OR18-2 Clinical, Hormonal and Genetic Characterization of Familial Central Precocious Puberty

 

Context: Familial central precocious puberty (CPP) is a prevalent form (about 27.5%) of precocious puberty. Loss-of-function mutations in two maternally imprinted genes, MKRN3 and DLK1, were identified in families with CPP showing dominant autosomal inheritance with paternal transmission. Maternally transmitted CPP was previously demonstrated in up to 60% of families using pedigree analysis, however, no definitive genetic abnormality has been identified so far.

Objectives

To estimate the prevalence of familial cases in a multiethnic cohort with CPP. To characterize the genetic basis and the mode of inheritance of the affected families. To compare clinical and hormonal features of patients with familial CPP due to different modes of transmission.

Patients and Methods

Clinical and hormonal data were obtained from medical registries of 495 patients with CPP and no brain MRI alterations. Familial CPP was defined as the presence of one or more close relatives with CPP or precocious menarche (≤9 yr). Sanger sequencing of MKRN3 and DLK1 was performed in 427 index cases. Targeted gene panel sequencing was performed in 79 cases, while whole exome sequencing was performed in 101 cases from 36 families

Results

Among 495 index cases, 159 had familial CPP (31%). The mode of transmission of CPP was identified as paternal in 58 (35%), maternal in 59 (38%), indeterminate in 34 (22%), and both maternal and paternal transmission in 8 (5%). Most families with paternal or maternal transmission had 2 generations known to be affected (51 and 77%, respectively). Notably, 67% of index cases with maternally transmitted CPP had their mother affected. In girls with CPP, the median age of thelarche was 6.5 yr in the paternally transmitted group, 6.9 yr in the maternally transmitted group, and 7.3 yr in the indeterminate group (p= 0.547). Median bone age advancement was 2.1, 2.3 and 1.2 yr, respectively (p= 0.013). Basal LH levels were higher in girls with paternally transmitted CPP (p= 0.047). Among those with paternally transmitted CPP, MKRN3 and DLK1 mutations were identified in, respectively, 63.8% and 10.3% of the families.

Conclusions

A significant prevalence (31%) of familial CPP was demonstrated in a multiethnic cohort. Maternally transmitted CPP represented the most frequent form of familial CPP (38%). MKRN3 loss-of-function mutations were responsible for most paternally transmitted CPP cases (63.8%), followed by DLK1 loss-of-function mutations (10.3%).

Presentation: Monday, June 13, 2022 11:15 a.m. - 11:30 a.m.

Adult Height of Patients with SHOX Haploinsufficiency with or without GH Therapy: A Real-World Single-Center Study

INTRODUCTION

Isolated SHOX haploinsufficiency is a common monogenic cause of short stature. Few studies compare untreated and rhGH-treated patients up to adult height (AH). Our study highlights a growth pattern from childhood to AH in patients with SHOX haploinsufficiency and analyzes the real-world effectiveness of rhGH alone or plus GnRH analog (GnRHa).

METHODS

Forty-seven patients (18 untreated and 29 rhGH-treated) with SHOX haploinsufficiency were included in a longitudinal retrospective study. Adult height was attained in 13 untreated and 18 rhGH-treated (rhGH alone [n = 8] or plus GnRHa [n = 10]) patients.

RESULTS

The untreated group decreased height SDS from baseline to AH (-0.8 [-1.1; -0.4]), with an increase in the prevalence of short stature from 31% to 77%. Conversely, the rhGH-treated group had an improvement in height SDS from baseline to AH (0.6 [0.2; 0.6]; p < 0.001), with a reduction in the prevalence of short stature (from 61% to 28%). AH in the rhGH-treated patients was 1 SD (6.3 cm) taller than in untreated ones. Regarding the use of GnRHa, the subgroups (rhGH alone or plus GnRHa) attained similar AH, despite the higher prevalence of pubertal patients and worse AH prediction at the start of rhGH treatment in patients who used combined therapy.

CONCLUSION

The use of rhGH treatment improves AH in patients with SHOX haploinsufficiency, preventing the loss of height potential during puberty. In peripubertal patients, the addition of GnRHa to rhGH allows AH attainment similar to the AH of patients who start rhGH alone in the prepubertal age.

