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Marques V, Ferreira S, Costa C, Castro-Correia C, Santos Silva R. Treatment modalities and outcomes in pediatric Cushing's disease - report of three cases and literature review. J Pediatr Endocrinol Metab 2024; 37:663-667. [PMID: 38785276 DOI: 10.1515/jpem-2024-0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Cushing's disease (CD) is a diagnostic and therapeutic challenge, especially in pediatric patients. CD, primarily caused by adrenocorticotropic hormone-secreting pituitary adenomas, manifests typically with growth retardation and weight gain. There are no published guidelines for pediatric patients. CASE PRESENTATION We report three pediatric patients diagnosed with CD in a Portuguese tertiary hospital. All patients presented with hypercortisolism features. All patients underwent transsphenoidal pituitary surgery (TSS) as a first-choice treatment; however, it was unsuccessful in one patient and the other patients experienced recurrence. Patients were submitted to different approaches so basal serum cortisol levels could be achieved. Two of three patients achieved remission. CONCLUSIONS TSS remains the first-line treatment yet challenging due to microadenomas and technical complexities. Medical therapy with agents like metyrapone or ketoconazole, pituitary radiotherapy, or bilateral adrenalectomy are, usually, second-line interventions, unless there is a contraindication to surgery. Our findings support the finding that a shorter hypothalamic-pituitary-adrenal axis recovery time increases the risk of recurrence of CD. Our cases illustrate the intricate management and variable outcomes of pediatric CD, underscoring the importance of multidisciplinary care and continuous surveillance.
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Affiliation(s)
- Viviana Marques
- Faculdade de Medicina da Universidade do Porto (FMUP), Alameda Prof. Hernâni Monteiro, Porto, Portugal
| | - Sofia Ferreira
- Serviço de Pediatria, ULS São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto (FMUP), Porto, Portugal
| | - Carla Costa
- Serviço de Pediatria, ULS São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto (FMUP), Porto, Portugal
| | - Cíntia Castro-Correia
- Serviço de Pediatria, ULS São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto (FMUP), Porto, Portugal
| | - Rita Santos Silva
- Serviço de Pediatria, ULS São João, Alameda Prof. Hernâni Monteiro, Porto, Portugal
- Departamento de Ginecologia-Obstetrícia e Pediatria, Faculdade de Medicina da Universidade do Porto (FMUP), Porto, Portugal
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Castillo-Huerta NM, Carassa de la Cruz JI, Quispe-Garate L, Lévano-Martínez MA, Cabrera BM, Sheen EC. Neurosurgical aspects and clinical outcomes on the treatment of Cushing disease in pediatric patients: Case series and literature review. Surg Neurol Int 2023; 14:123. [PMID: 37151460 PMCID: PMC10159280 DOI: 10.25259/sni_64_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/16/2023] [Indexed: 05/09/2023] Open
Abstract
Background Cushing disease (CD) is a state of hypercortisolism caused by an adrenocorticotropic hormone-(ACTH) producing pituitary adenoma which rarely occurs in pediatric patients. The outstanding features are weight gain and growth retardation. However, the insidious onset and rarity of the disease in children and adolescents often result in delayed diagnosis. Case Description We present five patients <14 years of age who underwent neurosurgical treatment for CD at the Department of Neurosurgery of a public referral hospital in Lima, Peru. Age at diagnosis ranged from 5.5 to 12.5 years with a history of disease from 9 months to 3.5 years of moderate to severe stunting and obesity, among other features of Cushing syndrome (CS). Although biochemical tests and cerebral imaging were crucial for the diagnosis, confirmation was made by bilateral petrosal sinuous sampling. Regarding treatment, three patients underwent transcranial surgery, one patient underwent endoscopic transsphenoidal surgery, and one patient underwent microscopic transsphenoidal surgery. None of the patients underwent radiotherapy or pharmacological treatment. Only one patient had a recurrence and achieved remission until an endoscopic transsphenoidal approach was performed. Short- and long-term endocrinologic follow-up is also described in detail. Conclusion CD is a heterogeneous disorder that requires multidisciplinary diagnosis and management. Transsphenoidal selective adenomectomy is the optimal treatment because of its higher remission rates. However, technical and anatomic aspects should be considered in pediatric patients.
