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Grimberg A, Hawkes CP. Growth Hormone Treatment for Non-GHD Disorders: Excitement Tempered by Biology. J Clin Endocrinol Metab 2024; 109:e442-e454. [PMID: 37450564 PMCID: PMC10795916 DOI: 10.1210/clinem/dgad417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
The success of growth hormone (GH) replacement in children with classical GH deficiency has led to excitement that other causes of short stature may benefit similarly. However, clinical experience has shown less consistent and generally less dramatic effects on adult height, perhaps not surprising in light of increased understanding of GH and growth plate biology. Nonetheless, clinical demand for GH treatment continues to grow. Upon the 20th anniversary of the US Food and Drug Administration's approval of GH treatment for idiopathic short stature, this review will consider the factors underlying the expansion of GH treatment, the biological mechanisms of GH action, the non-GH-deficient uses of GH as a height-promoting agent, biological constraints to GH action, and future directions.
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Affiliation(s)
- Adda Grimberg
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Colin P Hawkes
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- INFANT Research Centre, University College Cork, Cork T12 DC4A, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork T12 R229, Ireland
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2
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Sodero G, Cipolla C, Pane LC, Sessa L, Malavolta E, Arzilli F, Leoni C, Zampino G, Rigante D. Efficacy and safety of growth hormone therapy in children with Noonan syndrome. Growth Horm IGF Res 2023; 69-70:101532. [PMID: 37084633 DOI: 10.1016/j.ghir.2023.101532] [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: 01/18/2023] [Revised: 03/14/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023]
Abstract
Patients with Noonan syndrome typically have a target height <2 standard deviations compared to the general population, and half of the affected adults remain permanently below the 3rd centile for height, though their short stature might result from a multifactorial etiology, not-yet fully understood. The secretion of growth hormone (GH) following the classic GH stimulation tests is often normal, with baseline insulin-like growth factor-1 (IGF-1) levels at the lower normal limits, but patients with Noonan syndrome have also a possible moderate response to GH therapy, leading to a final increased height and substantial improvement in growth rate. Aim of this review was to evaluate both safety and efficacy of GH therapy in children and adolescents with Noonan syndrome, also evaluating as a secondary aim the possible correlations between the underlying genetic mutations and GH responses.
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Affiliation(s)
- Giorgio Sodero
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Clelia Cipolla
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Celeste Pane
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Linda Sessa
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena Malavolta
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federica Arzilli
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Chiara Leoni
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Zampino
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
| | - Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy
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Tamburrino F, Scarano E, Schiavariello C, Perri A, Pession A, Mazzanti L. Endocrinological manifestations in RASopathies. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2022; 190:471-477. [PMID: 36401574 DOI: 10.1002/ajmg.c.32013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/26/2022] [Accepted: 11/03/2022] [Indexed: 11/21/2022]
Abstract
The evaluation of endocrine involvement in RASopathies is important for the care and follow-up of patients affected by these conditions. Short stature is a cardinal feature of RASopathies and correlates with multiple factors. Growth hormone treatment is a therapeutic possibility to improve height and quality of life. Assessment of growth rate and growth laboratory parameters is routine, but age at start of therapy, dose and effects of growth hormone on final height need to be clarified. Puberty disorders and gonadal dysfunction, in particular in males, are other endocrinological areas to evaluate for their effects on growth and development. Thyroid dysfunction, autoimmune disease and bone involvement have also been reported in RASopathies. In this brief review, we describe the current knowledge on growth, growth hormone therapy, endocrinological involvement in patients affected by RASopathies.
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Affiliation(s)
- Federica Tamburrino
- Rare Diseases Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Emanuela Scarano
- Rare Diseases Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Concetta Schiavariello
- Rare Diseases Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Annamaria Perri
- Rare Diseases Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Laura Mazzanti
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Solman M, Woutersen DTJ, den Hertog J. Modeling (not so) rare developmental disorders associated with mutations in the protein-tyrosine phosphatase SHP2. Front Cell Dev Biol 2022; 10:1046415. [PMID: 36407105 PMCID: PMC9672471 DOI: 10.3389/fcell.2022.1046415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
Src homology region 2 (SH2)-containing protein tyrosine phosphatase 2 (SHP2) is a highly conserved protein tyrosine phosphatase (PTP), which is encoded by PTPN11 and is indispensable during embryonic development. Mutations in PTPN11 in human patients cause aberrant signaling of SHP2, resulting in multiple rare hereditary diseases, including Noonan Syndrome (NS), Noonan Syndrome with Multiple Lentigines (NSML), Juvenile Myelomonocytic Leukemia (JMML) and Metachondromatosis (MC). Somatic mutations in PTPN11 have been found to cause cancer. Here, we focus on the role of SHP2 variants in rare diseases and advances in the understanding of its pathogenesis using model systems.
