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Published by Oxford University Press on behalf of the Endocrine Society 2024. This work is written by (a) US
Government employee(s) and is in the public domain in the US.

The spectrum of growth hormone excess in Carney complex and genotype-phenotype

correlations

Christina Tatsi

, Georgia Pitsava

, Fabio R. Faucz

, Meg Keil

, Constantine A. Stratakis

1, 2, 3, 4

(1)

Unit on Hypothalamic and Pituitary Disorders,

Eunice Kennedy Shriver

National Institute of

Child Health, and Human Development, National Institutes of Health, Bethesda, Maryland,

USA

(2)

Molecular Genomics Core,

Eunice Kennedy Shriver

National Institute of Child Health and

Human Development, National Institutes of Health, Bethesda, Maryland, USA

(3)

Office of the Clinical Director,

Eunice Kennedy Shriver

National Institute of Child Health, and

Human Development (NICHD), National Institutes of Health, Bethesda, Maryland, USA

(4)

Human Genetics & Precision Medicine, IMBB, FORTH, Heraklion, Greece

(5)

Medical Genetics, H. Dunant Hospital, Athens, Greece

(6)

ELPEN Research Institute, Athens, Greece

Running title:

Growth hormone excess in Carney complex

Keywords

: Carney complex, growth hormone, pituitary, acromegaly

Corresponding author and person to whom reprints should be addressed:

Christina Tatsi MD, MHSc, PhD (ORCID: 0000-0002-2882-4585)

Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)

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10 Center Drive, Building 10, Rom 1-3330, MSC1103

Bethesda, Maryland 20892

E-mail: christina.tatsi3@nih.gov

Funding:

The work was supported by the Intramural Research Program,

Eunice Kennedy Shriver

National

Institute of Child Health & Human Development (NICHD), National Institutes of Health.

ClinicalTrials.gov ID

NCT00001452

Disclosure Statement:

CAS holds patents on technologies involving

PRKAR1A, PDE11A, GPR101

andtheir function ;

SEGEN received research funding support by Pfizer Inc. for work unrelated to this project. CAS

receives remuneration from ELPEN, Sterotherapeutics, and Lundbeck pharmaceuticals and is a

consultant for Human Longevity, Inc. CT received research funding on treatment of abnormal

growth hormone secretion by Pfizer, Inc for unrelated studies.

Data Availability

Restrictions apply to the availability of some or all data generated or analyzed during this study

to preserve patient confidentiality or because they were used under license. The corresponding

author will on request detail the restrictions and any conditions under which access to some

data may be provided.

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Abstract

Context:

Carney complex (CNC) is a familial neoplasia syndrome associated with growth

hormone (GH) excess (GHE).

Objective:

To describe the frequency of GHE in a large cohort of patients with CNC, and to

identify genotype-phenotype correlations.

Methods:

Patients with CNC with at least one biochemical evaluation of GH secretion at our

center from 1995-2021 (n=140) were included in the study. Diagnosis of GHE was based on

levels of insulin-like growth factor-1 (IGF-1), GH suppression during oral glucose tolerance test

(OGTT), GH stimulation after thyrotropin (TRH) administration and overnight GH secretion.

Results:

Fifty patients (35.7%) had GHE and 28 subjects (20%) had symptomatic acromegaly,

with median age at diagnosis of 25.3 and 26.1 years respectively. Most of the patients (99.3%)

had a

PRKAR1A

gene defect. There was a higher risk of GHE in patients harboring a variant that

led to no expression of the affected allele [Hazard risk (HR): 3.06, 95% Confidence Intervals (CI):

1.2-7.8] and for patients harboring the hotspot variant c.491_492delTG (HR: 2.10, 95%CI: 1.1-

4.1). Almost half of patients with CNC had an abnormal finding on pituitary imaging. CNC

patients with an abnormal pituitary imaging had higher risk of GHE (HR: 2.94, 95%CI: 1.5-5.8),

especially when single or multiple adenoma-like lesions were identified. Management of

patients with symptomatic acromegaly involved surgical and medical approaches.

Conclusion:

Dysregulation of GH secretion is a common finding in CNC. The clinical spectrum of

this disorder and its association with genetic and imaging characteristics of the patient make

prompt diagnosis and management more successful.

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Introduction

Carney complex (CNC) is a multiple neoplasia syndrome presenting as the complex of

myxomas, spotty skin pigmentation and endocrine overactivity [1]. Most of the patients with

CNC harbor an inactivating defect in the

PRKAR1A

gene which codes for the regulatory subunit

1A of protein kinase A (PKA). Additional gene defects such as the CNC2 locus on chromosome 2

and

PRKACB

abnormalities have been described in a few cases of CNC or CNC-like conditions [2-

4].

The main presenting features of patients with CNC include cardiac myxomas, skin

findings (cutaneous myxomas, lentigines and others), Cushing syndrome (CS) due to primary

pigmented nodular adrenocortical disease (PPNAD), thyroid nodules or carcinomas, breast and

testicular tumors, and more rare tumors, such as psammomatous melanotic schwannoma(PMS)

and osteochondromyxomas (Table 1) [5]. Growth hormone (GH) excess (GHE) and acromegaly

is the most common endocrine manifestation of pituitary involvement in CNC and is included in

the main diagnostic criteria of the syndrome [6]. GHE is the result of gradual evolution from

somatotroph hyperplasia to the formation of distinct GH-secreting pituitary adenomas which

are often but not always the cause of clinically significant gigantism or acromegaly [7]. Previous

studies on patients with CNC have reported that dysregulation of GH secretion presents in 30-

75% of patients and almost 15-18.9% develop acromegaly [7 8]. However, the spectrum of GHE

in this syndrome still remains unclear.

