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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; 0:jpem-2024-0138. [PMID: 38785276 DOI: 10.1515/jpem-2024-0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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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Pomahacova R, Paterova P, Nykodymova E, Sykora J, Krsek M. Pediatric Cushing's disease: Case reports and retrospective review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:85-91. [PMID: 36504094 DOI: 10.5507/bp.2022.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We report four pediatric subjects with Cushing's disease (CD) diagnosed in the Czech Republic. We focus on initial symptoms of Cushing's syndrome (CS) which can lead to early diagnosis, on typical symptoms of CS in children, their age and sex distribution, the mean length of symptoms prior to diagnosis, indication for examination, post-cure growth, sexual development and pituitary function in our four CD patients after transsphenoidal pituitary surgery (TSS). We describe the diagnostic process leading to confirmation of CD and we emphasize the biochemical and radiological diagnostic difficulties. CONCLUSIONS Pediatric CD has a number of features distinct from adult CD. Our retrospective analysis confirmed the presence of growth retardation and change in facial appearance with development of moon face as the first symptoms of CS. According to our observation, growth retardation is prior to development of moon face. The other typical symptoms frequently seen in pediatric patients are pseudo-precocious puberty in both sexes, hirsutism in pubertal girls due to excessive adrenal androgen secretion and pubertal delay. A corticotropin-releasing hormone (CRH) test and especially bilateral inferior petrosal sinus sampling for ACTH (BIPSS) contribute to confirming the diagnosis of CD and excluding ectopic ACTH syndrome in children with unvisible adenoma on pituitary magnetic resonance imaging (MRI).
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Affiliation(s)
- Renata Pomahacova
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Petra Paterova
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Eva Nykodymova
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Josef Sykora
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Czech Republic
| | - Michal Krsek
- Third Department of Medicine, First Faculty of Medicine in Prague, Charles University, Czech Republic
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Pomahacova R, Paterova P, Nykodymova E, Polak P, Sladkova E, Skalicka E, Sykora J. Overweight and obesity in children and adolescents with endocrine disorders. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:328-334. [PMID: 37712247 DOI: 10.5507/bp.2023.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023] Open
Abstract
Obesity has become a serious medical condition where many factors can contribute to excess weight gain. The most common type of childhood obesity is simple obesity, which is due to gene-obesogenic environment interaction. Only a minority are due to pathological causes. Secondary causes of obesity, while less common, include these: genetic syndromes, drug-related obesity, as well as endocrine disorders (hypothyroidism, Cushing's syndrome, growth hormone deficiency, hypogonadism, pseudohypoparathyroidism type Ia, insulinoma, hypothalamic obesity and polycystic ovary syndrome). Given that some conditions may be treatable, physicians must be aware of obesity due to endocrinopathies and distinguish them from simple obesity, and treat them properly. Although rare among children, early detection of the endocrine cause of obesity leads to reduced morbidity and, in some cases, reduced mortality in these individuals. The aim of this review is to summarize the current findings on obesity-related endocrinopathies in children (illustrated by clinical examples), highlighting aspects of pathogenetic mechanisms, genetics, the clinical diagnosis, growth, body mass index and possible therapeutic approaches. Early detection and correction of endocrine obesity is of paramount importance for obese children who could benefit from timely diagnosis and an improved management of obesity as many disturbances related to obesity can be reversed at the early stage, if weight loss is achieved.
