Effectiveness of rhGH treatment on adult height in GH-deficient childhood survivors of medulloblastoma

BACKGROUND

GH deficiency (GHD) and spine irradiation (SI) have been implicated in the mechanism of reduced adult height (AH) in childhood survivors of medulloblastoma. However, growth dynamics after tumor diagnosis and the effectiveness of rhGH on AH in comparison with rhGH-untreated survivors have not been reported.

AIM

To follow height (H) SDS (HSDS) since tumor diagnosis and the effect of rhGH in GHD patients, comparing with GH-untreated GHD patients.

METHODS

14 patients received rhGH treatment until AH (medulloblastoma GH-treated group, MGHGr). 19 patients refused rhGH therapy (GH-untreated control medulloblastoma group, MCGr). Standing H and sitting H (SitH) were measured.

RESULTS

In MGHGr, mean +/- SD HSDS decreased from 0.09 +/- 0.63 at tumor diagnosis to -1.38 +/- 0.91 at diagnosis of GHD, and to -1.90 +/- 0.72 at the onset of rhGH, p < 0.01, but it remained unchanged during rhGH (AH -2.12 +/- 0.55). MCGr HSDS (-0.25 +/- 0.88) was not different from MGHGr at tumor diagnosis, but it was -3.40 +/- 0.88 at AH, significantly lower than in MGHGr, p = 0.001. SitH SDS at AH (-4.56 +/- 0.82) was significantly lower than at the onset of rhGH (-2.86 +/- 0.75), p = 0.003, and it was not different from MCGr (-4.85 +/- 1.77).

CONCLUSIONS

rhGH treatment improves AH in GH-deficient childhood medulloblastoma survivors but not spinal growth.

Gender-dependent effects of early maternal separation and variable chronic stress on vasopressinergic activity and glucocorticoid receptor expression in adult rats

The aim of the present study was to investigate the influence of early maternal separation on Fos, arginine vasopressin (AVP) and glucocorticoid receptor (GR) expression in the medial parvocellular portion of the paraventricular hypothalamic nucleus (PaMP), and GR expression in the hippocampus of adult male and female rats subjected to variable chronic stress (VCS). Male and female Wistar rats were isolated 4.5 h daily, during the first 3 weeks of life. At 48 days of age, the rats were exposed to VCS. Nonmaternally separated (NMS) females had a higher number of activated AVP neurons than NMS male rats. Maternally separated (MS) females subjected to VCS also showed a higher number of Fos/AVP double-labeled neurons than males with the same treatment. Males and females subjected to early maternal separation and VCS, compared with the MS animals, showed a decrease in the expression of GR in the PaMP. As regards GR expression in the hippocampus, MS animals subjected to VCS as adults, both males and females, showed an increase in GR expression in the subfields CA1, CA2 and CA3. The increase in AVP-immunoreactive neurons coexpressing Fos in response to stress in females exposed to early maternal separation suggests that perhaps early life stress results in a more reactive neuroendocrine stress response in females. Furthermore, our results demonstrate that the different anatomical levels of the hypothalamic-pituitary-adrenal axis have different roles related to its stress response and support the evidence of regional specificity in GR regulation.

Serum IGF-I and IGFBP-3 reference values from a chemiluminescent assay in normal children and adolescents of hispanic and italian origin: presence of sexual dimorphism in IGF-I values

Serum IGF-I and IGFBP-3 assays are used to monitor rhGH treatment. Some discrepancies in results obtained by means of different assays have been reported. The aim of this study was to establish normal ranges for circulating IGF-I and IGFBP-3 in children and adolescents of Hispanic and Italian origin. Circulating levels of IGF-I and IGFBP-3 were measured in 169 Hispanic and Italian prepubertal children and 66 adolescents of both sexes, using a chemiluminescent assay. Serum levels of IGF-I and IGFBP-3 increased from early childhood into adolescence. After pubertal peaks of IGF-I and IGFBP-3, slight decreases were observed with increasing age. Furthermore, serum IGF-I levels were significantly higher in girls than in boys, suggesting a sexual dimorphism in serum IGF-I values in late prepuberty and early puberty. Differences in IGF-I and IGFBP-3 absolute values between our study and previous studies suggest the need to establish reference ranges for each ethnic group.

Unexpected Peripheral Markers of Thyroid Function in a Patient with a Novel Mutation of the MCT8 Thyroid Hormone Transporter Gene

The specific thyroid hormone transporter, MCT8, located on the X chromosome, has led to the identification a novel syndrome. The objective is to relate phenotype with several tissue-specific thyroid functions. A 1-year-old boy, who had severe psychological damage and low serum T4, had received l-T4 for 3 months. At admission, body length was normal but weight was low. Off therapy, serum TSH was mildly elevated, serum T4 and free T4 were low, and serum T3 and free T3 were high. Direct sequencing of the MCT8 gene revealed a single nucleotide change that resulted in a novel nonsense mutation at codon 261 (Q261X) in exon 3. Since serum T3 was high, peripheral markers of hyperthyroidism were looked for. Bone age was advanced, despite the presence of malnutrition and low T4. Serum SHBG, a marker of thyroid hormone action in liver, was markedly elevated. Markers of skeletal muscle catabolism, ammonemia and lactic acid, were found to be elevated. The phenotype of MCT 8 mutation might be explained by differences in the entry of thyroid hormones into different cells. In the presence of an inactive MCT8 transporter, the high blood T3 levels might not be enough to prevent brain damage early in life, while they seem to be able to induce a postnatal state of peripheral hyperthyroidism in other tissues, such as liver, bone and skeletal muscle.

Differences in serum GH cut-off values for pharmacological tests of GH secretion depend on the serum GH method. Clinical validation from the growth velocity score during the first year of treatment

BACKGROUND

The serum GH cut-off value for pharmacological tests of GH secretion (PhT GH) depends on the type of test and also on the method used for determining serum GH. Cut-off serum GH values as different as 5-10 ng/ml, have been reported, and have been validated biochemically. We have used the growth velocity (GV)-standard deviation score (SDS) during the first year of treatment with rhGH to validate these cut-offs on a biological basis.

METHODS

Fifty pre-pubertal patients with short stature (height < or =-2 SDS and GV < or =-1.2 SDS) were studied. GH deficiency (GHD) was diagnosed in 39 patients, on the basis of clinical and auxological parameters and on the serum concentration of IGF-1, and non-GHD in the other 11 patients. Two PhT GH (arginine and clonidine) were carried out in the 50 patients. Serum GH was determined by two different methods: one detecting most of serum GH isoforms, named Total GH (HGH Bio-Tech, MAIA Clone), and another one, only detecting the 22 kDa GH, named 22K GH (GH-22K IFMA, Wallac).

RESULTS

Basal data: all patients with GHD and with non-GHD had maximal serum GH response (MaxR) values below and above the cut-off, respectively, for the serum Total GH and 22K GH. The mean 22K GH/Total GH ratio was similar to previous publications. Post-rhGH treatment data: the two groups improved their height SDS during the first year of treatment, particularly patients with GHD. A receiver-operator curve was used to define the best threshold for post-treatment GV-SDS that separates GHD from non-GHD patients. This value was 1.91 GV-SDS. A negative correlation between first year treatment GV-SDS and pre-treatment serum GH MaxR was found for the two assays (p < 0.001). Then, the best cut-off GV-SDS, previously calculated with the receiver-operator curve (1.91 SDS) was used to interpolate the corresponding serum GH values, as determined by the two methods. For Total GH, the value was 10.8 ng/ml, and for 22K GH, it was 5.4 ng/ml.

CONCLUSION

The cut-off values calculated by biological means to separate GHD from non-GHD were remarkably similar to those calculated biochemically (10.0 and 4.8 ng/ml, respectively) for Total and 22K GH. This is a biological validation for using different cut-off values, appropriate for each assay, to diagnose GHD.

Dose dependency of the serum bio/immuno GH ratio in children during pharmacological secretion tests

Dissociation between GH bioactivity (bio-GH) and GH immunoactivity (immuno-GH) is due to the heterogeneity of the molecule: the measurements do not always provide reliable information on the bio-GH. We studied the ratio of bio-GH and immuno-GH during pharmacological secretion tests in 211 sera to study the concentration-response curve of the assay (C1), 16 samples of normally growing subjects with idiopathic short stature (C2), 13 samples from patients with GH deficiency (GHD1) and 6 samples of 3 patients with GHD and normal provocative tests (GHD2). GH bioactivity was determined by the Nb2 cell proliferation assay (bio-GH) and immuno-GH by a time-resolved immunofluorometric assay (IFMA) (immuno-GH). A non-linear negative relationship between the serum bio-GH/immuno-GH ratio and serum immuno-GH was observed in C1. In log-log plotting representation, two cut-off lines were drawn: a vertical cut-off line separating above-below cut-off serum peak immuno-GH values in provocative tests, and a diagonal cut-off line separating normal-abnormal serum bio-GH/immunoGH ratio; four areas were defined. GHD1 had normal ratios, but below cut-off peak immuno-GH responses. P2 and P3 of Group GHD2 had abnormal ratios in samples with low serum immuno-GH but only P2 had autosomal dominant mutation. P1 had the same autosomal dominant isolated GHD as P2 but a low normal ratio. Our data underline the importance of relatively low serum GH concentrations in mediating GH biological actions. An abnormal serum bio-GH/immuno-GH ratio might explain certain cases of GHD and might be useful in detecting abnormal circulating isoforms of GH in patients with growth failure.

