Clinical Practice Guideline

Hypothalamic–Pituitary and Growth Disorders in Survivors of Childhood Cancer

August 01, 2018

 

Full Guideline: Hypothalamic–Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline
JCEM August 2018
Charles A. Sklar (Chair), Zoltan Antal, Wassim Chemaitilly, Laurie E. Cohen, Cecilia Follin, Lillian Meacham, M. Hassan Murad

The 2018 guideline on hypothalamic–pituitary and growth disorders in survivors of childhood cancer:

  • Provides recommendations for the diagnosis and treatment of hypothalamic-pituitary abnormalities and management of impaired growth in childhood cancer survivors
  • Emphasizes improving the quality of life and reducing morbidity of cancer survivors
  • Prioritizes routine lifelong follow-up with an appropriate specialist



Essential Points

  • Establishes a framework for the appropriate diagnosis and treatment of these high-risk individuals;
  • Hypothalamic-pituitary dysfunction is frequently observed in childhood cancer survivors, especially those with tumors involving the hypothalamic-pituitary region or those previously exposed to radiation to the central nervous system;
  • Radiation-induced hypothalamic-pituitary dysfunction is both dose- and time-dependent; doses to the hypothalamus-pituitary <30 Gy are associated primarily with GH deficiency and precocious puberty whereas deficits of LH/FSH, TSH and ACTH are seen following hypothalamic-pituitary doses >30 Gy, often years after completion of cancer therapy;
  • Impaired linear growth and short adult height are most common in survivors exposed at a young age to central nervous system, spinal or total body irradiation;
  • While the testing for and treatment of many of these disorders in cancer survivors are like that in the non-cancer population, the guideline emphasizes key differences and unique features/findings that are specific to the cancer survivor.


List of Recommendations

+ 1.0 SHORT STATURE/IMPAIRED LINEAR GROWTH IN CHILDHOOD CANCER SURVIVORS

Technical Remark
Sitting height is measured directly using a sitting height stadiometer, and lower segment can be determined by subtracting sitting height from standing height.  Alternatively, lower segment can be determined by measuring from the pubic symphysis to the floor, and upper segment can be determined by subtracting leg length from height. Upper to lower segment ratio can then be calculated but differ depending on method used and ethnicity.  In situations where clinicians are unable to measure sitting height, measuring arm span and comparing it to standing height will provide an estimate of spinal foreshortening due to prior spinal radiation.

 

+ 2.0 GROWTH HORMONE DEFICIENCY IN CHILDHOOD CANCER SURVIVORS

Technical Remark
The consensus of the writing committee is to assess height in children every 6-12 months.

 

+ 3.0 CENTRAL PRECOCIOUS PUBERTY IN CHILDHOOD CANCER SURVIVORS

Technical Remark
Clinicians need to interpret plasma luteinizing hormone levels in patients exposed to gonadotoxic treatments in the context of their medical history and physical examination. Elevated luteinizing hormone levels in such patients may be due to primary gonadal injury rather than to the onset of central puberty.

 

+ 4.0 HYPOGONADOTROPIC HYPOGONADISM IN CHILDHOOD CANCER SURVIVORS

+ 5.0 CENTRAL HYPOTHYROIDISM—THYROID-STIMULATING HORMONE DEFICIENCY IN CHILDHOOD CANCER SURVIVORS

+ 6.0 ADRENOCORTICOTROPHIC HORMONE DEFICIENCY IN CHILDHOOD CANCER SURVIVORS

Technical Remark
Clinicians should consider the influence of oral estrogen on total cortisol levels, as it can increase cortisol-binding globulin raising total, but not free, cortisol levels.

 

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