Diagnostic value of pituitary MRI in differentiation of children with normal growth hormone secretion, isolated growth hormone deficiency and multiple pituitary hormone deficiency

Pituitary height, volume and morphology were investigated by MRI in patients aged 3.5-24.9 years with growth hormone deficiency (GHD) in relation to birth history and hormonal findings. Three groups with comparable age, sex and pubertal stage were studied: group I (n=42)--patients with isolated growth hormone deficiency (IGHD); group II (n=22)-- patients with multiple pituitary hormone deficiency (MPHD); and group III (n=30)--healthy controls. Pituitary height and volume differed significantly between the three groups, with the smallest in group II and largest in group III (p <0.001 for both). Both variables correlated significantly with peak GH value in the patient groups (p <0.001). The specificity of pituitary dysmorphology in the determination of GHD was 100% and its sensitivity in differentiation of IGHD and MPHD was 95%. Ectopic neurohypophysis was present in 75% of breech births and 27% of head-presenting patients (p <0.01). This study emphasizes the differential diagnostic value of pituitary MRI and its contribution to the understanding of the pathogenesis and prognosis in GHD.     

Auxological, clinical and MRI findings in Taiwanese children with growth hormone deficiency

Growth hormone deficiency (GHD) may be classified into partial isolated GHD (partial IGHD), severe IGHD or multiple pituitary hormone deficiency (MPHD) by the severity of GHD or associated with deficiency of one or more other anterior pituitary hormones during provocative tests. Morphological alterations on magnetic resonance imaging (MRI) in patients with GHD include pituitary hypoplasia, absence or interruption of pituitary stalk, and absence or ectopic posterior lobe. This study investigated the auxological, clinical severity, and anatomical characteristics of the pituitary hypothalamic region by MRI and correlated their relationships. We evaluated these parameters in 45 Taiwanese children with GHD (31 males and 14 females), aged from 3.13 to 17.91 years (10.5+/-2.5), who were divided into diagnostic subgroups of partial IGHD (18 patients), severe IGHD (13 patients), and MPHD (14 patients). We found that BA-CA, peak GH, IGF-I, IGF-I SDS, and height SDS were significantly different among these three groups. The partial IGHD group had significantly higher IGF-I than the MPHD group. There was no significant difference in prematurity, cesarean delivery, birth order, neonatal jaundice, and target height among these three groups. On MRI, patients with MPHD had significantly smaller pituitary height (PHt) SDS (p = 0.0012) and higher frequency of pituitary hypoplasia, pituitary stalk interruption, and ectopic posterior lobe (p = 0.026, 0.008, 0.005, respectively) than the other two groups. Furthermore, PHt SDS was correlated not only with peak GH (r = 0.40, p = 0.0058), but also with basal IGF-I SDS (r = 0.49, p = 0.0007) and body height SDS (r = 0.44, p = 0.025). In conclusion, morphological alterations on MRI of the hypothalamic-pituitary area are correlated with the severity of hypopituitarism. Meticulous evaluation of auxological, clinical and MRI findings can help evaluation of the severity of hypopituitarism and facilitate appropriate treatment in children with GHD.     

生长激素缺乏症患儿垂体MRI检查的临床应用价值

目的 研究特发性生长激素缺乏症(GHD)儿童垂体MRI检查的临床应用价值,为进一步探索GHD病理机制提供临床依据.方法 选取100例2005-2007年内分泌专科就诊的GHD儿童乖体MRI资料,其中男74例,女26例;平均年龄为(8.82±3.68)岁.于SE序列T1WI头颅正中矢状及冠状面上观测垂体大小形态及信号特征,并比较其与临床的联系.结果 在10～15岁GHD患儿头颅MRI检查垂体矢状高径明显优于其他各径线(P<0.01);在联合垂体功能缺陷(MPHD)中垂体后叶异位(EPP)的发生率(92.3%)显著高于CHD(7.7%,P<0.01).结论 对GHD儿童应重视头颅MRI检查,其垂体形态、结构的阳性发现可有助于临床疾病的诊断及鉴别诊断,必要时应随访MRI,结合临床综合判断诊治及其预后.     