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Affiliation(s)
- Renata Pomahacova
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Petra Paterova
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Eva Nykodymova
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Petr Polak
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Eva Sladkova
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Eva Skalicka
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
| | - Josef Sykora
- Department of Paediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czech Republic
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Kang KM, Muralidharan K, Knowlton H, Hassan KIA, Yekula A, Misra M, Swearingen B, Jones PS. Utility of bilateral inferior petrosal sinus sampling for diagnosis and lateralization of Cushing's disease in the pediatric population: case series and review of the literature. J Endocrinol Invest 2022; 45:617-627. [PMID: 34655038 DOI: 10.1007/s40618-021-01680-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/16/2021] [Indexed: 12/01/2022]
Abstract
OBJECTS Cushing's disease (CD) is the most common cause of ACTH-dependent hypercortisolism in children age ≥ 7. The utility of bilateral inferior petrosal sinus sampling (BIPSS), an important test in adults, is less defined in children. We present a case series of children with ACTH-dependent hypercortisolemia and review the literature to assess the utility of BIPSS in the diagnosis and localization of CD. METHODS We performed an IRB-approved chart review of patients aged ≤ 18 with ACTH-dependent hypercortisolism at MGH between 2000 and 2019 and collected clinical, laboratory, radiographic, BIPSS, surgical, and outcomes data. RESULTS In our cohort (n = 21), BIPSS had a sensitivity of 93% and specificity of 100% for diagnosis of CD. Compared to surgery, successful BIPSS correctly predicted adenoma laterality in 69% of cases vs. 70% by MRI. Among patients with lesions ≥ 4 mm (n = 9), BIPSS correctly lateralized in 50% vs. 100% by MRI. In patients with subtle lesions (< 4 mm, n = 7), BIPSS correctly lateralized in 80% vs. 71% by MRI. In patients (n = 4) with CD and negative MRIs, BIPSS correctly lateralized in 75% cases. Surgical cure was achieved in 90% of patients and 95% of patients had long-term disease control. CONCLUSIONS In our cohort (n = 21; n = 20 CD, n = 1 ectopic ACTH secretion), BIPSS was sensitive and specific for the diagnosis of CD. Compared to MRI, BIPSS was not additionally helpful for lateralization in patients with lesions ≥ 4 mm on MRI. BIPSS was helpful in guiding surgical exploration and achieving immediate postoperative remission among patients with subtle and negative MRI findings.
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Affiliation(s)
- K M Kang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
- University of California San Diego, San Diego, CA, USA.
| | - K Muralidharan
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - H Knowlton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - K I A Hassan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - A Yekula
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - M Misra
- Division of Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - B Swearingen
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - P S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Banerjee RR, Marina N, Katznelson L, Feldman BJ. Mifepristone Treatment of Cushing's Syndrome in a Pediatric Patient. Pediatrics 2015; 136:e1377-81. [PMID: 26459648 DOI: 10.1542/peds.2015-0684] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2015] [Indexed: 11/24/2022] Open
Abstract
Cushing's syndrome (CS) in the pediatric population is challenging to diagnose and treat. Although next-generation medical therapies are emerging for adults with CS, none are currently approved or used in children. Here we describe the first use of mifepristone, a glucocorticoid receptor antagonist, to treat CS in a pediatric subject. The patient, a 14-year-old girl with an 18-month history of metastatic neuroendocrine carcinoma, suffered from fatigue, profound myopathy, irritability, and depression. She was found to have hypertension, hypokalemia, and worsening control of her preexisting type 1 diabetes. In this report, we detail our clinical evaluation that confirmed CS caused by an ectopic adrenocorticotropic hormone secreting tumor. Surgical and radiation therapies were not pursued because of her poor functional status and limited life expectancy, and medical treatment of CS was indicated for symptom relief. Mifepristone treatment provided rapid improvement in glycemic control, insulin resistance, and hypertension as well as significant diminishment of her myopathy and fatigue. Hypokalemia was managed with an oral potassium replacement and dose escalation of spironolactone; no other significant adverse effects were observed. Despite successful palliation of Cushing's signs and symptoms, the patient died of progression of her cancer. This case demonstrates the safety and efficacy of mifepristone treatment in a pediatric patient with symptomatic, ectopic CS. We conclude that, in appropriate pediatric patients with CS, glucocorticoid receptor antagonism with mifepristone should be considered to control the effects of hypercortisolism and to improve quality of life.
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Affiliation(s)
| | | | - Laurence Katznelson
- Departments of Medicine, Neurosurgery, Stanford School of Medicine, Stanford, California
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Abstract
Chronic exposure to excess glucorticoids results in diverse manifestations of Cushing's syndrome, including debilitating morbidities and increased mortality. Genetic and molecular mechanisms responsible for excess cortisol secretion by primary adrenal lesions and adrenocorticotropic hormone (ACTH) secretion from corticotroph or ectopic tumours have been identified. New biochemical and imaging diagnostic approaches and progress in surgical and radiotherapy techniques have improved the management of patients. The therapeutic goal is to normalise tissue exposure to cortisol to reverse increased morbidity and mortality. Optimum treatment consisting of selective and complete resection of the causative tumour is necessay to allow eventual normalisation of the hypothalamic-pituitary-adrenal axis, maintenance of pituitary function, and avoidance of tumour recurrence. The development of new drugs offers clinicians several choices to treat patients with residual cortisol excess. However, for patients affected by this challenging syndrome, the long-term effects and comorbidities associated with hypercortisolism need ongoing care.
