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Costa R, Carneiro BA, Tavora F, Pai SG, Kaplan JB, Chae YK, Chandra S, Kopp PA, Giles FJ. The challenge of developmental therapeutics for adrenocortical carcinoma. Oncotarget 2018; 7:46734-46749. [PMID: 27102148 PMCID: PMC5216833 DOI: 10.18632/oncotarget.8774] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/10/2016] [Indexed: 12/11/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare disease with an estimated incidence of only 0.7 new cases per million per year. Approximately 30-70% of the patients present with advanced disease with very poor prognosis and without effective therapeutic options. In the recent years, unprecedented progresses in cancer biology and genomics have fostered the development of numerous targeted therapies for various malignancies. Immunotherapy has also transformed the treatment landscape of malignancies such as melanoma, among others. However, these advances have not brought meaningful benefits for patients with ACC. Extensive genomic analyses of ACC have revealed numerous signal transduction pathway aberrations (e.g., insulin growth factor receptor and Wnt/β-catenin pathways) that play a central role in pathophysiology. These molecular alterations have been explored as potential therapeutic targets for drug development. This manuscript summarizes recent discoveries in ACC biology, reviews the results of early clinical studies with targeted therapies, and provides the rationale for emerging treatment strategies such as immunotherapy.
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Affiliation(s)
- Ricardo Costa
- Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA.,Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Benedito A Carneiro
- Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA.,Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Fabio Tavora
- Department of Pathology, Messejana Heart and Lung Hospital, Fortaleza, Brazil
| | - Sachin G Pai
- Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA.,Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jason B Kaplan
- Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA.,Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Young Kwang Chae
- Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA.,Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sunandana Chandra
- Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA.,Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Peter A Kopp
- Division of Endocrinology, Metabolism, and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Francis J Giles
- Northwestern Medicine Developmental Therapeutics Institute, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA.,Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Payabyab EC, Balasubramaniam S, Edgerly M, Velarde M, Merino MJ, Venkatesan AM, Leuva H, Litman T, Bates SE, Fojo T. Adrenocortical Cancer: A Molecularly Complex Disease Where Surgery Matters. Clin Cancer Res 2018; 22:4989-5000. [PMID: 27742785 DOI: 10.1158/1078-0432.ccr-16-1570] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 08/24/2016] [Indexed: 11/16/2022]
Abstract
The development of new therapies has lagged behind for rare cancers without defined therapeutic targets. Adrenocortical cancer is no exception. Mitotane, an older agent considered "adrenolytic," is used both to control symptoms in advanced disease and as adjuvant therapy after surgical resection. Molecular characterization of adrenocortical cancer has deepened our understanding of this genetically complex disease while identifying subgroups whose importance remains to be determined. Unfortunately, such studies have yet to demonstrate a therapeutic target for drug development, and to date, no targeted therapy has achieved meaningful outcomes. Consequently, first-line therapy for metastatic disease remains a combination regimen of etoposide, doxorubicin, and cisplatinum established in a randomized clinical trial. In addition to evaluating recent studies in adrenocortical cancer, we raise one critical clinical issue-the risk of peritoneal dissemination following laparoscopic resection of adrenocortical cancer. In a retrospective case series of 267 patients referred to the NCI for the treatment of recurrent or advanced adrenocortical cancer, we found extensive peritoneal dissemination in 25 of the 45 patients (55.6%) who had undergone laparoscopic resection, compared with only 7 of the 222 patients (3%) who had undergone an open resection (P < 0.0001). Although this has been debated in the literature, our data argue for an end to laparoscopic resection of adrenocortical cancers to avoid peritoneal dissemination, a complication of laparoscopy that is uniformly fatal. Clin Cancer Res; 22(20); 4989-5000. ©2016 AACR SEE ALL ARTICLES IN THIS CCR FOCUS SECTION, "ENDOCRINE CANCERS REVISING PARADIGMS".
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Affiliation(s)
- Eden C Payabyab
- Surgery Branch and Thoracic & GI Oncology Branch, NCI, NIH, Bethesda, Maryland
| | - Sanjeeve Balasubramaniam
- Division of Oncology Products 1, OHOP, CDER, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Maureen Edgerly
- Medical Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Margarita Velarde
- Medical Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Maria J Merino
- Laboratory of Pathology, Center for Cancer Research, NCI, NIH, Bethesda, Maryland
| | - Aradhana M Venkatesan
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Harshraj Leuva
- James J. Peters Veterans Administration Medical Center, Bronx, New York
| | - Thomas Litman
- Medical Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Susan E Bates
- James J. Peters Veterans Administration Medical Center, Bronx, New York. Division of Medical Oncology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Tito Fojo
- James J. Peters Veterans Administration Medical Center, Bronx, New York. Division of Medical Oncology, Department of Medicine, Columbia University Medical Center, New York, New York.