A retrospective evaluation of psychosocial impact of long-term growth hormone therapy

Fifty-eight growth hormone (hGH) deficient adults who had received long-term hGH therapy and their families were contacted to assess their past and current status regarding peer relationships, educational and vocational achievements, and self-concepts. Both heterosexual and same-sex peer relationships were reported as troublesome; most reported problems with having been treated as younger than their chronologic ages. The majority reported average or above average academic performance; there were no significant differences between academic achievements of the expatients and their siblings; the greatest portion of the sample were employed at least part-time and were satisfied with their employment status. On self-concept measures, the sample rated themselves higher in self-satisfaction, personal work, and sociality, but lower on physical self and self-criticism than norms; most of the parents reported no significant differences between the patients' adjustment and that of their siblings. In addition, the recommendations from the group to others considering hGH treatment and to medical personnel working with such families are noted; implications for hGH intervention are discussed.     

生长激素在儿科应用进展

自1985年重组人生长激素开始在生长激素缺乏症中应用以来,二十多年间其应用范围扩展至先天性卵巢发育不全综合征、小于胎龄儿、特发性矮小、慢性肾功能不全等疾病,取得良好的临床效果,总体安全性良好.但仍需注意监测治疗期间及其后可能出现的不良反应,注意严格选择使用生长激素治疗的适应证,选择治疗最佳时机和合理剂量,这样才能既获得较理想的疗效,又节省治疗费用.同时,长效生长激素及不同给药途径生长激素等的研制,使其应用更方便,增加了依从性.该文就其在临床上的应用进展做一综述.     

Effect of growth hormone therapy on bone metabolism of growth hormone deficient children

The effects of human growth hormone (hGH) therapy on biochemical markers of bone metabolism were studied in 17 children (10 boys and 7girls, aged 3.7–13.1 years old) with idiopathic GH deficiency, before and 1 and 6 months after GH therapy (0.5–0.7 IU/kg weekly, SC). Serum levels of calcium, phosphate, alkaline phosphatase, osteocalcin, parathyroid hormone, 1,25 dihydroxyvitamin D, insulin-like growth factor I (IGF-I) and renal phosphate per 100 ml glomerular filtrate (TPO₄/GFR) were assessed. During therapy with hGH, a significant decrease of serum calcium levels and increases of phosphate, osteocalcin, parathyroid hormone 1,25 dihydroxyvitamin D and IGF-I were observed. TPO₄/GFR was also significantly increased. Growth response (increment in HV) was positively related with changes in alkaline phosphatase and IGF-I levels after 6 months of hGH therapy. There was also a significant positive correlation between increment in HV and increment in TPO₄/GFR after 1 month of GH therapy, whereas no correlation between HV and changes in osteocalcin levels was found. Conclusion GH treatment significantly influences mineral metabolism and the measurement of TPO₄/GFR after 1 month of GH therapy may serve as a useful predictor of growth response to hGH therapy in GH-deficient children. Received: 16 August 1996 / Accepted: 5 February 1997     

Posterior pituitary ectopy in children with idiopathic growth hormone deficiency

AIMS: To evaluate the underlying pathogenesis in children with pituitary hormone deficiency by means of high resolution MRI of the brain. PATIENTS/METHODS: Thirty-seven children with short stature and isolated GH deficiency (IGHD, n = 17) or multiple pituitary hormone deficiency (MPHD, n = 20) were subjected to an MRI of the brain at the age of 1.0-17.3 years. The anatomic condition of the hypothalamo-pituitary area was analyzed and the height of the pituitary gland was measured and compared to the data of age-matched healthy subjects. RESULTS: Seventy percent of the patients had a characteristic anomaly: the adenohypophysis was hypoplastic, the infundibulum was absent and the posterior pituitary lobe was ectopic at the bottom of the median eminence. The height of the anterior pituitary was significantly reduced in these patients (1.9 +/- 0.1 mm; mean +/- SD) when compared to age-matched healthy controls (4.1 +/- 0.8 mm, p<0.001) or hypopituitary patients with a normal MRI (4.3 +/- 0.8 mm). MPHD was found in 62% of patients with the pituitary anomaly whereas only 27% of children with a normal MRI had MPHD (p<0.05). CONCLUSIONS: The pathogenesis of the pituitary anomaly is unknown; a disorder during embryonal development or perinatal events have been discussed as causal factors. MRI should have a prominent position in the work-up of hypopituitary children. When an anatomical malformation is visualized by MRI, the diagnostic terminology should be adapted accordingly.     