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We studied the spectrum of GHE in a large cohort of patients with CNC. The data

provide important insight for the monitoring and management of the disease.

Subjects and methods

Subjects

Subjects enrolled under the protocol 95-CH-0059 at the

Eunice Kennedy Shriver

National

Institute of Child Health and Human Development (NICHD) from 1995 until 2021, were

screened for eligibility in the study. Patients with clinical diagnosis of CNC who have been

evaluated at the NIH Clinical Research Center (CRC) and had at least one biochemical evaluation

of GH secretion were included. Clinical diagnosis of CNC was based on previously published

criteria shown in Table 1 [6]. Informed consent was obtained from all adult patients and

parents of pediatric patients, and assent was obtained from children and adolescents if

developmentally appropriate. All study procedures were approved by the

Eunice Kennedy

Shriver

National Institute of Child Health & Human Development (NICHD) Institutional Review

Board (IRB).

Biochemical evaluation of growth hormone secretion

Patients underwent measurement of insulin-like growth factor-1 (IGF-1, n=132) and assessment

of GH nadir during an oral glucose tolerance test (OGTT, n=109). In a subset of patients

recruited before 2000, the evaluation of GHE included also a thyrotropin-releasing hormone

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(TRH) stimulation test (n=18, total number of tests= 26) and overnight GH-serial sampling

(n=20, total number of tests= 24). IGF-1 is reported as z-

score based on the laboratory’s age,

sex and Tanner stage specific reference range, and was considered abnormal when z-score was

>2 standard deviation scores (SDS). IGF-1 levels measured at the time of active CS were

excluded. OGTT was performed with the administration of 1.75 g/kg (max 75 g) of dextrose and

measurement of GH at times 0, 30, 60, 90, 120, and 180 min. Glucose and prolactin (in certain

occasions) were also measured at the same timepoints. OGTTs where patients did not achieve

sufficient hyperglycemia (glucose >135 mg/dL) were excluded. OGTT was considered suggestive

of GH excess if nadir GH was >2 ng/dL before 1999 and >1 ng/dL after 1999 (following

corresponding changes in the assay). Overnight GH serial sampling was performed during an

inpatient admission. Briefly, an IV catheter was inserted, and serial samples were collected

every 20 min from 20:00h until 08:00h. Mean integrated GH secretion, pulse frequency, nadir

GH level and area under the curve (AUC) were calculated. The test was considered abnormal

when mean GH levels were >2.5 ng/dL and nadir GH was >2 ng/dL before 1999 or > 1 ng/dL

after 1999 [9]. TRH stimulation test was performed as previously described. Briefly, TRH (200



g) was administered via rapid IV injection and GH levels were measured at times -15, 0, 30, 45,

60 and 90 min. The test was considered suggestive of GH excess if GH increased by more than

50% after TRH administration [10]. Patients with inconsistent biochemical testing (for example

normal IGF-1 with non-suppressed GH to glucose suppression or elevated IGF-1 with

suppressed GH during OGTT) and lack of clinical findings consistent with acromegaly were

considered as GHE whereas patients with multiple labs and clinical picture consistent with

acromegaly as assessed by the treating physician were classified as acromegaly. GH was

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measured with polyclonal radioimmunoassay until 1999, and with chemiluminescence

immunoassay on Siemens Immulite 2000 XPI analyzer after 1999 (latest antibody: Siemens Cat#

L2KGRH2, RRID: AB_2811291, Siemens, Erlangen, Germany; older antibodies unable to retrieve

RRID), and because of assay differences GH results were analyzed separately for the two

periods (before 1999 and after 1999). IGF-1 was measured with radioimmunoassay until 1998

and with chemiluminescence immunoassay on Siemens Immulite 2000 XPI analyzer afterwards

(latest antibody: Siemens Cat# L2KGF2, RRID: AB_2756880, Siemens, Erlangen, Germany; older

antibodies unable to retrieve RRID). Prolactin was measured with radioimmunoassay until

2004, microparticle enzyme immunoassay on Abbott AxSYM System (Abbott, Illinois, USA) from

2004-2007, and with chemiluminescent immunometric assay on Siemens Immulite 2000 XPi

analyzer after 2007 (latest antibody: Siemens Cat# L2KPR2, RRID: AB_2827375, Siemens,

Erlangen, Germany; older antibodies unable to retrieve RRID).

Genetic evaluation

Evaluation of

PRKAR1A

gene (NM_212471.2, OMIM: 188830) was performed in house

and confirmed for clinical use by GeneDx (Gaithersburg, MD; www.genedx.com). The molecular

evaluation included Sanger sequencing and multiplex ligation-dependent probe amplification

(MLPA) analysis for assessment of deletions/duplications (https://www.genedx.com/test-

catalog/disorders/carney-complex/). Variants were classified as expressed or not expressed

based on previously published data [11] and data reported in the

PRKAR1A

mutation database

(https://prkar1a.nichd.nih.gov/hmdb/mutations.html).

