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Kadom N, Nance M, Patterson B, Palasis S. Guidance for Pediatric Pituitary MRI Ordering: A Single Institution Improvement Initiative. AJNR Am J Neuroradiol 2024:ajnr.A8314. [PMID: 39122467 DOI: 10.3174/ajnr.a8314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/12/2024] [Indexed: 08/12/2024]
Abstract
We identified inconsistencies in the pituitary MRI ordering practices at our pediatric institution. We used an interdepartmental collaboration to develop a pituitary MRI ordering guide based on available evidence and local expertise. The initiative has led to an improvement in the appropriate use of intravenous gadolinium-based contrast agents for pediatric pituitary MRI studies.
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Affiliation(s)
- Nadja Kadom
- From the Department of Radiology (N.K., S.P.), Children's Healthcare of Atlanta, Atlanta, Georgia
- Department of Radiology and Imaging Sciences (N.K., M.N., S.P.), Emory School of Medicine, Atlanta, Georgia
| | - Michael Nance
- Department of Radiology and Imaging Sciences (N.K., M.N., S.P.), Emory School of Medicine, Atlanta, Georgia
| | - Briana Patterson
- Division of Endocrinology, Department of Pediatrics (B.P.), Emory University, Atlanta, Georgia
| | - Susan Palasis
- From the Department of Radiology (N.K., S.P.), Children's Healthcare of Atlanta, Atlanta, Georgia
- Department of Radiology and Imaging Sciences (N.K., M.N., S.P.), Emory School of Medicine, Atlanta, Georgia
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Kiremitci Yilmaz S, Yilmaz Ovali G, Ozalp Kizilay D, Tarhan S, Ersoy B. Pitfalls of diagnosing pituitary hypoplasia in the patients with short stature. Endocrine 2024:10.1007/s12020-024-03951-9. [PMID: 38969909 DOI: 10.1007/s12020-024-03951-9] [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: 04/19/2024] [Accepted: 06/27/2024] [Indexed: 07/07/2024]
Abstract
PURPOSE Height age (HA) and bone age (BA) delay is well known in the patients with short stature. Therefore assessing pituitary hypoplasia based on chronological age (CA) might cause overdiagnosis of pituitary hypoplasia. We aimed to investigate the diagnostic and prognostic value of the PH and PV based on CA, HA, or BA in the patients with GHD. METHODS Fifty-seven patients with severe and 40 patients with partial GHD and 39 patients with ISS assigned to the study. For defining the most accurate diagnosis of pituitary hypoplasia, PH and PV were evaluated based on CA, BA and HA. The relationship of each method with clinical features was examined. RESULTS The mean PV was significantly larger in patients with ISS compared to the GH-deficient patients. PV was more correlated with clinical features including height SDS, stimulated GH concentration, IGF-1 and IGFBP-3 SDS, height velocity before and after rGH therapy. We found BA-based PV could discriminate GHD from ISS (Sensitivity: 17%, specificity: 98%, positive predictive value: 94%, negative predictive value: 39%), compared to the other methods based on PH or PV respect to CA and HA. 3% of patients with ISS, 17% of patients with GHD had pituitary hypoplasia based on PV-BA. CONCLUSION PV based on BA, has the most accurate diagnostic value for defining pituitary hypoplasia. But it should be kept in mind that there might be still misdiagnosed patients by this method. PV is also a significant predictor for the rGH response.
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Affiliation(s)
- Seniha Kiremitci Yilmaz
- Division of Pediatric Endocrinology, Health Sciences University, Istanbul Haseki Training and Research Hospital, Istanbul, Turkey.