MON-247 Clinical Characterization of Female Peripheral Precocious Puberty Due to McCune-Albright Syndrome

Background: McCune-Albright syndrome (MAS) is a rare and sporadic disease caused by a post-zygotic mutation in GNAS1 gene. It is characterized by the classical triad of polyostotic fibrous dysplasia, café-au-lait skin spots and peripheral precocious puberty (PPP). However, clinical presentation of MAS is highly variable depending on mosaic tissue distribution of mutant-bearing cells. Due to the low prevalence of MAS, detailed data of clinical and laboratory presentation are scarce. Aim: To describe the clinical and hormonal features of PPP due to MAS from a single tertiary center. Patients and Methods: The medical records of girls with PPP due to MAS diagnosed and treated from 1990 and 2018 were systematically revised. We analyzed initial clinical presentation, Tanner stage, gonadotropins and estradiol levels, and pelvic ultrasound findings of a MAS cohort. Results: From a total of 37 patients (35 girls and 2 boys) with clinical diagnosis of MAS, 14 (37.8%) female patients presented PPP. The first clinical manifestation was thelarche in 12/14 (85.7%), followed by vaginal bleeding in 7/14 (50%), and pubarche in 5/14 (35.7%). The mean height (SDS) was 109 ± 35 cm (SDS: 1.3 ± 1.6). All girls had Tanner-staging ≥ B2 (ranging from B2-B4) and 8/14 (57.1%) had pubarche. Fibrous bone dysplasia was detected in 9/14 (64.2%) by bone scintigraphy and café-au-lait skin spots were found in 10/14 (71.4%) of these girls. Menarche occurred at mean age of 3.75 ± 2 yr (2 - 7.2 yr). Mean basal LH and FSH were 0.36 ± 0.24 IU/L and 1.27± 1.0 IU/L, respectively. Estradiol levels ranged from < 13 to 783 pg/mL (mean 96.8 pg/mL). Basal estradiol levels were at prepubertal range in 8/14 (57%) on several occasions. All girls underwent a GnRH-analogue stimulated test showing a prepubertal LH response (2.9 ± 2.1 IU/L); 2 patients showed completely suppressed basal and stimulated gonadotropin levels. Uni- or bilateral ovarian cysts were identified in 9/14 patients (64.2%) being bilateral in 50% of them. Mean ovarian volumes were 2.63 ± 1.4 cm³ for right and 2.05 ± 1.9 cm³ for left ovarian, with mean cyst volumes ranging from 2.7 to 45 cm³. Other endocrine hyperfunctions were not identified in this MAS cohort. Conclusion: PPP in girls with MAS has a heterogeneous clinical presentation. It was characterized by menarche at very early age as a first sign associated with variable values of estradiol levels (pre- and pubertal) and ovarian sizes. Pediatric endocrinologists must be aware of atypical clinical and laboratory presentation of PPP due to MAS.

MON-245 Sexuality and Fertility Issues in 46,XY Disorders of Sex Development Individuals

Abstract: The sexuality of 46,XY DSD individuals can be affected by several factors as external genitalia appearance, negative body image, traumas, social stigma, and previous genital surgery. Previous studies has been reported an impaired sexual quality of life (SexQoL) in 46,XY DSD individuals in comparison with controls. To observe aspects regarding sexual life, 144 individuals with 46,XY DSD (100 female; 44 male) were enrolled in this study. All of them were adults (>16 years old) and had completed all surgical treatments. Sexual life and fertility issues were assessed using self-developed questionnaire with likert-scale questions. Sexual orientation was assessed on the basis of orientation, sexual behavior and sexual attraction. For comparison, the cohort was divided into 3 subgroups (A: gender at adulthood; B: genitalia appearance at birth; and C: male individuals at adulthood who were assigned as male versus who changed from female to male). About fertility issues, 12 individuals (8%) had children (7 male; 5 female). 10 out of 12 were adopted children and 2 patients had children by Intravaginal insemination (IVI). Desire of fertility was similar in women and men (78.3%, 80.7% respectively; p = NS). Fear of rejection due to infertility was reported by 28% (34 out of 117). More women than men considered infertility a barrier to a steady relationship (p=0.04). Regarding sexual orientation, more than 90% referred themselves as heterosexual. Homosexuality was reported by 4% in both genders. Most 46,XY DSD women reported androphilic sexual attraction and female sexual behavior (have sex with male partners), regardless of the appearance of external genitalia. The opposite (gynephilic sexual attraction and male sexual behavior) was observed in most male patients either in individuals who were assigned male at birth and in individuals who changed from female to male. Regarding sexual life, there was significant difference between males and females on sexual fantasies, masturbation practice and fixed sexual partner, which were more frequent in males. Nevertheless, both gender reported a similar sexual life satisfaction (76% and 80%). All sexual parameters were similar comparing individuals who changed from female to male and who were assigned as male. In conclusion, sexual life satisfaction was reported by the majority of adult patients with 46,XY DSD in both gender. Among female patients, the appearance of external genitalia did not influence on sexuality, once the surgical correction of atypical genitalia have been performed. In male individuals, the sexual life was similar either if they were assigned as male or changed for that gender later. Fertility desire was common among 46,XY DSD people, regardless of gender or 46,XY etiology, which should be taken into consideration in the 46,XY DSD management.