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Magnetic Resonance Imaging (MRI)

MRI scans (MRIs) were performed as previously described [12]. All MRIs were

performed before and after intravenous administration of gadolinium contrast material. MRIs

were reviewed by a radiologist and the principal investigator of the protocol. We classified MRIs

as abnormal when a lesion consistent with an adenoma (hypoenhancing after contrast

administration), heterogeneity suggestive of an adenoma or multiple adenomas, and

asymmetry of the gland were identified.

Statistical analysis

Categorical data are presented as counts and proportions and compared between

groups using χ

test or Fisher’s exact test as appropriate and presented as odds ratio (OR) and

95% confidence intervals (CI) as necessary. Continuous data were checked for normality based

on histogram distribution and the Shapiro-Wilk statistical test. Continuous data with normal

distribution are described as mean (standard deviation) and were compared between groups

using student’s t

-test. Continuous data without normal distribution are presented as median

(interquartile range) and were compared between groups using Wilcoxon rank-sum test. Cox

proportional hazard (PH) was used to compute hazard risk (HR) and 95% CI. Adjustment for

multiple comparisons was performed in results of effects of genetic findings on the risk for GHE

using the Benjamin and Hochberg method. Results were considered significant if p-value was <

0.05. Statistical analyses were performed in R.

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Results

Patient characteristics

We identified 140 patients from 78 unique families, with clinical diagnosis of CNC who

met the inclusion criteria of this study (Table 2). GHE suggested by biochemical dysregulation of

GH secretion as described above was present in 50 patients (35.7%) from 36 unique families.

The median age at diagnosis of GHE was 25.3 years (range: 9.5-61.2), with the youngest patient

diagnosed at the age of 9.5 years old. The penetrance of GHE is shown in Figure 1A. From the

cohort of patients with GHE, clinical acromegaly was present in 28 patients (20%) from 22

unique families. The median age at diagnosis of acromegaly was 26.1 years (range: 9.5-61.2)

and the penetrance of the disease over time is shown in Figure 1B. We did not identify a

significant difference at the age of diagnosis in patients with previous family history of CNC

compared to those without [median age of GH dysregulation and clinical acromegaly in patients

with positive family history 23.3 (20.3) and 20.7 (20.2) vs. the corresponding age in patients

without family history 26.9 (22.8) and 29.4 (18.6), p= 0.48 and p= 0.13 respectively]. We did

however note that many patients were diagnosed with GH dysregulation or clinical acromegaly

at the time of their first evaluation at our center.

We investigated whether patients who developed biochemical dysregulation of GH

secretion differed from those without (Table 2), and no significant difference was identified in

their demographic characteristics. As expected, there were differences in anthropometric

factors (height and weight z-scores), which were more pronounced when we excluded patients

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with diagnosis of CS which may also affect these factors (data not shown). Similar findings were

seen when we compared patients with and without clinical acromegaly.

Evaluation of GH secretion

Biochemical evaluation of GH secretion was performed with several markers. Table 3

presents the results of the diagnostic tests at the time of GHE, acromegaly or no GH secretion

dysregulation. Of note, some patients underwent these tests multiple times during their follow-

ups; Table 3 includes results under the corresponding category of the overall evaluation of the

GH axis at the time of the test. Table 4 summarizes their diagnostic yield at the time of

diagnosis of GHE or clinical acromegaly. All patients with clinical acromegaly had abnormal IGF-

1 and lack of GH suppression in OGTT at the time of diagnosis. On the contrary, dysregulation of

GH secretion in subclinical biochemical GHE was identified in a variety of tests. More

specifically, IGF-1 and GH suppression during OGTT were within the normal range for patients

with GHE in 18.8% and 27.9% respectively. Baseline prolactin levels were not suggestive of

combined GH and prolactin secretion in any patients [median prolactin: 13 mcg/L (12.2) in

patients with GH dysregulation and 12.5 mcg/L (16.8) in patients with clinical acromegaly].

Overnight GH secretion and TRH stimulation tests were performed as part of the

diagnostic evaluation of GH secretion in a subset of patients and provided important insights in

the presentation of GHE. Serial overnight sampling yielded various patterns that represented

the evolution of GH dysregulation in this population (Figure 2). Results from patients without

GH dysregulation at the time of the test revealed a median of 4 pulses with undetectable GH

levels between the pulses. In contrast, results from patients with GH dysregulation at the time

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of the test showed overall increased GH without reaching undetectable levels. The GH levels

were significantly higher in tests performed at the time of clinical acromegaly. Additionally, not

only the mean GH levels but also the AUC were significantly different in these groups of

patients. Prolactin levels measured in a portion of patients did not reveal any characteristic

pattern. TRH stimulation test was consistent with abnormal GH secretion regulation. Both the

peak GH and the ratio of peak to baseline GH were different in patients with GHE compared to

the remaining patients. Prolactin responses to TRH did not show similar pattern (Table 3).

When looking into the OGTT results, data collected at the time of GHE showed, as

expected, higher nadir GH level. It is worth noting that certain patients with GHE showed

suppression of GH after glucose, but dysregulation of their GH secretion was evident by

overnight GH sampling and TRH stimulation data, or they had consistently elevated IGF1.

Additionally, patients with GHE showed a higher level of GH at 3 hours suggesting an

exaggerated paradoxical response and a slightly higher nadir prolactin level.

