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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] [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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Savage MO, Ferrigno R. Paediatric Cushing's disease: long-term outcome and predictors of recurrence. Front Endocrinol (Lausanne) 2024; 15:1345174. [PMID: 38318299 PMCID: PMC10838966 DOI: 10.3389/fendo.2024.1345174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024] Open
Abstract
Paediatric Cushing's disease (CD) is characterized by excess ACTH secretion from a pituitary adenoma, leading to hypercortisolism. It has approximately 5% of the incidence of adult CD and is a rare disorder in the paediatric age range. The four most specific presenting features of hypercortisolism are: change in facial appearance, weight gain, decreased linear growth and virilisation shown by advanced pubic hair for the stage of breast development or testicular volume. The main diagnostic priority is the demonstration of hypercortisolism followed by distinction between its ACTH-dependent and ACTH-independent origin, thus leading to identification of aetiology. All treatment options aim to resolve or control hypercortisolism. Consensus favours transsphenoidal (TSS) pituitary surgery with selective removal of the corticotroph adenoma. TSS in children with CD is now well established and induces remission in 70-100% of cases. External pituitary radiotherapy and bilateral adrenalectomy are second-line therapeutic approaches in subjects not responding to TSS. Long-term medical treatment is less frequently adopted. Recurrence in paediatric CD cases is low with factors predicting relapse being higher post-TSS cortisol and ACTH levels and rapid recovery of the hypothalamic-pituitary-adrenal axis after TSS. In summary, complete excision of the microadenoma with histological and biochemical evidence for this, predicts a low rate of recurrence of CD. Due to the need for rapid diagnosis and management to avoid the burden of prolonged exposure to hypercortisolism, tertiary university centres comprising both paediatric and adult endocrinology specialists together with experienced pituitary surgery and, eventually, radiotherapy units are recommended for referral of these patients.
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Affiliation(s)
- Martin O. Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School for Medicine & Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Rosario Ferrigno
- UOSD di Auxologia e Endocrinologia, AORN Santobono-Pausilipon, Napoli, Italy
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3
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Ryder CY, Bellile EL, VanKoevering KK, McKean EL. Assessing Quality of Life among Radiation-Induced Hypopituitary Patients. J Neurol Surg B Skull Base 2023; 84:567-577. [PMID: 37854537 PMCID: PMC10581824 DOI: 10.1055/a-1934-9377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 08/29/2022] [Indexed: 10/14/2022] Open
Abstract
Introduction Radiation-induced hypopituitarism (RIH) has long been recognized as one of the deleterious side effects of skull base radiation. This study aims to assess the quality of life (QoL) among patients with RIH compared with radiated patients who did not develop hypopituitarism using the validated Anterior Skull Base Questionnaire (ASBQ). Methods This was a single-institution retrospective cohort study. Included patients had a history of anterior skull base tumor, underwent at least one round of radiation to the skull base, and had filled out at least one ASBQ survey after their radiation treatment. Three statistical models were used to determine the effect of hypopituitarism and treatment on QoL scores. Results A total of 145 patients met inclusion criteria, and 330 ASBQ surveys were analyzed. Thirty-five percent (51/145) had evidence of RIH at some point after their radiation treatment. Those with hypopituitarism had significantly lower overall ASBQ scores across all three models even after adjusting for potential confounders and intraperson correlation (average decrease of 0.24-0.45 on a 5-point Likert scale; p -values ranging from 0.0004 to 0.018). The increase in QoL with hormonal replacement was modulated by time out from radiation, with long-term survivors (5+ years out from radiation) gaining the most benefit from treatment (increase of 0.89 on a 5-point Likert scale, p 0.0412), especially in the vitality domain. Conclusion This data demonstrates that hypopituitarism is an independent predictor of lower QoL. Early detection and appropriate treatment are essential to avoid the negative impact of hypopituitarism on QoL.