Responses of bone turnover markers and bone mineral density to growth hormone therapy in children with isolated growth hormone deficiency and multiple pituitary hormone deficiencies

Growth hormone deficiency (GHD) is an important cause of decreased bone mass in childhood and adolescence. The role of other pituitary hormone deficiencies on bone mass is still a query in children. Thirty-nine children (28 with isolated GHD [IGHD] and 11 with multiple pituitary hormone deficiency [MPHD]) were investigated to show the effects of IGHD vs MPHD on bone status. Bone turnover markers (calcium, phosphate, alkaline phosphatase [ALP] Bone ALP [BALP], osteocalcin [OSC], carboxyterminal propeptide of type-1 collagen [CPP-I], parathyroid hormone [PTH]) were measured before and every four months during growth hormone (GH) therapy; bone mineral density (BMD) of the lumbar spine was measured before and every six months during therapy. All bone turnover markers except calcium and PTH increased significantly during 1 year of GH therapy. There were no differences in the levels of bone turnover markers between children with IGHD and MPHD at baseline, and after 4, 8 and 12 months of therapy. Lumbar spine BMD SDS of all patients increased significantly during 1 year of therapy (p = 0.035 after 6 months and p <0.001 after 12 months compared with baseline). BMD SDS of both IGHD and MPHD groups were similar at baseline and after 6 and 12 months of therapy (p = 0.235, p = 0.295 and p = 0.384). Height SDS (HtSDS) at baseline was the most important predictor of baseline BMD SDS in children with GHD (t = 4.166, p <0.001). DeltaHtSDS was also positively related to deltaBMD SDS after 1 year of GH therapy. In conclusion, there was no difference in bone status of the patients with IGHD and MPHD at baseline. GH therapy yielded similar increases in bone mass in both groups. Increase in height contributed to increase in BMD during 1 year of GH therapy.     

Human growth hormone therapy of non-growth hormone deficient children

With biosynthetically derived human growth hormone (hGH) available in large quantities, attempts will be made to promote growth in short children who do not fulfill the 'classical' criteria for growth hormone deficiency (GHD). By these criteria, GHD is excluded if hGH levels to pharmacological stimuli exceed a definite level. Several studies have shown that a variety of short children, who are not growth hormone deficient by these criteria, will demonstrate an increased growth rate with hGH treatment. A subpopulation of children with clinical features of GHD, delayed bone age and low somatomedin levels, have low levels of spontaneously secreted growth hormone or 'bioinactive' growth hormone. These children increase their growth rates to substitution doses of hGH. In other children whose growth disorder is not likely to be caused by a disorder in the growth hormone-somatomedin axis, growth increments are occasionally seen on higher hGH doses. Future long-term studies--carefully considering the ethics of such approaches--will have to evaluate the relationships between hGH dose and both metabolic and growth responses and side effects in children with short stature in order to define more specifically further target groups of short children who will benefit from hGH therapy.     

磁共振成像在生长激素缺乏症中的应用

磁共振成像(MRI)技术可观察患儿垂体大小、形态、结构的变化及与周围结构的关系,结合多种激素检查,对于生长激素缺乏症的精确诊断、合理治疗及其预后的判断均有较大价值.生长激素缺乏所致的侏儒症是儿童矮小最常见的原因之一,常见原因为原发性垂体发育不良、空蝶鞍、颅咽管瘤.     