Sex differences in rats: Effects of chronic stress on sympathetic system and anxiety

In this study we tested whether periodic maternal deprivation (MD) (4.5 h daily during the first 3 weeks of life) caused chronic changes in anxiety and medullo-adrenal responses to chronic stress in either male or female adult (2.5 months of age) rats, or both. Repeated maternal deprivation had a sex-specific effect on epinephrine (E) and norepinephrine (NE) levels: an increase in both measures was observed only in females. Unpredictable stress did not produce changes on plasma catecholamine levels either in males or females. However, when the females were maternally deprived as well as stressed they showed an increase in plasma NE p < 0.05. On the other hand, non-maternally deprived (NMD), maternally-deprived and stressed males showed high levels of catecholamines compared to females p < 0.001. In the elevated plus maze test, MD-treated males displayed a slight increase in anxiety-related behavior compared with NMD rats. This was indicated by a reduction in the time spent on the open arms, whereas females showed less anxiety, indicated by an increase in the number of entries, and in the time spent on the open arms. After exposure to chronic stress only the females displayed decreased anxiety-related behavior. These results suggest that there are sex-induced effects in emotional reactivity, perception of the stressor and in the evaluation of novel situations. Thus, maternal deprivation and chronic variable stress caused both long-term alterations in sympathetic response and gender-dependent changes in the anxiety index of adult rats.

The role of the anterodorsal thalami nuclei in the regulation of adrenal medullary function, beta-adrenergic cardiac receptors and anxiety responses in maternally deprived rats under stressful conditions

Maternal separation can interfere with growth and development of the brain and represents a significant risk factor for adult psychopathology. In rodents, prolonged separation from the mother affects the behavioral and endocrine responses to stress for the lifetime of the animal. Limbic structures such as the anterodorsal thalamic nuclei (ADTN) play an important role in the control of neuroendocrine and sympathetic-adrenal function. In view of these findings we hypothesized that the function of the ADTN may be affected in an animal model of maternal deprivation. To test this hypothesis female rats were isolated 4.5 h daily, during the first 3 weeks of life and tested as adults. We evaluated plasma epinephrine (E) and norepinephrine (NE), cardiac adrenoreceptors and anxiety responses after maternal deprivation and variable chronic stress (VCS) in ADTN-lesioned rats. Thirty days after ADTN lesion, in non-maternally deprived rats basal plasma NE concentration was greater and cardiac beta-adrenoreceptor density was lower than that in the sham-lesioned group. Maternal deprivation induced a significant increase in basal plasma NE concentration, which was greater in lesioned rats, and cardiac beta-adrenoreceptor density was decreased in lesioned rats. After VCS plasma catecholamine concentration was much greater in non-maternally deprived rats than in maternally-deprived rats; cardiac beta-adrenoreceptor density was decreased by VCS in both maternally-deprived and non-deprived rats, but more so in non-deprived rats, and further decreased by the ADTN lesion. In the plus maze test, the number of open arm entries was greater in the maternally deprived and in the stressed rats. Thus, sympathetic-adrenal medullary activation produced by VCS was much greater in non-deprived rats, and was linked to a down regulation of myocardial beta-adrenoceptors. The ADTN are not responsible for the reduced catecholamine responses to stress in maternally-deprived rats. Maternal deprivation or chronic stress also induced a long term anxiolytic effect, which was also not affected by ADTN lesion.

Effects of maternal deprivation on adrenal and behavioural responses in rats with anterodorsal thalami nuclei lesions

There is evidence that repeated maternal isolation of neonatal rats may influence both emotional behavior and Hypothalamic-Pituitary Adrenal (HPA) activity. On the other hand the Anterodorsal Thalami Nuclei (ADTN) exerts an inhibitory influence on the hypophyso-adrenal system under basal and stressful conditions. In the present work we investigated whether neonatal maternal deprivation produces long term effects on the ADTN regulation of behavioral patterns (open field test) and on HPA axis activity. Specifically, we sought to determine whether adult female rats with ADTN lesions, previously isolated for 4.5 hours daily during the first 3 weeks of life, react in endocrinologically and behaviourally distinct manner as compared to controls. The examined groups were: non maternally deprived (NMD)/sham lesioned, NMD/lesioned, maternally deprived (MD)/sham lesioned, MD/lesioned with and without the open field test. At 3 months MD/sham lesioned animals showed a marked decrease in ambulation (P < 0.01), and with ADTN lesion, the rearing values were lower (P < 0.01) and grooming higher (P < 0.05) than NMD. This last data would indicate a high emotional index. Regarding the activity of the HPA axis, maternal deprivation induced a significant decrease in plasma ACTH concentration both in sham and lesioned animals (P < 0.001), and plasma Corticosterone (C) increased in sham animals (P < 0.001). This data would indicate a higher sensitivity of the adrenal glands. After the open field test ACTH and C were different between deprived and non-deprived animals depending on the ADTN lesion. Taking into consideration the increase of ACTH levels in sham lesioned MD animals exposed to the test, we could conclude that this new situation was a stressful situation. Finally in the present work, it was very difficult to relate the behavioral parameters with the endocrine data. It is known that depending on the context, corticosteroids may produce opposite effects on emotional behavior via different receptors in the brain.In summary, neonatal maternal deprivation induced alterations of behavioral patterns and affected the ADTN inhibitory influence on ACTH and C secretion.

Periodic maternal deprivation and lesion of anterodorsal thalami nuclei induce alteration on hypophyso adrenal system activity in adult rats

The hypothalamic-pituitary-adrenal (HPA) axis is normally regulated by extrahypothalamic limbic structures, among these, the anterodorsal thalami nuclei (ADTN), which exert an inhibitory influence on HPA, in basal and acute stress conditions in rats. In the present work we have investigated whether neonatal maternal deprivation (MD) produces long-term changes in the ADTN regulation of HPA activity. Maternal deprivation, in female rats, for 4.5 hs daily, during the first 3 weeks of life, produced at 3 months old, a significant decrease in plasma ACTH concentration (p<0.001) and an increase in plasma corticosterone (C) (p<0.001), compared to control non-deprived rats (NMD). Also MD showed higher plasma epinephrine (E) and norepinephrine (NE) levels than NMD rats. The increase of NE (66.6% p<0.001) was higher than that observed in E (19%). After 30 days of ADTN lesion, plasma ACTH values were higher than in sham lesioned rats, in both NMD and MD animals. ACTH response was greater in MD rats. Plasma C, in NMD, was higher, whereas in MD lesioned animals, it was significantly lower than in sham lesioned. In MD rats, lesion produced a significant increase in plasma E and NE (p<0.001), and again, NE increase was higher than E increase. The more accentuated increase of NE than E, suggests sympathetic nervous system hyperactivity. In summary, neonatal maternal deprivation induces long-term alterations on HPA axis sensitivity and medullo adrenal secretion; enhanced sympathetic nervous system activity and, therefore affected the ADTN inhibitory influence on ACTH and adrenal glands secretion.

[Molecular analysis of the most frequent mutations associated with congenital adrenal hyperplasia secondary to 21-hydroxylase enzyme deficiency]

Most cases (90%) of congenital adrenal hyperplasia (CAH) are secondary to steroid 21-hydroxylase enzyme deficiency (P450c21). In human, the P450c21 gene (CYP21B) is present along with a non functional pseudogene (CYP21A). These genes, located in chromosome 6, present a sequence homology of 98%. This high homology and the complexity of this gene locus brings about considerable difficulties in its molecular analysis and in the interpretation of the results. The aim of the present study was to elaborate an adequate strategy for the analysis of the most frequent mutations described in the CYP21B gene. A total of 77 patients with clinical and biochemical diagnosis of CAH secondary to P450c21 enzyme deficiency, as well as 170 unaffected relatives, were studied. They belonged to 73 unrelated families (146 chromosomes). The strategy allowed for the differentiation of patients with homozygous point mutations (PM), with PM in one allele and deletions, conversions, Ex3 or Cluster Ex6 PM in the other, even though parents were not always available for the study. Furthermore, it allowed for the discrimination of heterozygous deletions or conversions of the CYP21B gene from duplications of the non functional gene CYP21A, as well as CYP21B and A deletions from normal copies of the two genes. An exhaustive molecular analysis of this gene is necessary for an adequate characterization of the alterations present in this locus.