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Affiliation(s)
- Maja Solman
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Jeroen den Hertog
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Utrecht, Netherlands
- Institute Biology Leiden, Leiden University, Leiden, Netherlands
- *Correspondence: Jeroen den Hertog,
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Dahlgren J, Noordam C. Growth, Endocrine Features, and Growth Hormone Treatment in Noonan Syndrome. J Clin Med 2022; 11:jcm11072034. [PMID: 35407641 PMCID: PMC8999676 DOI: 10.3390/jcm11072034] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/24/2022] [Accepted: 03/30/2022] [Indexed: 12/23/2022] Open
Abstract
Noonan syndrome is a heterogeneous congenital disorder. The main features are typical facial features, short stature and cardiac defects. The diagnosis is clinical: in 80% of patients with Noonan syndrome a genetic defect can be shown. Inheritance is predominantly autosomal dominant and seldom autosomal recessive. In 2001, PTPN11 was the first gene connected to Noonan syndrome, and until now, at least 20 other genes have been discovered. All genes code for proteins involved in the RAS-MAP-kinase pathway, and therefore, Noonan syndrome is one of the known RASopathies. Other RASopathies include neurofibromatosis and CFC syndrome. Short stature is one of the defining features of Noonan syndrome. The cause is not fully understood but is multifactorial. Other endocrinological features are confined to delayed puberty and hypogonadism in boys and males. To increase adult height, children with Noonan syndrome have been treated with human growth hormone since the 1990s. This seems to be beneficial in most of the children treated. In this narrative review, we describe the current knowledge on growth, endocrinological features and growth hormone treatment in patients with Noonan syndrome.
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Affiliation(s)
- Jovanna Dahlgren
- Department of Pediatrics, University of Gothenburg, 41685 Gothenburg, Sweden;
| | - Cees Noordam
- Centre for Paediatric Endocrinology Zurich (PEZZ), 8006 Zurich, Switzerland
- Department of Pediatrics, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
- Correspondence: ; Tel.: +41-4-4364-3700
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Edouard T, Zenker M, Östman-Smith I, Ortega Castelló E, Wolf CM, Burkitt-Wright E, Verloes A, García-Miñaúr S, Tartaglia M, Shaikh G, Lebl J. Management of growth failure and other endocrine aspects in patients with Noonan syndrome across Europe: A sub-analysis of a European clinical practice survey. Eur J Med Genet 2021; 65:104404. [PMID: 34896604 DOI: 10.1016/j.ejmg.2021.104404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 02/07/2023]
Abstract
AIM To date, there is a lack of international guidelines regarding the management of the endocrine features of individuals with Noonan syndrome (NS). The aim was to develop a clinical practice survey to gather information on current treatment and management of these patients across Europe. MATERIALS AND METHODS A group of 10 experts from three clinical specialities involved in the management of NS patients (clinical geneticists, paediatric endocrinologists, and paediatric cardiologists) developed a 60-question clinical practice survey. The questionnaire was implemented in Survey Monkey and sent to physicians from these three specialities via European/national societies. Contingency tables and the Chi-Squared test for independence were used to examine differences between specialities and countries. RESULTS In total, responses of 364 specialists (paediatric endocrinologists, 40%; geneticists, 30%; paediatric cardiologists, 30%) from 20 European countries were analysed. While endocrinologists mostly referred to national growth charts for the general population, geneticists mostly referred to NS-specific growth charts. Approximately half of the endocrinologists perform growth hormone (GH) stimulation tests in short patients with low IGF1 levels. Two thirds of endocrinologists begin GH treatment for short patients in early childhood (4-6.9 years), and over half of them selected a threshold of -2 standard deviation score (SDS) according to national growth charts. The main concerns about GH treatment appear to be presence of hypertrophic cardiomyopathy (HCM) (59%), increased risk of malignancy (46%), and limited efficacy (31%). When asked if they consider HCM as a contraindication for GH treatment, one third of respondents skipped this question, and among those who replied, two thirds selected 'cannot answer', suggesting a high level of uncertainty. A total of 21 adverse cardiac responses to GH treatment were reported. Although most respondents had not encountered any malignancy during GH treatment, six malignancies were reported. Finally, about half of the endocrinologists expected a typical final height gain of 1-1.5 SDS with GH treatment. CONCLUSION This survey describes for the first time the current clinical practice of endocrine aspects of NS across Europe and helps us to identify gaps in the management but also in the knowledge of this genetic disorder.
