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Sbardella E, Crocco M, Feola T, Papa F, Puliani G, Gianfrilli D, Isidori AM, Grossman AB. GH deficiency in cancer survivors in the transition age: diagnosis and therapy. Pituitary 2020; 23:432-456. [PMID: 32488760 DOI: 10.1007/s11102-020-01052-0] [Citation(s) in RCA: 4] [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] [Indexed: 01/05/2023]
Abstract
BACKGROUND Survival rates among childhood cancer survivors (CCSs) have significantly risen in the last 40 years due to substantial improvements in treatment protocols. However, this improvement has brought with it serious late effects that frequently involve the endocrine system. Of the endocrine disorders, GH deficiency (GHD) is the most common among CCSs as a consequence of a history of cancers, surgery, and/or radiotherapy involving the hypothalamo-pituitary region. METHODS A comprehensive search of English language articles regardless of age was conducted in the MEDLINE database between December 2018 and October 2019. We selected all studies on GH therapy in CCSs during the transition age regarding the most challenging topics: when to retest; which diagnostic tests and cut-offs to use; when to start GH replacement therapy (GHRT); what GH dose to use; safety; quality of life, compliance and adherence to GHRT; interactions between GH and other hormonal replacement treatments. RESULTS In the present review, we provide an overview of the current clinical management of challenges in GHD in cancer survivors in the transition age. CONCLUSIONS Endocrine dysfunction among CCSs has a high prevalence in the transition age and increase with time. Many endocrine disorders, including GHD, are often not diagnosed or under-diagnosed, probably due to the lack of specialized centers for the long-term follow-up. Therefore, it is crucial that transition specialized clinics should be increased in terms of number and specific skills in order to manage endocrine disorders in adolescence, a delicate and complex period of life. A multidisciplinary approach, also including psychological counseling, is essential in the follow-up and management of these patients in order to minimize their disabilities and maximize their quality of life.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Marco Crocco
- Department of Pediatrics, IRCCS Giannina Gaslini Institute, University of Genoa, Genoa, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Fortuna Papa
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, EC1M 6BQ, UK
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Patti G, Noli S, Capalbo D, Allegri AME, Napoli F, Cappa M, Ubertini GM, Gallizia A, Notarnicola S, Ibba A, Crocco M, Parodi S, Salerno M, Loche S, Garré ML, Tornari E, Maghnie M, Di Iorgi N. Accuracy and Limitations of the Growth Hormone (GH) Releasing Hormone-Arginine Retesting in Young Adults With Childhood-Onset GH Deficiency. Front Endocrinol (Lausanne) 2019; 10:525. [PMID: 31417499 PMCID: PMC6684745 DOI: 10.3389/fendo.2019.00525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Re-testing for GH secretion is needed to confirm the diagnosis of GH deficiency (GHD) after adult height achievement in childhood-onset GHD (COGHD). Aim: To define the cut-off of GH peak after retesting with GH-releasing hormone plus arginine (GHRHarg) in the diagnosis of permanent GHD in COGHD of different etiology. Patients and methods: Eighty-eight COGHD (median age 17.2 y), 29 idiopathic GHD (IGHD), 44 cancer survivors (TGHD) and 15 congenital GHD (CGHD) were enrolled in the study; 54 had isolated GHD (iGHD) and 34 had multiple pituitary hormone deficiencies (MPHD). All were tested with insulin tolerance test (ITT) and GHRHarg. IGHD with a GH response to ITT ≥6μg/L were considered true negatives and served as the control group, and patients with a GH response <6μg/L as true positives. Baseline IGF-I was also measured. The diagnostic accuracy of GHRHarg testing and of IGF-I SDS in patients with GHD of different etiologies was evaluated by ROC analysis. Results: Forty-six subjects with a GH peak to ITT ≥6μg/L and 42 with GH peak <6 μg/L showed a GH peak after GHRHarg between 8.8-124μg/L and 0.3-26.3μg/L, respectively; 29 IGHD were true negatives, 42 were true positives and 17 with a high likelihood GHD showed a GH peak to ITT ≥6μg/L. ROC analysis based on the etiology indicated the best diagnostic accuracy for peak GH cutoffs after GHRHarg of 25.3 μg/L in CGHD, 15.7 in TGHD, and 13.8 in MPHD, and for IGF-1 SDS at -2.1 in CGHD, -1.5 in TGHD, and -1.9 in MPHD. Conclusions: Our findings indicate that the best cut-off for GH peak after retesting with GHRHarg changes according to the etiology of GHD during the transition age. Based on these results the diagnostic accuracy of GHRHarg remains questionable.