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Affiliation(s)
- C Yoonhee Ryder
- University of Michigan Medical School, Office of Medical Student Education, Ann Arbor, Michigan, United States
| | - Emily L. Bellile
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, United States
| | - Kyle K. VanKoevering
- Department of Otolaryngology, Ohio State University, Columbus, Ohio, United States
| | - Erin L. McKean
- Department of Otolaryngology Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States
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4
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Ferrigno R, Hasenmajer V, Caiulo S, Minnetti M, Mazzotta P, Storr HL, Isidori AM, Grossman AB, De Martino MC, Savage MO. Paediatric Cushing's disease: Epidemiology, pathogenesis, clinical management and outcome. Rev Endocr Metab Disord 2021; 22:817-835. [PMID: 33515368 PMCID: PMC8724222 DOI: 10.1007/s11154-021-09626-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
Cushing's disease (CD) is rare in paediatric practice but requires prompt investigation, diagnosis and therapy to prevent long-term complications. Key presenting features are a change in facial appearance, weight gain, growth failure, virilization, disturbed puberty and psychological disturbance. Close consultation with an adult endocrinology department is recommended regarding diagnosis and therapy. The incidence of CD, a form of ACTH-dependent Cushing's syndrome (CS), is equal to approximately 5% of that seen in adults. The majority of ACTH-secreting adenomas are monoclonal and sporadic, although recent studies of pituitary tumours have shown links to several deubiquitination gene defects. Diagnosis requires confirmation of hypercortisolism followed by demonstration of ACTH-dependence. Identification of the corticotroph adenoma by pituitary MRI and/or bilateral inferior petrosal sampling for ACTH may contribute to localisation before pituitary surgery. Transsphenoidal surgery (TSS) with selective microadenomectomy is first-line therapy, followed by external pituitary irradiation if surgery is not curative. Medical therapy to suppress adrenal steroid synthesis is effective in the short-term and bilateral adrenalectomy should be considered in cases unfit for TSS or radiotherapy or when urgent remission is needed after unsuccessful surgery. TSS induces remission of hypercortisolism and improvement of symptoms in 70-100% of cases, particularly when performed by a surgeon with experience in children. Post-TSS complications include pituitary hormone deficiencies, sub-optimal catch-up growth, and persisting excess of BMI. Recurrence of hypercortisolism following remission is recognised but infrequent, being less common than in adult CD patients. With experienced specialist medical and surgical care, the overall prognosis is good. Early referral to an experienced endocrine centre is advised.
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Affiliation(s)
- Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Federico II University, Naples, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvana Caiulo
- Primary care Paediatrician, Local Health Unit of Brindisi, Brindisi, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Paola Mazzotta
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ashley B Grossman
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK
- Royal Free Hospital ENETs Centre of Excellence, London, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | | | - Martin O Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK.
- Centre for Endocrinology, William Harvey Research Institute, Charterhouse Square, London, EC1M 6BQ, UK.
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Tong CV, Tee CK. Recurrent cavernous sinus thrombosis: a rare complication of Cushing disease. BMJ Case Rep 2021; 14:14/6/e243786. [PMID: 34158336 DOI: 10.1136/bcr-2021-243786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 14-year-old girl who presented in 2017 with headache, unilateral right eye ptosis and secondary amenorrhoea had an initial workup consistent with non-functioning pituitary macroadenoma. She underwent debulking of pituitary tumour in October 2017. Postoperatively, she developed recurrent cavernous sinus thrombosis. In view of recurrent thrombosis, she was reinvestigated and was found to have adrenocorticotropic hormone-dependent Cushing. Follow-up MRI 1 year after initial presentation showed that there was structural recurrence of pituitary macroadenoma. She subsequently underwent a petrosal craniotomy for debulking of tumour. Postsurgery she remained biochemically Cushingnoid. MRI 5 months after second surgery showed an enlarging pituitary mass which was deemed inoperable. A multidisciplinary meeting discussion consensus for treatment included radiotherapy and somatostatin analogue, pasireotide. She completed 30 cycles of radiotherapy and MRI post radiotherapy showed reduction in the size of the macroadenoma. Currently, she is waiting for pasereotide initiation.