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Deng W, Qiu J, Wang S, Yuan Z, Jia Y, Tan H, Lu J, Zheng R. Development of biocompatible and VEGF-targeted paclitaxel nanodrugs on albumin and graphene oxide dual-carrier for photothermal-triggered drug delivery in vitro and in vivo. Int J Nanomedicine 2018; 13:439-453. [PMID: 29403275 PMCID: PMC5777379 DOI: 10.2147/ijn.s150977] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
In this study, we performed the characterization and synthesis of biocompatible and targeted albumin and graphene oxide (GO) dual-carrier paclitaxel (PTX) nanoparticles for photothermal-triggered tumor therapy. PTX absorbed on GO nanosheets as cores were coated with human serum albumin (HSA), following surface conjugation with monoclonal antibodies (mAb) against vascular endothelial growth factor (VEGF; denoted as mAbVEGF) via polyethylene glycol linker to form targeted nanoparticles (PTX-GHP-VEGF). The spherical nanoparticles were 191±5 nm in size with good stability and biocompatibility. GO functioned as the first carrier and a near infrared absorber that can generate photothermal effects under 5-minute 808-nm laser irradiation to thermal trigger the release of PTX from the second carrier HSA nanoparticles. The mechanism of thermal-triggered drug release was also investigated preliminarily, in which the heat generated by GO induced swelling of PTX-GHP-VEGF nanoparticles which released the drugs. In vitro studies found that PTX-GHP-VEGF can efficiently target human SW-13 adrenocortical carcinoma cells as evaluated by confocal fluorescence microscopy as well as transmission electron microscopy, and showed an obvious thermal-triggered antitumor effect, mediated by apoptosis. Moreover, PTX-GHP-VEGF combined with near infrared irradiation showed specific tumor suppression effects with high survival rate after 100 days of treatment. PTX-GHP-VEGF also demonstrated high biosafety with no adverse effects on normal tissues and organs. These results highlight the remarkable potential of PTX-GHP-VEGF in photothermal controllable tumor treatment.
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Affiliation(s)
- Wentao Deng
- Department of Urinary Surgery, Dongying People’s Hospital, Dongying
| | - Juhui Qiu
- Department of Urinary Surgery, Dongying People’s Hospital, Dongying
| | - Shaoting Wang
- Department of Urinary Surgery, Dongying People’s Hospital, Dongying
| | - Zhi Yuan
- Department of Urinary Surgery, Dongying People’s Hospital, Dongying
| | - Yuefeng Jia
- Department of Urinary Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Hailin Tan
- Department of Urinary Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jiru Lu
- Department of Urinary Surgery, Dongying People’s Hospital, Dongying
| | - Ruqiang Zheng
- Department of Urinary Surgery, Dongying People’s Hospital, Dongying
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Aronova A, Min IM, Crowley MJP, Panjwani SJ, Finnerty BM, Scognamiglio T, Liu YF, Whitsett TG, Garg S, Demeure MJ, Elemento O, Zarnegar R, Fahey TJ. STMN1 is Overexpressed in Adrenocortical Carcinoma and Promotes a More Aggressive Phenotype In Vitro. Ann Surg Oncol 2017; 25:792-800. [PMID: 29214451 DOI: 10.1245/s10434-017-6296-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with a poor prognosis and few therapeutic options. Stathmin1 (STMN1) is a cytosolic protein involved in microtubule dynamics through inhibition of tubulin polymerization and promotion of microtubule depolymerization, which has been implicated in carcinogenesis and aggressive behavior in multiple epithelial malignancies. We aimed to evaluate expression of STMN1 in ACC and to elucidate how this may contribute to its malignant phenotype. METHODS STMN1 was identified by RNA sequencing as a highly differentially expressed gene in human ACC samples compared with benign adrenal tumors. Expression was confirmed by quantitative reverse transcription-polymerase chain reaction (qRT-PCR), Western blot, and immunohistochemical (IHC) staining of a tissue microarray (TMA) from two independent cohorts. The biologic relevance of STMN1 was investigated in NCI-H295R cells by lentivirus-mediated silencing. RESULTS Differential gene expression demonstrated an eightfold increase in STMN1 messenger RNA (mRNA) in malignant compared with benign adrenal tissue. IHC showed significantly higher expression of STMN1 protein in ACC compared with normal and benign tissues. STMN1 knockdown in an ACC cell line resulted in decreased cell viability, cell-cycle arrest at G0/G1, and increased apoptosis in serum-starved conditions compared with scramble short hairpin RNA (shRNA) controls. STMN1 knockdown also decreased migration, invasion, and anchorage-independent growth compared with controls. CONCLUSIONS STMN1 is overexpressed in human ACC samples, and knockdown of this target in vitro resulted in a less aggressive phenotype of ACC, particularly under serum-starved conditions. Further study is needed to investigate the feasibility of interfering with STMN1 as a potential therapeutic target.
