Treatment of pituitary gigantism with the growth hormone receptor antagonist pegvisomant

CONTEXT

Treatment of pituitary gigantism is complex and the results are usually unsatisfactory.

OBJECTIVE

The objective of the study was to describe the results of therapy of three children with pituitary gigantism by a GH receptor antagonist, pegvisomant.

DESIGN

This was a descriptive case series of up to 3.5 yr duration.

SETTING

The study was conducted at a university hospital.

PATIENTS

Patients included three children (one female, two males) with pituitary gigantism whose GH hypersecretion was incompletely controlled by surgery, somatostatin analog, and dopamine agonist.

INTERVENTION

The intervention was administration of pegvisomant.

MAIN OUTCOME MEASURES

Plasma IGF-I and growth velocity were measured.

RESULTS

In all three children, pegvisomant rapidly decreased plasma IGF-I concentrations. Growth velocity declined to subnormal or normal values. Statural growth fell into lower growth percentiles and acromegalic features resolved. Pituitary tumor size did not change in two children but increased in one boy despite concomitant therapy with a somatostatin analog.

CONCLUSIONS

Pegvisomant may be an effective modality for the therapy of pituitary gigantism in children. Titration of the dose is necessary for optimal efficacy, and regular surveillance of tumor size is mandatory.

[Physical development of the teenagers who were exposed to radiation in utero after the accident on the Chernobyl Nuclear Power Plant]

Some features of physical development of teenagers exposed to radiation during utero development are revealed. These teenagers have been found to have more often, than in the control group disorders connected with harmonicity of physical development. Thus in the group of teenagers who have been exposed to acute radiation in utero period of their development prevails tall young men and girls while among the teenagers who have been born in 1986 and stayed living in the polluted territories low growth, subnanysm and nanysm is more often observed.

McCune-Albright syndrome: clinical picture and natural history in children and adolescents

The classical triad of McCune-Albright syndrome (MAS) consists of polyostotic fibrous dysplasia (FD), skin hyperpigmentation (café-au-lait spots), and endocrine dysfunction, frequently seen in females as precocious puberty. Patients with MAS display mosaicism of activating somatic mutations of the alpha-subunit of Gs. Thus, the clinical presentation of each individual is dependent on the particular distribution of affected cells, causing a broad spectrum of endocrine and non-endocrine manifestations. Typical endocrinopathies are precocious puberty, hyperthyroidism, growth hormone excess, hyperprolactemia, and hypercortisolism. The onset of these manifestations is usually during infancy and childhood. Since specific treatment is required, the prognosis depends on the severity of each individual endocrine manifestation. Additionally, there are non-endocrine manifestations, such as fibrous dysplasia of bone (FD), renal phosphate wasting, and skin hyperpigmentation, i.e. café-au-lait spots. FD, mostly polyostotic, causes fractures needing surgical and orthopedic treatment. Since previous studies have suggested the overall prognosis of patients with McCune-Albright syndrome to be non-fatal, recent data have drawn our attention to non-endocrine affections, including hepatobiliary dysfunction and cardiac disease, which are probably an important risk factor for early death. In summary, the clinical picture in MAS is related to its mosaic nature, i.e. any cell, tissue and organ in any site of the body could be affected to varying degrees, ranging from one or two mild clinical signs with excellent long-term prognosis to a severe life-threatening multiorgan disease.

Macrossomia e habilidades auditivas: estudo comparativo

TEMA:macrossomia é o desvio positivo dos padrões de crescimento normal. OBJETIVO: devido à escassez de estudos das habilidades auditivas nas síndromes macrossômicas, este trabalho objetivou verificar e comparar o desempenho auditivo de dois pacientes e correlacioná-los aos achados complementares. MÉTODO: anamnese, avaliação audiológica, de linguagem, psicológica e de neuroimagem em dois sujeitos do gênero feminino, de oito e dezessete anos. RESULTADOS: sujeito I - normal, sujeito II - alterado. CONCLUSÃO: há uma crescente necessidade em investigar a neurofisiologia da audição nessa população, visto que estudos fonoaudiológicos poderiam propiciar o diagnóstico precoce, favorecendo o processo de intervenção.