Irreversible increase of serum IGF-1 and IGFBP-3 levels in GnRH-dependent precocious puberty of different etiologies: implications for the onset of puberty

In normal puberty, as well as in precocious puberty, serum GH, IGF-1 and IGFBP-3 are increased as a consequence of the increase in sex hormone secretion. However, the effect of suppressing sex hormones on serum GH and IGF-1 in precocious puberty is controversial. On the other hand, the interest in the interaction between the GH-IGF-1 system and the hypothalamic-pituitary gonadal axis has been reinforced by experimental evidence which indicates that IGF-1 might be involved in the regulation of the onset of puberty. We have studied 11 girls with GnRH-dependent precocious puberty (Gr1), before and during treatment with GnRH analog for 1.43+/-0.81 years, and 4 children (3 boys and 1 girl) with GnRH-dependent precocious puberty secondary to congenital adrenal hyperplasia (Gr2), before and during treatment with hydrocortisone (HC) alone for 0.32+/-0.23 years, and during combined treatment with GnRH analog, for 1.87+/-1.43 additional years. The etiology of precocious puberty in Gr1 was either idiopathic or associated with several brain lesions (hydrocephalia, hypothalamic hamartoma, suprasellar astrocytoma). During follow-up, clinical status as well as gonadotropin suppression, tested with the acute GnRH test, was checked every 3 months. Peptides and steroid hormones were determined by radioimmunoassay. Normal values for serum IGF-1 and serum IGFBP-3 were established in our laboratory from a population of 165 clinically controlled subjects, aged 0.5-15 years. In Gr1, treatment arrested breast development and blunted LH and FSH response to GnRH in all subjects. In Gr2, during HC treatment, all patients had a pubertal type of response to the acute GnRH test which was suppressed during combination treatment. In Gr1, serum IGF-1 SDS for chronological age (CA), but not IGFBP-3 SDS CA, was significantly high before GnRH analog treatment (mean+/-SD 1.33+/-1.84 and -0.68+/-1.55, p < 0.05 and p = NS, respectively). IGF-1 SDS CA remained high and IGFBP-3 SDS CA remained normal during treatment (1.34+/-2.0 and 0.73+/-1.93). In Gr2, serum IGF-1 and IGFBP-3 SDS CA were high before treatment (3.11+/-0.74 and 1.31+/-1.43, p < 0.02 and p < 0.05, respectively), and they remained high during HC or combined treatment. In the two groups, serum IGF-1 SDS BA and serum IGFBP-3 SDS BA levels were similar to control subjects before and during treatments. In Gr1, mean serum dehydroepiandrosterone sulfate (DS) was within prepubertal preadrenarche values but serum androstenedione (delta4) was significantly higher (6.35+/-3.45 nmol/l) than in our own normal control group (1.84+/-1.18, n = 20), both before and during treatment (p < 0.02). In Gr2, serum DS and serum delta4 were high before treatment but they decreased to prepubertal values during combined treatment. It is concluded that (1) the CNS maturational events which change the regulation of serum IGF-1 and IGFBP-3 are induced by the pubertal increase in sex steroids in a nonreversible way and (2) the high adrenal steroid levels present in CAH induce a nonreversible activation of the GH-IGF-1 axis and of the GnRH pulse generator.

Secretion of inhibin B by human prepubertal testicular cells in culture

OBJECTIVE

Inhibin B is a secretory product of Sertoli cells of the human testis. It has been reported that serum levels of inhibin B in infant boys, peaking at 3 months of age, exceed levels in adult men. The aim of this study was to evaluate inhibin B secretion in primary prepubertal mixed testicular cell cultures, prepared from testes collected at necropsy.

DESIGN AND METHODS

Cell cultures were divided into three age groups on the basis of differences in testicular histology: group 1 (n = 7), 1- to 10-day-old newborns, group 2 (n = 7), 1- to 9-month-old infants, and group 3 (n = 8), 12- to 84-month-old children. Cells were maintained in culture for 6 days, harvested and counted. In some samples, during the last 4 days, cells were stimulated with 10ng/ml highly purified human (h) LH (n = 9), 2 ng/ml recombinant human (rh) FSH (n = 9) or 50 ng/ml rhGH (n = 4). On day 6, the secretion of inhibin B and testosterone into the medium was estimated in triplicate. Inhibin B was determined by ELISA and testosterone by RIA.

RESULTS

Median (range) inhibin B secretion was 465 (225-1007), 275 (107-298), and 58 (15-184) pg/million cells.24h in groups 1, 2 and 3 respectively. A logarithmic transformation of these values was performed to normalize data. Mean+/-s.d. of transformed inhibin B secretion in group 1 was significantly higher than in group 2 or 3 (P<0.005) and the values for groups 1 and 2 were significantly higher than that for group 3 (P< 0.005). No significant correlation between testosterone and inhibin B secretion into the medium was found when the 22 culture samples were analyzed as a whole. Inhibin B secretion was significantly increased after stimulation with highly purified hLH, rhFSH and rhGH (P < 0.05) and a significant positive correlation between inhibin B and testosterone was found under both hLH and rhFSH stimulation.

CONCLUSIONS

It is concluded that cells collected from newborns have the highest capacity to secrete inhibin B in vitro, and that this capacity decreases with age during the first years of life. Since no data are available on serum inhibin levels in newborns, it is possible that concentrations at 3 months of age do not represent a post-natal peak but a declining level of high newborn values. As expected, FSH stimulated inhibin B secretion in culture. LH stimulation was probably mediated by paracrine factors secreted by interstitial cells. Finally, our results add new evidence of the involvement of GH in testicular maturation.

Expression of the aromatase gene in the human prepubertal testis

It has been proposed that estrogens might play a negative feedback role in the local regulation of androgen biosynthesis in the testis. Although aromatase has been reported to be present in human adult Leydig cells, CYP19 gene expression in the human prepubertal testis has not been studied. Human prepubertal testicular tissue was obtained from 12 testes collected at necropsy. Ages ranged from 0.07 to 7 years, but 7 of the 12 subjects were younger than 3 months old. Tissue mRNA was subjected to RT-PCR analysis by two methods. Cytochrome P450arom mRNA was detected by non-radioactive RT-PCR in five of the 12 prepubertal testes collected from 0.05-7 year-old subjects, and in one testis collected from a 15 year-old pubertal control. Four of these five prepubertal samples belonged to the youngest infant group. Using a more sensitive, radioactive RT-PCR, aromatase mRNA was detected in all prepubertal testes. This study shows that the CYP19 gene is expressed in the prepubertal human testis including the period of early postnatal activation. It is possible that estrogens may have a role in prepubertal males during this period.

Insulin-like growth factor binding protein (IGFBP)-3-bound IGF-I and IGFBP-3-bound IGF-II in growth hormone deficiency

In blood, circulating IGFs are bound to six high-affinity IGFBPs, which modulate IGF delivery to target cells. Serum IGFs and IGFBP-3, the main carrier of IGFs, are upregulated by GH. The functional role of serum IGFBP-3-bound IGFs is not well understood, but they constitute the main reservoir of IGFs in the circulation. We have used an equation derived from the law of mass action to estimate serum IGFBP-3-bound IGF-I and IGFBP-3-bound IGF-II, as well as serum free IGF-I and free IGF-II, in 129 control children and adolescents (48 girls and 81 boys) and in 13 patients with GHD. Levels of serum total IGF-I, total IGF-II, IGFBP-1, IGFBP-2 and IGFBP-3 were determined experimentally, while those of IGFBP-4, IGFBP-5 and IGFPB-6, as well as the 12 affinity constants of association of the two IGFs with the six IGFBPs, were taken from published values. A correction for in vivo proteolysis of serum IGFBP-3 was also considered. In controls, serum total IGF-I, total IGF-II, IGFBP-3, IGFBP-3-bound IGF-I, IGFBP-3-bound IGF-II and free IGF-I increased linearly with age, from less than 1 to 15 years, in the two sexes. The concentrations of serum free IGF-I and free IGF-II were approximately two orders of magnitude below published values, as well as below the affinity constant of association of IGF-I with the type-1 IGF receptor. Therefore, it is unlikely that these levels can interact with the receptor. In the 13 patients with GHD, mean (+/- SD) SDS of serum IGFBP-3-bound IGF-I was -2.89 +/- 0.97. It was significantly lower than serum total IGF-I, free IGF-I or IGFBP-3 SDSs (-2.35 +/- 0.83, -1.12 +/- 0.78 and -2.55 +/- 1.07, respectively, p = 0.0001). The mean SDS of serum total IGF-II, IGFBP-3-bound IGF-II and free IGF-II were -1.25 +/- 0.68, -2.03 +/- 0.87 and 0.59 +/- 1.10, respectively, in GHD. In control subjects, 89.8 +/- 4.47% of serum total IGF-I and 77.3 +/- 9.4% of serum total IGF-II were bound to serum IGFBP-3. In patients with GHD, the mean serum IGFBP-3-bound IGF-I and IGFBP-3-bound IGF-II were 8.63 +/- 8. 53 and 19.1 +/- 14.7% below the respective means of control subjects (p < 0.02). In conclusion, in GHD there was a relative change in the distribution of serum IGFs among IGFBPs, due to the combined effects of the decrease in both total IGF-I and IGFBP-3. As a result, serum IGFBP-3-bound IGF-I and IGFBP-3 bound IGF-II, the main reservoirs of serum IGFs, were severely affected. This suggests that the decrease in serum IGFPB-3-bound IGF-I and IGFBP-3-bound IGF-II might have a negative effect for growth promotion and other biological effects of IGF-I and IGF-II. Finally, the estimation of serum IGFBP-3-bound IGF-I, or the percentage of total IGF-I and IGF-II bound to IGFBP-3, might be useful markers in the diagnosis of GHD.

Decrease in the expression of the 3beta-hydroxysteroid dehydrogenase gene in human adrenal tissue during prepuberty and early puberty: implications for the mechanism of adrenarche

Adrenarche is the increase of adrenal androgen secretion, mainly dehydroepiandrosterone and dehydroepiandrosterone sulfate, that occurs during prepuberty in higher primates. This event takes place at about 6-8 y of age in humans. It had been postulated that adrenarche might reflect an increase in the 17,20 lyase:17OH-ase activity ratio of microsomal cytochrome P450c17. However, studies to demonstrate this mechanism have been unsuccessful. Because it has been described that virilizing adrenocortical carcinomas have high dehydroepiandrosterone sulfate secretion and low 3beta-hydroxysteroid dehydrogenase (3betaHSD) activity, in this study we evaluated the possible existence of maturative changes of the level of 3betaHSD type II mRNA in 11 normal prepubertal and early pubertal human adrenals. Adrenal glands from subjects aged 0.1 to 13 y were obtained from organ donors, patients undergoing resection of the kidney for renal neoplasms or necropsies with less than 6 h of postmortem time. The expression of 3betaHSD type II gene was studied by dot blot in all samples and by relative reverse transcriptase (RT)-PCR in nine samples. The size of the transcripts was evaluated by Northern blot. Hybridization was performed using labeled human 3betaHSD cDNA probes. The uniformity of loading was tested using labeled human beta actine cDNA. The relative intensities of hybridization signals were quantified by scanning densitometry. The expected bands after relative RT-PCR were eluted, and radioactivity was measured in a scintillation counter. For the analysis of the results, subjects were divided into two groups as a function of age: group 1, less than 8 y (n = 6; range 0.1-2.48 y) and group 2, equal or older than 8 y (n = 5; range 8-13 y). 3BetaHSD type II mRNA expression, analyzed by dot blot and relative RT-PCR, was significantly higher (p < 0.05) in group 1 (median and range 4.99, 0.50-8.00 and 16.3, 13.5-40.0 arbitrary units, respectively) than in group 2 (0.15, 0.12-0.75 and 5.66, 3.18-13.0, respectively). In conclusion, we have shown a decrease of the expression 3betaHSD type II gene as a function of age in prepubertal and early pubertal normal human adrenal tissue. This maturative change might be involved in the mechanism of human adrenarche.