SUN-265 Performance of Basal and GnRH Analog-Stimulated LH Levels Assessed by an Electrochemiluminescence Assay in Girls with Central Precocious Puberty

Background: The laboratory evaluation of patients with precocious puberty is useful to differentiate central precocious puberty (CPP) from isolated thelarche (IPT) and peripheral precocious puberty (PPP). Ultrasensitive immunoassays, such as electrochemiluminescence (ECLIA), improved sensitivity and specificity of basal and GnRH-stimulated LH levels to establish the differential diagnosis among these conditions. Aim: To establish the diagnostic value of basal and GnRHa-stimulated LH values and basal estradiol assessed by ECLIA in pubertal disorders. Patients and Methods: We included 38 girls with pubertal disorders (28 CPP, 8 IPT, and 2 PPP). Their medical records were systematically revised. Clinical and hormonal data [basal and GnRH analog -stimulated LH levels (2 hs after leuprorrelin 3.75 mg) and basal estradiol] were analyzed. Gonadotropins and estradiol levels were assessed by ECLIA (Roche, Cobas e 6000). The functional sensitivity of the assays was 0.15 IU/L for LH, FSH 0.6 IU/L for FSH and 17 pg/mL for estradiol. Basal gonadotropins and estradiol were also assessed in a control group composed by 16 prepubertal and 19 pubertal girls. The cutoff values for basal and GnRH analog- stimulated LH for diagnosis of CPP was set at < 0.3 IU/L and 8 IU/L, respectively (1). Results: The mean age of girl with CPP, IPT, and PPP at the first clinical visit was 8 ± 0.9yr (5.25- 9.6 yr), 4.25± 2.6 (0.7-7.8 yr), and 5.12±2.9 (3.1 -7.1 yr), respectively. All CPP girls presented breast development ranging from B2 to B5, whereas IPT group B2-B4 and PPP group (B2). Pubarche was presented in 86% of girls with CPP (PH 2- PH 5). Only one girl in IPT group also presented pubarche (PH3), associated to zinc oxide cream use and none in PPP group presented pubarche. The mean basal LH was 3.4 ± 1.6 (<0.1- 8.6 IU/L), 0.15 ± 0.03 (< 0.15-0.2 IU/L), and <0.15 IU/L for CPP, IPT, and PPP, respectively. In CPP group, GnRHa- stimulated LH and basal estradiol levels were 6 ± 2.8 (4-61.4 IU/L) and 21 ± 17 (<17- 90 pg/ml), respectively. The sensitivity and specificity of basal and GnRHa-stimulated LH values for diagnosis of CPP was 64.7 % and 100%, respectively. However, the cutoff of 5 IU/L for GnRHa-stimulated LH improved sensitivity to 87.5% but with lower specificity of 67%. Estradiol was undetectable (<17 pg/ml) in 48% girls with CPP. In the IPT and PPP groups, basal LH <0.3 IU/L was detected in all patients. In the control group, all but one prepubertal girl had basal LH <0.15 IU/L. In addition, basal estradiol > 17 pg/ml was present in two girls from control prepubertal group. In the control pubertal group (B3-B4), mean basal LH was 4.2± 2.3 (<015- 8.8 IU/L) and basal estradiol was 61 ± 34 (<17-135pg/mL). Conclusion: The diagnostic value of basal and GnRH-stimulated LH levels assessed by ECLIA to diagnosis CPP is limited and must be interpreted together with clinical data. Reference: (1) Freire AV et al, Clin Endocrinol (Oxf), 2013.