Genotype-phenotype correlation

Genetic evaluation for

PRKAR1A

gene defects identified a pathogenic variant or gene

deletion in most patients (137 out of 138 with available results, 99.3%). The diagnosis of GHE or

acromegaly was not associated with the type of mutation (missense, nonsense, frameshift,

splice site, partial or complete gene deletion), or with the location of the pathogenic variant in

the gene (exon vs intron, or domain of the protein). However, there was an association of GHE

and the expression status of the

PRKAR1A

affected allele. Specifically, patients harboring a

variant that led to a non-expressed allele, either because of deletion of the gene or non-sense

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mediated decay (NMD), had a higher risk for developing GHE (HR: 3.06, 95%CI: 1.2-7.8, Figure

3A).

Investigating the risk of individual mutations for dysregulation of GH secretion was

difficult to interpret in most cases, because most variants were present in single families. The

common frameshift variant c.491_492delTG (p.Val164Aspfs*5, rs281864790), reported in 15

patients from 6 separate families, was associated with increased risk for developing GHE (HR:

2.10, 95%CI: 1.1-4.1) None of the other variants present in more than one family was

associated with change in the risk for GHE or acromegaly after correcting for multiple

comparisons.

MRI findings and GH dysregulation

MRI abnormalities were present in 67 of 120 patients (55.8%) with available images for

review of the whole cohort. The frequency of GHE or acromegaly was higher in patients with

abnormal MRI compared to those without any abnormality (OR: 3.74, 95%CI: 1.7-8.3, and OR:

6.40, 95%CI: 2.1-20.0, for GHE and acromegaly respectively) (Figure 4A). The MRI abnormalities

ranged from asymmetry of the pituitary gland and heterogeneous enhancement after contrast

administration (which could represent hyperplasia though this is hypothetical and not

confirmed histologically), to single or multiple adenomas (Figure 5). To account for the fact that

pituitary abnormalities may develop over time, we also looked at the probability of developing

GHE in patients with and without MRI abnormality with a time-to-even analysis; there was an

overall increased risk for developing GHE for patients with abnormal MRI compared to those

without (HR: 2.94, 95%CI: 1.5-5.8). When looking at the findings of the MRI, the presence of

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single or multiple adenomas yielded a higher risk for GHE compared to patients with a normal

MRI (HR: 3.22, 95%CI: 1.6-6.6 for single adenoma, and HR: 6.88, 95%CI: 2.8- 17.1 for multiple

adenomas, Figure 4B), while other subtle abnormalities did not confer additional risk compared

to a normal MRI (HR: 0.68, 95%CI: 0.1-3.0).

Management of patients with clinical acromegaly

The management of patients was often individualized based on the patient’s age at

diagnosis, degree of GHE as shown on biochemical results and clinical findings, imaging findings,

and the presence of other comorbidities, such as cardiac myxomas. Of the 28 patients with

clinically significant GHE, 13 patients underwent transsphenoidal surgery with or without

previous trial of medical therapy; 9 (69.2%) of these patients showed signs of remission at 1.3

to 21.5 years of follow up after treatment, while 3 patients had persistent disease that required

medical therapy and 1 had an unknown outcome due to lack of follow up. One of the 3 patients

with persistent disease after TSS discontinued medical therapy 10 years later and did not

experience recurrence of her symptoms while the pituitary MRI also showed a small gland with

no signs of adenoma, suggesting potential apoplexy of the residual tumor. In 11 patients,

medical treatment was recommended or started with either a somatostatin analogue or a

dopamine agonist. In the remaining 4 patients, monitoring was recommended. Unfortunately,

as our center does not provide primary endocrine care, we are not able to provide data on long

term efficacy of medical therapy in our complete cohort.

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Genetic evaluation of resected tumors

We were able to confirm loss of heterozygosity (LOH) in two available pituitary resected

lesions (data not shown). In a third available resected material, we were not able to confirm

LOH but neither the presence of adenoma in the resected material available for research

purposes, which is not uncommon given the small size of these pituitary lesions.

Discussion

GHE is one of the presenting features of CNC. We provide in this report the largest data

set focusing on the spectrum of GHE in the context of CNC. Gigantism or acromegaly are

present in up to one third of patients with CNC. We identified a higher risk of GHE in patients

with abnormal MRI findings, including single or multiple adenomas. Additionally, patients

harboring variants that lead to a non-expressed allele had a higher risk for GHE. Symptomatic

acromegaly was present in 20% of patients and surgical approaches in cases where an adenoma

was present offered sustained remission.

The clinical presentation of GHE in CNC has significant heterogeneity. The younger

patient with signs of GHE in our cohort was 9.5 years old and 13 of the 50 patients (26%)

presented with GHE before the age of 18 years. We would thus recommend that along with

annual monitoring of the growth chart, screening with IGF-1 should start at least at the age of 9

years or at the start of puberty as current expert recommendations suggest (whichever occurs

first) and continue annually. Clues of the history that may suggest more comprehensive testing

may derive from the MRI findings. Since patients with GHE have higher odds of having an MRI

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with adenoma-like lesion, especially when multiple adenomas are present, these patients

should be investigated with both IGF-1 and OGTT, and if results are not consistent with further

testing as mentioned above.