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Affiliation(s)
- Chin Voon Tong
- Department of Medicine, Hospital Melaka, Melaka, Malaysia
| | - Chee Kit Tee
- Department of Medicine, Hospital Melaka, Melaka, Malaysia
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6
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Minnetti M, Caiulo S, Ferrigno R, Baldini-Ferroli B, Bottaro G, Gianfrilli D, Sbardella E, De Martino MC, Savage MO. Abnormal linear growth in paediatric adrenal diseases: Pathogenesis, prevalence and management. Clin Endocrinol (Oxf) 2020; 92:98-108. [PMID: 31747461 DOI: 10.1111/cen.14131] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/10/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022]
Abstract
Abnormal adrenal function can interfere with linear growth, potentially causing either acceleration or impairment of growth in paediatric patients. These abnormalities can be caused by direct effects of adrenal hormones, particularly glucocorticoids and sex steroids, or be mediated by indirect mechanisms such as the disturbance of the growth hormone-insulin-like growth factor-1 axis and aromatization of androgens to oestrogens. The early diagnosis and optimal treatment of adrenal disorders can prevent or minimize growth disturbance and facilitate improved height gain. Mechanisms of growth disturbance in the following abnormal states will be discussed; hypercortisolaemia, hyperandrogenaemia and obesity. Prevalence and features of growth disturbance will be discussed in ACTH-dependent and ACTH-independent Cushing's syndrome, adrenocortical tumours, premature adrenarche, congenital adrenal hyperplasia and adrenal insufficiency disorders. Recommendations for management have been included.
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Affiliation(s)
- Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvana Caiulo
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Federico II University, Naples, Italy
| | - Barbara Baldini-Ferroli
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesu' Children's Hospital, Rome, Italy
| | - Giorgia Bottaro
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesu' Children's Hospital, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Martin O Savage
- Endocrinology Centre, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, London, UK
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7
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Pasternak-Pietrzak K, Moszczyńska E, Szalecki M. Treatment challenges in pediatric Cushing's disease: Review of the literature with particular emphasis on predictive factors for the disease recurrence. Endocrine 2019; 66:125-136. [PMID: 31701434 PMCID: PMC6838046 DOI: 10.1007/s12020-019-02036-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
Cushing's disease (CD) is a rare endocrine condition caused by a corticotroph pituitary tumor that produces adrenocorticotropic hormone. The current state of knowledge of CD treatment is presented in this article including factors that can be helpful in predicting remission and/or recurrence of the disease. The primary goals in CD treatment are quick diagnosis and effective, prompt treatment as the persistent disease is associated with increased morbidity and mortality. Cooperation of a team consisting of experienced pediatrician/adult endocrinologist, neuroradiologist, transsphenoidal neurosurgeon and (if necessary) radiotherapist contribute to the best treatment effects.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland.
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
- The Medicine and Health Sciences Faculty, University of Jan Kochanowski, Al. IX Wieków Kielc 19A, 25-317, Kielce, Poland
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Abstract
Cushing syndrome (CS) is a multisystem disorder resulting from the prolonged exposure to excess glucocorticoids. In children, CS most commonly results from the exogenous administration of steroids and the typical presentation is height deceleration concomitant with weight gain. Endogenous and ectopic causes are rare. CS in children may be associated with distinct germline and somatic mutations. Clinical practice guidelines are available assist clinicians. Patients should be referred to multidisciplinary centers of excellence with experience in endocrinology and surgery. Early detection and treatment is essential to reduce associated acute and long-term morbidity and potential death.
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Affiliation(s)
- Maya B Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), NIH-Clinical Research Center, 10 Center Drive, Building 10, Room 1E-3330, MSC1103, Bethesda, MD 20892, USA
| | - Margaret F Keil
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), NIH-Clinical Research Center, 10 Center Drive, Building 10, Room 1E-3330, MSC1103, Bethesda, MD 20892, USA.