Elevation of serum luteinizing hormone levels during hydrocortisone treatment in infant girls with 21-hydroxylase deficiency

During the first months of postnatal life serum luteinizing hormone (LH) levels in girls are lower than in boys. The mechanism of this sex difference is not known. In order to study the possible influence of high levels of androgens and other adrenal steroids on serum gonadotropins during the first months of life, nine girls with salt-losing congenital adrenal hyperplasia (CAH), mean +/- SD age 17.1 +/- 7.52 days at diagnosis, were studied before and during oral hydrocortisone replacement therapy for 45.7 +/- 29.8 days. A control group of 16 girls (C1) and 15 boys (C2), mean ages 41.7 +/- 33.6 and 59.3 +/- 43.3 days, respectively, was also studied. Serum LH and follicle stimulating hormone (FSH) were determined by enzymoimmunoassay in the presence of one monoclonal and one polyclonal antibody. In treated girls with CAH, mean +/- SD LH (3.49 +/- 4.82 IU 1-1) was significantly higher than in C1, (0.47 +/- 0.38) p < 0.02, and similar to C2 (2.52 +/- 1.74), while mean +/- SD serum FSH (3.72 +/- 1.78 IU l-1) was not different from C1 (6.57 +/- 5.23). The mean +/- SD serum FSH/ serum LH ratio (2.53 +/- 1.44) was lower than in C1 (14.9 +/- 13.6) and similar to C2 (1.60 +/- 1.69). These data suggest that high levels of foetal and/or perinatal adrenal steroids, probably androgens, might modulate gonadotropin secretion after the neonatal period. The fact that, after adrenal steroid suppression, serum LH and the serum FSH/serum LH ratio in these infant girls with CAH were similar to that of control boys suggests that foetal or perinatal androgenic steroids have an effect on the control of LH secretion that persists after androgen withdrawal.

Thyroid function and serum thyroid binding proteins in prepubertal and pubertal children with chronic renal insufficiency receiving conservative treatment, undergoing hemodialysis, or receiving care after renal transplantation

OBJECTIVE

The abnormalities reported in some thyroid function tests in children with renal disease could be adaptive phenomena, shared by a variety of other nonthyroidal illnesses, or could reflect hypothyroidism.

STUDY DESIGN

To answer this question, we studied thyroid function and serum thyroid binding proteins in 36 prepubertal and 23 pubertal patients with renal disease receiving three different therapies: conservative treatment, hemodialysis, and care after renal transplantation.

RESULTS

During prepuberty, the serum concentration thyroxine binding globulin (mean +/- SE) in the three groups of patients (294 +/- 18, 303 +/- 18, and 323 +/- 16 nmol/L, respectively) was significantly lower than in prepubertal control subjects (451 +/- 71 nmol/L). Only in prepubertal patients after renal transplantation (3583 +/- 573 nmol/L) were serum thyroxine binding prealbumin values lower than in respective control subjects (5999 +/- 908 nmol/L). The serum total thyroxine concentration in the three groups of patients (108 +/- 41.9, 121 +/- 5.7, and 123 +/- 5.5 nmol/L, respectively) was significantly lower than in prepubertal control subjects (149 +/- 10 nmol/L), whereas serum free thyroxine and serum albumin-bound thyroxine concentrations were similar to those in control subjects. The serum total triiodothyronine level in the three groups of patients (2.29 +/- 0.82, 2.13 +/- 0.13, and 2.01 +/- 0.20 nmol/L respectively) was significantly lower than in prepubertal control subjects (3.04 +/- 0.24 nmol/L), whereas serum levels of free triiodothyronine and serum albumin-bound triiodothyronine were similar to those in prepubertal control subjects. During puberty, serum thyroxine binding globulin and serum thyroxine binding prealbumin levels in the three groups of patients were not statistically different from those in pubertal control subjects (309 +/- 47 and 4950 +/- 1230 nmol/L, respectively). Serum levels of total thyroxine, free thyroxine, albumin-bound thyroxine, total triiodothyronine, free triiodothyronine, and albumin-bound triiodothyronine were similar to those in pubertal control subjects except for pubertal patients undergoing hemodialysis. In all clinical groups the basal serum thyrotropin concentration was similar to those in respective control subjects. The frequency of goiter was increased in patients undergoing hemodialysis, probably as a result of iodide washout with dialysis.

CONCLUSION

Children and adolescents with chronic renal insufficiency or endstage renal disease or after renal transplantation do not have a primary abnormality of thyroid function and therefore are not candidates for thyroid hormone treatment.

Serum concentrations of follicle stimulating hormone and luteinizing hormone in normal girls and boys during prepuberty and at early puberty

Serum luteinizing hormone (LH) and follicle stimulating hormone (FSH) morning levels were determined in 327 normal prepubertal and early pubertal children of both sexes, utilizing a highly sensitive and specific microparticle enzyme immunoassay. Female (F) and male (M) prepubertal (Tanner's stage I) subjects were divided into 4 age groups: less than 3 months (F1, M1), 3 to 12 months (F2, M2) 12 to 24 months (F3, M3) and older than 24 months (F4 and M4). F pubertal subjects were classified in Tanner's stage breast II (F5) and III F6), while M pubertal subjects belonged to Tanner's stage genitalia II (M5). Serum LH levels were relatively low in prepubertal girls and showed a significant increment in group F6. By contrast, serum LH levels were relatively high in M1 and M2, decreased to levels similar to F in M3 and M4, and increased again at puberty in M5. Serum FSH levels were relatively high in girls of all prepubertal groups, even though they decrease significantly in M4. An increase was detected in pubertal group M6. All M prepubertal groups had significantly lower FSH levels than F prepubertal groups. The high serum LH of boys during the first year of life is probably a consequence of an activation of the hypothalamic GnRH pulse generator that is not apparent in girls. On the other hand, the high serum FSH of prepubertal girls is probably a consequence of a weak restraint influence of the prepubertal ovary on pituitary FSH secretion. This sexual dimorphism in gonadotropin secretion regulates, in a sex-specific fashion, prepubertal gonadal function in the two sexes.

Basal testosterone secretion and response to human luteinizing, follicle-stimulating, and growth hormones in culture of cells isolated from testes of infants and children

Little is known on the hormonal regulation of the early postnatal phase of Leydig cell activation in the human. Testosterone secretion by prepubertal testicular cells in culture was studied in two different age groups, 0-7-mo-old (group 1) and 16-36-mo-old (group 2) boys. A mixed cell preparation was isolated from testes collected at necropsy and maintained in culture for 6 d. Cells were cultured in serum-free medium in basal conditions and under the stimulation of human (h)LH, hFSH, or recombinant hGH, and the secretion of testosterone was determined on d 6 by RIA. In basal conditions, cells of group 1 secreted more testosterone (median 5.83 pmol/10(6) cells.d, n = 7) than cells of group 2 (median 1.73, n = 5), p < 0.05, reflecting the steroidogenic potential of the testes in vivo. Under hLH stimulation, cells of group 1 responded by increasing testosterone secretion significantly. Surprisingly, hFSH stimulation elicited a similar response in cells of group 1. Because FSH receptors are presumably located in Sertoli cells, it is concluded that these cells secreted a paracrine factor that stimulated testosterone secretion by Leydig cells. On the other hand, recombinant hGH also stimulated the secretion of testosterone by cells of group 1. Recombinant hGH could have interacted with either GH or prolactin receptors of testicular cells. Cells of group 2 did not respond to any stimulus. Because serum levels of LH, FSH, GH, and prolactin are higher during the first months of life than later in childhood, it is possible that the early postnatal activation of the testis is under multiple pituitary hormone influence.

