Endokrynologia Pediatryczna Pediatric Endocrinology
Transkrypt
Endokrynologia Pediatryczna Pediatric Endocrinology
Vol. 3/2004 Nr 4(9) Endokrynologia Pediatryczna Pediatric Endocrinology Precocious puberty in children triggered by a hypothalamic hamartoma – report of 3 cases and literature overview Przedwczesne dojrzewanie płciowe spowodowane przez hamartoma podwzgórza Jerzy Starzyk, 1Dominika Januś, 2Bożena Starzyk, 3Wiesław Urbanowicz, 4Stanisław Kwiatkowski, 1 Dorota Tylek-Lemańska 1 Department of Pediatric and Adolescent Endocrinology Radiology Department 3 Urology Department 4 Department of Pediatric Surgery, Polish-American Children’s Hospital, Faculty of Medicine, Jagiellonian University, Cracow, Poland 1 2 Address for correspondence: Jerzy Starzyk, MD, PhD, Department of Pediatric and Adolescent Endocrinology, Polish-American Children’s Hospital, Faculty of Medicine, Jagiellonian University, Cracow, Poland, 265 Wielicka St., 30-663 Kraków, Poland, e-mail: [email protected] Key words: precocious puberty, hypothalamic hamartoma, long-acting gonadotropin releasing hormone agonist Słowa kluczowe: przedwczesne dojrzewanie, hamartoma STRESZCZENIE/ STRESZCZENIE/ABSTRACT The investigations included 3 children aged 2 (female Patient 1), 2.4 (male Patient 2) and 8.1 years (male Patient 3) with rapidly progressing isosexual precocious puberty (IPP), in whom breast and pubic hair development and menstrual bleeding or testicular enlargement occurred at the age of 3 months, 1 month and 6 years, respectively. MRI showed pedunculated hypothalamic hamartoma (HH) in Patient 1 and sessile HH in Patients 2 and 3, which were non-progressing in size over the 4-years follow-up period. Apart from IPP no other abnormalities were noted such as neurological signs and symptoms, diabetes insipidus or anterior hypophyseal insufficiency. The children were treated employing a long-acting GnRH analogue (Diphereline) at the dose of 3.75 μg administered every 4 weeks over the mean period of 4 years which resulted in a decreased intensity and/or complete regression of IPP signs and gonadal axis suppression. Simultaneously, pretreatment height age/bone age ratio improved in all patients from 0.7; 0.8; 1.02 to 1.0; 1.02; 1.07, respectively at the time of last visit. We suggest that regardless of the morphological type of HH, in cases without progression of HH and other endocrine and neurological abnormalities, treatment employing a longacting GnRH-analogue seems to be well founded. Badaniami objęto 3 dzieci w wieku 2 lat (pacjentka1), 2,4 lat (pacjent 2) oraz 8,1 lat (pacjent 3) z gwałtowną progresją izoseksualnego przedwczesnego pokwitania (pp), u których objawy pp takie jak powiększenie gruczołów piersiowych i owłosienie łonowe oraz krwawienie lub powiększenie jąder wystąpiły kolejno w 3 mż, 1 mż oraz w 6 rż. Badanie MRI okolicy podwzgórzowo-przysadkowej ujawniło guz uszypułowany podwzgórza u pacjentki 1 oraz Vol. 3/2004, Nr 4(9) 69 Praca kazuistyczna Endokrynol. Ped., 3/2004;4(9):69-74 guzy nieuszypułowane podwzgórza u pacjentów 2 i 3. Nie stwierdzono progresji zmian w okresie 4 lat obserwacji. Poza pp guzy nie powodowały zaburzeń neurologicznych, moczówki prostej ani niedoczynności przedniego płata przysadki. Leczenie zachowawcze długodziałającym analogiem GnRH w dawce 3,75 ug co 4 tygodnie w ciągu 4-letniego okresu leczenia spowodowało zmniejszenie lub całkowitą regresję cech przedwczesnego pokwitania. Obserwowano także poprawę prognozy wzrostu końcowego wyrażoną wskaźnikiem wiek wzrostowy/ wiek kostny, odpowiednio: 0,7; 0,8; 1,02 (przed leczeniem) do 1,0; 1,02; 1,07 (przy ostatniej wizycie). Wydaje się, że niezależnie od morfologicznego typu guza, w przypadku braku progresji zmiany oraz objawów neurologicznych i innych niż pp zaburzeń endokrynologicznych, stosowane leczenie zachowawcze analogiem GnRH jest uzasadnione. Introduction As a consequence of the use of new brain imaging techniques, hypothalamic hamartoma (HH) is now considered the most common cause of isosexual precocious puberty (IPP), especially in young children [1, 2]. HH is a congenital malformation, consisting of a tumor-like nodule mimicking a normal hypothalamus in the interpeduncular cistern, and usually demonstrating an anatomical connection to the hypothalamus [1, 3, 4]. It can be associated with gelastic seizures, petit-mal or generalized tonic/clonic seizures, developmental delay, behavioral