Comparison of growth hormone releasing hormone therapy and growth hormone therapy in growth hormone deficiency

Seven children with growth hormone deficiency of hypothalamic origin responded to an i.v. bolus of growth hormone releasing hormone (GHRH) (1–29)-NH2 with a mean serum increase of 10.7 ng/ml growth hormone (GH) (range 2.5–29.3 ng/ml). Continuous s.c. administration of GHRH of 4–6 g/kg twice daily for at least 6 months did not improve the growth rate in five of the patients. One patient increased his growth rate from 1.9 to 3.8 cm/year and another from 3.5 to 8.2 cm/year; however, the growth rate of the latter patient then decreased to 5.4 cm/year. When treatment was changed to recombinant human growth hormone (rhGH) in a dose of 2 U/m² daily, given s.c. at bedtime, the growth rate improved in all patients to a mean of 8.5 cm/year (range: 6.2 to 14.6). Presently GHRH cannot be recommended for the routine therapy of children with growth hormone deficiency since a single daily dose of rhGH produced catch-up growth which GHRH therapy did not.Abbreviations GH growth hormone - GHD growth hormone deficiency - GHRH growth hormone releasing hormone - hGH human growth hormone - rhGH recombinant human growth hormone - SM C/IGF I somatomedin C/insulin-like growth factor I On the occasion of the 85th birthday of Prof. Dr.Dr.h.c. mult. Adolf Butenandt     

The effect of human growth hormone therapy on skinfold thickness in growth hormone-deficient children

Skinfold thickness (ST) was measured in 43 children with various forms of growth hormone (GH) deficiency during the first year of GH therapy. The average (and SEM) initial ST, expressed as standard deviation score (SDS) was 1.17 (0.25) for subscapular, 0.63 (0.18) for triceps, and 0.40 (0.21) for biceps ST. During therapy the average decrease is 1 SD. Children in the pubertal age group and those with partial GH deficiency showed smaller decreases. A larger decrease of triceps ST was associated with lower GH and insulin peaks, and lower age, bone age and initial weight-for-height. Some correlations between ST decrease and growth response in the first year were significant, but still too low to allow of reliable predictions. The same was true for other clinical parameters. These data indicate that a chronic lack of GH leads to unequal fat distribution, possibly due to different sensitivities to GH in the trunk and extremities. The variability of ST responses to GH therapy limits clinical applications.Abbreviations GH growth hormone - hGH human growth hormone - SDS standard deviation score - SDS_BA standard deviation score for bone age - SDS_CA standard deviation score for chronological age - SEM standard error of the mean - ST skin fold thickness - ST-SDS skinfold thickness, expressed as a standard deviation score - ST-log skinfold thickness, expressed as 100.log₁₀ (reading in 0.1 mm-18) - TSH thyroid stimulating hormone     

Sustained effect of human growth hormone therapy on children with intrauterine growth retardation

Previous studies have not clarified whether human growth hormone (HGH) therapy can significantly increase the height of patients with intrauterine growth retardation (IUGR). To determine whether the initial increase in growth rate is sustained through subsequent treatment, 19 prepubertal patients who had IUGR were treated with HGH. Ten of them received a second treatment course. Growth rates (in centimeters per year) were 4.8 +/- 1.4 (mean +/- SD) for the pretreatment period, 7.6 +/- 2.3 for the first treatment period, 4.2 +/- 2.5 for the interval between treatments, 5.9 +/- 1.4 for the second treatment period, and 4.3 +/- 2.6 for the posttreatment period. Growth rates for the two treatment periods were significantly greater than for the periods before, interval between, and posttreatment. Height expressed as the number of standard deviations below the mean for age increased significantly between the onset of treatment and the most recent measurement. These data indicate that HGH has a sustained positive effect on increasing growth rates in children with IUGR, although the magnitude of the effect may decrease with further treatment. Furthermore, we suggest that it is worthwhile to treat patients who have IUGR with HGH for prolonged periods of time, if supplies exceed those necessary to treat children with growth hormone deficiency.     

