insulin-like growth factor IGF-I and insulin-like growth factor binding protein IGFBP3, insulin tolerance test and arginine stimulation test were most frequently used. Sixty-four percent of centers performed GHT and endocrinologists were more likely to prescribe GH (74%) compared to HSCT-clinicians (33%). The most frequent indication for GHT was GHD in 60%, with a distinct different approach of endocrinologists in comparison with HSCT-clinicians.Our study reveals substantial variation in practice and emphasizes the need for endocrine aftercare performed by dedicated endocrinologists in close collaboration with the HSCT-center. Our results indicate that the management of GHT depends on the structure of endocrine aftercare, which is important for the future development and distribution of studies and guidelines.
Collapse
Affiliation(s)
- A Lawitschka
- St. Anna Children's Hospital, Vienna Medical University, Vienna, Austria
| | - P Schwarze
- Department of General Pediatrics, Hematology/Oncology, University Children's Hospital, Tuebingen, Germany
| | - A Rovelli
- MBBM Foundation, Bone Marrow Transplantation Unit, Pediatric Department of Milano-Bicocca University, Monza, Italy
| | - M Badoglio
- Department of Haematology, EBMT Paris Study Office, Saint Antoine Hospital, Paris, France
| | - G Socie
- Department of Hematology, Hôpital Saint Louis, Paris, France
| | - A Tichelli
- Department for Haematology, University Hospital Basel, Basel, Switzerland
| | - D Bauer
- St. Anna Children's Hospital, Vienna Medical University, Vienna, Austria
| | - A Rovo
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern
| | - G Basak
- Department of Hematology, Oncology, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - H Schoemans
- Department of Hematology, University Hospital Leuven and KU Leuven, Leuven, Belgium
| | - C Peters
- St. Anna Children's Hospital, Vienna Medical University, Vienna, Austria
| | - N Salooja
- Centre for Haematology, Imperial College London, London, UK
| |
Collapse
|
5
|
Patti G, Noli S, Capalbo D, Allegri AME, Napoli F, Cappa M, Ubertini GM, Gallizia A, Notarnicola S, Ibba A, Crocco M, Parodi S, Salerno M, Loche S, Garré ML, Tornari E, Maghnie M, Di Iorgi N. Accuracy and Limitations of the Growth Hormone (GH) Releasing Hormone-Arginine Retesting in Young Adults With Childhood-Onset GH Deficiency. Front Endocrinol (Lausanne) 2019; 10:525. [PMID: 31417499 PMCID: PMC6684745 DOI: 10.3389/fendo.2019.00525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Re-testing for GH secretion is needed to confirm the diagnosis of GH deficiency (GHD) after adult height achievement in childhood-onset GHD (COGHD). Aim: To define the cut-off of GH peak after retesting with GH-releasing hormone plus arginine (GHRHarg) in the diagnosis of permanent GHD in COGHD of different etiology. Patients and methods: Eighty-eight COGHD (median age 17.2 y), 29 idiopathic GHD (IGHD), 44 cancer survivors (TGHD) and 15 congenital GHD (CGHD) were enrolled in the study; 54 had isolated GHD (iGHD) and 34 had multiple pituitary hormone deficiencies (MPHD). All were tested with insulin tolerance test (ITT) and GHRHarg. IGHD with a GH response to ITT ≥6μg/L were considered true negatives and served as the control group, and patients with a GH response <6μg/L as true positives. Baseline IGF-I was also measured. The diagnostic accuracy of GHRHarg testing and of IGF-I SDS in patients with GHD of different etiologies was evaluated by ROC analysis. Results: Forty-six subjects with a GH peak to ITT ≥6μg/L and 42 with GH peak <6 μg/L showed a GH peak after GHRHarg between 8.8-124μg/L and 0.3-26.3μg/L, respectively; 29 IGHD were true negatives, 42 were true positives and 17 with a high likelihood GHD showed a GH peak to ITT ≥6μg/L. ROC analysis based on the etiology indicated the best diagnostic accuracy for peak GH cutoffs after GHRHarg of 25.3 μg/L in CGHD, 15.7 in TGHD, and 13.8 in MPHD, and for IGF-1 SDS at -2.1 in CGHD, -1.5 in TGHD, and -1.9 in MPHD. Conclusions: Our findings indicate that the best cut-off for GH peak after retesting with GHRHarg changes according to the etiology of GHD during the transition age. Based on these results the diagnostic accuracy of GHRHarg remains questionable.