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Affiliation(s)
- Thomas Edouard
- Endocrine, Bone Diseases, and Genetics Unit, Children's Hospital, Toulouse University Hospital, RESTORE INSERM UMR1301, Toulouse, France.
| | - Martin Zenker
- Institute of Human Genetics, University Hospital Magdeburg, Magdeburg, Germany
| | - Ingegerd Östman-Smith
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Eduardo Ortega Castelló
- Department of Statistics and Data Science, Faculty of Statistical Studies, Complutense University of Madrid, Madrid, Spain
| | - Cordula M Wolf
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Emma Burkitt-Wright
- Manchester Centre for Genomic Medicine, Manchester University NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Alain Verloes
- Department of Genetics, APHP-Robert Debré University Hospital and Université de Paris Medical School, Paris, France
| | - Sixto García-Miñaúr
- Institute of Medical and Molecular Genetics (INGEMM), Hospital Universitario La Paz Research Institute (IdiPAZ), Hospital Universitario La Paz, Madrid, Spain
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Guftar Shaikh
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Jan Lebl
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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7
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Rodríguez F, Gaete X, Cassorla F. Etiology and Treatment of Growth Delay in Noonan Syndrome. Front Endocrinol (Lausanne) 2021; 12:691240. [PMID: 34149626 PMCID: PMC8212989 DOI: 10.3389/fendo.2021.691240] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/12/2021] [Indexed: 12/05/2022] Open
Abstract
Noonan syndrome is characterized by multiple phenotypic features, including growth retardation, which represents the main cause of consultation to the clinician. Longitudinal growth during childhood and adolescence depends on several factors, among them an intact somatotrophic axis, which is characterized by an adequate growth hormone (GH) secretion by the pituitary, subsequent binding to its receptor, proper function of the post-receptor signaling pathway for this hormone (JAK-STAT5b and RAS/MAPK), and ultimately by the production of its main effector, insulin like growth factor 1 (IGF-1). Several studies regarding the function of the somatotrophic axis in patients with Noonan syndrome and data from murine models, suggest that partial GH insensitivity at a post-receptor level, as well as possible derangements in the RAS/MAPK pathway, are the most likely causes for the growth failure in these patients. Treatment with recombinant human growth hormone (rhGH) has been used extensively to promote linear growth in these patients. Numerous treatment protocols have been employed so far, but the published studies are quite heterogeneous regarding patient selection, length of treatment, and dose of rhGH utilized, so the true benefit of GH therapy is somewhat difficult to establish. This review will discuss the possible etiologies for the growth delay, as well as the outcomes following rhGH treatment in patients with Noonan syndrome.
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Affiliation(s)
- Fernando Rodríguez
- Institute of Maternal and Child Research, University of Chile, Santiago, Chile
| | - Ximena Gaete
- Institute of Maternal and Child Research, University of Chile, Santiago, Chile
- Pediatrics Department, Hospital Clínico San Borja – Arriarán, Santiago, Chile
| | - Fernando Cassorla
- Institute of Maternal and Child Research, University of Chile, Santiago, Chile
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Apperley LJ, Ramakrishnan R, Dharmaraj P, Das U, Didi M, Blair J, Senniappan S. Effect of Growth Hormone Therapy in Patients with Noonan Syndrome: A Retrospective Study. Int J Endocrinol Metab 2020; 18:e107292. [PMID: 33613679 PMCID: PMC7887459 DOI: 10.5812/ijem.107292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Noonan syndrome is an autosomal dominant condition with an incidence of 1:1000 to 1:2500. The disorder is associated with distinct dysmorphic features, cardiac anomalies, developmental delay and delayed puberty. Short stature is a recognised feature of Noonan syndrome. OBJECTIVES The aim of this study is to assess the effect of growth hormone treatment in patients with Noonan syndrome. METHODS Retrospective data was collected from patients with Noonan syndrome treated with growth hormone. The results were analysed with variables expressed as mean values and standard deviation scores. RESULTS Twelve Noonan syndrome patients (M: F = 10:2) treated with growth hormone were identified. The mean age of starting growth hormone was 8 years, with baseline height standard deviation score of -2.96 (range: -1.64 to -5.54). The height standard deviation score significantly improved to -2.50 (P = 0.0035) and then -2.22 (P = 0.0025), following one and two years of treatment, respectively. The average height velocity for the patients prior to starting treatment was 5.16cm/year (range: 2.4 - 8.2 cm/year), which significantly improved to 7.76cm/year (ranging from 4.1 to 12.8 cm/year) after one year of growth hormone treatment (P = 0.020) and to 6.51cm/year at the end of two years. CONCLUSIONS Our study has shown that growth hormone treatment significantly improves the height standard deviation score of patients with Noonan syndrome over a two-year course of growth hormone therapy without any side effects. Further research is required to analyse the long-term effect of growth hormone therapy in patients with Noonan syndrome, including the impact on final adult height.