A review of growth hormone deficiency

Growth hormone deficiency (GHD) is a rare but important cause of short stature in children. It is treatable. However, diagnosis is challenging and often requires referral to a specialist paediatric endocrinologist to facilitate testing and the interpretation of results. Careful history and examination with meticulous auxology data are critical components of the initial evaluation in clinic. Thereafter, further investigations are required to exclude other causes of short stature, and to establish the diagnosis. It is a highly variable condition and to an extent the clinical features depend upon the severity of GHD itself. GH stimulation tests may be indicated in the short child who is growing slowly and who has low growth factor concentrations. There is, however, no consensus with respect to a diagnostic gold standard test for GHD, and this is usually based upon a combination of clinical, biochemical, and neuroradiological data, although molecular diagnosis may aid in years to come. This short article gives an overview of the importance of GHD and offers advice on how to take a history, conduct and examination and begin investigation for a child with suspected GHD. It discusses the known benefits and potential risks of treatment and offers practical advice for the generalist.     

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??Abstract??Objective??To study the changes of shape?? size and signal intensity of pituitary gland in idiopathic growth hormone deficiency??IGHD??in adolescent. Methods??Clinical data of pituitary MRI of 100 puberty with IGHD were chosen from the Endocrine Department of Peking Union Medical College Hospital from January 2005 to January 2010??Compared these results with the normal. Results??There were significant difference of the superior shape of the pituitary and the MRI signal between the study group and control group. The height of pituitary gland and the width of pituitary stalk in the study group were significantly smaller than the control group ??P < 0.01??. There were three major imaging features of the pituitary MRI in IGHD cases?? the pituitary hypoplasia?? the posterior lobe of pituitary dystopia or disappear and the pituitary stalk thinning or disappear. Conclusion??There is a remarkable change of the pituitary in IGHD cases.It is necessary to combine the MRI of the pituitary with the clinical and laboratory findings to diagnose IGHD.     

Correlation between pituitary growth hormone reserve and degree of growth failure in children with short stature

The correlation between a releasable pituitary growth hormone (GH) pool and degree of growth failure was examined in 30 children with GH deficiency (group I) and 19 children with normal short stature (group II). Based on the responsiveness of GH to GH-releasing hormone (GHRH), group I, with low GH responses (below 7 ng/ml) to both insulin and arginine, was classified into three subgroups; I_a (peak value less than 10 ng/ml, n=19), I_b (10–20 ng/ml, n=5) and I_c (above 20 ng/ml, n=6). Group II, with a GH response above 10 ng/ml to either insulin or arginine, was also divided into II_a (below 20 ng/ml, n=5) and II_b (above 20 ng/ml, n=14). Body length and growth velocity in I_a and I_b were significantly reduced vs I_c; bone age in I_a was retarded vs I_c; plasma somatomedin C (Sm-C) levels in I_a and I_b were decreased vs I_c, who had almost normal levels (0.90±0.55 U/ml). The incidence of other combined pituitary hormone deficiencies and previous perinatal distress was definitely high in I_a and I_b, but zero in I_c. In group II also, body length and growth velocity were significantly decreased in II_a vs II_b (P<0.01). These results indicate that [1] the pituitary reserve of GH estimated by GHRH is a good reflection of the degree of growth failure in GH-deficient children as well as in those of normal short stature, [2] hypothalamic GHRH deficiency tends to have a milder effect on growth retardation than pituitary GH deficiency, and [3] normal short children with a diminished GH reserve may be potential candidates for the GH treatment.Abbreviations ACTH adrenocorticotropin - LH luteinizing hormone - LH-RH luteinizing hormone-releasing hormone - GH growth hormone - GHRH growth hormone-releasing hormone - Sm-C somatomedin C - TRH thyrotropin-releasing hormone - TSH thyrotropin