Previous studies have well described the possibility of discrepancy of IGF-1 and GH

secretion in patients with acromegaly [13]. In our cohort relying on IGF-1 and GH suppression

during OGTT would miss approximately 1 in 5 and 1 in 3 patients with GHE respectively. This

shows the importance of performing additional tests for GH secretion when appropriate.

Although TRH stimulation test is not widely available in the US, it may help identify a subset of

patients with GHE where somatotroph cells abnormally respond to TRH [14]. Further, overnight

GH sampling provides substantial information on the overall pattern of GH secretion and should

be considered in cases where GHE is suspected but OGTT and/or IGF-1 are not consistent with

the diagnosis. Significant hyperprolactinemia was not present in our cohort. This is consistent

with previous literature suggesting that patients with CNC do not present with significantly

elevated prolactin levels, and even if hyperprolactinemia is present this is always accompanied

by growth hormone excess which is the main pituitary abnormality.[15-17]

Genotype-phenotype correlations in CNC have yielded important findings in certain

settings . For example, large gene deletions including the

PRKAR1A

gene lead to a unique

phenotype of CNC associated with developmental delay and/or skeletal abnormalities and

possibly an earlier overall presentation [18]. Bertherat

et al

also performed a phenotype-

genotype correlation in patients with CNC and reported potential associations [19]. Specifically,

exonic variants were more often associated with cardiac myxomas, lentigines and PMS. More

interestingly, the variant c.491_492delTG (p.Val164Aspfs*5) was associated with the presence

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of cardiac myxomas, lentigines and thyroid disease [19]. This variant is one of the few that is

identified in several kindreds and considered a “hot

spot mutation”, while most of the

remaining variants are identified in single families (also known as “private mutations”).

Expressed variants were previously associated with higher number of stigmata [19]. We were

surprised to report the opposite finding regarding GH dysregulation, i.e. patients with

expressed variants harbor lower risk for GHE. One can hypothesize that expression of even a

defective allele mitigates the effects on PKA activity.

The management of patients with GHE depends on the clinical severity of GHE and the

MRI findings. Similar with McCune-Albright syndrome, somatotroph hyperplasia in CNC is

affecting all somatotroph cells of the pituitary gland. However, unlike McCune-Albright

syndrome where transsphenoidal surgery is not recommended as initial treatment, in our

cohort of patients with distinct adenomas, as also reported previously, resection of the

adenoma provided immediate and durable remission in several patients and may be considered

as initial management.[20 21] Medical therapy can be considered in cases of normal MRI or

mild GHE. Although our experience in this cohort was limited to certain somatostatin analogues

(octreotide and lanreotide) other medical therapies such as pegvisomant and pasireotide (or

combination of those) are reasonable alternative medical approaches [22-24].

In this study we included a large cohort of patients with a rare disease and we provide a

detailed analysis of biochemical, imaging and genetic evaluation with regards to GH secretion.

This study was only possible because we served as a center of referral and research for CNC for

several years. However, we acknowledge certain limitations: our cohort only includes patients

who were evaluated at the NIH CRC and who may represent a group of patients that may be

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more severely affected with CNC. Additionally, since the study was performed over the span

over two decades, assays with different sensitivities and reference ranges were used. To

accommodate for the assay variability, we used z-scores for IGF- 1 levels based on age, sex and

Tanner stage cutoffs. However, there is no similar approach in presenting GH levels. Thus, the

GH levels presented here should be used to provide to general picture of the pattern of GH

dysregulation, but specific cutoffs and levels should be critically considered. Further, there is

much scientific discussion on the nadir GH levels for the interpretation of OGTT results [25]. The

latest recommendation from the Endocrine Society still supports the use of cut-off of 1ng/dL,

but recent studies and consensus statements suggest that lower thresholds should be adopted

[26 27]. We opted to use the cutoff of 1 ng/dL, and thus may have missed some of the patients.

Finally, as not all patients underwent all the diagnostic tests described in our methods, it is

possible that we have missed patients and have underestimated the overall frequency of this

diagnosis.

To conclude, dysregulation of GH secretion remains one of the main features of patients

with CNC, present in more than one third of patients. The diagnosis of GHE is variable and

patients may be identified by a variety of diagnostic tests. Additional clues from the genetic and

imaging evaluation of patients with CNC provide information regarding their risk for this

manifestation and should be considered when evaluating them. The management of the

patients remains challenging but TSS of isolated adenomas may provide sustained remission

and biochemical control of the disorder.

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References

1. Salpea P, Stratakis CA. Carney complex and McCune Albright syndrome: an overview of

clinical manifestations and human molecular genetics. Mol Cell Endocrinol 2014;

386

(1-

2):85-91 doi: 10.1016/j.mce.2013.08.022.

2. Kirschner LS, Carney JA, Pack SD, et al. Mutations of the gene encoding the protein kinase A

type I-alpha regulatory subunit in patients with the Carney complex. Nat Genet

2000;

(1):89-92 doi: 10.1038/79238 [published Online First: 2000/09/06].

3. Stratakis CA, Carney JA, Lin JP, et al. Carney complex, a familial multiple neoplasia and

lentiginosis syndrome. Analysis of 11 kindreds and linkage to the short arm of

chromosome 2. J Clin Invest 1996;

(3):699-705 doi: 10.1172/JCI118467 [published

Online First: 1996/02/01].