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Affiliation(s)
- Louise Jayne Apperley
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Renuka Ramakrishnan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Poonam Dharmaraj
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Urmi Das
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Mohammed Didi
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Jo Blair
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
- Corresponding Author: Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK.
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Seok EM, Park HK, Rho JG, Kum CD, Lee HS, Hwang JS. Effectiveness of growth hormone therapy in children with Noonan syndrome. Ann Pediatr Endocrinol Metab 2020; 25:182-186. [PMID: 32871657 PMCID: PMC7538297 DOI: 10.6065/apem.1938154.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/04/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Recombinant human growth hormone (rhGH) has been used to improve growth in children with Noonan syndrome (NS). This study aimed to investigate the efficacy of rhGH therapy in Korean children with NS. METHODS Seventeen prepubertal children (10 boys, 7 girls) with NS who received rhGH therapy for at least 3 years between 2008 and 2017 were included. To compare the response, age- and sex-matched children with GH deficiency (GHD; n=31) were included. Height and growth velocity before and during treatment were analyzed. RESULTS The mean age of NS patients was 6.34±2.32 years. After treatment, the height standard deviation score (SDS) increased from -2.93±0.81 to -1.51±1.00 in patients with NS and from -2.45±0.42 to -1.09±0.47 in patients with GHD. There were no significant differences in growth velocity or change in height SDS between patients with NS and GHD. Growth velocity in the first year of treatment was higher in patients with PTPN11 mutations than those without PTPN11 mutations, but the change in height SDS was not significantly different between those 2 groups. CONCLUSION rhGH therapy can increase linear growth in prepubertal children with NS. The growth response between patients with NS and patients with GHD was not significantly different. Furthermore, we observed that lower doses of growth hormone have a similar effect on height compared to previous studies in patients with NS. Our study indicates that rhGH treatment is useful for growth promotion.
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Affiliation(s)
- Eun mi Seok
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Hong Kyu Park
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Jung Gi Rho
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Change Dae Kum
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Hae Sang Lee
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea,Address for correspondence: Hae Sang Lee, PhD Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, 164 World cupro, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-4454 Faxl: +82-31-219-5169 E-mail:
| | - Jin Soon Hwang
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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Noonan syndrome: genetic and clinical update and treatment options. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2020.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Carcavilla A, Suárez-Ortega L, Rodríguez Sánchez A, Gonzalez-Casado I, Ramón-Krauel M, Labarta JI, Quinteiro Gonzalez S, Riaño Galán I, Ezquieta Zubicaray B, López-Siguero JP. [Noonan syndrome: genetic and clinical update and treatment options]. An Pediatr (Barc) 2020; 93:61.e1-61.e14. [PMID: 32493603 DOI: 10.1016/j.anpedi.2020.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/20/2022] Open
Abstract
Noonan syndrome (NS) is a relatively common genetic condition characterised by short stature, congenital heart defects, and distinctive facial features. NS and other clinically overlapping conditions such as NS with multiple lentigines (formerly called LEOPARD syndrome), cardiofaciocutaneous syndrome, or Costello syndrome, are caused by mutations in genes encoding proteins of the RAS-MAPKinases pathway. Because of this shared mechanism, these conditions have been collectively termed «RASopathies». Despite the recent advances in molecular genetics, nearly 20% of patients still lack a genetic cause, and diagnosis is still made mainly on clinical grounds. NS is a clinically and genetically heterogeneous condition, with variable expressivity and a changing phenotype with age, and affects multiple organs and systems. Therefore, it is essential that physicians involved in the care of these patients are familiarised with their manifestations and the management recommendations, including management of growth and development. Data on growth hormone treatment efficacy are sparse, and show a modest response in height gains, similar to that observed in Turner syndrome. The role of RAS/MAPK hyper-activation in the pathophysiology of this group of disorders offers a unique opportunity for the development of targeted approaches.