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Affiliation(s)
- Nicole M. Castillo-Huerta
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- Corresponding author: Nicole M. Castillo-Huerta, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | | | - Luz Quispe-Garate
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Bianca Miranda Cabrera
- Department of Pediatric Endocrinology, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Erick Custodio Sheen
- Department of Pediatric Neurosurgery, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
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Kelly AP, Greenfield JP, Dobri GA, Schwartz TH. Pediatric pituitary adenomas are more aggressive, more likely to be hormone producing and are more difficult to cure than adult pituitary adenomas: case series and systematic literature review. Childs Nerv Syst 2022; 38:729-738. [PMID: 35048170 DOI: 10.1007/s00381-022-05445-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Pediatric pituitary adenomas (pPAs) are uncommon. Thus, their presentation and outcomes after treatment are less well-understood than those of pituitary adenomas in adulthood (aPAs). METHODS A retrospective chart review was conducted for all patients who underwent endoscopic endonasal transsphenoidal surgery (EETS) for pPA at NewYork-Presbyterian Hospital/Weill Cornell Medicine (NYP/WCM) from 2005-2020. Eleven patients were identified, and information pertaining to age, sex, adenoma characteristics, procedural details, and outcomes was reviewed. A systematic review of the literature was also performed to compare outcomes of EETS versus microscopic endonasal transsphenoidal surgery (METS) for pPA. RESULTS From 2005-2020, 11 patients underwent EETS for pPA at NYP/WCM. Mean age at operation was 14.9 ± 2.7 years, and 5 patients (45.5%) were male. 10 adenomas (90.9%) were hormone-producing. Of the functional adenomas, 8 (80.0%) were PRL-secreting and 2 (20.0%) were GH-secreting. Maximum adenoma diameter (MAD) ranged from 1.2-5.1 cm, with a median of 1.55 cm. Cavernous sinus invasion (CSI) occurred in 2 patients with macroprolactinoma. Gross total resection (GTR) was achieved in 10 (90.9%). Biochemical remission occurred in 5/10 (50.0%). Post-operative complications were documented in 8 cases (72.7%) and included diabetes insipidus, hypopituitarism, sinusitis, weight gain, cerebrospinal fluid leak, meningitis, and hydrocephalus. Systematic literature review of 105 microscopic and 175 endoscopic cases revealed high frequency of hormone-producing tumors (83.6%) and similar rates of GTR (82.4% vs 85.1%) and biochemical cure (75.8% vs 64.3%). CONCLUSIONS pPAs are more likely to be hormone producing and may be more aggressive and difficult to cure than aPAs. EETS is an effective treatment, although complication rates may be higher than in adult populations.
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Affiliation(s)
- Alexander P Kelly
- Weill Cornell Medical College, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Georgiana A Dobri
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY, USA.
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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: 19] [Impact Index Per Article: 6.3] [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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Dhandapani S, Narayanan R, Jayant SS, Sahoo SK, Dutta P, Walia R, Chhabra R, Singh A, Verma R, Gupta R, Virk RS, Dhandapani M, Bhagat H, Bhansali A, Mukherjee KK, Gupta SK. Endonasal endoscopic versus microscopic transsphenoidal surgery in pituitary tumors among the young: A comparative study & meta-analysis. Clin Neurol Neurosurg 2020; 200:106411. [PMID: 33338824 DOI: 10.1016/j.clineuro.2020.106411] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/08/2020] [Accepted: 11/28/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE The transsphenoidal approach presents unique challenges in young, with scanty literature. This study compares the outcome of pituitary tumors among young in our center between endoscopic(EES) and microscopic(MTS) transsphenoidal surgery, with a meta-analysis. METHODS Patients within 20 years were studied for their surgical approach to a favorable outcome of endocrine remission (ER) (functioning) or Gross/Near-Total resection (nonfunctioning), besides the need for retreatment. Relevant studies were pooled and analyzed according to PRISMA guidelines. RESULTS Out of 64 young patients with pituitary tumors, 48 underwent transsphenoidal surgery using MTS(33) or EES(15). Of these, 21, 14, 5, and 8 had Cushing's, somatotropinomas, prolactinomas, and non-secreting tumors, respectively. Mean symptom duration was 28months, with weight gain(50 %) and visual complaints(29 %) most prevalent. Hypogonadism(21 %) was the most frequent endocrinopathy. The mean tumor volume was 3.8 cm3. Over mean follow-up of 4.4years, favorable outcome was significantly higher after EES than MTS(78.6 % vs. 46.7 %)(odds ratio 4.18, p = 0.05). EES's better outcome was homogeneous across subgroups of age and tumor type, with no significant subgroup difference. Symptom duration was significantly higher among those who required retreatment(p = 0.05), while ER had a non-significant association with tumor volume(p = 0.07). Overall, 40 %, 27 %, 17 %, and 8% were on hydrocortisone, thyroxine, sex hormone, and desmopressin, respectively, at follow-up with no significant difference between EES and MTS. In pooled analysis of literature, both favorable outcome(74 % vs. 48 %,p = 0.02) and retreatment rate(8% vs. 37 %,p = 0.004) were significantly better with EES than MTS. CONCLUSION Among young patients with pituitary tumors, the favorable outcome and retreatment rates are better with endonasal endoscopy and associated with symptom duration and tumor volume.
