PMC4743750_01
This graph shows the patient's time of diagnosis (Dx) and surgery (Sx), along with duration of radiation therapy (RT), chemotherapy (Chemo Tx), and growth hormone treatment (GH Tx). The patient's growth chart reveals height trajectory far below the 5th percentile (mid-parental height of 65 inches) with limited height increase before the initiation of growth hormone (GH) at approximately age 7 years. Height velocity briefly increased with the initiation of GH therapy but faltered shortly afterwards, despite continued GH treatment, due to prematurely closed epiphyseal growth plates of the lower extremities.
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F1
Prior to initiation of GH, height (102 cm) (Figure 1) and armspan (102 cm) were similar, with upper segment/lower segment ratio of one; seven months after GH, height increased minimally (105.6 cm) compared to the more significant increase in armspan (109.2 cm), with upper segment/lower segment ratio remaining at one.
(A) Radiographs of the knee and (B) ankles at age 8.4 years revealed metaphyseal widening with diffuse skeletal demineralization and poor visualization of the growth plates at left and right distal and proximal femurs and tibias, demonstrating premature closure of epiphyseal growth plates. In contrast to closed lower extremity growth plates, bone ages from (C) January 1, 2013 (chronological age 7 years) and (D) April 24, 2014 (chronological age 8.4 years) were normal and less than 2 standard deviations below chronological age with open growth plates.
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F2
Radiographs revealed poorly visualized growth plates in both distal and proximal femurs and tibias (Figure 2A-B), raising concern for premature closure of the physes. By contrast, all bone ages using left hand and wrist radiographs over the preceding two years displayed open growth plates (Figure 2C-D).