4. Beuschlein F, Fassnacht M, Assie G, et al. Constitutive activation of PKA catalytic subunit in

adrenal Cushing's syndrome. N Engl J Med 2014;

370

(11):1019-28 doi:

10.1056/NEJMoa1310359 [published Online First: 2014/02/28].

5. Courcoutsakis NA, Tatsi C, Patronas NJ, Lee CC, Prassopoulos PK, Stratakis CA. The complex of

myxomas, spotty skin pigmentation and endocrine overactivity (Carney complex):

imaging findings with clinical and pathological correlation. Insights Imaging

2013;

(1):119-33 doi: 10.1007/s13244-012-0208-6.

6. Kamilaris CDC, Faucz FR, Voutetakis A, Stratakis CA. Carney Complex. Exp Clin Endocrinol

Diabetes 2019;

127

(2-03):156-64 doi: 10.1055/a-0753-4943 [published Online First:

2018/11/15].

7. Boikos SA, Stratakis CA. Pituitary pathology in patients with Carney Complex: growth-

hormone producing hyperplasia or tumors and their association with other

abnormalities. Pituitary 2006;

(3):203-9 doi: 10.1007/s11102-006-0265-2 [published

Online First: 2006/09/27].

8. Espiard S, Vantyghem MC, Assie G, et al. Frequency and Incidence of Carney Complex

Manifestations: A Prospective Multicenter Study With a Three-Year Follow-Up. J Clin

Endocrinol Metab 2020;

105

(3) doi: 10.1210/clinem/dgaa002 [published Online First:

2020/01/09].

9. Ho KY, Weissberger AJ. Characterization of 24-hour growth hormone secretion in

acromegaly: implications for diagnosis and therapy. Clin Endocrinol (Oxf) 1994;

(1):75-

83 doi: 10.1111/j.1365-2265.1994.tb03787.x [published Online First: 1994/07/01].

10. Arosio M, Giovanelli MA, Riva E, Nava C, Ambrosi B, Faglia G. Clinical use of pre- and

postsurgical evaluation of abnormal GH responses in acromegaly. J Neurosurg

1983;

(3):402-8 doi: 10.3171/jns.1983.59.3.0402 [published Online First: 1983/09/01].

11. Correa R, Salpea P, Stratakis CA. Carney complex: an update. Eur J Endocrinol

2015;

173

(4):M85-97 doi: 10.1530/EJE-15-0209 [published Online First: 2015/07/02].

12. Patronas N, Bulakbasi N, Stratakis CA, et al. Spoiled gradient recalled acquisition in the

steady state technique is superior to conventional postcontrast spin echo technique for

magnetic resonance imaging detection of adrenocorticotropin-secreting pituitary

ACCEPTED MANUSCRIPT

Downloaded from https://academic.oup.com/jcem/advance-article/doi/10.1210/clinem/dgae253/7646787 by UCSD-Philosophy user on 23 April 2024

tumors. J Clin Endocrinol Metab 2003;

(4):1565-9 doi: 10.1210/jc.2002-021438

[published Online First: 2003/04/08].

13. Dimaraki EV, Jaffe CA, DeMott-Friberg R, Chandler WF, Barkan AL. Acromegaly with

apparently normal GH secretion: implications for diagnosis and follow-up. J Clin

Endocrinol Metab 2002;

(8):3537-42 doi: 10.1210/jcem.87.8.8658 [published Online

First: 2002/08/06].

14. Faglia G, Beck-Peccoz P, Ferrari C, Travaglini P, Ambrosi B, Spada A. Plasma growth hormone

response to thyrotropin-releasing hormone in patients with active acromegaly. J Clin

Endocrinol Metab 1973;

(6):1259-62 doi: 10.1210/jcem-36-6-1259 [published Online

First: 1973/06/01].

15. Stergiopoulos SG, Abu-Asab MS, Tsokos M, Stratakis CA. Pituitary pathology in Carney

complex patients. Pituitary 2004;

(2):73-82 doi: 10.1007/s11102-005-5348-y.

16. Raff SB, Carney JA, Krugman D, Doppman JL, Stratakis CA. Prolactin secretion abnormalities

in patients with the "syndrome of spotty skin pigmentation, myxomas, endocrine

overactivity and schwannomas" (Carney complex). J Pediatr Endocrinol Metab

2000;

(4):373-9.

17. Pack SD, Kirschner LS, Pak E, Zhuang Z, Carney JA, Stratakis CA. Genetic and histologic

studies of somatomammotropic pituitary tumors in patients with the "complex of spotty

skin pigmentation, myxomas, endocrine overactivity and schwannomas" (Carney

complex). J Clin Endocrinol Metab 2000;

(10):3860-5 doi: 10.1210/jcem.85.10.6875

[published Online First: 2000/11/04].

18. Salpea P, Horvath A, London E, et al. Deletions of the PRKAR1A locus at 17q24.2-q24.3 in

Carney complex: genotype-phenotype correlations and implications for genetic testing. J

Clin Endocrinol Metab 2014;

(1):E183-8 doi: 10.1210/jc.2013-3159 [published Online

First: 2013/10/31].

19. Bertherat J, Horvath A, Groussin L, et al. Mutations in regulatory subunit type 1A of cyclic

adenosine 5'-monophosphate-dependent protein kinase (PRKAR1A): phenotype analysis

in 353 patients and 80 different genotypes. J Clin Endocrinol Metab 2009;

(6):2085-91

doi: 10.1210/jc.2008-2333 [published Online First: 2009/03/19].