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), NIH-Clinical Research Center, 10 Center Drive, Building 10, Room 1E-3330, MSC1103, Bethesda, MD 20892, USA
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9
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Stratakis CA. An update on Cushing syndrome in pediatrics. ANNALES D'ENDOCRINOLOGIE 2018; 79:125-131. [DOI: 10.1016/j.ando.2018.03.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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10
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Gheorghiu ML, Fleseriu M. STEREOTACTIC RADIATION THERAPY IN PITUITARY ADENOMAS, IS IT BETTER THAN CONVENTIONAL RADIATION THERAPY? ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:476-490. [PMID: 31149219 DOI: 10.4183/aeb.2017.476] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Pituitary radiotherapy (RT) has undergone important progress in the last decades due to the development of new stereotactic techniques which provide more precise tumour targeting with less overall radiation received by the adjacent brain structures. Pituitary surgery is usually first-line therapy in most patients with nonfunctioning (NFPA) and functioning adenomas (except for prolactinomas and large growth hormone (GH) secreting adenomas), while RT is used as second or third-line therapy. The benefits of RT (tumour volume control and, in functional tumours, decreased hormonal secretion) are hampered by the long latency of the effect and the potential side effects. This review presents the updates in the efficacy and safety of the new stereotactic radiation techniques in patients with NFPA, GH-, ACTH- or PRL-secreting pituitary adenomas. Methods A systematic review was performed using PubMed and articles/abstracts and reviews detailing RT in pituitary adenomas from 2000 to 2017 were included. Results Stereotactic radiosurgery (SRS) and fractionated stereotactic RT (FSRT) provide high rates of tumour control i.e. stable or decrease in tumour size, in all types of pituitary adenomas (median 92 - 98%) at 5 years. Endocrinological remission is however significantly lower: 44-52% in acromegaly, 54-64% in Cushing's disease and around 30% in prolactinomas at 5 years. The rate of new hypopituitarism varies from 10% to 50% at 5 years in all tumour types and as expected increases with the duration of follow-up (FU). The risk for other radiation-induced complications is usually low (0-5% for new visual deficits, cranial nerves damage or brain radionecrosis and extremely low for secondary brain tumours), however longer FU is needed to determine rates of secondary tumours. Notably, in acromegaly, there may be a higher risk for stroke with FSRT. Conclusion Stereotactic radiotherapy can be an effective treatment option for patients with persistent or recurrent pituitary adenomas after unsuccessful surgery (especially if residual tumour is enlarging) and/or resistance or unavailability of medical therapy. Comparison with conventional radiation therapy (CRT) is rather difficult, due to the substantial heterogeneity of the studies. In order to evaluate the potential brain-sparing effect of the new stereotactic techniques, suggested by the current data, long-term studies evaluating secondary morbidity and mortality are needed.
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Affiliation(s)
- M L Gheorghiu
- "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - M Fleseriu
- Oregon Health & Science University, Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Portland, USA
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Mazziotti G, Formenti AM, Adler RA, Bilezikian JP, Grossman A, Sbardella E, Minisola S, Giustina A. Glucocorticoid-induced osteoporosis: pathophysiological role of GH/IGF-I and PTH/VITAMIN D axes, treatment options and guidelines. Endocrine 2016; 54:603-611. [PMID: 27766553 DOI: 10.1007/s12020-016-1146-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/06/2016] [Indexed: 01/29/2023]
Abstract
Glucocorticoid-induced osteoporosis is the most frequent form of secondary osteoporosis caused by chronic exposure to glucocorticoid excess. Pathogenesis of glucocorticoid-induced osteoporosis is multifactorial including direct effects of glucocorticoids on bone cells and indirect effects of glucocorticoids on several neuroendocrine and metabolic pathways. Fragility fractures occur early in glucocorticoid-induced osteoporosis and anti-osteoporotic drugs along with calcium and vitamin D should be started soon after exposure to glucocorticoid excess. This paper summarizes some of the main topics discussed during the 9th Glucocorticoid-Induced Osteoporosis Meeting (Rome, April 2016) with a specific focus on the role of growth hormone/insulin-like growth factor-1 and parathyroid hormone/vitamin D axes in the pathogenesis of glucocorticoid-induced osteoporosis and the controversial aspects concerning therapeutic approach to skeletal fragility in this clinical setting.