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Affiliation(s)
- Giuseppa Patti
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Serena Noli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | | | | | - Flavia Napoli
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, Genova, Italy
| | - Marco Cappa
- Unit of Endocrinology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Annalisa Gallizia
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Sara Notarnicola
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Anastasia Ibba
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao," Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Marco Crocco
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Stefano Parodi
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Mariacarolina Salerno
- Department of Translational Medical Sciences-Pediatric Section, University of Naples Federico II, Naples, Italy
| | - Sandro Loche
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao," Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Maria Luisa Garré
- Dipartimento di Neuroncologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Elena Tornari
- Health Science Department (DISSAL), University of Genova, Genova, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
| | - Natascia Di Iorgi
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini Institute, University of Genova, Genova, Italy
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3
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Aimaretti G, Attanasio R, Cannavò S, Nicoletti MC, Castello R, Di Somma C, Garofalo P, Iughetti L, Loche S, Maghnie M, Mazzanti L, Saggese G, Salerno M, Tonini G, Toscano V, Zucchini S, Cappa M. Growth hormone treatment of adolescents with growth hormone deficiency (GHD) during the transition period: results of a survey among adult and paediatric endocrinologists from Italy. Endorsed by SIEDP/ISPED, AME, SIE, SIMA. J Endocrinol Invest 2015; 38:377-82. [PMID: 25362629 DOI: 10.1007/s40618-014-0201-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 10/10/2014] [Indexed: 10/24/2022]
Abstract
Treatment of adolescents with growth hormone deficiency (GHD) during the transition period is a controversial issue. This paper is a contribution from the Italian community of paediatric and adult endocrinologists surveyed in a Delphi panel. The Delphi method is a structured communication technique, originally developed as a systematic, interactive forecasting method that relies on a panel of experts. The experts answer questionnaires in two or more rounds. There was substantial agreement on the definition of the problems associated with the diagnosis and treatment of adolescents with GHD in the transition period, as well as on the identification of the controversial issues which need further studies. There is general consensus on the need of re-testing all isolated idiopathic GHD after at least 30-day withdrawn from treatment, while in patients with multiple pituitary deficiency and low IGF-I levels there is generally no need to re-test. In patients with permanent or confirmed GHD, a starting low rhGH dose (0.01-0.03 mg per day) to be adjusted according to IGF-I concentrations is also widely accepted. For those continuing treatment, the optimal therapeutic schedule to obtain full somatic maturation, normalization of body composition and bone density, cardiovascular function and Quality of Life, need to be evaluated.
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Affiliation(s)
- G Aimaretti
- Diabetology, Metabolic and Endocrinologic diseases, "Maggiore della Carità" Hospital, Novara, Italy
| | - R Attanasio
- Endocrinology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - S Cannavò
- Endocrinological Unit of Clinic-Sperimental Medicine and Surgery Department, University of Messina, Messina, Italy
| | - M C Nicoletti
- Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - R Castello
- Endocrinology UOC, General Medicine, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - C Di Somma
- "Federico II" University of Naples, Naples, Italy
| | - P Garofalo
- UO of Endocrinology, Ospedale Villa Sofia-Cervello, Palermo, Italy
| | - L Iughetti
- Pediatric Clinic, University of Modena, Modena, Italy
| | - S Loche
- Pediatric Endocrinology Service, Ospedale Microcitemico, Cagliari, Italy
| | - M Maghnie
- Department of Pediatrics, University of Genova Pediatric Endocrine Unit, Children's Hospital Giannina Gaslini, IRCCS, Genoa, Italy
| | - L Mazzanti
- Pediatric UO, Programme of Endocrinology, Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy
| | - G Saggese
- Department of Pediatrics, University of Pisa, Pisa, Italy
| | - M Salerno
- Department of Pediatrics, University "Federico II" of Naples, Naples, Italy
| | - G Tonini
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - V Toscano
- II Faculty of Medicine, "La Sapienza", University, Rome, Italy
| | - S Zucchini
- Pediatric UO, Programme of Endocrinology, Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy
| | - M Cappa
- Endocrinology and Diabetology Unit, Department of Pediatrics, Bambino Gesù Children's Hospital, P.za Sant'Onofrio n. 4, 00165, Rome, Italy.