| | - Gülgün Yilmaz Ovali
- Department of Radiology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Deniz Ozalp Kizilay
- Division of Pediatric Endocrinology and Metabolism, Ege University, Faculty of Medicine, İzmir, Turkey
| | - Serdar Tarhan
- Department of Radiology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Betul Ersoy
- Division of Pediatric Endocrinology and Metabolism, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
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Li MWT, Poon SWY, Cheung C, Wong CKC, Shing MMK, Chow TTW, Lee SLK, Pang GSW, Kwan EYW, Poon GWK, Yau HC, Tung JYL, Liu APY. Incidence and Predictors for Oncologic Etiologies in Chinese Children with Pituitary Stalk Thickening. Cancers (Basel) 2023; 15:3935. [PMID: 37568752 PMCID: PMC10417368 DOI: 10.3390/cancers15153935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND With the increasing use of magnetic resonance imaging (MRI) in the evaluation of children with endocrine disorders, pituitary stalk thickening (PST) poses a clinical conundrum due to the potential for underlying neoplasms and challenges in obtaining a tissue biopsy. The existing literature suggests Langerhans cell histiocytosis (LCH) to be the commonest (16%) oncologic cause for PST, followed by germ cell tumors (GCTs, 13%) (CCLG 2021). As the cancer epidemiology varies according to ethnicity, we present herein the incidence and predictors for oncologic etiologies in Hong Kong Chinese children with PST. METHODS Based on a territory-wide electronic database, we reviewed patients aged < 19 years who presented to three referral centers with endocrinopathies between 2010 and 2022. Records for patients who underwent at least one MRI brain/pituitary were examined (n = 1670): those with PST (stalk thickness ≥ 3 mm) were included, while patients with pre-existing cancer, other CNS and extra-CNS disease foci that were diagnostic of the underlying condition were excluded. RESULTS Twenty-eight patients (M:F = 10:18) were identified. The median age at diagnosis of PST was 10.9 years (range: 3.8-16.5), with central diabetes insipidus (CDI) and growth hormone deficiency (GHD) being the most frequent presenting endocrine disorders. At a median follow-up of 4.8 years, oncologic diagnoses were made in 14 patients (50%), including 13 GCTs (46%; germinoma = 11, non-germinoma = 2) and one LCH (4%). Among patients with GCTs, 10 were diagnosed based on histology, two by abnormal tumor markers and one by a combination of histology and tumor markers. Three patients with germinoma were initially misdiagnosed as hypophysitis/LCH. The cumulative incidence of oncologic diagnoses was significantly higher in boys and patients with PST at presentation ≥6.5 mm, CDI or ≥2 pituitary hormone deficiencies at presentation and evolving hypopituitarism (all p < 0.05 by log-rank). CONCLUSIONS A higher rate of GCTs was observed in Chinese children with endocrinopathy and isolated PST. The predictors identified in this study may guide healthcare providers in Asia in clinical decision making. Serial measurement of tumor markers is essential in management.
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Affiliation(s)
- Mario W. T. Li
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, China; (M.W.T.L.); (S.L.K.L.); (J.Y.L.T.)
| | - Sarah W. Y. Poon
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong, China
| | - Claudia Cheung
- Department of Radiology, The Hong Kong Children’s Hospital, Hong Kong, China
| | - Chris K. C. Wong
- Department of Radiology, The Hong Kong Children’s Hospital, Hong Kong, China
| | - Matthew M. K. Shing
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, China; (M.W.T.L.); (S.L.K.L.); (J.Y.L.T.)
| | - Terry T. W. Chow
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, China; (M.W.T.L.); (S.L.K.L.); (J.Y.L.T.)
| | - Samantha L. K. Lee
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, China; (M.W.T.L.); (S.L.K.L.); (J.Y.L.T.)
| | - Gloria S. W. Pang
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, China; (M.W.T.L.); (S.L.K.L.); (J.Y.L.T.)
| | - Elaine Y. W. Kwan
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, China; (M.W.T.L.); (S.L.K.L.); (J.Y.L.T.)
| | - Grace W. K. Poon
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Hong Kong, China
| | - Ho-Chung Yau
- Department of Paediatrics, Prince of Wales Hospital, Hong Kong, China
| | - Joanna Y. L. Tung
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, China; (M.W.T.L.); (S.L.K.L.); (J.Y.L.T.)
| | - Anthony P. Y. Liu
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children’s Hospital, Hong Kong, China; (M.W.T.L.); (S.L.K.L.); (J.Y.L.T.)
- Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
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Huang J, Sarma A, Gupta N, Little S, Pruthi S. Noncontrast MRI Protocol for Selected Pediatric Pituitary Endocrinopathies: A Procedure with High Diagnostic Yield and Potential to Reduce Anesthesia and Gadolinium-Based Contrast Exposure. AJNR Am J Neuroradiol 2021; 42:1884-1890. [PMID: 34475192 PMCID: PMC8562761 DOI: 10.3174/ajnr.a7228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/03/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Although many pediatric neuroradiology practices empirically use noncontrast brain and pituitary MR imaging for evaluation of growth hormone deficiency, central precocious puberty, and short stature, there are currently insufficient published data to support this practice in an evidence-based fashion. Therefore, the use of contrast-enhanced MR imaging for all pediatric pituitary endocrinopathies remains widespread. We evaluated whether noncontrast MR imaging has adequate diagnostic yield for the evaluation of pediatric growth hormone deficiency, central precocious puberty, and short stature. MATERIALS AND METHODS Pituitary MR imaging studies obtained for growth hormone deficiency, central precocious puberty, or short stature in patients 0-18 years of age from 2010 to 2019 were analyzed. Separate blinded review of noncontrast images in cases with abnormalities on the original radiology report was performed by 2 subspecialty-trained pediatric neuroradiologists, with discrepancies resolved by consensus. RESULTS Of the 134/442 MR imaging studies obtained for growth hormone deficiency, central precocious puberty, or short stature with hypothalamic-pituitary region abnormalities, there was 70% concordance with the original reports on blinded review of noncontrast images. Twenty-two of 40 discrepancies were deemed unrelated to the indication, and 9 cases originally interpreted as possible microadenoma were read as having normal findings on blinded review. Only 9 of 40 discrepancies required contrast for further characterization. CONCLUSIONS In our study, most relevant radiologic findings in patients with growth hormone deficiency, central precocious puberty, and short stature were detectable without contrast, providing evidence that contrast can be avoided in routine MR imaging evaluation of these indications. We propose a "rapid noncontrast pituitary" MR imaging protocol for pediatric patients presenting with growth hormone deficiency, central precocious puberty, or short stature, which may increase efficiency and decrease contrast and anesthesia exposure.
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Affiliation(s)
- J Huang
- From the Department of Radiology (J.H., A.S., S.L., S.P.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Sarma
- From the Department of Radiology (J.H., A.S., S.L., S.P.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - N Gupta
- Division of Pediatric Endocrinology and Diabetes (N.G.), Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - S Little
- From the Department of Radiology (J.H., A.S., S.L., S.P.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - S Pruthi
- From the Department of Radiology (J.H., A.S., S.L., S.P.), Vanderbilt University Medical Center, Nashville, Tennessee
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Mohamed M, Mediratta S, Chari A, da Costa CS, James G, Dawes W, Aquilina K. Post-haemorrhagic hydrocephalus is associated with poorer surgical and neurodevelopmental sequelae than other causes of infant hydrocephalus. Childs Nerv Syst 2021; 37:3385-3396. [PMID: 34148130 PMCID: PMC8578110 DOI: 10.1007/s00381-021-05226-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE This retrospective cohort study aimed to investigate the surgical and neurodevelopmental outcomes (NDO) of infant hydrocephalus. We also sought to determine whether these outcomes are disproportionately poorer in post-haemorrhagic hydrocephalus (PHH) compared to other causes of infant hydrocephalus. METHODS A review of all infants with hydrocephalus who had ventriculoperitoneal (VP) shunts inserted at Great Ormond Street Hospital (GOSH) from 2008 to 2018 was performed. Demographic, surgical, neurodevelopmental, and other clinical data extracted from electronic patient notes were analysed by aetiology. Shunt survival, NDO, cerebral palsy (CP), epilepsy, speech delay, education, behavioural disorders, endocrine dysfunction, and mortality were evaluated. RESULTS A total of 323 infants with median gestational age of 37.0 (23.29-42.14) weeks and birthweight of 2640 g (525-4684 g) were evaluated. PHH was the most common aetiology (31.9%) and was associated with significantly higher 5-year shunt revision rates, revisions beyond a year, and median number of revisions than congenital or "other" hydrocephalus (all p < 0.02). Cox regression demonstrated poorest shunt survival in PHH, related to gestational age at birth and corrected age at shunt insertion. PHH also had the highest rate of severe disabilities, increasing with age to 65.0% at 10 years, as well as the highest CP rate; only genetic hydrocephalus had significantly higher endocrine dysfunction (p = 0.01) and mortality rates (p = 0.04). CONCLUSIONS Infants with PHH have poorer surgical and NDO compared to all other aetiologies, except genetic hydrocephalus. Research into measures of reducing neurodisability following PHH is urgently required. Long-term follow-up is essential to optimise support and outcomes.