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Affiliation(s)
| | | | - Robert A Adler
- McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Medicine Richmond, Virginia, USA
| | - John P Bilezikian
- Department of Medicine Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Ashley Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK
| | - Emilia Sbardella
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines "Sapienza" Rome University, Rome, Italy
| | - Andrea Giustina
- Chair of Endocrinology, University of Brescia, Brescia, Italy.
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12
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Güemes M, Murray PG, Brain CE, Spoudeas HA, Peters CJ, Hindmarsh PC, Dattani MT. Management of Cushing syndrome in children and adolescents: experience of a single tertiary centre. Eur J Pediatr 2016; 175:967-76. [PMID: 27169546 DOI: 10.1007/s00431-016-2727-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 04/18/2016] [Indexed: 11/30/2022]
Abstract
UNLABELLED The diagnosis and management of paediatric Cushing syndrome (CS) is highly challenging. This study aims to characterise its presentation, diagnosis, management and outcome by a retrospective case review of 30 patients (14 females) followed at a single tertiary paediatric endocrinology centre over a 30-year period. At presentation, median age was 8.9 years (0.2-15.5) and the commonest manifestations were weight gain (23/30), hirsutism (17/30), acne (15/30) and hypertension (15/30). Growth retardation was present in 11/30. Median body mass index (BMI) was +2.1 standard deviation score (SDS) (-6.5 to +4.6). Urinary free cortisol (UFC) was abnormal in 17/18 (94 %), midnight cortisol in 27/27 (100 %) and low-dose dexamethasone suppression (LDDS) test in 20/20 (100 %). High-dose dexamethasone suppression (HDDS) test was abnormal in 6/6 (100 %) of adrenal tumours, 1/10 (10 %) of Cushing disease (CD) and 1/2 (50 %) of ectopic tumours. Bilateral inferior petrosal sinus sampling (IPSS) identified five CD cases and one ectopic tumour. All patients underwent surgery and subsequently required cortisol replacement. Final diagnoses were 16 CD, 11 adrenal disease, 2 ectopic ACTH-secreting lesions and 1 case of unidentified aetiology. One year post-diagnosis, median BMI was 0.5 SDS (-2.5 to +3.7), hypertension was present in 4/14 (28 %), and 43 % (12/30) of individuals were off hydrocortisone. CONCLUSION The prevalence of the clinical manifestations differs from that reported in other series. Screening tests were highly sensitive, with UFC, midnight cortisol and LDDS performing well. One year post-treatment, BMI and BP normalised in the majority of patients and almost half of them were able to discontinue replacement hydrocortisone. WHAT IS KNOWN •Cushing syndrome is an extremely rare entity in the paediatric and adolescent age groups, so not many cohort studies have been published in this population. •Several tests can be employed to firstly diagnose hypercortisolaemia and secondly identify the source of origin of it. The efficacy and safety of these tests in children is still uncertain. What is New: •This study includes cases due to the different aetiologies of endogenous hypercortisolaemia (pituitary, adrenal and ectopic hypercortisolaemia) allowing us to compare the differences in presentation, diagnosis, management and long-term outcome between the groups. •There is a difference in the prevalence of Cushing syndrome symptoms and in the performance of the tests in our cohort compared to previously published studies in the literature.
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Affiliation(s)
- Maria Güemes
- London Centre for Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children, London, UK.,Section of Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Philip G Murray
- London Centre for Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children, London, UK
| | - Caroline E Brain
- London Centre for Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children, London, UK
| | - Helen A Spoudeas
- London Centre for Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children, London, UK
| | - Catherine J Peters
- London Centre for Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children, London, UK
| | - Peter C Hindmarsh
- London Centre for Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children, London, UK.,Section of Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Mehul T Dattani
- London Centre for Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children, London, UK. .,Section of Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, UCL Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
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Nieman LK, Biller BMK, Findling JW, Murad MH, Newell-Price J, Savage MO, Tabarin A. Treatment of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015; 100:2807-31. [PMID: 26222757 PMCID: PMC4525003 DOI: 10.1210/jc.2015-1818] [Citation(s) in RCA: 660] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/19/2015] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The objective is to formulate clinical practice guidelines for treating Cushing's syndrome. PARTICIPANTS Participants include an Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer. The European Society for Endocrinology co-sponsored the guideline. EVIDENCE The Task Force used the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned three systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS The Task Force achieved consensus through one group meeting, several conference calls, and numerous e-mail communications. Committees and members of The Endocrine Society and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. CONCLUSIONS Treatment of Cushing's syndrome is essential to reduce mortality and associated comorbidities. Effective treatment includes the normalization of cortisol levels or action. It also includes the normalization of comorbidities via directly treating the cause of Cushing's syndrome and by adjunctive treatments (eg, antihypertensives). Surgical resection of the causal lesion(s) is generally the first-line approach. The choice of second-line treatments, including medication, bilateral adrenalectomy, and radiation therapy (for corticotrope tumors), must be individualized to each patient.