Human prepubertal testicular cells in culture: steroidogenic capacity, paracrine and hormone control

The neonatal human Leydig cell undergoes a transient period of activation during the first months of life. The biological significance of this activation is unknown. Furthermore, little is known about the hormonal regulation of this biological process, even though it coincides with an elevation of LH levels in serum. In order to study the function of human prepubertal testicular culture cells, obtained during the neonatal period, a method for maintaining primary culture cells (isolated from testes collected at necropsy) in culture was developed. Within 24 h after death, testes were collected from 1-36-month-old subjects. Subjects were divided into two age groups, based on the presence or absence of fetal Leydig cells: 1-7-month-old infants (group 1) and 12-36-month-old children (group 2). Testes were digested with collagenase, and cells were seeded in multi-well dishes. Cells were grown in serum-free conditioned media supplemented with 5 mg/l vitamin C, 0.2 IU/l vitamin E and 10% fetal bovine serum for 2 days. Cells were then grown for an additional 4 days in serum-free media in the presence or absence of hLH (40 IU/l), hCG (135 IU/l), rh FSH (1.5 IU/l), rhGH (0.12 IU/l) or insulin (0.9 mumol/l). Concentrations of steroids in media were determined by RIA on day 6 of culture. In basal conditions cells of group 1 (n = 11) secreted more testosterone, androstendione, 17-hydroxyprogesterone, progesterone and dehydroepiandrosterone (mean +/- SE: 6.76 +/- 1.86, 7.37 +/- 1.82, 61.9 +/- 1.86, 5.75 +/- 1.74 and 8.51 +/- 3.23 pmol/10(6) cells/24 h, respectively) than cells of group 2 (n = 5) (2.95 +/- 1.15, 1.50 +/- 2.75, 1.44 +/- 2.75, 0.78 +/- 1.74 and 3.23 +/- 1.32, respectively). Under hLH stimulation, cells of group 1 increased testosterone, androstendione and 17-hydroxyprogesterone secretions (to 38.2 +/- 0.89, 13.5 +/- 1.17 and 51.7 +/- 3.23), while progesterone secretion remained unchanged (2.82 +/- 1.20). Cell response to rhFSH and rhGH was similar to that of hLH. On the other hand, medium collected from cultures of cells isolated from a Sertoli cell tumor was able to stimulate testosterone secretion in subcultures of control testicular cells in a way similar to that of hCG. In conclusion, (1) these prepubertal human testicular cells can be maintained in primary culture for several days keeping their in vivo steroidogenic potential; (2) cells isolated from young infants can respond to hLH in culture; (3) response to rhFSH is probably mediated by a paracrine factor; (4) response to rhGH is observed in the absence of gonadotropins.(ABSTRACT TRUNCATED AT 400 WORDS)

Testicular steroid biosynthesis in a boy with a large cell calcifying Sertoli cell tumor producing prepubertal gynecomastia

A study of a large cell calcifying Sertoli cell tumor of the testis associated with bilateral gynecomastia in an 8-year-old boy is presented. Macroscopically, the two testes showed multiple, large, and hard calcified nodules. Histology revealed clusters or cords of tumor cells with foci of calcifications as well as evidences, in the adjacent testicular parenchyma, of initiation of gonadal development, such as early signs of spermatogenesis and sparse Leydig cell differentiation. In vivo, serum hormone studies showed gonadotropin-independent gonadal activity. After orchidectomy two macroscopically distinct fractions of the removed testes, tumoral and extratumoral, were processed separately for cell isolation and culture. The secretion of testosterone, androstenedione, and 17-hydroxyprogesterone to the medium on day 6 of culture showed that steroidogenesis in cells of the extratumoral fraction was more active than in the tumoral fraction. On the other hand, tumoral fraction cells showed much higher aromatase activity than extratumoral cells. Furthermore, conditioned medium of tumoral fraction cells was able to stimulate testosterone secretion when it was added to subcultures of testicular cells isolated from a control subject. It is postulated that tumoral cells might have stimulated neighboring interstitial cells to differentiate into Leydig cells and to secrete androgens, which in turn might have been aromatized to estrogens by tumoral cells.

Differences in serum insulin-like growth factor I and sex-hormone-binding globulin levels between late and early prepuberty in patients with idiopathic and organic growth hormone deficiency

It has been reported that growth hormone modulates serum levels of insulin-like growth factor I (IGF-I) positively and serum levels of sex-hormone-binding globulin (SHBG) negatively. We have measured IGF-I and SHBG concentrations in 24 prepubertal patients with growth hormone deficiency. Twelve of these patients had had intracranial tumors removed (organic growth hormone deficiency) and 12 had growth hormone deficiency of unknown etiology (idiopathic). Fifty-two prepubertal control subjects, admitted for elective surgery, were also studied. All prepubertal patients were divided into two age groups: older and younger than 7 years of age. In both groups there were patients with multiple pituitary deficiencies on hydrocortisone and/or levothyroxine sodium replacement therapy. In the age group younger than 7 years, serum IGF-I was not significantly different between organic and idiopathic growth hormone deficiency (0.28 +/- 0.21 versus 0.062 +/- 0.071 mU/l) but serum SHBG levels were different (74.6 +/- 33.5 versus 173 +/- 59 nmol/l, p < 0.05). These values were not significantly different from controls (0.47 +/- 0.25 mU/l and 132 +/- 47 nmol/l, respectively). In the age group older than 7 years, there was no significant difference between organic and idiopathic growth hormone deficiency in serum IGF-I (0.33 +/- 0.17 versus 0.16 +/- 0.11 mU/l) or serum SHBG (113 +/- 72 versus 108 +/- 17 nmol/l). These values were significantly different from controls (1.04 +/- 0.36 mU/l and 68.7 +/- 31.7 nmol/l, p < 0.05, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of serum total thyroxine and triiodothyronine and their serum fractions in nonthyroidal illness secondary to congenital heart disease. Studies before and after surgery

Serum thyroid hormones, serum thyroxine-binding proteins and serum thyroid hormone fractions have been measured in children with congenital heart disease before and after open cardiac surgery. Twenty prepubertal patients, mean (+/- SD) age 3.6 +/- 3.7 yr, were studied before, immediately after, and 24 and 48 h after surgery. A control group of 6 normal prepubertal children was also studied in basal conditions. Serum TSH was normal in all samples collected. Significantly low mean levels of serum TBG (261 +/- 57 vs 456 +/- 71 nmol/L in normals), serum TBPA (2692 +/- 1119 vs 5999 +/- 2226 nmol/L), serum TBG-bound T4, serum TBPA-bound T4, serum TT3, serum TBG-bound T3 and free T3 were found before cardiac surgery in the patients. While serum binding proteins did not change after surgery, significant decrements in serum TT4, serum TBG-bound T4, serum TT3, serum TBG-bound T3, serum albumin-bound T3 and free T3 were observed after surgery. Free T4 and albumin-bound T4 remained normal. Our study shows that many features of nonthyroidal illness were present in our patients before surgery. In this context, the stress of surgery induced further alterations in several parameters of thyroid metabolism. It is concluded that the changes occurring in this model of chronic, as well as acute, nonthyroidal illness reflect adaptative changes, rather than altered thyroid function, as shown by normal serum free T4, serum albumin-bound T4 and serum TSH.

Hypothalamic-pituitary-gonadal function in prepubertal boys and girls with chronic renal failure

Hypothalamic-pituitary-gonadal function was evaluated in 24 prepubertal children with chronic renal failure (CRF). Among the 17 boys, 5 were receiving conservative treatment and four long-term dialysis. Another eight boys were studied 6 months to 3.3 years after renal transplantation; their ages ranged from 5 years 8 months to 15 1/2 years. Among the girls, two patients were receiving conservative treatment and five long-term dialysis; their ages ranged from 3 1/2 years to 11 years 2 months. In boys with CRF, but not in those after transplantation, mean serum follicle-stimulating hormone 60 minutes after administration of gonadotropin releasing hormone (GnRH) was lower than in 18 control prepubertal boys (mean +/- SD: 2.53 +/- 1.34 vs 6.25 +/- 2.84 IU/L, respectively; p < 0.01). Testosterone steroidogenic capacity after 1 week of stimulation with human chorionic gonadotropin and androgen sensitivity (percentage of decrease of serum sex hormone-binding globulin 1 week after intramuscular administration of testosterone enanthate) were normal. In girls, no difference between those with CRF and a control group of 19 girls was found after intravenous administration of GnRH. However, after intramuscular administration of GnRH agonist, serum follicle-stimulating hormone concentration was lower in girls with CRF than in control girls (p < 0.02); six of seven control girls had an increase of serum estradiol to more than 55 pmol/L, whereas three of seven girls with CRF had no response, and serum follicle-stimulating hormone failed to increase after GnRH agonist therapy in two of these patients. We conclude that hypothalamic-pituitary function is not normal in some prepubertal boys and girls with CRF, particularly in those with low serum albumin concentrations. On the other hand, testicular and ovarian steroidogenic capacity is not impaired, and the biologic response to androgens in boys is preserved.

High serum sex hormone-binding globulin (SHBG) in premature thelarche

OBJECTIVE

We determined serum sex hormone-binding globulin (SHBG), serum dehydroepiandrosterone sulphate, serum oestradiol and serum testosterone and its fractions in girls with premature thelarche.

DESIGN

Blood was drawn from girls with recently diagnosed (3-12 weeks) premature thelarche. Serum was kept frozen for at least one year before hormonal determination to exclude precocious puberty by clinical evaluation.

PATIENTS

Seventeen girls with premature thelarche aged 0.83-7.16 years were studied, and compared with a group of 22 normal prepubertal girls.

MEASUREMENTS

SHBG was measured by saturation analysis and serum dehydroepiandrosterone sulphate, serum total oestradiol and serum total testosterone were determined by radioimmunoassay. Non-SHBG-bound testosterone and free testosterone were calculated from an equation derived from the law of mass action.

RESULTS

Median serum SHBG in premature thelarche was 137 nmol/l (range 64-221), significantly higher than in normal controls, 93.7 (32-172) (P < 0.05) non-parametric test of medians. Serum SHBG decreased significantly with age in controls but not in premature thelarche. No difference was found in serum dehydroepiandrosterone sulphate. Median serum total testosterone (0.34 nmol/l, 0.17-0.97), median serum non-SHBG-bound testosterone (0.04 nmol/l, 0.02-0.10) and median free testosterone (2.2 pmol/l, 1.0-4.5) were significantly lower in premature thelarche than in control (P < 0.001).