disturbances and dysmorphic syndromes [5]. The indication for surgery of a HH associated with IPP is controversial. At present, both medical and surgical therapies are seen to variably influence precocious puberty and to slow progressive skeletal maturation [1, 6–9]. Current data support the effectiveness and safety of long-acting Gonadotropin Releasing Hormone (Gn-RH) analogue therapy for IPP due to HH [1, 3, 10–12], when the risk involved and the effect of surgery on endocrinological abnormalities is difficult to predict, even employing the recently refined microsurgical techniques. We present the auxological, hormonal and radiological outcome of long-acting Gn-RH analogue treatment in children with IPP due to pedunculated and sessile HH. Patients and methods The investigations included 3 children with rapidly progressing IPP aged 2 years (female Patient 1), 2.4 years (male Patient 2) and 8.1 years (male Patient 3), in whom breast enlargement and menarche were noted at 3 months of age (Patient 1), while testicular enlargement and pubic hair growth were respectively observed at 1 month of age and 6 years of life (Patient 2 and 3) (Table I). The diagnosis of GnRH-dependent IPP was confirmed in all patients by GnRH test (measuring luteinizing hormone (LH) and folliculo-stimulating hormone (FSH) levels before and 20, 30, and 60 min after the administration of 100 ug LHRH, (Ferring, Germany) in IV bolus. Magnetic resonance imaging (MRI) of the hypothalamic-hypophyseal region was performed employing a 1.5 Tesla MRI unit (Signa-Horizon, Hi-Speed, General Electric, USA), with 3-mm slices obtained on sagittal and coronal planes using SE T1 weighted sequences before and after contrast enhancement (Magnevist). In Patient 1 MRI revealed a pedunculated tumor adjacent to the optic nerve chiasm and not communicating with the hypo- Table I. Auxological data Tabela I. Dane auksologiczne Before treatment Last visit Patient Thelarche / Testes P A CA HA BA HA/BA GV Thelarche /Testes P A CA HA BA HA/ BA GV 1. III II + 2.3 3 4 0.7 11.1 II III – 9.3 10 10 1.0 4.3 2. LT-14ml RT-14ml III + 3 5 6 0.83 24.3 LT-9ml RT-9ml II – 6.5 10.2 10 1.02 3.4 3. LT-15ml RT-18ml IV + 8.2 10.2 10 1.02 10 LT-10ml RT-10ml III – 9.7 11.8 11 1.07 3.8 P – pubarche, A-axillarche, LT – left testis, RT – right testis, CA – chronological age, BA – bone age, GV – growth velocity (cm/year), HA/BA – height age/bone age ratio 70 Starzyk J. i inni – Precocious puberty in children triggered by a hypothalamic hamartoma... Figure 2. Cranial MRI of Patient 2 demonstrated sessile (HH – arrow) Rycina 2. MRI czaszki u pacjenta 2 Figure 1. Cranial MRI of Patient 1 demonstrated pedunculated (HH – arrow) Rycina 1. MRI u pacjenta 1 thalamus and the cavernous sinuses, measuring 9 x 9 x 12 mm (Fig. 1), while Patients 2 and 3 were shown to have a sessile tumor situated on the floor of the anterior cranial fossa, adjacent to the mamillary bodies and optic nerve chiasm but not infiltrating the said chiasm, and extending to the hypothalamus, measuring respectively 12 x 11 x 10 mm (Fig. 2) and 12 x 11 x 13 mm (Fig. 3). In none of the patients did the tumor impair the CNS flow, result in elevated intracranial pressure or compression of the optic nerves and cavernous sinuses. No neurological and behavioral abnormalities were noted, or diabetes insipidus or anterior pituitary insufficiency. In all the patients conservative treatment was initiated with a long-acting Gn-RH analogue (Diphereline, Beaufour Ipsen) at the dose of 3.75 ug i.m. administered every 4 weeks, with age at onset of the- Figure 3. Cranial MRI of Patient 3 demonstrated sessile (HH – arrow) Rycina 3. MRI czaszki u pacjenta 3 rapy being 2.3 years (Patient 1), 3 years (Patient 2) and 8.2 years (Patient 3). The follow-up was from 1.5 to 5.6 years mean 3.5 years. In the course of therapy, all the patients demonstrated a partial or total regression of IPP signs according to Tanner (Table I), corresponding to the total or partial gonadal axis suppression detected in the children (Table II). The auxological analysis showed a decelera71 Praca kazuistyczna Endokrynol. Ped., 3/2004;4(9):69-74 Table II. Hormonal data Tabela II. Parametry hormonalne Before the treatment FSH basal uIU/ml (N < 0.1) During the Diphereline treatment Patients LH basal uIU/ml (N < 0.1) LH max (GnRH test*) uIU/ml FSH max (after T E2 pg/ml GnRH ng/ml (N < 7.0) stimulation) (N < 0.5) uIU/m 1.B.A. 2.17 35.7 6.87 11.1 42.6 0.11 0.82 1.16 13.3 0.09 2.W.A 1.2 16.9 1.48 1.24 3.35 4.28 0.6 0.28 2.55 0.07 3.A.