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Affiliation(s)
- Lynnette K Nieman
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - Beverly M K Biller
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - James W Findling
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - M Hassan Murad
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - John Newell-Price
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - Martin O Savage
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - Antoine Tabarin
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
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Abstract
Cushing's disease (CD) is the commonest form of ACTH-dependent Cushing's syndrome and is a rare clinical diagnosis in paediatric and adolescent patients. CD is caused by an ACTH-secreting pituitary corticotroph adenoma and is associated with significant morbidity in children; therefore, early diagnosis and treatment are critical for optimal therapeutic outcome. This review highlights the key clinical and biochemical features of paediatric CD and appraises current practices in diagnosis and management. A close liaison with adult endocrinology colleagues, particularly, for interpretation of investigations and definition of therapeutic strategy is strongly advised.
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Affiliation(s)
- Helen L Storr
- Barts and the London School of Medicine and DentistryWilliam Harvey Research Institute, Centre for Endocrinology, Queen Mary University of London, 1st Floor, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, UK
| | - Martin O Savage
- Barts and the London School of Medicine and DentistryWilliam Harvey Research Institute, Centre for Endocrinology, Queen Mary University of London, 1st Floor, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, UK
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Abstract
PURPOSE OF REVIEW To provide an update on the genes associated with Cushing's syndrome in children, as well as to familiarize the clinician with recent treatment guidelines and outcome data for children with Cushing's syndrome. RECENT FINDINGS The list of genes associated with Cushing's syndrome continues to grow. In addition, treatment for childhood Cushing's syndrome is evolving. As long-term follow-up data on children becomes available, clinicians need to be aware of the issues that require attention. SUMMARY Knowledge of the specific genetic causes of Cushing's syndrome has potential implications for treatment, surveillance, and counseling. Advances in surgical technique, radiation modalities, and medical therapies offer the potential for additional treatment options in Cushing's syndrome. Early identification and management of post-treatment morbidities in children treated for Cushing's syndrome is crucial in order to optimize care.
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Affiliation(s)
- Maya Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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Guaraldi F, Storr HL, Ghizzoni L, Ghigo E, Savage MO. Paediatric pituitary adenomas: a decade of change. Horm Res Paediatr 2014; 81:145-55. [PMID: 24525527 DOI: 10.1159/000357673] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 11/29/2013] [Indexed: 11/19/2022] Open
Abstract
Pituitary adenomas, although rare in the paediatric age range and mostly benign, represent very challenging disorders for diagnosis and management. The recent identification of genetic alterations in young individuals with pituitary adenomas has broadened the scope of molecular investigations and contributed to the understanding of mechanisms of tumorigenesis. Recent identification of causative mutations of genes such as GNAS, PRKAR1A, MEN1 and AIP has introduced the concept of molecular screening of young apparently healthy family members. Population-based studies have reported a significantly higher number of affected subjects and genetic variations than expected. Radiological techniques have advanced, yet many microadenomas remain undetectable on scanning. However, experience with transsphenoidal and endoscopic pituitary surgery has led to higher rates of cure. Prolactinomas, corticotroph and somatotroph adenomas remain the most prevalent, with each diagnosis presenting its own challenges. As paediatric pituitary adenomas occur very infrequently within the paediatric age range, paediatric endocrine units cannot provide expert management in isolation. Consequently, close co-operation with adult endocrinology colleagues with experience of pituitary disease is strongly recommended.