Gigantism and comparative life-history parameters of tyrannosaurid dinosaurs

How evolutionary changes in body size are brought about by variance in developmental timing and/or growth rates (also known as heterochrony) is a topic of considerable interest in evolutionary biology. In particular, extreme size change leading to gigantism occurred within the dinosaurs on multiple occasions. Whether this change was brought about by accelerated growth, delayed maturity or a combination of both processes is unknown. A better understanding of relationships between non-avian dinosaur groups and the newfound capacity to reconstruct their growth curves make it possible to address these questions quantitatively. Here we study growth patterns within the Tyrannosauridae, the best known group of large carnivorous dinosaurs, and determine the developmental means by which Tyrannosaurus rex, weighing 5,000 kg and more, grew to be one of the most enormous terrestrial carnivorous animals ever. T. rex had a maximal growth rate of 2.1 kg d(-1), reached skeletal maturity in two decades and lived for up to 28 years. T. rex's great stature was primarily attained by accelerating growth rates beyond that of its closest relatives.

Growth hormone in musculoskeletal pain states

Growth hormone is essential for normal linear growth and the attainment of an adult mature height. It also plays an important role in cartilage growth and the attainment of normal bone mass. There is only one rheumatic disorder, namely acromegaly, in which abnormalities of growth hormone production play a major etiologic role. However, there is increasing appreciation that suboptimal growth hormone secretion, leading to a state of adult growth hormone deficiency, may occur in the setting of chronic inflammatory disease, chronic corticosteroid use, and fibromyalgia. Therefore, the evaluation and effective management of growth hormone oversecretion and undersecretion is relevant to practicing rheumatologists.

Mouse cellular cementum is highly dependent on growth hormone status

Cementum is known to be growth-hormone (GH)-responsive, but to what extent is unclear. This study examines the effects of extremes of GH status on cementogenesis in three lines of genetically modified mice; GH excess (giant), GH antagonist excess (dwarf), and GH receptor-deleted (GHR-KO) (dwarf). Age-matched mandibular molar tissues were processed for light microscope histology. Digital images of sections of first molar teeth were captured for morphometric analysis of lingual root cementum. Cross-sectional area of the cellular cementum was a sensitive guide to GH status, being reduced nearly 10-fold in GHR-KO mice, three-fold in GH antagonist mice, and increased almost two-fold in giant mice (p < 0.001). Cellular cementum length was similarly influenced by GH status, but to a lesser extent. Acellular cementum was generally unaffected. This study reveals cellular cementum to be a highly responsive GH target tissue, which may have therapeutic applications in assisting regeneration of the periodontium.

Diagnostic approach and therapy of overgrowth and tall stature in childhood

Although referral for evaluation of tall stature is much less common than for short stature, early diagnosis in the paediatric age of clinical pictures leading to tall stature is crucial, both in order to detect conditions which can be properly treated and in order to limit excessive final heights; nowadays tall stature may be cause of psychosocial problems. This paper reviews different items related to tall stature in childhood. First of all, our review focuses on the definition of tall stature and the classification of the main clinical conditions associated with either tallness or excessive growth is discussed. Secondly, the clinical picture and the most recent breakthroughs of each of these conditions are reviewed. A diagnostic flow-chart meant to approach a patient presenting with tall stature is designed according to a few simple parameters such as chronological age, height age, bone age and growth velocity. The novel advances in the understanding of constitutional and secondary tall stature are presented and discussed, together with the hormonal treatment of constitutional tall stature and other related outstanding questions.

Sotos syndrome (cerebral gigantism): analysis of 8 cases

Sotos syndrome or cerebral gigantism is characterized by macrocephaly, overgrowth, mental retardation and central nervous system abnormalities. Congenital heart defects may be present. We report 8 patients with this syndrome and relate their clinical features, neuroimaging and echocardiographic findings.

Gps mutations in Chilean patients harboring growth hormone-secreting pituitary tumors

Hypersecretion of GH is usually caused by a pituitary adenoma and about 40% of these tumors exhibit missense gsp mutations in Arg201 or Gln227 of the Gs, gene. We studied 20 pituitary tumors obtained from patients with GH hypersecretion. One tumor was resected from an 11 year-old boy with a 3 year history of accelerated growth, associated with increased concentrations of serum GH and IGF-I, which were not suppressed by glucose administration. The remaining 19 tumors were obtained from adult acromegalic patients, who had elevated baseline serum GH levels that did not show evidence of suppression after administration of glucose. The gsp mutations were studied by enzymatic digestion of the amplified PCR fragment of exon 8 (Arg201) and exon 9 (Gln227) with the enzymes NlaIII and NgoAIV, respectively. The tumors obtained from the boy and from nine of the 19 patients with acromegaly exhibited the gsp mutation R201H. None of the tumors had the Gln227 mutation. The gsp positive patients tended to be older, had smaller tumors, and had preoperative basal serum GH levels which were significantly lower (21 +/- 6 vs 56 +/- 16 microg/l, p<0.05) than the gsp negative patients. In this study, we documented the presence of a gsp mutation in Arg201 in a boy with gigantism and in approximately half of 19 Chilean adult patients with acromegaly, similar to other populations.