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Affiliation(s)
- André Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada.
| | - Richard A Feelders
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Constantine A Stratakis
- Section on Genetics and Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Lynnette K Nieman
- Program on Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
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Noctor E, Gupta S, Brown T, Farrell M, Javadpour M, Costigan C, Agha A. Paediatric cyclical Cushing's disease due to corticotroph cell hyperplasia. BMC Endocr Disord 2015; 15:27. [PMID: 26063496 PMCID: PMC4464624 DOI: 10.1186/s12902-015-0024-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 06/01/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cushing's disease is very rare in the paediatric population. Although uncommon, corticotroph hyperplasia causing Cushing's syndrome has been described in the adult population, but appears to be extremely rare in children. Likewise, cyclical cortisol hypersecretion, while accounting for 15 % of adult cases of Cushing's disease, has only rarely been described in the paediatric population. Here, we describe a very rare case of a 13-year old boy with cyclical cortisol hypersecretion secondary to corticotroph cell hyperplasia. CASE PRESENTATION The case is that of a 13-year old boy, presenting with a long history of symptoms and signs suggestive of hypercortisolism, who was found to have cyclical ACTH-dependent hypercortisolism following dynamic pituitary testing and serial late-night salivary cortisol measurements. The patient underwent endoscopic transsphenoidal resection of the pituitary. Early surgical remission was confirmed by undetectable post-operative morning plasma cortisol levels. Histology and immunocytochemistry of the resected pituitary tissue showed extensive corticotroph cell hyperplasia. CONCLUSION This report describes a rare case of cyclical Cushing's disease secondary to corticotroph hyperplasia in a paediatric patient. This highlights the challenging and varied nature of Cushing's disease and its diagnosis, and the need to keep a differential diagnosis in mind during the diagnostic process.
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Affiliation(s)
- E Noctor
- Department of Endocrinology and Neurosurgery, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland.
| | - S Gupta
- Department of Endocrinology and Neurosurgery, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland.
| | - T Brown
- Department of Endocrinology and Neurosurgery, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland.
| | - M Farrell
- Department of Neuropathology, Beaumont Hospital, Dublin, Ireland.
| | - M Javadpour
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland.
| | - C Costigan
- Department of Paediatric Endocrinology, Our Lady's Hospital for Sick Children, Dublin, Ireland.
| | - A Agha
- Department of Endocrinology and Neurosurgery, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland.
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Zada G. Diagnosis and Multimodality Management of Cushing's Disease: A Practical Review. Int J Endocrinol 2013; 2013:893781. [PMID: 23401686 PMCID: PMC3562580 DOI: 10.1155/2013/893781] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 12/12/2012] [Indexed: 11/18/2022] Open
Abstract
Cushing's Disease is caused by oversecretion of ACTH from a pituitary adenoma and results in subsequent elevations of systemic cortisol, ultimately contributing to reduced patient survival. The diagnosis of Cushing's Disease frequently involves a stepwise approach including clinical, laboratory, neuroimaging, and sometimes interventional radiology techniques, often mandating multidisciplinary collaboration from numerous specialty practitioners. Pituitary microadenomas that do not appear on designated pituitary MRI or dynamic contrast protocols may pose a particularly challenging subset of this disease. The treatment of Cushing's Disease typically involves transsphenoidal surgical resection of the pituitary adenoma as a first-line option, yet may require the addition of adjunctive measures such as stereotactic radiosurgery or medical management to achieve normalization of serum cortisol levels. Vigilant long-term serial endocrine monitoring of patients is imperative in order to detect any recurrence that may occur, even years following initial remission. In this paper, a stepwise approach to the diagnosis, and various management strategies and associated outcomes in patients with Cushing's Disease are discussed.