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Affiliation(s)
- Atilano Carcavilla
- Servicio de Endocrinología Pediátrica, Hospital Universitario La Paz, Madrid, España
| | - Larisa Suárez-Ortega
- Servicio de Endocrinología Pediátrica, Hospital Sant Joan de Déu, Esplugues del Llobregat, Barcelona, España
| | | | | | - Marta Ramón-Krauel
- Servicio de Endocrinología Pediátrica, Hospital Sant Joan de Déu, Esplugues del Llobregat, Barcelona, España
| | | | - Sofia Quinteiro Gonzalez
- Servicio de Endocrinología Pediátrica, Complejo Universitario Insular, Gran Canaria, Las Palmas de Gran Canaria, España
| | - Isolina Riaño Galán
- Servicio de Endocrinología Pediátrica, Hospital Central de Asturias, Oviedo/Uviéu, España
| | | | - Juan Pedro López-Siguero
- Servicio de Endocrinología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, España.
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Malaquias AC, Noronha RM, Souza TTO, Homma TK, Funari MFA, Yamamoto GL, Silva FV, Moraes MB, Honjo RS, Kim CA, Nesi-França S, Carvalho JAR, Quedas EPS, Bertola DR, Jorge AAL. Impact of Growth Hormone Therapy on Adult Height in Patients with PTPN11 Mutations Related to Noonan Syndrome. Horm Res Paediatr 2020; 91:252-261. [PMID: 31132774 DOI: 10.1159/000500264] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 04/10/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the response to recombinant human growth hormone (rhGH) treatment in patients with Noonan syndrome (NS). MATERIALS AND METHODS Forty-two patients (35 PTPN11+) were treated with rhGH, and 17 were followed-up until adult height. The outcomes were changes in growth velocity (GV) and height standard deviation scores (SDS) for normal (height-CDC SDS) and Noonan standards (height-NS SDS). RESULTS The pretreatment chronological age was 10.3 ± 3.5 years. Height-CDC SDS and height-NS SDS were -3.1 ± 0.7 and -0.5 ± 0.6, respectively. PTPN11+ patients had a better growth response than PTPN11- patients. GV SDS increased from -1.2 ± 1.8 to 3.1 ± 2.8 after the first year of therapy in PTPN11+ patients, and from -1.9 ± 2.6 to -0.1 ± 2.6 in PTPN11- patients. The gain in height-CDC SDS during the first year was higher in PTPN11+ than PTPN11- (0.6 ± 0.4 vs. 0.1 ± 0.2, p = 0.008). Similarly, the gain was observed in height-NS SDS (0.6 ± 0.3 vs. 0.2 ± 0.2, respectively, p < 0.001). Among the patients that reached adult height (n = 17), AH-CDC SDS and AH-NS SDS were -2.1 ± 0.7 and 0.7 ± 0.8, respectively. The total increase in height SDS was 1.3 ± 0.7 and 1.5 ± 0.6 for normal and NS standards, respectively. CONCLUSIONS This study supports the advantage of rhGH therapy on adult height in PTPN11+ patients. In comparison, PTPN11- patients showed a poor response to rhGH. However, this PTPN11- group was small, preventing an adequate comparison among different genotypes and no guarantee of response to therapy in genes besides PTPN11.
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Affiliation(s)
- Alexsandra C Malaquias
- Unidade de Endocrinologia-Genetica, LIM/25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), Sao Paulo, Brazil, .,Departamento de Pediatria, Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Sao Paulo, Brazil,
| | - Renata M Noronha
- Unidade de Endocrinologia-Genetica, LIM/25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), Sao Paulo, Brazil.,Departamento de Pediatria, Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Sao Paulo, Brazil
| | - Thaiana T O Souza
- Departamento de Pediatria, Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Sao Paulo, Brazil
| | - Thais K Homma
- Unidade de Endocrinologia-Genetica, LIM/25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), Sao Paulo, Brazil.,Laboratorio de Hormonios e Genetica Molecular (LIM/42), Unidade de Endocrinologia do Desenvolvimento, Hospital das Clinicas, FMUSP, Sao Paulo, Brazil
| | - Mariana F A Funari
- Laboratorio de Hormonios e Genetica Molecular (LIM/42), Unidade de Endocrinologia do Desenvolvimento, Hospital das Clinicas, FMUSP, Sao Paulo, Brazil
| | | | - Fernanda Viana Silva
- Unidade de Endocrinologia-Genetica, LIM/25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), Sao Paulo, Brazil
| | | | - Rachel S Honjo
- Unidade de Genetica, Instituto da Crianca, FMUSP, Sao Paulo, Brazil
| | - Chong A Kim
- Unidade de Genetica, Instituto da Crianca, FMUSP, Sao Paulo, Brazil
| | - Suzana Nesi-França
- Unidade de Endocrinologia Pediatrica, Departamento de Pediatria, Universidade Federal do Parana, Curitiba, Brazil
| | - Julienne A R Carvalho
- Unidade de Endocrinologia Pediatrica, Departamento de Pediatria, Universidade Federal do Parana, Curitiba, Brazil
| | - Elisangela P S Quedas