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Affiliation(s)
- Federica Guaraldi
- Division of Endocrinology, Diabetology and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
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Ragnarsson O, Höybye C, Jönsson PJ, Feldt-Rasmussen U, Johannsson G, Biller BMK, Koltowska-Häggström M. Comorbidity and cardiovascular risk factors in adult GH deficiency following treatment for Cushing's disease or non-functioning pituitary adenomas during childhood. Eur J Endocrinol 2012; 166:593-600. [PMID: 22258111 DOI: 10.1530/eje-11-0942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Cushing's disease (CD) and non-functioning pituitary adenoma (NFPA) are rare in paediatric patients. The aim of this study was to describe long-term consequences in adults with GH deficiency (GHD) treated for CD or NFPA during childhood. DESIGN, PATIENTS AND METHODS This was a retrospective analysis of data from KIMS (Pfizer International Metabolic Database). Background characteristics, anthropometry and comorbidity were studied in 47 patients diagnosed with childhood-onset (CO)-CD and 62 patients with CO-NFPA. Data from 100 ACTH-sufficient patients with CO-idiopathic hypopituitarism (CO-Idio) were used for comparison. Cardiovascular risk profile was analysed at baseline and at 1 year on GH treatment in a subgroup of patients (17 CO-CD, 24 CO-NFPA and 55 CO-Idio) not receiving GH treatment at study entry. RESULTS The median age at diagnosis of pituitary tumour was 14.0 years (range 10-17) in patients with CO-CD and 13.7 years (range 8-17) in CO-NFPA. In addition to GHD, 41% of patients with CO-CD had three or four other pituitary hormone deficiencies compared with 78% of patients with CO-NFPA (P<0.001). Eighty-nine per cent of patients with CO-CD had height SDS lower than 0 compared with 61% of patients with CO-NFPA (P=0.002). Hypertension was more common in CO-CD compared with CO-Idio (23 vs 9%, P=0.018). At 1 year on GH treatment, total- and low-density lipoprotein-cholesterol decreased significantly in CO-CD but not in CO-NFPA. CONCLUSION Adult patients with GHD following treatment for paediatric CD and NFPA have long-term adverse consequences. Despite more severe hypopituitarism in CO-NFPA, patients with CO-CD have more frequently compromised final stature.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital and University of Gothenburg, Gröna Stråket 8, Gothenburg, Sweden.
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Acharya SV, Gopal RA, Goerge J, Menon PS, Bandgar TR, Shah NS. Radiotherapy in paediatric Cushing's disease: efficacy and long term follow up of pituitary function. Pituitary 2010; 13:293-7. [PMID: 20411340 DOI: 10.1007/s11102-010-0231-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pituitary radiotherapy (RT) is an effective second-line treatment for paediatric Cushing's disease (CD). We report long-term efficacy and anterior pituitary function in a cohort of paediatric CD patients treated with RT. Between 1988 and 2008, from our cohort of 48 paediatric CD patients, eight paediatric CD patients (5 males and 3 females) underwent second-line pituitary RT (45 Gy in 25 fractions), following unsuccessful transsphenoidal surgery. Out of eight whose long term follow up is available, four patients were cured by RT. Minimum follow up of 2 years is available for all patients. Four patients achieved cure after RT. Two patients were not cured even after follow up of 60 and 132 months, respectively. Out of four uncured patients, two of them had suppressible low dose dexamethasone cortisol with altered circadian rhythm suggesting possibility of response in near future with follow up of just 26 months. Five patients were hypogonadal and one patient was hypothyroid. All patients were below their target height at the time of last follow up. None of the patients had posterior pituitary dysfunction. This series of patients illustrates the efficacy and long-term follow up of pituitary function in children with CD treated with RT. This study also emphasizes the need of growth hormone statues assessment and timely intervention.
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Affiliation(s)
- Shrikrishna V Acharya
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, 12 Maharashtra, India.