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Affiliation(s)
- Anna Aronova
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Irene M Min
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Michael J P Crowley
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Suraj J Panjwani
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Theresa Scognamiglio
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Yi-Fang Liu
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | | | - Shipra Garg
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | | | - Olivier Elemento
- Department of Physiology and Biophysics, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
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Angelousi A, Dimitriadis GK, Zografos G, Nölting S, Kaltsas G, Grossman A. Molecular targeted therapies in adrenal, pituitary and parathyroid malignancies. Endocr Relat Cancer 2017; 24:R239-R259. [PMID: 28400402 DOI: 10.1530/erc-16-0542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022]
Abstract
Tumourigenesis is a relatively common event in endocrine tissues. Currently, specific guidelines have been developed for common malignant endocrine tumours, which also incorporate advances in molecular targeted therapies (MTT), as in thyroid cancer and in gastrointestinal neuroendocrine malignancies. However, there is little information regarding the role and efficacy of MTT in the relatively rare malignant endocrine tumours mainly involving the adrenal medulla, adrenal cortex, pituitary, and parathyroid glands. Due to the rarity of these tumours and the lack of prospective studies, current guidelines are mostly based on retrospective data derived from surgical, locoregional and ablative therapies, and studies with systemic chemotherapy. In addition, in many of these malignancies the prognosis remains poor with individual patients responding differently to currently available treatments, necessitating the development of new personalised therapeutic strategies. Recently, major advances in the molecular understanding of endocrine tumours based on genomic, epigenomic, and transcriptome analysis have emerged, resulting in new insights into their pathogenesis and molecular pathology. This in turn has led to the use of novel MTTs in increasing numbers of patients. In this review, we aim to present currently existing and evolving data using MTT in the treatment of adrenal, pituitary and malignant parathyroid tumours, and explore the current utility and effectiveness of such therapies and their future evolution.
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Affiliation(s)
- Anna Angelousi
- Department of PathophysiologySector of Endocrinology, National & Kapodistrian University of Athens, Athens, Greece
| | - Georgios K Dimitriadis
- Division of Translational and Experimental MedicineUniversity of Warwick Medical School, Clinical Sciences Research Laboratories, Coventry, UK
| | - Georgios Zografos
- Third Department of SurgeryAthens General Hospital "Georgios Gennimatas", Athens, Greece
| | - Svenja Nölting
- Department of Internal Medicine IICampus Grosshadern, University-Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Gregory Kaltsas
- Department of PathophysiologySector of Endocrinology, National & Kapodistrian University of Athens, Athens, Greece
- Division of Translational and Experimental MedicineUniversity of Warwick Medical School, Clinical Sciences Research Laboratories, Coventry, UK
- Department of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
| | - Ashley Grossman
- Department of EndocrinologyOxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK
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Abstract
PURPOSE OF REVIEW To present an update on the management of and future directions in adrenocortical carcinoma (ACC). RECENT FINDINGS ACC is a rare malignancy with high morbidity and mortality. Surgery remains the mainstay treatment for localized disease, but it is often not feasible in more advanced cases. There is an ongoing controversy about the routine use of adjuvant treatments after surgery. Hormonal overproduction can complicate the management and worsen the prognosis of the disease. Systemic therapy with multiple cytotoxic drugs is often combined with the adrenolytic agent mitotane. Genomic analyses of ACC revealed numerous signal transduction pathway aberrations (insulin-like growth factor 2 overexpression, TP53 mutations and Wnt/β-catenin pathway activation), but so far, there has been no clinically meaningful breakthrough in targeting these genes. Immunotherapy offers hope for altering the orthodox management of cancer, and its role in ACC is being explored in multiple ongoing trials. SUMMARY Surgery by experienced team is the key treatment for localized ACC, whereas currently used chemotherapy has limited efficacy in advanced ACC. The improved understanding of the molecular pathways involved in ACC has not been translated into effective therapy. The development of new therapies requires collaborative effort to fight this disease.