- Unidade de Endocrinologia-Genetica, LIM/25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), Sao Paulo, Brazil
| | - Debora R Bertola
- Unidade de Genetica, Instituto da Crianca, FMUSP, Sao Paulo, Brazil
| | - Alexander A L Jorge
- Unidade de Endocrinologia-Genetica, LIM/25, Disciplina de Endocrinologia da Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), Sao Paulo, Brazil.,Laboratorio de Hormonios e Genetica Molecular (LIM/42), Unidade de Endocrinologia do Desenvolvimento, Hospital das Clinicas, FMUSP, Sao Paulo, Brazil
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13
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Ranke MB, Lindberg A, Carlsson M, Camacho-Hübner C, Rooman R. Treatment with Growth Hormone in Noonan Syndrome Observed during 25 Years of KIGS: Near Adult Height and Outcome Prediction. Horm Res Paediatr 2019; 91:46-55. [PMID: 30939478 DOI: 10.1159/000498859] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/11/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS There is little information how rhGH treatment affects height in NS. This study aims to analyze data from the NS patients assembled in KIGS over 25 years. PATIENTS/METHODS Of 613 (389 m/224 f) NS patients documented, 476 (302 m/174 f) were treated for 1 year, 237 (160 m/77 f) of which served to develop a 1st year height velocity (HV) prediction algorithm. One-hundred and forty (74 m/66 f) had reached near adult height (NAH). Factors affecting NAH on rhGH were determined. RESULTS At the start of rhGH, the NAH groups were (median, m, f) 11.0 and 10.3 years, with a height SDS of -3.2 and -3.8 SDS (Prader), respectively. The total gain after 6.3 and 5.6 years on rhGH (0.27 and 0.30 mg/kg/week) was 1.2 and 1.3 SDS. Age at the start of rhGH (negative), height at the start of rhGH, rhGH dose, number of rhGH injections/wk and birth weight (all positive) explained 36% of the variability of 1st year HV. Height at the start of rhGH, 1st year growth on rhGH, birth weight, and gender explained 74% of the variability of NAH. Causes for rhGH treatment discontinuation and adverse events were also analyzed. CONCLUSION rhGH treatment increases NAH in NS. Prediction algorithms may optimize treatment in the future.
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Affiliation(s)
- Michael B Ranke
- Division of Paediatric Endocrinology, University Children's Hospital, Tübingen, Germany,
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14
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Tajan M, Pernin-Grandjean J, Beton N, Gennero I, Capilla F, Neel BG, Araki T, Valet P, Tauber M, Salles JP, Yart A, Edouard T. Noonan syndrome-causing SHP2 mutants impair ERK-dependent chondrocyte differentiation during endochondral bone growth. Hum Mol Genet 2019; 27:2276-2289. [PMID: 29659837 DOI: 10.1093/hmg/ddy133] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/09/2018] [Indexed: 01/30/2023] Open
Abstract
Growth retardation is a constant feature of Noonan syndrome (NS) but its physiopathology remains poorly understood. We previously reported that hyperactive NS-causing SHP2 mutants impair the systemic production of insulin-like growth factor 1 (IGF1) through hyperactivation of the RAS/extracellular signal-regulated kinases (ERK) signalling pathway. Besides endocrine defects, a direct effect of these mutants on growth plate has not been explored, although recent studies have revealed an important physiological role for SHP2 in endochondral bone growth. We demonstrated that growth plate length was reduced in NS mice, mostly due to a shortening of the hypertrophic zone and to a lesser extent of the proliferating zone. These histological features were correlated with decreased expression of early chondrocyte differentiation markers, and with reduced alkaline phosphatase staining and activity, in NS murine primary chondrocytes. Although IGF1 treatment improved growth of NS mice, it did not fully reverse growth plate abnormalities, notably the decreased hypertrophic zone. In contrast, we documented a role of RAS/ERK hyperactivation at the growth plate level since 1) NS-causing SHP2 mutants enhance RAS/ERK activation in chondrocytes in vivo (NS mice) and in vitro (ATDC5 cells) and 2) inhibition of RAS/ERK hyperactivation by U0126 treatment alleviated growth plate abnormalities and enhanced chondrocyte differentiation. Similar effects were obtained by chronic treatment of NS mice with statins. In conclusion, we demonstrated that hyperactive NS-causing SHP2 mutants impair chondrocyte differentiation during endochondral bone growth through a local hyperactivation of the RAS/ERK signalling pathway, and that statin treatment may be a possible therapeutic approach in NS.