CONCLUSIONS

Serum SHBG is high and bioavailable T is low in girls with premature thelarche. This might alter the oestrogen/androgen ratio in the breast.

Primary culture of prepubertal human testicular cells isolated from testes collected at necropsy

The aim of the present work was to develop a method for maintaining prepubertal human testicular cells in culture. Seven pairs of testes of boys who died of causes unrelated to endocrine or metabolic diseases were obtained at necropsy. Histology of the testes was normal. Testes were digested with collagenase and dispersed cells were seeded in multi-well dishes in the presence of 5% bovine fetal serum. After the first day, cells were cultured for five days in serum-free medium in the presence or absence of 918 pmol/l insulin. At the end of culture, microscopic examination showed healthy looking cells with characteristics compatible with pre-Sertoli cells; peritubular cells were identified by immunocytochemistry. In the presence of insulin, cells were able to secrete either testosterone or estradiol into the medium, as well as to reveal aromatase activity. In order to study the effect of the time elapsed between death and beginning of cultures, steroidogenic activity was related to this post mortem time. It was found that, in the presence of insulin, cells obtained from testes with less than 24 h of post mortem time secreted testosterone (64 +/- 7.2 pmol/10(6) cells.24 h, mean +/- SD) while cells obtained from testes with more than 24 h of post mortem time did not secrete testosterone. With long post mortem times, aromatase activity under insulin increased from non-detectable to 35 pmol/10(6) cells.24 h. Time course studies showed that cells with capacity to secrete testosterone increase this secretion gradually up to day 10 of culture, while those with detectable aromatase activity showed increments in this activity during the first week of culture.(ABSTRACT TRUNCATED AT 250 WORDS)

Endocrine disorders in 66 suprasellar and pineal tumors of patients with prepubertal and pubertal ages

Tumor oncotypes, initial symptoms and endocrine disturbances before and/or 1 month after surgery were studied in 66 patients with prepubertal and pubertal ages having suprasellar or pineal intracranial tumors. Neoplasms found in patients of prepubertal age were: 15 craniopharyngiomas (CRA), 24 neuroepithelial-cell-derived tumors (NEC), 5 germ cell tumors (GERM) and 4 other lesions (OTHER). In patients of pubertal age, there were 7 CRA, 7 pituitary tumors (PIT), 2 NEC, 1 GERM and 1 OTHER. Approximately 90% of patients had visual abnormalities as one of the initial signs and symptoms, while 59% had increased intracranial pressure. Short stature was observed in only 10% of patients. Before surgery, somatotropic function was found to be deficient (by 2 pharmacological tests) in 90-100% of patients with CRA, PIT or GERM and in 40% of patients with NEC. Overt hypothyroidism was found in 5-25% of CRA, NEC or GERM but in 40% of PIT. Abnormal TSH responses to TRH were observed in 64% of CRA and in 29% of NEC. Low basal serum cortisol was found in 21 or 6% of patients with CRA or NEC, but in 100 or 60% of patients with PIT or GERM, respectively. Diabetes insipidus was diagnosed in 13.6% of all patients. Surgery produced few additional disturbances in endocrine function, except for the incidence of diabetes insipidus which was doubled. Gonadotropic deficiency was found in most patients of pubertal age with CRA and PIT. They were readily differentiated by the high prolactin or growth hormone (GH) levels of the latter.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum sex hormone-binding globulin and serum nonsex hormone-binding globulin-bound testosterone fractions in prepubertal boys with chronic renal failure

We had previously reported that serum sex hormone binding-globulin (SHBG) decreases and serum non-SHBG-bound testosterone (T) and free T increase significantly from infancy to late prepuberty in normal prepubertal children of both sexes. We had also shown an age-related delay in these changes in hypopituitary boys, which was reversed by GH treatment. Stunted growth and delayed puberty are conspicuous features of chronic renal failure (CRF). As another model of delay of growth and development, serum SHBG and serum T fractions were determined in 13 boys with CRF on chronic dialysis. In CRF, mean serum SHBG was significantly higher (99.1 +/- 68.9 nmol/L; P less than 0.05) than in 31 control (C) children of similar ages (66.2 +/- 34.9 nmol/L), while serum non-SHBG-bound T and free T were significantly lower (0.16 +/- 0.12 in CRF vs. 0.24 +/- 0.12 in C and 0.010 +/- 0.005 in CRF vs. 0.016 +/- 0.01 in C, respectively). On the other hand, serum total T (1.31 +/- 0.88 in CRF vs. 1.08 +/- 0.56 in C) and serum insulin-like growth factor-I (IGF-I; 1.06 +/- 0.74 in CRF vs. 1.35 +/- 1.70 in C) were not significantly different. A significant negative correlation between serum SHBG and chronological age as well as a significant positive correlation between serum non-SHBG-bound T and chronological age were found. For a given age, serum SHBG was higher, while serum non-SHBG-bound T was lower in patients with CRF (by analysis of covariance, P less than 0.01). It is postulated that, as has been proposed for hypopituitary boys, this delayed increment in serum T fractions could be responsible for the delay in the onset of puberty reported in CRF. It is known that GH decreases serum SHBG, acting on hepatic cells either directly or through the action of IGF-I. Since it has been suggested that patients with CRF have peripheral resistance to GH or IGF-I, the high levels of SHBG that we have detected in prepubertal boys with CRF could be taken as an additional evidence of this biological resistance.

Glucocorticoids and adrenal androgens in children with end stage renal disease

We studied the effects of chronic renal failure on the pituitary-cortisol axis and adrenal androgen function in 26 patients (16 male and 10 female), aged 6.5 to 22.5 years (mean 14.5). Ten patients were prepubertal, 8 pubertal, and 8 post-pubertal. All of them were on chronic hemodialysis. Pubic hair development was delayed in 56% of the patients. Serum cortisol was increased in 15 out of the 26 patients. Serum delta 4-androstenedione was high in 11 out of 15 patients in Tanner's stage I or II and in 1 out of 11 patients in Tanner's stage III, IV or V (p less than 0.01). Serum cortisol was elevated in 10 out of 12 patients with high serum delta 4-androstenedione and in only 5 out of 14 with normal delta 4-androstenedione (p less than 0.02). Serum dehydroepiandrosterone sulphate was normal in 22 patients and elevated in 4 males. There was a significant inverse correlation between bone age and serum cortisol (r: -0.59; p less than 0.005) and a significant positive correlation between bone age and serum dehydroepiandrosterone sulphate (r: 0.45 p less than 0.01). Serum ACTH was normal. A reduction by 50% in cortisol and 78% in dehydroepiandrosterone sulphate was found after dexamethasone suppression, but delta 4-androstenedione did not suppress after dexamethasone. After ACTH stimulation test cortisol increased by 50% and delta 4-androstenedione by 80%.

CONCLUSIONS

The increased levels of cortisol and delta 4-androstenedione with partial resistance to dexamethasone suggest that these patients have a hypothalamic-pituitary dysfunction similar to that found in Cushing's disease or in chronic stress. The difference in the responses of delta 4-androstenedione and dehydroepiandrosterone sulphate observed is consistent with the existence of different mechanisms of control for these two steroids.

Hormonal and paracrine regulation of gamma-glutamyl transpeptidase in rat Sertoli cells

The effects of follicle-stimulating hormone (FSH) and testosterone on Sertoli cell gamma-glutamyl transpeptidase (gamma-GTP) activity have been studied in vitro. Addition of FSH to Sertoli cell cultures for 5 days induced stimulation of gamma-GTP activity. No testosterone effect was observed alone or in combination with different doses of FSH. Time course studies for a supramaximal dose of FSH showed that enzyme induction could be achieved after a 48 h stimulation. Furthermore, a gradual stimulation of gamma-GTP activity in response to increasing numbers of germinal cells (GC) added in coculture, was observed. Stimulation was also demonstrated with germinal cell-conditioned medium (GCCM). Stimulatory effects of GC and GCCM were additive with those of FSH, suggesting that different mechanisms were involved.

Lack of correlation of serum estradiol with growth velocity during male pubertal growth

The adolescent growth spurt in boys is under hormonal control. It is accepted that androgens and growth hormone contribute to male pubertal growth, but the role of estrogens is uncertain even though low-dose estradiol administration stimulates growth in prepubertal boys. In the present work, the correlation of serum testosterone and serum estradiol with growth velocity was studied in 16 pubertal normal boys. The study included correlations of growth velocity with serum nonsex hormone-binding globulin-bound testosterone and with serum nonsex hormone-binding globulin-bound estradiol, which are parameters of serum bioavailable sex hormones. A statistically significant positive correlation was found between serum testosterone and growth velocity but not between serum estradiol and growth velocity. These findings are against the hypothesis that estrogens play a growth promoting role during male puberty.