Growth in Sotos syndrome

Although there are several reports on infant and childhood growth in patients with Sotos syndrome, there is little information on the final height achieved and puberty. Growth data on 40 patients (20 female and 20 male) aged 2-31 years were collected. These showed that patients with Sotos syndrome are excessively tall at birth, during infancy, and during childhood. Disproportionately long limbs constitute much of the increase in stature. However, the combination of advanced bone age and early onset of menarche led to a mean (SD) final height of 172.9 (5.7) cm in women. This is within the normal range for the population. Most of the men also attained a final height (mean, 184.3 cm; SD, 6.0) within the normal range, although exceptions were more likely in men than in women. Therefore, these results show that most patients with Sotos syndrome do not require intervention to limit their adult height.

Gigantism of the foot: our experience in seven cases

We report our experience in seven patients with congenital gigantism of the foot with the following diagnoses: neurofibromatosis (two), fibrolipomatosis (two), Proteus syndrome (two), and idiopathic localized gigantism (one). Our purpose is to introduce a new classification of foot gigantism, based on the concept of "neuroinduction." In our experience, intraoperative examination and subsequent histologic examination show consistently pathologic findings in the plantar nerve and its terminal branches in the foot affected by gigantism. Limited surgical treatment was used in five patients. To prevent forefoot enlargement and recurrence of deformity, we suggest complete ray resection. We evaluated our results using radiographs, functional status, and cosmetic considerations.

Serial neuroimaging studies in Sotos syndrome (cerebral gigantism syndrome)

To elucidate the mechanism of excessive size of the head in Soto syndrome, serial neuroimaging features from birth were reviewed in two patients. Macrocephaly shortly after birth was attributed to increased volume of the cerebral parenchyma itself (megalencephalon). Subsequent excessive size of the head was related to retention of cerebrospinal fluid in the ventricles and the subarachnoid spaces. Thus, macrocephaly in Sotos syndrome reflects two different mechanisms. The value of serial evaluation of intracranial structures is emphasized.

Craniofacial features in patients with deficient and excessive growth hormone

We studied the role of growth hormone (GH) in craniofacial growth by analyzing the craniofacial structures in patients with either deficient or excessive GH. The cephalogrammes of 21 patients with isolated or combined GH deficiency and of two patients with GH excess were compared with cephalogrammes of age and sex matched controls, and the patients with deficient GH also with height and sex matched controls. In cephalometric measurements, skeletal anatomy was followed as closely as possible. All patients had a Class I or an end-to-end dental occlusion. Head circumference was normal in all patients. Facial widths were significantly smaller in patients with deficient GH but at the level of + 2 SDs in the two with GH excess when compared to Finnish norms. In patients with deficient GH, facial heights were significantly smaller than in age matched controls, but of the same order with height controls for anterior facial height. Posterior facial height was smaller even in this comparison. In patients with GH excess, facial heights were much larger and at the levels of +3 and +6 SD. Clivus was shorter in patients with deficient GH and longer (+ 1.9 and +3 SD) in the two with GH excess. All angulations of the sphenoidal plane deviated from those of the controls in the group with GH deficiency. The cranial base angle (CL-SPhen) was smaller than in controls while it was normal in patients with GH excess. We are inclined to interpret the craniofacial structure of those with deficient GH as being unique to the condition rather than merely negative allometry.(ABSTRACT TRUNCATED AT 250 WORDS)

The 24-hour growth hormone secretion in a boy with giantism

The endocrinological and radiological findings in a 7.5-year-old boy with giantism are reported and compared with an age and sex matched normal tall boy. A 24-h GH profile demonstrated a persistently elevated GH concentration (mean GH concentration: giant 19.3 mU/l; tall boy 5.4 mU/l) with loss of the dominant GH periodicity of 3 h seen in the boy with tall stature and substitution with one of 8 h. These data support the view that giantism and acromegaly are similar diseases occurring prior to and following epiphyseal fusion, respectively.

[Physiologic, pathologic and manipulated body growth]

On the basis of the Zurich growth studies the following aspects of growth are discussed: Multifactorial dependency. Secular trend in young men still present but no longer in infants. Normal distance and velocity curve. Sex dependency of skeletal maturation, pubertal growth-spurt and adult size, but sex independency of the mid-growth spurt around age 7. Independency of adult size from timing and height of the pubertal growth spurt. Growth standards, perinatal standards for intra- and extra-uterine growth, growth chart for each child. Correlation of present height with future adult height and with mean parental height. Estimation of future adult height and comparison with target height estimated from mid-parent-height. Extreme normal variations of height and velocity, hormonal interventions. Catch-up-growth as compensatory growth acceleration after elimination of the cause of pathological growth retardation, and catch-down-growth as compensatory growth retardation after elimination of the cause of pathological growth acceleration.