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Affiliation(s)
- Mylène Tajan
- INSERM UMR 1048, Institute of Cardiovascular and Metabolic Diseases (I2MC)
| | - Julie Pernin-Grandjean
- INSERM UMR 1043, Centre of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France
| | - Nicolas Beton
- INSERM UMR 1043, Centre of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France
| | - Isabelle Gennero
- INSERM UMR 1043, Centre of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France
| | - Florence Capilla
- INSERM, US006, ANEXPLO/CREFRE, Histopathology Unit, Purpan Hospital, Toulouse, France
| | - Benjamin G Neel
- Laura and Isaac Perlmutter Cancer Center, NYU-Langone Medical Center, NY 10016, USA
| | - Toshiyuki Araki
- Laura and Isaac Perlmutter Cancer Center, NYU-Langone Medical Center, NY 10016, USA
| | - Philippe Valet
- INSERM UMR 1048, Institute of Cardiovascular and Metabolic Diseases (I2MC)
| | - Maithé Tauber
- INSERM UMR 1043, Centre of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France.,Pediatric Department, Endocrine, Bone Diseases, and Genetics Unit, Children's Hospital, Toulouse University Hospital, Toulouse, France
| | - Jean-Pierre Salles
- INSERM UMR 1043, Centre of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France.,Pediatric Department, Endocrine, Bone Diseases, and Genetics Unit, Children's Hospital, Toulouse University Hospital, Toulouse, France
| | - Armelle Yart
- INSERM UMR 1048, Institute of Cardiovascular and Metabolic Diseases (I2MC)
| | - Thomas Edouard
- INSERM UMR 1043, Centre of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France.,Pediatric Department, Endocrine, Bone Diseases, and Genetics Unit, Children's Hospital, Toulouse University Hospital, Toulouse, France
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15
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Pediatric endocrinology through syndromes. Eur J Med Genet 2019; 63:103614. [PMID: 30654153 DOI: 10.1016/j.ejmg.2019.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 11/20/2018] [Accepted: 01/12/2019] [Indexed: 11/22/2022]
Abstract
In everyday practice, a pediatric endocrinologist will face a variety of different endocrine issues (such as short or tall stature, dysthyroidism, abnormal pubertal timing or impaired glucose metabolism), which relevantly contribute to the global care of a number of syndromic conditions. On the other hand, the presence of endocrine features may assist in the diagnostic process, leading to final diagnosis of a syndromic disorder. The intention of this review is to provide a referenced overview of different genetic syndromes characterized by endocrine features, and to present a possible classification, based on whether the endocrinopathy or the syndrome is typically recognized first. Thus, the first part of the manuscript deals with the most common syndromes associated with endocrine dysfunctions, while the second part describes the conditions by which a syndrome is most frequently diagnosed after an endocrine finding. The aim is to provide a practical overview of the assessment of syndromic patients, so that they can be recognized and managed in an integrated, multidisciplinary fashion.
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16
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Jo KJ, Kim YM, Yoon JY, Lee YJ, Han YM, Yoo HW, Kim HS, Cheon CK. Comparison of effectiveness of growth hormone therapy according to disease-causing genes in children with Noonan syndrome. KOREAN JOURNAL OF PEDIATRICS 2018; 62:274-280. [PMID: 30514065 PMCID: PMC6642922 DOI: 10.3345/kjp.2018.06842] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/03/2018] [Indexed: 12/27/2022]
Abstract
Purpose To analyze the growth response to growth hormone (GH) therapy in prepubertal patients with Noonan syndrome (NS) harboring different genetic mutations. Methods Twenty-three patients with prepubertal NS treated at Pusan National University Children’s Hospital between March 2009 and July 2017 were enrolled. According to the disease-causing genes identified, the patients with NS were divided into 4 groups. Three groups were positive for mutations of the PTPN11, RAF1, and SOS1 genes. The five genes undetected (FGU) group was negative for PTPN11, RAF1, SOS1, KRAS, and BRAF gene mutations. The influence of genotype was retrospectively analyzed by comparing the growth parameters after GH therapy. Results The mean chronological age at the start of GH treatment was 5.85±2.67 years. At the beginning of the GH treatment, the height standard deviation score (SDS), growth velocity (GV), and lower levels of insulin-like growth factor-1 (IGF)-1 levels were not statistically different among the groups. All the 23 NS patients had significantly increased height SDS and serum IGF-1 level during the 3 years of treatment. GV was highest during the first year of treatment. During the 3 years of GH therapy, the PTPN11, RAF1, and SOS1 groups showed less improvement in height SDS, IGF-1 SDS, and GV, and less increase in bone age-to-chronological age ratio than the FGU group. Conclusion The 3-year GH therapy in the 23 prepubertal patients with NS was effective in improving height SDS, GV, and serum IGF-1 levels. The FGU group showed a better response to recombinant human GH therapy than the PTPN11, RAF1, and SOS1 groups.