Thyroid dysfunction in Hodgkin's disease

Radiotherapy to the neck and/or polychemotherapy late effects on the thyroid were investigated in 51 patients (34 males and 17 females) with Hodgkin's disease. Except for two untreated, recently diagnosed patients, all were studied after 1 to 105 months (median, 27.5 months) of completion of polychemotherapy. Age ranged from 6.2 to 36.6 years (median, 13.6 years). Patients were divided according to treatment into four groups: (A) patients treated with CVPP (cyclophosphamide, vinblastine, procarbazine, and prednisone); (B) 22 patients treated with CVPP plus radiotherapy (median radiation dose to the thyroid, 3000 cGy); (C) seven patients with ACOP/BVP (adriamycin, cyclophosphamide, vincristine, prednisone, bleomycin, vinblastine, procarbazine); and (D) seven patients treated with different polychemotherapy protocols, four of whom also received radiotherapy. Elevated basal and/or post-TRH, -TSH levels were found in the following: Group A: two of 12 patients (17%); Group B: 11 of 22 (50%); Group C: four of seven (57%); and Group D: two of seven (28%). Positive antimicrosomal thyroid antibody titers (AM Ab) were found in the following: Group A: three of 12 patients (25%); Group B: six of 21 (28%), Group C: two of seven (28%); and Group D: one of six (17%). Of 46 patients studied, 12 (26%) had positive AM Ab; 37 of 46 patients were younger than 20 years of age, 11 (30%) of whom had positive AM Ab versus 4% in the normal population (P less than 0.001). Two recently diagnosed, untreated patients had either high TSH response to TRH or positive AM Ab. In conclusion, higher frequency of thyroid dysfunction was observed in patients receiving radiotherapy (50% versus 27%). Prevalence of positive AM Ab, apparently unrelated to therapy, was higher in young patients than in the normal population. A predisposition to autoimmune thyroid disease seems to be present in these patients, but it is not possible to discern how lymphoma and thyroiditis are interrelated.

Progressive increase in nonsex hormone-binding globulin-bound testosterone and estradiol from infancy to late prepuberty in girls

We previously reported that serum sex hormone-binding globulin (SHBG) decreases and serum non-SHBG-bound testosterone (T) increases with age in normal prepubertal boys from infancy to late prepuberty. In this study we measured serum SHBG, T, estradiol (E2), and dehydroepiandrosterone sulfate (DS), and we calculated serum non-SHBG-bound T and E2 and free T and E2 in 22 normal prepubertal girls, aged 1-9.4 yr. The girls were divided into 3 groups of different ages: group A, 1.7 +/- 1.0 (mean +/- SE) yr; group B, 4.6 +/- 0.8 yr; and group C, 7.3 +/- 0.8 yr. In group C, mean serum SHBG level was lower, and serum T, non-SHBG-bound T, free T, DS, total E2, non-SHBG-bound E2, and free E2 were higher than in group A or B. Furthermore, a negative correlation was found between serum SHBG and age [y(nmol/L) = 144 - 9.07 x (yr); r = 0.57; P less than 0.001], while positive correlations were found between non-SHBG-bound T and age [y(nmol/L = 0.043 + 0.023 x (yr); r = 0.68; P less than 0.001], non-SHBG-bound E2 and age [y(pmol/L) = 0.69 + 2.82 x (yr); r = 0.6; P less than 0.001], and DS and age [y(nmol/L) = 25.2 + 63.8 x (yr); r = 0.59, P less than 0.001]. In a group of 19 normal age-matched prepubertal boys, we also found a significant correlation between non-SHBG-bound E2 and age. Since non-SHBG-bound sex hormone levels are good indicators of tissue available sex hormones, we conclude that in prepubertal girls, there is a progressive increase in the exposure of peripheral tissues to T and E2 with advancing age. Since sex hormones enhance tissue maturation, these increments might play a role in the somatic and psychic development of girls before the onset of the clinical signs of puberty.

Hormonal regulation of rat testicular gamma-glutamyl-transpeptidase "in vivo" and "in vitro"

The hormonal regulation of gamma-glutamyl transpeptidase (gamma-GTP), an enzyme marker of Sertoli cells, was studied in immature rats that received 50 micrograms/day of testosterone propionate (TP) during 6 days to suppress pituitary LH and FSH. Suppression of LH was monitored indirectly by the determination of intratesticular levels of testosterone and suppression of FSH by radioimmunoassay of serum FSH. Enzyme activity in the testis decreased in parallel to intratesticular testosterone suppression, and it did recover up to control values when animals received 500 micrograms/day of TP, a dose that was able to maintain intratesticular testosterone at normal levels. beta-glucuronidase, another enzyme marker of Sertoli cells, was not affected by these treatments. A significant decrease in gamma-GTP was detected 24h after significant suppression of intratesticular testosterone and it returned to control levels 2 days after increasing the dose of TP to 500 micrograms/day. Administration of FSH to rats with depletion of intratesticular testosterone was able to maintain testicular gamma-GTP at control levels. An stimulatory action of FSH could also be demonstrated in primary Sertoli cell cultures. It is concluded that testicular gamma-GTP is under the regulation of both androgens and FSH while beta-glucuronidase is not. Eventhough the function of gamma-GTP in the testis is not known, the key role that it plays in other tissues suggests that it might be important in the regulation of Sertoli cell-germ cell interactions.

High serum sex hormone-binding globulin (SHBG) and low serum non-SHBG-bound testosterone in boys with idiopathic hypopituitarism: effect of recombinant human growth hormone treatment

We measured serum sex hormone-binding globulin (SHBG), total testosterone (T), non-SHBG-bound T, albumin-bound T, free T, and SHBG-bound T in 19 prepubertal boys with hypopituitarism. Serum SHBG decreased with age with a slope similar to that in 91 normal prepubertal boys at higher level, and therefore, it reached similar values at a later age. Serum SHBG was significantly higher in hypopituitary prepubertal boys [mean, 123 +/- 12 (+/- SE) nmol/L] than in normal prepubertal boys (76 +/- 4; P less than 0.001) despite the fact that their mean age was also higher (10.0 +/- 4 vs. 7.1 +/- 4.1 yr; P less than 0.001). In 4 boys with isolated hypogonadotropic hypogonadism (Kallman's syndrome), aged 15.6 +/- 1.5 yr, serum SHBG was 21 +/- 14 nmol/L, a value below the 95% confidence limit of the regression line in GH-deficient boys. The affinity constants of association of the SHBG-DHT complex were similar in hypopituitary and normal boys. Eleven of the 19 hypopituitary boys (mean chronological age, 8.3 +/- 2.5 yr; mean bone age, 4.1 +/- 2.1 yr) were treated with recombinant hGH (0.5 U/kg BW.week) for 1 yr. Their mean serum SHBG level before treatment was 154 +/- 14 nmol/L, and it decreased gradually to 106 +/- 5 nmol/L (P less than 0.01) after 12 months of treatment. The tendency toward normalization of serum SHBG during treatment suggested that GH deficiency was responsible for the high serum SHBG levels. Serum SHBG correlated negatively with age in both treated hypopituitary and normal boys, but the slope of the regression line was significantly steeper in treated hypopituitary boys (P less than 0.01). On the other hand, the mean serum non-SHBG-bound T level was 0.10 +/- 0.02 (+/- SE) nmol/L in hypopituitary boys, significantly lower than that in normal boys (0.21 +/- 0.02 nmol/L; P less than 0.02). Since serum total T concentrations were similar in the two groups, the higher serum SHBG concentration resulted in lower serum bioavailable T levels in the hypopituitary boys. These changes might explain the poor response to T treatment reported in GH-deficient patients. The lower serum non-SHBG-bound T concentrations in the GH-deficient boys suggest there may be delayed exposure of central nervous system structures to increased levels of sex hormones, which, in turn, may slow body maturation. This mechanism might play a role in the delay of puberty that occurs in patients with isolated GH deficiency.

Validity of the calculation of non-sex hormone-binding globulin-bound estradiol from total testosterone, total estradiol and sex hormone-binding globulin concentrations in human serum

Recent evidences indicate that biologically available serum testosterone (T) and estradiol (E2) include not only the free fractions but also most of the albumin-bound fractions. These two serum T or E2 fractions constitute most of non-sex hormone-binding globulin (SHBG)-bound T or E2, respectively. It has been reported that the estimation of serum non-SHBG-bound T gives identical results when it is assayed experimentally or when it is calculated by a formula derived from the law of mass action assuming two binding systems (T-SHBG and T-albumin). In the present work, we have compared the results of the experimental measurement of non-SHBG-bound E2 with the calculated value derived by an equation based on the law of mass action considering four binding systems (E2-SHBG, T-SHBG, E2-albumin, T-albumin). It was found that the two estimations of non-SHBG-bound E2 correlated closely in normal men (r = 0.80), normal women (r = 0.90) and hirsute women (r = 0.98). When compared with a more complex calculation which includes 21 steroids and 3 binding proteins results also agreed closely. Values for the different T and E2 fractions in these groups of subjects are given. These calculations could be used, not only for clinical research, but also in clinical practice as an useful tool for evaluation of the sex hormone status of patients.

Hormonal profile in pubertal females with chronic renal failure: before and under haemodialysis and after renal transplantation

The effects of chronic renal failure on the hypothalamic-pituitary-ovarian axis in 25 girls, aged 9.1 to 20.9 years (mean 13.8) were studied. Twelve patients on conservative treatment (group A) had serum creatinine values between 176.8 and 1502.8 mumol/l; 9 patients were on haemodialysis (group B); and 12 patients had received a renal transplant (group C). Tanner stage of breast development was delayed relative to chronological age in 5 out of 18 patients. Serum oestradiol was normal or low when related to pubertal stages in all groups. Serum LH was elevated in group A and B patients, but normal in group C patients. Serum FSH was elevated in 6 out of the 21 patients in group A plus B, and in 2 out of the 12 patients in group C. Serum PRL was elevated in 12/12, 6/8, and 4/11 patients in group A, B, and C respectively. After GnRH administration to 4 patients in group A, 3 showed delayed or absent gonadotropin response; all 4 patients studied in group C showed normal gonadotropin response. The data indicate a decreased E2 secretion, abnormal gonadotropin and PRL levels and a blunted gonadotropin response to GnRH in girls with chronic renal failure. These results seem to indicate an alteration of the hypothalamic-pituitary unit that can be reversed after successful renal transplantation.