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Cushing's disease in children: report of three cases. Pediatr Neonatol 2010; 51:303-7. [PMID: 20951363 DOI: 10.1016/s1875-9572(10)60059-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 04/08/2010] [Accepted: 05/01/2010] [Indexed: 11/20/2022] Open
Abstract
Cushing's disease is rare in children and adolescents. We report the clinical presentations of three children with Cushing's disease. All three exhibited the typical symptoms and signs of weight gain and growth retardation. Tw o also demonstrated personality changes, hypertension and hypokalemia, the last of these being rarely reported in patients with Cushing's disease. Lack of diurnal changes in serum cortisol levels was the most common biochemical finding. Serum cortisol levels were suppressed by low-dose dexamethasone in one patient, which is not typical for patients with Cushing's disease. Imaging studies are essential for localizing the tumor. Transsphenoidal surgery remains the treatment of choice, and pituitary irradiation should be considered for those patients whose tumors cannot be totally removed. Careful follow-up of these patients with awareness of the possibilities of relapse and the complications of hypopituitarism is indicated.
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Savage MO, Chan LF, Grossman AB, Storr HL. Work-up and management of paediatric Cushing's syndrome. Curr Opin Endocrinol Diabetes Obes 2008; 15:346-51. [PMID: 18594275 DOI: 10.1097/med.0b013e328305082f] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Paediatric Cushing's syndrome presents a diagnostic and therapeutic challenge. Most paediatric endocrinologists have limited experience in managing children or adolescents with Cushing's syndrome and thus benefit from close consultation with adult colleagues. A protocol for investigation of the child with suspected Cushing's syndrome is presented followed by principles of management. RECENT FINDINGS Cushing's syndrome is rare in childhood, but causes serious morbidity. Investigations have evolved and now include new genetic and imaging techniques as well as classical endocrine studies. In Cushing's disease trans-sphenoidal surgery has transformed management, although only a few surgeons have experience in children. Pituitary radiotherapy is effective second-line therapy. SUMMARY Early diagnosis and treatment of Cushing's syndrome is vital for long-term outcome. The overall prognosis for Cushing's syndrome is good but challenges remain to ensure normal postcure growth and body composition.
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Affiliation(s)
- Martin O Savage
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, London, UK.
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Bibliography. Current world literature. Adrenal cortex. Curr Opin Endocrinol Diabetes Obes 2008; 15:284-299. [PMID: 18438178 DOI: 10.1097/med.0b013e3283040e80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chan LF, Storr HL, Grossman AB, Savage MO. Pediatric Cushing's syndrome: clinical features, diagnosis, and treatment. ACTA ACUST UNITED AC 2007; 51:1261-71. [DOI: 10.1590/s0004-27302007000800012] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 09/28/2007] [Indexed: 11/21/2022]
Abstract
Cushing's syndrome (CS) results from prolonged exposure to supraphysiological levels of circulating glucocorticoids, endogenously or exogenously derived. Although rare in childhood, CS remains a difficult condition to diagnose and treat. A multidisciplinary approach and close collaboration with adult colleagues is adopted at most large centres that manage pediatric CS patients. Although pediatric protocols are derived from adult data, significant differences exist between adult and childhood CS. Furthermore, long term outcome parameters including final height, bone mineral density, reproductive function, body composition and psychological health pose challenges for pediatric care. This article will aim to provide an overall view of pediatric CS highlighting some of the differences between adult and pediatric CS.
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Affiliation(s)
- Li F. Chan
- St Bartholomew's; The Royal London School of Medicine and Dentistry
| | - Helen L. Storr
- St Bartholomew's; The Royal London School of Medicine and Dentistry
| | | | - Martin O. Savage
- St Bartholomew's; The Royal London School of Medicine and Dentistry
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Abstract
Cushing's disease (CD) is rare in the pediatric age range, but may present a diagnostic and therapeutic challenge. Most pediatric endocrinologists have limited experience managing children or adolescents with CD and thus benefit from close consultation with adult colleagues. A diagnostic protocol for investigation is required which broadly follows the model for adult patients. Treatment strategies for CD are described and critically appraised. The management of pediatric CD patients after cure also presents challenges for optimizing growth, bone health, reproduction and body composition from childhood into and during adult life.
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Affiliation(s)
- Martin O Savage
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, UK.
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