Collapse
Affiliation(s)
- Giuseppa Patti
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Serena Noli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | | | | | - Flavia Napoli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, Genova, Italy
| | - Marco Cappa
- Unit of Endocrinology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Annalisa Gallizia
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Sara Notarnicola
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Anastasia Ibba
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao," Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Marco Crocco
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Stefano Parodi
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Mariacarolina Salerno
- Department of Translational Medical Sciences-Pediatric Section, University of Naples Federico II, Naples, Italy
| | - Sandro Loche
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao," Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Maria Luisa Garré
- Dipartimento di Neuroncologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Elena Tornari
- Health Science Department (DISSAL), University of Genova, Genova, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| |
Collapse
|
6
|
Hua C, Wu S, Chemaitilly W, Lukose RC, Merchant TE. Predicting the probability of abnormal stimulated growth hormone response in children after radiotherapy for brain tumors. Int J Radiat Oncol Biol Phys 2012; 84:990-5. [PMID: 22483696 DOI: 10.1016/j.ijrobp.2012.01.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 01/13/2012] [Accepted: 01/16/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To develop a mathematical model utilizing more readily available measures than stimulation tests that identifies brain tumor survivors with high likelihood of abnormal growth hormone secretion after radiotherapy (RT), to avoid late recognition and a consequent delay in growth hormone replacement therapy. METHODS AND MATERIALS We analyzed 191 prospectively collected post-RT evaluations of peak growth hormone level (arginine tolerance/levodopa stimulation test), serum insulin-like growth factor 1 (IGF-1), IGF-binding protein 3, height, weight, growth velocity, and body mass index in 106 children and adolescents treated for ependymoma (n=72), low-grade glioma (n=28) or craniopharyngioma (n=6), who had normal growth hormone levels before RT. Normal level in this study was defined as the peak growth hormone response to the stimulation test≥7 ng/mL. RESULTS Independent predictor variables identified by multivariate logistic regression with high statistical significance (p<0.0001) included IGF-1 z score, weight z score, and hypothalamic dose. The developed predictive model demonstrated a strong discriminatory power with an area under the receiver operating characteristic curve of 0.883. At a potential cutoff point of probability of 0.3 the sensitivity was 80% and specificity 78%. CONCLUSIONS Without unpleasant and expensive frequent stimulation tests, our model provides a quantitative approach to closely follow the growth hormone secretory capacity of brain tumor survivors. It allows identification of high-risk children for subsequent confirmatory tests and in-depth workup for diagnosis of growth hormone deficiency.
Collapse
Affiliation(s)
- Chiaho Hua
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA.
| | | | | | | | | |
Collapse
|
7
|
Abstract
Deficiencies in anterior pituitary hormones secretion ranging from subtle to complete occur following radiation damage to the hypothalamic-pituitary (h-p) axis, the severity and frequency of which correlate with the total radiation dose delivered to the h-p axis and the length of follow up. Selective radiosensitivity of the neuroendocrine axes, with the GH axis being the most vulnerable, accounts for the high frequency of GH deficiency, which usually occurs in isolation following irradiation of the h-p axis with doses less than 30 Gy. With higher radiation doses (30-50 Gy), however, the frequency of GH insufficiency substantially increases and can be as high as 50-100%. Compensatory hyperstimulation of a partially damaged h-p axis may restore normality of spontaneous GH secretion in the context of reduced but normal stimulated responses; at its extreme, endogenous hyperstimulation may limit further stimulation by insulin-induced hypoglycaemia resulting in subnormal GH responses despite normality of spontaneous GH secretion in adults. In children, failure of the hyperstimulated partially damaged h-p axis to meet the increased demands for GH during growth and puberty may explain what has previously been described as radiation-induced GH neurosecretory dysfunction and, unlike in adults, the ITT remains the gold standard for assessing h-p functional reserve. Thyroid-stimulating hormone (TSH) and ACTH deficiency occur after intensive irradiation only (>50 Gy) with a long-term cumulative frequency of 3-6%. Abnormalities in gonadotrophin secretion are dose-dependent; precocious puberty can occur after radiation dose less than 30 Gy in girls only, and in both sexes equally with a radiation dose of 30-50 Gy. Gonadotrophin deficiency occurs infrequently and is usually a long-term complication following a minimum radiation dose of 30 Gy. Hyperprolactinemia, due to hypothalamic damage leading to reduced dopamine release, has been described in both sexes and all ages but is mostly seen in young women after intensive irradiation and is usually subclinical. A much higher incidence of gonadotrophin, ACTH and TSH deficiencies (30-60% after 10 years) occur after more intensive irradiation (>60 Gy) used for nasopharyngeal carcinomas and tumors of the skull base, and following conventional irradiation (30-50 Gy) for pituitary tumors. The frequency of hypopituitarism following stereotactic radiotherapy for pituitary tumors is mostly seen after long-term follow up and is similar to that following conventional irradiation. Radiation-induced anterior pituitary hormone deficiencies are irreversible and progressive. Regular testing is mandatory to ensure timely diagnosis and early hormone replacement therapy.
Collapse
Affiliation(s)
- Ken H Darzy
- Diabetes and Endocrinology, East & North Hertfordshire NHS Trust, Howlands, Welwyn Garden City AL7 4HQ, UK.
| | | |
Collapse
|