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Affiliation(s)
- Jeena Varghese
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Abstract
PURPOSE OF REVIEW Adrenocortical carcinoma is a rare cancer, but one that carries a poor prognosis due to its aggressive nature and unresponsiveness to conventional chemotherapeutic strategies. Over the past 12 years, there has been renewed interest in developing new therapies for this cancer, including identifying key signaling nodes responsible for cell proliferation. RECENT FINDINGS Clinical trials of tyrosine kinase inhibitors as monotherapy have generally been disappointing, although the identification of exceptional responders may lead to the identification of targeted therapies that may produce responses in subsets of patients. Agents targeted to the Wnt signaling pathway, a known player in adrenal carcinogenesis, have been developed, although they have not yet been used specifically for adrenal cancer. There is current excitement about inhibitors of acetyl-coA cholesterol acetyl transferase 1, an enzyme required for intracellular cholesterol handling, although trials are still underway. Tools to target other proteins such as Steroidogenic Factor 1 and mechanistic target of rapamycin have been developed and are moving towards clinical application. SUMMARY Progress is being made in the fight against adrenocortical carcinoma with the identification of new therapeutic targets and new means by which to attack them. Continued improvement in the prognosis for patients with adrenal cancer is expected as this research continues.
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Affiliation(s)
- Bhavana Konda
- aDivision of OncologybDivision of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio, USA
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Cheng Y, Kerppola RE, Kerppola TK. ATR-101 disrupts mitochondrial functions in adrenocortical carcinoma cells and in vivo. Endocr Relat Cancer 2016; 23:1-19. [PMID: 26843528 PMCID: PMC4887102 DOI: 10.1530/erc-15-0527] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/02/2016] [Indexed: 12/26/2022]
Abstract
Adrenocortical carcinoma (ACC) generally has poor prognosis. Existing treatments provide limited benefit for most patients with locally advanced or metastatic tumors. We investigated the mechanisms for the cytotoxicity, xenograft suppression, and adrenalytic activity of ATR-101 (PD132301-02), a prospective agent for ACC treatment. Oral administration of ATR-101 inhibited the establishment and impeded the growth of ACC-derived H295R cell xenografts in mice. ATR-101 induced H295R cell apoptosis in culture and in xenografts. ATR-101 caused mitochondrial hyperpolarization, reactive oxygen release, and ATP depletion within hours after exposure, followed by cytochrome c release, caspase-3/7 activation, and membrane permeabilization. The increase in mitochondrial membrane potential occurred concurrently with the decrease in cellular ATP levels. When combined with ATR-101, lipophilic free radical scavengers suppressed the reactive oxygen release, and glycolytic precursors prevented the ATP depletion, abrogating ATR-101 cytotoxicity. ATR-101 directly inhibited F1F0-ATPase activity and suppressed ATP synthesis in mitochondrial fractions. ATR-101 administration to guinea pigs caused oxidized lipofuscin accumulation in the zona fasciculate layer of the adrenal cortex, implicating reactive oxygen release in the adrenalytic effect of ATR-101. These results support the development of ATR-101 and other adrenalytic compounds for the treatment of ACC.