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Inzaghi E, Cianfarani S. The Challenge of Growth Hormone Deficiency Diagnosis and Treatment during the Transition from Puberty into Adulthood. Front Endocrinol (Lausanne) 2013; 4:34. [PMID: 23577001 PMCID: PMC3602795 DOI: 10.3389/fendo.2013.00034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 03/05/2013] [Indexed: 11/13/2022] Open
Abstract
In children with childhood-onset growth hormone deficiency, replacement GH therapy is effective in normalizing height during childhood and achieving adult height within the genetic target range. GH has further beneficial effects on body composition and metabolism through adult life. The transition phase, defined as the period from mid to late teens until 6-7 years after the achievement of final height, represents a crucial time for reassessing children's GH secretion and deciding whether GH therapy should be continued throughout life. Evidence-based guidelines for diagnosis and treatment of growth hormone deficient children during transition are lacking. The aim of this review is to critically review the up-to-date evidence on the best management of transition patients in order to ensure the correct definitive diagnosis and establish the appropriate therapeutic regimen.
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Affiliation(s)
- Elena Inzaghi
- Molecular Endocrinology Unit, Bambino Gesù Children’s HospitalRome, Italy
| | - Stefano Cianfarani
- Molecular Endocrinology Unit, Bambino Gesù Children’s HospitalRome, Italy
- Department of Women’s and Children’s Health, Karolinska InstitutetStockholm, Sweden
- *Correspondence: Stefano Cianfarani, Molecular Endocrinology Unit, Bambino Gesù Children’s Hospital, P.zza S. Onofrio 4, 00165 Roma, Italy. e-mail:
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di Iorgi N, Secco A, Napoli F, Tinelli C, Calcagno A, Fratangeli N, Ambrosini L, Rossi A, Lorini R, Maghnie M. Deterioration of growth hormone (GH) response and anterior pituitary function in young adults with childhood-onset GH deficiency and ectopic posterior pituitary: a two-year prospective follow-up study. J Clin Endocrinol Metab 2007; 92:3875-84. [PMID: 17666476 DOI: 10.1210/jc.2007-1081] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT The current criteria for definition of partial GHD in young adults are still a subject of debate. OBJECTIVES The objective of the study was to reinvestigate anterior pituitary function in young adults with congenital childhood-onset GHD associated with structural hypothalamic-pituitary abnormalities and normal GH response at the time of first reassessment of GH secretion. DESIGN AND SETTING This was a prospective explorative study conducted in a university research hospital. PATIENTS AND METHODS Thirteen subjects with a mean age of 17.2 +/- 0.7 yr and a peak GH after insulin tolerance test (ITT) higher than 5 microg/liter were recruited from a cohort of 42 patients with childhood-onset GHD and ectopic posterior pituitary at magnetic resonance imaging. GH secretion after ITT and GHRH plus arginine, IGF-I concentration, and body mass index, waist circumference, blood pressure, total cholesterol, and fibrinogen were evaluated at baseline and at 2-yr follow-up. RESULTS At mean age of 19.2 +/- 0.7 yr, the mean peak GH response decreased significantly after ITT (P = 0.00001) and GHRH plus arginine (P = 0.0001). GH peak values after ITT and GHRH plus arginine were less than 5 and 9 microg/liter in 10 and eight patients, respectively. Additional pituitary defects were documented in eight patients. Significant changes were found in the values of IGF-I sd score (P = 0.0026), waist circumference (P = 0.00001), serum total cholesterol (P = 0.00001), and serum fibrinogen (P = 0.0004). CONCLUSIONS The results of this study underline the importance of further reassessment of pituitary function in young adults with GHD of childhood-onset and poststimulation GH responses suggestive of partial GHD.
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Affiliation(s)
- Natascia di Iorgi
- AssociateDepartment of Pediatrics Istituto di Ricovero e Cura a Carattere Scientifico G. Gaslini, University of Genova, Largo Gerolamo Gaslini, 5, 16147 Genova, Italy.
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