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Affiliation(s)
- Sivashanmugam Dhandapani
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India.
| | - Rajasekhar Narayanan
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Satyam Singh Jayant
- Dept. of Endocrinology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Sushant K Sahoo
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Pinaki Dutta
- Dept. of Endocrinology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Rama Walia
- Dept. of Endocrinology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Rajesh Chhabra
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Apinderpreet Singh
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Roshan Verma
- Dept. of ENT, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Rijuneeta Gupta
- Dept. of ENT, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Ramandeep Singh Virk
- Dept. of ENT, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Manju Dhandapani
- Dept. of NINE, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Hemant Bhagat
- Dept. of Anesthesia, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Anil Bhansali
- Dept. of Endocrinology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Kanchan K Mukherjee
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Sunil K Gupta
- Dept. of Neurosurgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Pasternak-Pietrzak K, Moszczyńska E, Roszkowski M, Kot K, Marczak E, Grajkowska W, Pronicki M, Szalecki M. Long-term outcome in patients after treatment for Cushing's disease in childhood. PLoS One 2019; 14:e0226033. [PMID: 31830115 PMCID: PMC6907843 DOI: 10.1371/journal.pone.0226033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/17/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Cushing's disease (CD) is a rare cause of hypercortisolemia presenting a major diagnostic and therapeutic challenge. Data on pituitary function in long-term follow-up after CD treatment in childhood is limited. AIM Long-term assessment of patients of the Children's Memorial Health Institute (CMHI) after CD treatment in childhood. MATERIALS AND METHODS Retrospective analysis of 29 CD patients, mean age at the time of diagnosis 13.46 yrs. The long-term follow-up (FU) was done by: 1) obtaining the data from a patient's questionnaire (75% of adult patients); 2) using the data from the last clinic visit for patients who did not respond to the questionnaire and for current CMHI patients. The average long-term FU from transsphenoidal pituitary surgery (TSS) was 10.23 yrs. RESULTS At the latest FU: 18 patients (62%) had long-term disease remission after TSS1, 2 patients (6.9%) after TSS2, 1 patient (3.4%) after the post-TSS radiotherapy (XRT) cycle and 3 patients (10.3%) after bilateral adrenalectomy (BA). One patient (3.4%) died after TSS2 due to postoperative complications, 1 patient (3.4%) had persistent disease at latest FU, in 1 patient (3.4%) the long-term FU was not possible to perform. CD recurrence occurred in 4 out of 28 patients (14%) at an average time 3.6 yrs. from definitive treatment. One patient (3.4%) after BA was operated because of Nelson's syndrome. Two patients (6.9%) were suspected of relapse at latest assessment. At the time of the last evaluation, 17 patients (63%) were on levothyroxine therapy since definitive treatment, 16 patients (59%) were on hydrocortisone treatment, 10 patients (37%) were taking sex hormones replacement, 4 patients (15%)-antidiuretic hormone. CONCLUSIONS Relatively large number of patients after CD treatment in childhood have hormonal pituitary deficits as well as mood and cognitive disorders. CD recurrence can occur even after a long time post effective treatment.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
- * E-mail:
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Marcin Roszkowski
- Department of Neurosurgery, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Karolina Kot
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Elżbieta Marczak
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Wiesława Grajkowska
- Pathology Department, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Maciej Pronicki
- Pathology Department, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
- Collegium Medicum, University of Jan Kochanowski, Kielce, Poland
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