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Affiliation(s)
- Kyo Jin Jo
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Yoo Mi Kim
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Korea
| | - Ju Young Yoon
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Yeoun Joo Lee
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Young Mi Han
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Han-Wook Yoo
- Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyang-Sook Kim
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Chong Kun Cheon
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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17
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Tajan M, Paccoud R, Branka S, Edouard T, Yart A. The RASopathy Family: Consequences of Germline Activation of the RAS/MAPK Pathway. Endocr Rev 2018; 39:676-700. [PMID: 29924299 DOI: 10.1210/er.2017-00232] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 06/13/2018] [Indexed: 12/13/2022]
Abstract
Noonan syndrome [NS; Mendelian Inheritance in Men (MIM) #163950] and related syndromes [Noonan syndrome with multiple lentigines (formerly called LEOPARD syndrome; MIM #151100), Noonan-like syndrome with loose anagen hair (MIM #607721), Costello syndrome (MIM #218040), cardio-facio-cutaneous syndrome (MIM #115150), type I neurofibromatosis (MIM #162200), and Legius syndrome (MIM #611431)] are a group of related genetic disorders associated with distinctive facial features, cardiopathies, growth and skeletal abnormalities, developmental delay/mental retardation, and tumor predisposition. NS was clinically described more than 50 years ago, and disease genes have been identified throughout the last 3 decades, providing a molecular basis to better understand their physiopathology and identify targets for therapeutic strategies. Most of these genes encode proteins belonging to or regulating the so-called RAS/MAPK signaling pathway, so these syndromes have been gathered under the name RASopathies. In this review, we provide a clinical overview of RASopathies and an update on their genetics. We then focus on the functional and pathophysiological effects of RASopathy-causing mutations and discuss therapeutic perspectives and future directions.
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Affiliation(s)
- Mylène Tajan
- INSERM UMR 1048, Institute of Cardiovascular and Metabolic Diseases (I2MC), University of Toulouse Paul Sabatier, Toulouse, France
| | - Romain Paccoud
- INSERM UMR 1048, Institute of Cardiovascular and Metabolic Diseases (I2MC), University of Toulouse Paul Sabatier, Toulouse, France
| | - Sophie Branka
- INSERM UMR 1048, Institute of Cardiovascular and Metabolic Diseases (I2MC), University of Toulouse Paul Sabatier, Toulouse, France
| | - Thomas Edouard
- Endocrine, Bone Diseases, and Genetics Unit, Children's Hospital, Toulouse University Hospital, Toulouse, France
| | - Armelle Yart
- INSERM UMR 1048, Institute of Cardiovascular and Metabolic Diseases (I2MC), University of Toulouse Paul Sabatier, Toulouse, France
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18
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Abstract
PURPOSE OF REVIEW To provide an update on recent developments on Noonan syndrome with a special focus on endocrinology, bone, and metabolism aspects. The key issues still to be resolved and the future therapeutic perspectives will be discussed. RECENT FINDINGS The discovery of the molecular genetic causes of Noonan syndrome and Noonan-syndrome-related disorders has permitted us to better understand the mechanisms underlying the different symptoms of these diseases and to establish genotype-phenotype correlations (in growth patterns for example). In addition to the classical clinical hallmarks of Noonan syndrome, new important aspects include decreased fertility in men, lean phenotype with increased energy expenditure and possible impact on carbohydrate metabolism/insulin sensitivity, and impaired bone health. Further clinical studies are needed to investigate the long-term impact of these findings and their possible interconnections. Finally, the understanding of the crucial role of RAS/mitogen-activated protein kinases dysregulation in the pathophysiology of Noonan syndrome allows us to devise new therapeutic approaches. Some agents are currently undergoing clinical trials in Noonan syndrome patients. SUMMARY On the last 10 years, our knowledge of the molecular basis and the pathophysiology of Noonan syndrome has greatly advanced allowing us to gain insight in all the aspects of this disease and to devise new specific therapeutic strategies.
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Affiliation(s)
- Armelle Yart
- INSERM UMR1048, Institute of Cardiovascular and Metabolic Diseases (I2MC), Paul Sabatier University
| | - Thomas Edouard
- Endocrine, Bone Diseases, and Genetics Unit, Children's Hospital, Toulouse University Hospital
- INSERM UMR1043 - CNRS U5282, Physiopathology Center of Toulouse Purpan (CPTP), Paul Sabatier University, Toulouse, France
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