Progressive increase in non-sex-hormone-binding globulin-bound testosterone from infancy to late prepuberty in boys

Recent evidence suggests that human albumin-bound testosterone (HSA-bound T), the major constituent of nonsex hormone-binding globulin-bound T (non-SHBG-bound T), is biologically important. To examine the potential exposure of peripheral tissues to T in normal prepubertal boys, we determined the distribution of serum T into SHBG-bound, HSA-bound, non-SHBG-bound, and free fractions in 80 normal males, aged 0.5-14 yr, all at Tanner stage I of sexual development. A model assuming equilibrium between free T and T bound to 2-binding proteins (HSA and SHBG) was used. A computer program, using as constants the SHBG-T and HSA-T affinity constants and the serum HSA concentration and as variables the serum SHBG and total T concentrations, was used to calculate SHBG-bound T, HSA-bound T, non-SHBG-bound T, and free T. Serum total T increased 2.6-fold from 0.5 to 14 yr, whereas non-SHBG-bound T, HSA-bound T, and free T increased 8- to 9-fold during the same period. On the other hand, SHBG-bound T increased only 1.9-fold. Expressed as a function of serum total T, non-SHBG-bound T increased from 6.6% to 30.4%, the relative increment being greater for HSA-bound than for free T. We conclude that with advancing age, there is a progressive increase in the exposure of all tissues to T in normal prepubertal boys. At the level of the central nervous system, this increase in serum bioavailable T could induce maturative changes in brain cells that result in the onset of puberty in normal boys.

Evaluation of gonadal function following long-term treatment for acute lymphoblastic leukemia in girls

Twenty-four girls were studied following long-term treatment (mean: 50 months) for acute lymphoblastic leukemia; 14 were prepubertal and 10 pubertal. Follow-up during endocrine studies ranged from 2 months to 6.7 years (mean: 2.3 years). Five of 14 prepubertal patients started clinical pubertal development at a normal age and were reevaluated during puberty, increasing the pubertal group to 15 patients. Thirteen of 15 pubertal patients had received cranial radiotherapy. Ten of 15 pubertal patients started menses during the endocrine study. Although age of menarche was normal, in nine patients it was below the normal mean. Except for the remaining patient, all had received cranial cobalt therapy. In 6 of 19 patients bone age was significantly accelerated. Serum gonadotrophin response to LH-RH was normal in 13 prepubertal patients and in 10 pubertal patients. In 3 of 10 pubertal patients follicle-stimulating hormone (FSH) values were temporarily elevated. Only one pubertal patient had oligoamenorrhea. Five patients were studied by measuring serum progesterone on days 19-22 of the cycle to determine corpus luteum function. Three of them showed progesterone levels compatible with adequate corpus luteum function (6, 19, and 12 ng/ml, respectively) and two presented low progesterone levels (2 ng/ml), probably because of their short gynecological age (0.24 and 0.3 years, respectively). This study suggests that neither the disease nor the long-term antileukemia therapy seems to injure gonadal function in girls. A tendency to early sexual development was observed, which may be related to cranial cobalt therapy.

Changes in serum sex hormone-binding globulin and in serum non-sex hormone-binding globulin-bound testosterone during prepuberty in boys

Much evidence suggests that sex hormone-binding globulin (SHBG) influences the delivery of sex steroids to cells, probably by playing an important role in the distribution of serum sex hormones between SHBG-bound, albumin (HSA)-bound and free fractions. Recent evidence also suggests that HSA-bound testosterone (T), the major constituent of non-sex hormone-binding globulin-bound T, is biologically important. To examine the potential exposure of peripheral tissues to T during prepubertal years, the serum concentration of SHBG as well as the distribution of serum T in SHBG-bound, HSA-bound, free and non-SHBG-bound fractions was studied in 80 normal boys aged 0.5-14 yr, all at Tanner's stage G1 of sexual development. A gradual decrease in serum SHBG as a function of age was found without significant changes in the Ka of SHBG-dihydrotestosterone association. While regression analysis of serum total T vs age showed a 2.6-fold increase from 0.5 to 14 yr of age, those of non-SHBG-found, HSA-bound and free T vs age showed 8- to 9-fold increases during the same period. On the other hand, SHBG-bound T had only a 1.9-fold increase. Expressed as a function of serum total T, non-SHBG-bound T increased from 6.6 to 30.4%, the relative increment being greater for HSA-bound T than for free T. It is concluded that, with advancing age, there is a progressive increase in the T exposure of all tissues in normal prepubertal boys. It is speculated that, at the level of the central nervous system, this increase in serum bioavailable T could induce maturative changes in brain cells that result in the onset of puberty in normal boys.

Paracrine regulation of testicular function

Data from several experimental approaches have been reviewed and the findings clearly indicate the existence of multiple interactions between testicular cells and the potential role of these interactions in the paracrine control of testicular functions. Both testicular interstitial fluid and spent media from cultured Sertoli cells had an acute steroidogenic effect on Leydig cells, and this effect is not species specific. The secretion of this steroidogenic factor(s), which is probably a protein, is enhanced by previous FSH treatment of Sertoli cells. Coculture for 2-3 days of pig Leydig cells with homologous or heterologous Sertoli cells enhances Leydig cell specific functions (hCG receptor number and hCG responsiveness) and induces Leydig cell hypertrophy. A similar but less pronounced trophic effect is seen when Leydig cells are cultured with spent media from Sertoli cells cultured in the presence of FSH and high concentrations of insulin, but the spent media from Sertoli cells cultured in the absence of these two hormones inhibits Leydig cell specific functions. Somatomedin-C might play an important role in the positive trophic effect of Sertoli cells on Leydig cells, since this peptide is secreted by Sertoli cells and it has trophic effects on the specific function of Leydig cells. Moreover, Sertoli cells, probably through a diffusible factor and cell-to-cell contacts, control the multiplication, meiotic reduction and maturation of germ cells. In turn, the activity of Sertoli cells is modulated by the stage of neighbouring germ cells. Thus, if a normal Sertoli cell function (which depends not only on FSH but also on Leydig and myoid cell secretory products) is an absolute requirement for germ cell multiplication and maturation, these cells, in turn, cyclically regulate Sertoli cell function and through these cells the size and probably the function of Leydig cells.

Inhibition of RNA and DNA synthesis in Sertoli cells by co-culture with spermatogenic cells

Sertoli cell monolayers were prepared from 30-day-old rat testes and cultured for 7 days to eliminate contaminant germ cells. Some of these monolayers were co-cultured with a spermatogenic cell preparation enriched in pachytene spermatocytes and round spermatids (fraction 3 from a Percoll gradient), isolated from 30-day-old rat testes. After co-culture for 4 to 48 h, germ cells were removed. RNA synthetic activity in rat Sertoli cell cultures alone was 216,800 +/- 66,480 dpm [3H]uridine.2h-1 X 10(6) cells-1 (mean +/- SD) compared to 98,390 +/- 23,595 in rat Sertoli cells which had been co-cultured with germ cells of fraction 3 for 24 h (P less than 0.01). By contrast, RNA synthesis in Sertoli cell monolayers prepared from immature pigs were unaffected by co-culture with rat germ cells. A similar inhibitory effect of germ cells was observed in rat Sertoli cells stimulated with FSH or testosterone. Culture medium, conditioned by 20 h culture of a fresh preparation of rat spermatogenic cells of fraction 3, was active in inducing the inhibitory effect on RNA synthesis in rat Sertoli cells. Co-culture of rat Sertoli cells with germ cells of this fraction also decreased the incorporative of [3H]thymidine into DNA in rat Sertoli cells, from 9061 +/- 3339 to 4766 +/- 526 dpm.2h-1 X 10(6) cells-1 (P less than 0.01), but no such change was found in pig Sertoli cells. A different spermatogenic cell preparation, partially deprived of pachytene spermatocytes (fraction 5), stimulated rat Sertoli cell DNA synthesis (Sertoli alone 7833 +/- 2550, Sertoli cells which had been in co-culture with germ cells of fraction 5, 13,300 +/- 2279 dpm.2h-1 X 10(6) cells-1, P less than 0.05). These inhibitory actions of some germ cells on Sertoli cells were observed together with the previously reported simultaneous stimulatory effect of Sertoli cells on germ cells. These Sertoli cell-germ cell interactions of detected in culture may represent regulatory influences operating in vivo.

Pubertal development in male hypopituitarism

The spontaneous or therapeutically induced pubertal development of 65 male patients with idiopathic hypopituitarism was analysed. Spontaneous puberty occurred in 82% of the patients with prepubertal isolated growth hormone deficiency and in 32.5% of those with impairment in the secretion of more than one pituitary hormone. Out of this group, 36 patients could be studied longitudinally. In 15 patients, the onset of spontaneous puberty was delayed, on average, 3.2 years. It started at a bone age of 10.36 +/- 1.25 "years" and followed a pattern similar to that of normal boys. Testosterone levels at each pubertal stage were not different from those of normal boys. Mean peak height velocity reached 7.27 +/- 1.82 cm/year. In 21 patients with gonadotropin deficiency, hCG treatment was started at a chronological age of 19.04 +/- 2.17 years and a bone age of 12.94 +/- 0.80 "years". Plasma testosterone attained normal adult levels in the majority of boys, while the development of sexual characteristics showed a wide variation. Mean growth velocity during the first year of hCG therapy reached 6.11 +/- 2.47 cm/year. Partial gonadotropin deficiency was diagnosed in two boys. Although testosterone seems today to be, for practical reasons, the replacement therapy of choice, hCG treatment is an alternative for hypopituitary patients with absent gonadotropin function.