OR17-2 Comprehensive Genetic Investigation of Patients with Central Precocious Puberty Associated with Complex Phenotypes

Background: Idiopathic central precocious puberty (CPP) is mostly described as an isolated entity. A few studies have shown its association with clinical syndromes and rare cases of chromosomal abnormalities. Objective: To clinically characterize and to genetically investigate a cohort of patients with CPP associated with complex phenotypes. Patients and methods: Two hundred patients with idiopathic CPP were retrospectively evaluated, including phenotypic, metabolic and hormonal characterization. Thirty-two of them presented at least 3 other clinical features and conditions, characterizing complex phenotypes. Genomic microarray was performed in all sporadic and index cases, and MLPA and whole-exome sequencing were performed in a subset of cases. Results: In the group of 32 idiopathic CPP patients with complex phenotypes (28 girls, 4 boys; 16 sporadic, 16 familial), mean age at puberty onset was 6.2 yr (±1.9) for girls and 8 yr (±0.1) for boys. There was a wide phenotypic spectrum. The more prevalent clinical features described included metabolic, neurocognitive and growth phenotypes; less prevalent features included dysmorphic features and congenital anomalies. Genetic investigation resulted as follows: 3 sporadic cases with maternal uniparental disomy of chromosome 14 (Temple syndrome), with disruption at the imprinted locus of DLK1; 1 sporadic patient with a 7q11.23 deletion (Williams syndrome); 7 patients from 3 unrelated families with Xp22.33 deletions, including SHOX, upstream regulatory regions, and 3 other coding-genes. Moreover, whole-exome sequencing analysis revealed candidate pathogenic variants in 2 CPP cases. One girl with sporadic CPP associated with imperforate anus and learning difficulties presented rare frameshift variants in a dominant de novo mode in 2 genes: AREL1 (14:75142990; p.S229fs) coding an ubiquitin ligase; and TNRC6B (22:40662223-40662224; p.S663fs) coding a molecule with a role in RNA-mediated gene silencing. Both genes are expressed in hypothalamus. In addition, one boy with maternal familial CPP and autism had 2 rare potentially pathogenic variants in a dominant autosomal inheritance mode: a frameshift deletion in MKKS (20:10393728-10393731; p.F144fs) coding a protein with a role in cytokinesis; and a missense variant (4:70359481; p.P267L) in UGT2B4, coding a protein involved in estrogen hydroxylation and related to menarche timing in genome-wide association studies. Conclusion: CPP might be associated with additional clinical conditions, characterizing complex phenotypes. Two chromosomal regions, Xp22.33 and 7q11.23, represent novel candidate loci implicated in CPP. In addition, distinct novel genetic abnormalities were identified in CPP patients with complex phenotypes.

MON-251 Clinical Features of a Large Cohort of Patients with Familial Central Precocious Puberty Caused by Loss-of-Function Mutations in MKRN3

Context: Loss-of-function mutations in Makorin RING-finger 3 (MKRN3), a maternal imprinted gene located on the long arm of chromosome 15, are the most prevalent cause of familial central precocious puberty (CPP). Objectives: To describe the clinical and hormonal features of 70 patients with CPP due to MKRN3 mutations and to establish the phenotype-genotype correlation. Setting and Participants: We studied 70 individuals from 31 families originating from different ethnic backgrounds. DNA sequencing analysis of MKRN3 coding region by Sanger method was performed and loss-of-function MKRN3 mutations were identified in all of them. Results: The genetic analysis of MKRN3 revealed 15 different mutations in 70 affected patients with CPP (27 boys; 43 girls) who were studied in two university centers from 2013 to 2018. We identified frameshift (61%), missense (26%) and nonsense mutations (13%). Frameshift mutations affecting codon 162 were the most frequent. Female patients developed thelarche at a mean age of 5.9 ± 1.2 years, adrenarche at 6.4 ± 0.9 years, had bone age advance of 2.3 ± 1.6 years, a height standard deviation score (SDS) of 1.6 ± 1.2, and a BMI-SDS in the overweight range (1.05 ± 0.7) in the initial diagnosis. Eight patients (11%) developed thelarche and adrenarche simultaneously. Male patients developed pubertal signs at a median age of 8.0 years (range 5.9-8.5 years) and had a bone age advance of 1.7 years (0-2.7). Girls who harbored frameshift mutations were more likely to have simultaneous thelarche and adrenarche and had a more advanced bone age (2.7 ± 1.6 vs 1.3 ± 1.1 years, p = 0.003), but were otherwise unremarkable. Notably, 74% of the male patients were diagnosed in adulthood, during familial segregation analysis, suggesting that male CPP was under-diagnosed. Basal laboratory evaluation showed LH levels of 1.8 ± 1.5 IU/L and FSH levels of 4.4 ± 2.4 IU/L (n=37). GnRH stimulation tests resulted in a LH peak of 25 ± 24 IU/L and a FSH peak of 13.2 ± 9.5 IU/L. Nineteen patients were treated with depot GnRH analogue for 3.3 ± 0.8 years, achieving a final height of -0.6 ± 1.1 SDS, within their target height of -1.1 ± 1.0 SDS. Among the 7 untreated adult patients, height SDS was -1.8 ± 1.1, noticeably lower than that of treated patients, although not statistically significant (p=0.06). Conclusions: Deleterious MKRN3 mutations represent a frequent genetic cause of non-syndromic familial CPP in both sexes. Clinical and hormonal features of CPP caused by these mutations are indistinguishable from idiopathic CPP.