20. Vortmeyer AO, Glasker S, Mehta GU, et al. Somatic GNAS mutation causes widespread and

diffuse pituitary disease in acromegalic patients with McCune-Albright syndrome. J Clin

Endocrinol Metab 2012;

(7):2404-13 doi: 10.1210/jc.2012-1274 [published Online

First: 2012/05/09].

21. Watson JC, Stratakis CA, Bryant-Greenwood PK, et al. Neurosurgical implications of Carney

complex. J Neurosurg 2000;

(3):413-8 doi: 10.3171/jns.2000.92.3.0413 [published

Online First: 2000/03/04].

22. Trainer PJ, Drake WM, Katznelson L, et al. Treatment of acromegaly with the growth

hormone-receptor antagonist pegvisomant. N Engl J Med 2000;

342

(16):1171-7 doi:

10.1056/NEJM200004203421604 [published Online First: 2000/04/20].

23. Fleseriu M, Biller BMK, Freda PU, et al. A Pituitary Society update to acromegaly

management guidelines. Pituitary 2021;

(1):1-13 doi: 10.1007/s11102-020-01091-7

[published Online First: 2020/10/21].

ACCEPTED MANUSCRIPT

Downloaded from https://academic.oup.com/jcem/advance-article/doi/10.1210/clinem/dgae253/7646787 by UCSD-Philosophy user on 23 April 2024

24. Colao A, Bronstein MD, Brue T, et al. Pasireotide for acromegaly: long -term outcomes from

an extension to the Phase III PAOLA study. Eur J Endocrinol 2020;

182

(6):583 doi:

10.1530/EJE-19-0762 [published Online First: 2020/03/29].

25. Monaghan PJ, Trainer PJ. Determinants of the growth hormone nadir during oral glucose

tolerance test in adults. Eur J Endocrinol 2019;

181

(5):C17-C20 doi: 10.1530/EJE-19-0661

[published Online First: 2019/09/04].

26. Katznelson L, Laws ER, Jr., Melmed S, et al. Acromegaly: an endocrine society clinical

practice guideline. J Clin Endocrinol Metab 2014;

(11):3933-51 doi: 10.1210/jc.2014-

2700 [published Online First: 2014/10/31].

27. Melmed S, Bronstein MD, Chanson P, et al. A Consensus Statement on acromegaly

therapeutic outcomes. Nat Rev Endocrinol 2018;

(9):552-61 doi: 10.1038/s41574-018-

0058-5 [published Online First: 2018/07/28].

Tables

Table 1. Criteria for the diagnosis of Carney complex

. For the diagnosis of Carney complex a

patient needs to meet either 2 of the main criteria or one of the main criteria and one of the

supplemental criteria.

Main Criteria

Spotty skin pigmentation with a typical distribution (lips, conjunctiva and inner or outer canthi, vaginal and penile
mucosa)

Myxoma (cutaneous and mucosal)

Cardiac myxoma

Breast myxomatosis

or fat-suppressed MRI findings suggestive of this diagnosis

PPNAD

or paradoxical positive response of urinary glucocorticoids to dexamethasone administration during Liddle’s

test

Acromegaly due to GH-producing adenoma

LCCSCT

or characteristic calcification on testicular ultrasonography

Thyroid carcinoma (at any age)

or multiple, hypoechoic nodules on thyroid ultrasonography in a prepubertal child

Psammomatous melanotic schwannoma

Blue nevus, epithelioid blue nevus (multiple)

Breast ductal adenoma (multiple)

Osteochondromyxoma of bone

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Supplemental criteria

Affected first-degree relative

Inactivating mutation of the PRKAR1A gene

GH: growth hormone; LCCSCT: large-cell calcifying Sertoli cell tumor; PPNAD: primary

pigmented nodular adrenocortical disease

Histological confirmation is needed

Table 2

. Clinical and biochemical data of the patients in the cohort overall and those with

growth hormone excess and clinical acromegaly.

Characteristic

No GHE
(n= 90)

GHE
(n= 50)

Acromegaly
(n= 28)

Overall
(n= 140)

Age at diagnosis or last follow-up
in years, median (IQR)

24.7 (29.2)

25.3 (19.9)

26.1 (19.0)

25 (26.9)

Gender, n (%)

Female

52 (57.8%)

28 (56.0%)

12 (42.9%)

80 (57.1%)

Male

38 (42.2%)

22 (44.0%)

16 (57.1%)

60 (42.9%)

Race, n (%)

Asian

3 (3.3%)

1 (2.0%)

1 (3.6%)

4 (2.9%)

Black/African American

3 (3.3%)

3 (6.0%)

3 (10.7%)

6 (4.3%)

Unknown or other

13 (14.4%)

5 (10%)

2 (7.1%)

18 (12.8%)

White

71 (78.9%)

41 (82.0%)

22 (78.6%)

112
(80.0%)

Family history, n (%)

34 (37.8%)

22 (44.0%)

13 (46.4%)

56 (40.0%)

Yes

56 (62.2%)

28 (56.0%)

15 (53.6%)

84 (60.0%)

Parent of inheritance for those
with positive family history, n (%)

Father

21 (38.9%)

11 (40.7%)

6 (40%)

32 (39.5%)

Mother

33 (61.1%)

16 (59.3%)

9 (60%)

49 (60.5%)