[Pituitary adenoma secreting somatotropic hormone. Gigantism and peripheral neuropathy. A case]

Gigantism, an extremely rare condition, develops before puberty or in subjects in whom puberty is not yet completed. Hypersecretion of somatotropic hormone results in a tremendous surge in growth (our patient was 2.36 m tall). Among other clinical symptoms disabling peripheral neuropathy predominates and changes in nerve conduction velocity are not merely due to the increase in height. The increase in growth hormone concentrations combined with hypogonadotrophic hypogonadism with normal prolactinaemia is associated with peculiar cutaneous symptoms and with low levels of sex hormone-binding protein.

Prolactin-secreting pituitary adenoma in a man with gigantism: a case report

A prolactin-secreting pituitary adenoma was removed trans-sphenoidally from a 37 years old man with gigantism (218 cm). Serum levels of prolactin (PRL) were elevated pre-operatively and decreased after administration of L-Dopa with no increase after TRH as is usually observed in PRL-secreting adenomas. Growth hormone (GH) and somatomedin serum levels were normal with no modification of GH after insulin hypoglycemia, oral glucose loading or L-Dopa. Morphological examination of the tumour demonstrated the presence of lactotrophs by light and electron microscopy and by immunofluorescense staining. No somatotrophs were found. In this unique case, the relationship between a PRL-secreting adenoma and gigantism is discussed.

Endocrine function in a patient with asymmetrical acral hypertrophy and giantism: a possible variant of the Kippel-Trenaunay syndrome

Endocrine function was evaluated in a 38-year-old man who had patchy asymmetrical acral hypertrophy and giantism. The history and clinical manifestations were consistent with previously described cases of the Klippel-Trenaunay syndrome. Pituitary and peripheral hormone concentrations were generally elevated, but his endocrine status appeared normal by clinical evaluation. Of particular interest were elevated growth hormone and somatomedin-A concentrations and responses to provocative tests. These findings suggest that this patient had abnormal cell receptor pathophysiology as the cause of the asymmetrical acral hypertrophy and giantism, which often occurred in the same anatomical site.

[Reflexions and thoughts about one case of acromegalic gigantism (author's transl)]

Having observed a 22 year old man with a case of acromegalic-gigantism (2,30 m.) whose growth still continued after the ablation of a hypophyseal micro-adenoma, by trans-sphenoidale tract, the authors after making various neuroendocrine comments study from a psychological point of view the myth of the giant which appears to be linked to the myth of origins, from a phylogentical point of view (for example Atlantis) as well as from the ontogenetical point of view (identification to the father). The example is particularly ambivalent: at the same time idealized (the Heros), and rejected (the Ogre)--this is explained by the evolution of the father complex, and by the connections between, on the one hand the ego, and on the other hand the ideal ego and the couple ego ideal-super ego.

[Proposed new treatment for excessive statural growth using minimal corticotherapy. A propos of 11 cases treated with prednisone]

Treatment for excessive growth has alway constituted, in the endocrinological field, and particularly in the United States where such problems are frequently encountered, an incompletely solved problem, where the use of oestrogen therapy for girls has given more or less convincing results. We believe we have found a better solution which comes closer to tackling the real problem by using a minima corticotherapy, delayed until a height 1 or 2 cm short of the desired height is reached and bridging the time later required for the conjugation cartilages to fuse, under the influence of physiological puberty which is allowed to occur naturally under this method. 11 adolescents (1 boy, 10 girls) underwent this treatment at ages between 12 1/2 and 16 (average age 14 years 2 months), at a standard dose of 15 mg/day of prednisone in 3 equal doses over a period of between 7 and 25 months with periodical checking of the clinical condition, radiological bone structure and satisfactory biological tolerance. Results on growth were quite clear: growth rhythm was immediately inhibited, falling from 7,2 cm to 0,5 cm/year and there was total arrest of expected growth and a final height of about 1 or 2 cm more than the height at the onset of treatment was reached. The quality of the results obtained by this method seems to be considerably better than those obtained by other methods which have so far been suggested and this is all the more important as, provided specialised clinical and biological checks are carried out very regularly, it is not countered by unfortunate side-effects. Side-effects either do not occur at all with this method or are very minor and always regress when treatment is terminated.

Autonomic failure with persistent fever in cerebral gigantism

Images