Postoperative pulmonary complications after gynecologic surgery

OBJECTIVE

Investigate the frequency of, and risks for postoperative pulmonary complications after surgery for non-malignant gynecologic disorders.

METHOD

A retrospective component included medical record data for one year. A prospective component enrolled 300 patients consecutively who were scheduled for gynecologic surgeries.

RESULT

Postoperative pulmonary complications occurred in 1.22% of 328 open abdominal procedures in the retrospective study, and 2.16% of 232 in the prospective study. Pooling the data yielded a frequency estimate of 1.61%. Mean hospital length of stay (pooled data) increased 1.75 days in those with postoperative pulmonary complications. Smoking was the only significant risk factor (relative risk=3.9 using pooled data).

CONCLUSION

Postoperative pulmonary complications after surgery for non-malignant gynecologic disorders are infrequent but increase hospital length of stay. Smokers are at increased risk.

Neurotrophic Factors and Estradiol Interact To Control Axogenic Growth in Hypothalamic Neurons

Previous work from our laboratory has shown that in cultures of hypothalamic neurons obtained from male fetuses at embryonic day 16, the axogenic response to estrogen (E2) is contingent on coculture with target glia or target glia-conditioned media (CM). Neither the estrogen receptor blockers tamoxifen nor ICI 182,780 prevented the axogenic effects of the hormone. Estradiol made membrane-impermeable by conjugation to a protein of high molecular weight (E2-BSA) preserved its axogenic capacity, suggesting the possibility of a membrane effect responsible for the action of E2. Western blot analysis of extracts from homogenates of cultured neurons grown with E2 and CM from target glia had more TrkB than cultures with CM alone or E2 alone. To further investigate the interaction between E2 and the neurotrophin receptors, we used a specific antisense oligonucleotide (AS) to prevent the estradiol-induced increase of TrkB. The effect of E2 was suppressed in cultures in which TrkB was down-regulated by the AS, showing decreased axonal elongation when compared with neurons treated with E2 without AS or with sense TrkB. In cultures grown with AS, the axonal length of E2-treated cultures was not different from cultures without E2. Evidence suggesting cross-talk between E2 and neurotrophic factor(s) prompted investigation of signaling along the MAPK cascade. Immuno blotting of E2-treated cultures showed increased levels of phosphorylated ERK1 and ERK2. UO126 but not LY294002 blocked E2-induced axonal elongation, suggesting that the MAPKs are involved in this response.

Clinical evaluation of a new combined oral contraceptive desogestrel--ethinylestradiol

A clinical study was performed with a new progestogen, desogestrel, in a 0.15 mg dose associated with 0.03 mg of ethinylestradiol and was administered cyclically during 21 days; 632 cycles were evaluated in 56 women. Side-effects were scarce and generally of a mild nature. Monthly bleeding was normal and present in all cycles. Patients with irregular cycles were normalized to 28/29 days. The intermenstrual bleeding (spotting) was an isolated event in 16 cycles. Mastalgia, the most frequent symptom, disappeared spontaneously in the majority of patients. In only 2 cases was it necessary to stop medication because of side-effects. The contraceptive effect was excellent; no pregnancies occurred. A progestative effect was evident in the cervical mucus and the endometrium. The patients who started treatment with acne improved noticeably. In the mild cases, acne disappeared completely. A discrete improvement in hirsutism was reported. The body-weight variation was not significant. Biochemical studies revealed an increase in HDL-C and a decrease in the ratio LDL-C/HDL-C. Cholesterol and triglycerides did not show variations, which could indicate a lesser cardiovascular risk.