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Affiliation(s)
- Malak Mohamed
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK. .,Leeds School of Medicine, University of Leeds, Leeds, UK.
| | - Saniya Mediratta
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital & University of Cambridge, Cambridge, UK
| | - Aswin Chari
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK ,Department of Neurosurgery, Great Ormond Street Hospital, London, UK
| | | | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
| | - William Dawes
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK ,Department of Neurosurgery, Alder Hey Children’s Hospital, Liverpool, UK
| | - Kristian Aquilina
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK ,Department of Neurosurgery, Great Ormond Street Hospital, London, UK
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Abstract
Short stature in children is a diagnostic challenge to the physician. Bone age assessment can be done using various methods. The causes of short stature are variable; often leading to a series of investigations. The endocrine conditions have typical imaging features. This chapter provides a short overview of the methods of bone age estimation, and imaging findings and algorithmic approach towards a child with short stature.
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Ramzan K, Bin-Abbas B, Al-Jomaa L, Allam R, Al-Owain M, Imtiaz F. Two novel LHX3 mutations in patients with combined pituitary hormone deficiency including cervical rigidity and sensorineural hearing loss. BMC Endocr Disord 2017; 17:17. [PMID: 28302169 PMCID: PMC5356396 DOI: 10.1186/s12902-017-0164-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 02/22/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Congenital combined pituitary hormone deficiency (CPHD) is a rare heterogeneous group of conditions. CPHD-type 3 (CPHD3; MIM# 221750) is caused by recessive mutations in LHX3, a LIM-homeodomain transcription factor gene. The isoforms of LHX3 are critical for pituitary gland formation and specification of the anterior pituitary hormone-secreting cell types. They also play distinct roles in the development of neuroendocrine and auditory systems. CASE PRESENTATION Here, we summarize the clinical, endocrinological, radiological and molecular features of three patients from two unrelated families. Clinical evaluation revealed severe CPHD coupled with cervical vertebral malformations (rigid neck, scoliosis), mild developmental delay and moderate sensorineural hearing loss (SNHL). The patients were diagnosed with CPHD3 based on the array of hormone deficiencies and other associated syndromic symptoms, suggestive of targeted LHX3 gene sequencing. A novel missense mutation c.437G > T (p. Cys146Phe) and a novel nonsense mutation c.466C > T (p. Arg156Ter), both in homozygous forms, were found. The altered Cys146 resides in the LIM2 domain of the encoded protein and is a phylogenetically conserved residue, which mediates LHX3 transcription factor binding with a zinc cation. The p. Arg156Ter is predicted to result in a severely truncated protein, lacking the DNA binding homeodomain. CONCLUSIONS Considering genotype/phenotype correlation, we suggest that the presence of SNHL and limited neck rotation should be considered in the differential diagnosis of CPHD3 to facilitate molecular diagnosis. This report describes the first LHX3 mutations from Saudi patients and highlights the importance of combining molecular diagnosis with the clinical findings. In addition, it also expands the knowledge of LHX3-related CPHD3 phenotype and the allelic spectrum for this gene.
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Affiliation(s)
- Khushnooda Ramzan
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, P.O.Box 3354, Riyadh, 11211 Saudi Arabia
| | - Bassam Bin-Abbas
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Lolwa Al-Jomaa
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, P.O.Box 3354, Riyadh, 11211 Saudi Arabia
| | - Rabab Allam
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, P.O.Box 3354, Riyadh, 11211 Saudi Arabia
| | - Mohammed Al-Owain
- Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Faiqa Imtiaz
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, P.O.Box 3354, Riyadh, 11211 Saudi Arabia
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Abstract
High-resolution MRI of the pediatric sella can help identity or confirm clinical abnormalities, assess pituitary gland size and structure, and reveal acquired lesions. This article reviews contemporary techniques for imaging of the sella and associated structures in this population. Strengths and weaknesses of conventional imaging are discussed, as are techniques that can enhance yield. Some new and emerging technologies are discussed, including MR elastography, perfusion imaging, spectroscopy, and diffusion-weighted and diffusion-tensor imaging. It is expected that this overview will provide insight as to where pediatric sella imaging is currently and where it may head in the future.
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Affiliation(s)
- Jad M Bou-Ayache
- Department of Radiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029, USA
| | - Bradley N Delman
- Department of Radiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029, USA.
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