Height z-score at diagnosis or last
follow-up (pediatric patients

-0.32 (1.4)
n= 32

0.63 (1.6) *
n= 13

0.69 (1.6) *
n= 7

-0.14 (1.2)
n= 42

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only), median (IQR)

Weight z-score at diagnosis or
last follow-up, median (IQR)

0.93 (2.0)

1.02 (1.5)

1.48 (1.4) *

0.98 (1.8)

BMI z-score at diagnosis or last
follow-up, median (IQR)

1.13 (1.3)

1.02 (1.1)

1.30 (1.1)

1.12 (1.2)

* variables that are significantly different compared to non-GHE or non-Acromegaly as

appropriate

BMI: Body mass index, GHE: Growth hormone excess, IQR: Interquartile range

Table 3

. Results of diagnostic tests for growth hormone secretion in patients with GHE,

acromegaly and without any GH secretion dysregulation.

Diagnostic test/Variable

No GHE

GHE

IGF-1 at time of diagnosis or last follow-up

IGF-1 z-score

-0.75 (1.4)

3.09 (2.6) *

Oral Glucose Tolerance test (at time of diagnosis or last
follow-up)

Nadir GH level (ng/mL)

0.3 (0.15)/ 0.22(0.36)

3.3 (3.5)/ 1 (1.24)*

GH level at 3 hours (ng/mL)

0.35 (0.7)/ 0.77 (2.6)

8.7 (5.7)/ 2.68 (4.7) *

Mean prolactin (ng/mL)

10.2 [9.78]

16.2 [13.0] *

Nadir prolactin (ng/mL)

7.50 [5.48]

12.3 [9.13] *

TRH stimulation test

Ratio of peak GH/baseline GH

1.5 (0.7)/ 1.3 (0.3)

4.1 (3.3) / 6.1 (2.9) *

Peak GH (ng/mL)

0.9 (3.6) / 1.3 (0.9)

21.5 (16.9) / 6.2 (5.2)*

Ratio of peak prolactin/baseline prolactin

2.4 (3.5)

5.1 (4.0)

Peak prolactin(ng/mL)

44.5 (31.5)

42.2 (18.0)

Serial overnight GH sampling

Mean GH level (ng/mL)

1.7 (1.0) / 1.75 (0.7)

5.5 (3.9) / 5.4 (4.1) *

Nadir GH level (ng/mL)

0.4 (0.3) / 0.2 (0.3)

3.1 (3.2) / 1.8 (1.2) *

Number of pulses

4 (1)

5.5 (2)

Area under the curve (AUC) (ng/dL/min)

1.7 (1.0) / 1.7 (0.7)

5.6 (3.8) / 5.5 (4.1) *

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Mean prolactin (ng/mL)

14.6 (11.2)

14.7 (6.6)

* variables that are significantly different compared to non-GHE.

GH levels shown as (Before 1999)/(After 1999)

Table 4.

Summary of the yield of the diagnostic tests for growth hormone secretion in patients

with growth hormone excess (GHE) and acromegaly.

Diagnostic test

GHE

n= 50

Acromegaly

n= 28

IGF-1, total tested (%)

48 (96)

28 (100)

Positive

39 (81.2)

28 (100)

Negative

9 (18.8)

0 (0)

OGTT, total tested (%)

43 (86)

23 (82.1)

Positive

31 (72.1)

23 (100)

Negative

12 (27.9)

0 (0)

TRH stimulation test,

total tested (%)

9 (18)

6 (21.4)

Positive

7 (77.8)

5 (83.3)

Negative

2 (22.2)

1 (16.7)

Serial Sampling,

total tested (%)

12 (24)

6 (21.4)

Positive

8 (66.7)

4 (66.7)

Negative

4 (33.3)

2 (33.3)

Figure Legends

Figure 1

. Penetrance of growth hormone excess (GHE) (A) and acromegaly (B) in patients with

Carney complex. * Data for age >50 years old should be interpreted with caution as small

number of patients were available at that age group.

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Figure 2.

Overnight serial sampling for growth hormone (GH) reveals different patterns in

patients with and without GH excess (GHE). (A) Normal pattern of overnight GH secretion. (B)

Pattern of GH secretion in a patient with dysregulation of GH secretion showing overall

elevated GH levels which never reach suppressed levels. (C) Pattern of GH secretion in a patient

with clinical acromegaly showing persistently elevated GH levels with high area under the curve

(AUC).

Figure 3.

(A) Probability of developing growth hormone excess (GHE) based on the presence of

variant that is expressed compared to those not expressed. (B) Probability of developing GHE

based on the presence of the most common variant in our cohort, c.491_492delTG

(p.Val164fsX).

Figure 4

. (A) The presence of growth hormone excess (GHE) is more common in patients with

abnormal MRI compared to those without. (B) Probability of developing GHE based on the MRI

findings.

Figure 5

. Magnetic resonance images of the pituitary from patients with Carney complex. (A)

Postcontrast T1 coronal image in a patient without signs of growth hormone excess (GHE) with

heterogeneous contrast enhancement after contrast administration at the left side. (B)

Postcontrast T1 coronal image in a patient with GHE showing a 6mm hypoenhancing post-

contrast lesion suspicious for a single adenoma. (C) Postcontrast T1 coronal image in a patient

with GHE showing at least two separate hypoenhancing lesions, one at each side of the gland,

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