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Late Effects Case Presentation. Exeter Sept 2008. Ms J W . Diagnosed Acute Lymphoblastic Leukaemia 1981 aged 5 yrs UKALL X protocol 1981-1984 BCH 18 Gy prophylactic cranial irradiation Chemotherapy but no anthracyclines. Ms JW. First presented late effects clinic 06/2005 No complaints

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Presentation Transcript
ms j w
Ms J W
  • Diagnosed Acute Lymphoblastic Leukaemia 1981 aged 5 yrs
  • UKALL X protocol 1981-1984 BCH
  • 18 Gy prophylactic cranial irradiation
  • Chemotherapy but no anthracyclines
ms jw
Ms JW
  • First presented late effects clinic 06/2005
  • No complaints
  • No hormone replacement
  • 4 months Post Partum
  • Offered anterior pituitary function test
  • T4 TSH “normal”
ms j w4
Ms J W
  • Need for testing??
  • 58% have one or more medical problem
  • 32% have two or more medical problems
  • 41% have an endocrine disorder
  • Stevens et al 1998 Eur J can 34:694
ms j w5
Ms J W
  • Glucagon 1/07/2006
  • Pk GH <1.0 mU/L
  • Pk Cortisol 311 nmol/L
  • IGF1 34.8 nmol/L (14-48)
  • Borderline TFT’s
  • Ft4 9.7pmol/L
  • TSH 4.98mU/L
  • AGHDA 19/25
ms j w7
Ms J W
  • Started on T4 100mcgs
  • SST needed
  • Short synacthen test performed
  • 0mins) 222 nmol/L
  • 30mins) 572nmol/L
ms j w8
Ms J W
  • September 2006
  • T4 duration 5 weeks
  • Reported increased energy levels
  • Weight decreased 3kgs
  • “Feeling great”
  • AGHDA 21/25
ms j w9
Ms J W
  • Glucagon 16/02/2007
  • Pk Cortisol 286 nmol/L
  • Pk GH 5.5 mIU/L (baseline)
  • C/o profound lethargy
  • Started on hydrocortisone daily dose 10mgs/5mgs
ms j w10
Ms J W
  • June 2007
  • c/o profound fatigue
  • Headaches normally afternoons
  • Ringing inner ears
  • IGF1 increased to 51nmol/L (13-37)
  • CT head large atypical looking meningioma
ms j w14
Ms J W

Craniotomy and resection of tumour

January 2008

Neuropathology meningioma WHO

grade 1

Radiotherapy referral

ms j w15
Ms J W
  • March 2008
  • Extremely well
  • No headaches
  • See September with follow up scans
  • Continues hydrocortisone 10/5mgs
  • T4 100mcgs
  • Irregular periods
  • Sex steroids
ms j w summary
Ms J W Summary
  • Late Effects!!
  • Secondary tumours following prophylactic cranial irradiation
  • Progressive hypopituitarism rarely observed at lose radiation dose
  • Endocrinopathy
  • 2 failed glucagons V normal/high IGF1
  • Normal SST
  • Borderline AST