Ł 1.92 12.2 2.26 4.39 5.91 1.99 0.79 0.63 - 0.22 LH basal uIU/ml (N < 0.1) FSH E2 T basal pg/ml ng/ml uIU/ml (N < 7.0) (N < 0.5) (N < 0.1) * GnRH test was performed using 100 μg GnRH in i.v. bolus ted growth rate in the course of therapy, from 11.1; 24.3; 10 cm/year in Patients 1, 2 and 3, respectively to 4.3; 3.4; 3.8 cm/year. The predicted target height expressed as the ratio of height age (HA) to bone age (BA), determined according to Bayley-Pinneau [13], was improved in Patients 1, 2 and 3 from 0.7, 0.83, 1.02 to 1.0, 1.02, 1.07, respectively (Table I). No adverse side effects of the therapy were noted. A follow-up MRI performed every year for the mean period of 4 years showed stability of lesion shape, size and signal intensity, what support their hamartomatous and non-progressive nature [1, 14]. Discussion The association of HH with IPP is well established [1, 2, 15, 16]. Patients with HH and other suprasellar lesions (arachnoid cyst, germ cell tumor, glial cell tumor) have physical signs of IPP indistinguishable from those with idiopathic IPP [17–20], although some of them present with a higher post-GnRH stimuli gonadotropin response than do children with idiopathic IPP [1, 18, 21]. The diagnosis of IPP due to HH is suggested by onset of sexual precocity, before 2 or 4 years of age (Rivarola) and concomitant neurological abnormalities [5]. Nevertheless, patients with the above mentioned lesions other than HH were occasionally seen at the early age and presented with some neurological failure, although different from gelastic seizures [18, 19]. An excessive postimulated gonadotropin release was noted only in Patient 1, early onset of IPP in patients 1 and 2, and none of them demonstrated any neurological abnormalities. In accordance with the above data, the diagnosis of HH in all three patients was based 72 on routine head MRI scans performed in all children with IPP. Based on location on MRI scans Arita et al. classified HH into two types: the parahypothalamic type – generally associated with IPP but unaccompanied by seizures or developmental delay, and the intrahypothalamic type – generally associated with seizures and developmental delay, as well as IPP in 50% of patients [22]. The association of the shape of the HH (sessile or pedunculated) with the presence of seizures and IPP was also reported by other authors [3, 7, 23] who noted a higher incidence of seizures in children with sessile HH and IPP than in those with pedunculated HH. Regardless of such a classification, some authors found a correlation between the size of the HH and the occurrence of seizures demonstrating that no patients with a HH diameter of less than 10 mm had seizures, in contrast to all patients with a HH of 25 mm or larger who had seizures [1, 3]. The mean diameter of the HH in our patients ranged between 10 and 12 mm. In a female the lesion was parahypothalamic and pedunculated, while the lesions in both boys were partially intrahypothalamic and sessile. The resection of HH has been recommended as a treatment option for selected cases, such as pedunculated HH, and, independently of the shape of the lesion, in cases of incomplete response to the initial GnRH therapy, tumor mass enlargement or compression of adjacent tissues causing progressive neurological deficit, hydrocephalus or in cases of medically intractable seizures [24–26]. Surgical resection of HH carries an increased risk of morbidity and mortality and, if removal is incomplete, does not arrest the sexual precocity [1, 3]. In all three cases almost 4-year long- Starzyk J. i inni – Precocious puberty in children triggered by a hypothalamic hamartoma... acting GnRH analogue administration provided a satisfactory and safe control of precocity and growth, irrespectively of the morphological type of HH. None of our patients presented with other then IPP hormonal abnormalities, neurological signs and symptoms or tumor progression. A limited number of patients does not allow for formulating firm conclusions, yet – in agreement with observations made by other authors [1, 3, 10–12] – it appears that in patients without neurological signs and well monitored by MRI imaging, long-acting GnRHanalogue treatment can be recommended. 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