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Affiliation(s)
- Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, 1200 North State Street, Suite 3300, Los Angeles, CA 90089, USA
- *Gabriel Zada:
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Heneghan M, Alemzadeh R. Cushing disease as possible cause of persistent growth failure despite growth hormone therapy in a small for gestational age male. Pituitary 2011; 14:409-13. [PMID: 19771523 DOI: 10.1007/s11102-009-0201-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Growth hormone (GH) therapy in children with small for gestational age (SGA) has been shown to be of significant therapeutic benefit. We report the case of an 11-year-old Caucasian male who developed early adrenarche, hypertension and insulin resistance on GH therapy for SGA and profound short stature (ht -5 SD). This patient demonstrated a poor response to GH therapy and developed physical and biochemical findings of insulin resistance responsive to metformin therapy. He remained hypertensive, however, and continued to have elevated serum dehydroepiandrosterone sulfate levels. Urinary free cortisol excretion was subsequently found to be elevated. The diagnosis of Cushing's disease was confirmed with inferior petrosal sinus sampling and pituitary MRI. The patient underwent partial adenohypophysectomy with resulting normalization of plasma cortisol levels and associated symptoms. Our patient's diagnosis of Cushing's disease was complicated by his past history of poor growth since birth and history of SGA. The signs of Cushing's disease did not overtly appear until GH therapy was initiated to help treat severe short stature. It is possible that the metabolic effects of GH therapy unmasked the presence of underlying Cushing's disease.
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Affiliation(s)
- MaryKathleen Heneghan
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI 53226-0509, USA
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Oliveira RSD, Castro MD, Antonini SRR, Martinelli Júnior CE, Moreira AC, Machado HR. Surgical management of pediatric Cushing's disease: an analysis of 15 consecutive cases at a specialized neurosurgical center. ACTA ACUST UNITED AC 2010; 54:17-23. [DOI: 10.1590/s0004-27302010000100004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Accepted: 09/21/2009] [Indexed: 05/26/2023]
Abstract
OBJECTIVE: The aim of this study was to review the results of surgery for pediatric patients with Cushing's disease who were less than 18 years old and underwent transsphenoidal surgery in a specialized center during a 25-year period. SUBJECTS AND METHODS: Retrospective study, in which the medical records, histology and pituitary imaging of 15 consecutive pediatric patients with Cushing's disease (mean age: 13 years) were evaluated by the same team of endocrinologists and a neurosurgeon from 1982 to 2006. Patients were considered cured when there was clinical adrenal insufficiency and serum cortisol levels were below 1. 8 µg/dL or 50 nmol/L after one, two, three, or seven days following surgery; they therefore required cortisone replacement therapy. Follow-up was for a median time of 11.5 years (range: 2 to 25 years). RESULTS: Clinical and biochemical cure was achieved in 9/15 patients (60%) exclusively after transsphenoidal surgery. Hypopituitarism was observed in four patients; growth hormone deficiency, in two; permanent diabetes insipidus, in one case. CONCLUSIONS: Cushing's disease is rare in children and adolescents. Transsphenoidal surgery is an effective and safe treatment in most of these patients. Plasma cortisol level < 1. 8 µg/dL following surgery is the treatment goal and is a good predictive factor for long-term cure of Cushing's disease.
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Honour JW. Diagnosis of diseases of steroid hormone production, metabolism and action. J Clin Res Pediatr Endocrinol 2009; 1:209-26. [PMID: 21274298 PMCID: PMC3005746 DOI: 10.4274/jcrpe.v1i5.209] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 08/24/2009] [Indexed: 12/01/2022] Open
Abstract
Biochemical tests have been the basis for investigations of disorders affecting steroid hormones. In recent years it has been possible however to study the genes that determine functional enzymes, cofactors, receptors, transcription factors and signaling systems that are involved in the process. Analyses of mutations are available as a diagnostic service for only a few of these genes although research laboratories may be able to provide a service. Both biochemical and genetic research have brought to light new disorders. Some genes for transcription factors involved in the development of the endocrine organs have also been identified and patients with defects in these processes have been found. This paper will review general aspects of adrenal disorders with emphasis on clinical and laboratory findings. As with all endocrine investigations there are few single measurements that provide a definitive answer to a diagnosis. Timing of samples in relation to age, gender and time of day needs to be considered.
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