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Affiliation(s)
- Yunhui Cheng
- Department of Biological ChemistryUniversity of Michigan, Ann Arbor, MI, USA
| | | | - Tom Klaus Kerppola
- Department of Biological ChemistryUniversity of Michigan, Ann Arbor, MI, USA
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Zhang F, Lin H, Cao K, Wang H, Pan J, Zhuang J, Chen X, Huang B, Wang D, Qiu S. Vasculogenic mimicry plays an important role in adrenocortical carcinoma. Int J Urol 2016; 23:371-7. [PMID: 26915598 DOI: 10.1111/iju.13070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 01/20/2016] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To determine the prognostic role of vasculogenic mimicry in adrenocortical carcinoma, and to explore its relationship with vascular endothelial growth factor receptor 2 expression. METHODS A total of 46 samples of adrenocortical carcinoma were collected and reviewed. Vasculogenic mimicry and vascular endothelial growth factor receptor 2 were detected by immunohistochemistry and double staining. Survival analysis was carried out to access pronostic significance. Three-dimensional culture method was applied to test the ability of vasculogenic mimicry formation by adrenocortical carcinoma cell lines SW-13 and H295R. Quantitative polymerase chain reaction and western blotting were used to monitor the expression of vascular endothelial growth factor receptor 2 in SW-13 and H295R. After being treated with specific inhibitor or small interfering ribonucleic acid to downregulate expression of vascular endothelial growth factor receptor 2, vasculogenic mimicry formation and cell prolifration of SW-13 cells were evaluated by 3-D culture and Cell Counting Kit-8 methods. RESULTS Vasculogenic mimicry was observed in 19 of the 46 (41.30%) adrenocortical carcinoma samples. Both vasculogenic mimicry and vascular endothelial growth factor receptor 2 expressions showed a positive association with Weiss score and TNM stage, whereas vascular endothelial growth factor receptor 2 was also associated with tumor size (all P < 0.05). Vasculogenic mimicry was closely correlated with vascular endothelial growth factor receptor 2 expressions (r = 0.470, P < 0.01). The median overall survival of patients with vasculogenicmimicry-positive or vascular endothelial growth factor receptor 2-positive was shorter than that of patients with vasculogenic mimicry-negative or vascular endothelial growth factor receptor 2-negative (P = 0.001 and 0.028, respectively). The vasculogenic mimicry-forming SW-13 cells expressed higher levels of vascular endothelial growth factor receptor 2 than that of H295R, which was unable to form vasculogenic mimicry on Matrigel. However, downregulation of vascular endothelial growth factor receptor 2 only decreased cell proliferation, but not vasculogenic mimicry formation by SW-13 cells. CONCLUSIONS Vasculogenic mimicry and overexpression of vascular endothelial growth factor receptor 2 seem to correlate with poor prognostic outcomes in adrenocortical carcinoma. Anti-angiogenesis treatments targeting vascular endothelial growth factor receptor 2 should be combined with therapies targeting vasculogenic mimicry in adrenocortical carcinoma.
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Affiliation(s)
- Faming Zhang
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hao Lin
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Kaiyuan Cao
- Research Center for Clinical Laboratory Standard, Zhongshan Medical School, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hua Wang
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jincheng Pan
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Jintao Zhuang
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xu Chen
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Bin Huang
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Daohu Wang
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Shaopeng Qiu
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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5th International ACC Symposium: Future and Current Therapeutic Trials in Adrenocortical Carcinoma. Discov Oncol 2016; 7:29-35. [PMID: 26728470 DOI: 10.1007/s12672-015-0241-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 12/01/2015] [Indexed: 12/28/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare and complex disease associated with a high mortality rate. Despite intensive translational and clinical research, prognosis remains poor. Over the past decade, a significant effort has been made to develop multinational, collaborative studies to better understand the pathogenesis and clinical features of this rare disease in attempt to improve the therapeutic strategies and patient outcome. The results of both standard and newer treatments are discussed in this review as well as the recent discovery of pathways involved in ACC pathogenesis that provide the rationale to introduce new molecular target therapies. Finally, remaining issues regarding how to improve available therapies in adjuvant setting are raised and addressed.
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Gagliano T, Gentilin E, Tagliati F, Benfini K, Di Pasquale C, Feo C, Falletta S, Riva E, degli Uberti E, Zatelli MC. Inhibition of epithelial growth factor receptor can play an important role in reducing cell growth and survival in adrenocortical tumors. Biochem Pharmacol 2015; 98:639-48. [DOI: 10.1016/j.bcp.2015.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 10/15/2015] [Indexed: 12/13/2022]
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Creemers SG, Hofland LJ, Lamberts SWJ, Feelders RA. Cushing's syndrome: an update on current pharmacotherapy and future directions. Expert Opin Pharmacother 2015; 16:1829-44. [PMID: 26133755 DOI: 10.1517/14656566.2015.1061995] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Endogenous Cushing's syndrome (CS) is characterized by chronic overproduction of cortisol and is associated with increased mortality and morbidity. It can be caused by a pituitary adenoma, ectopic adrenocorticotropic hormone (ACTH) production or primary adrenal disease. Successful tumor-directed surgery is the keystone treatment. When surgery is unsuccessful, contraindicated or in case of acute disease, pharmacotherapy is indicated to treat hypercortisolism. AREAS COVERED In this review, pharmacotherapeutic options for CS will be covered discussing the different possible targets, that is: i) inhibition of ACTH secretion; ii) suppression of steroidogenesis; and iii) blockade of cortisol effects at tissue level. Preclinical and clinical studies will be discussed considering mono- and combination therapy, taking into account efficacy, toxicity and mechanism of action. Per CS entity, future directions of pharmacotherapies will be addressed. EXPERT OPINION The number of medical treatment options for CS has increased in the past years. In contrast to decades ago, prospective trials are now being performed focusing on pituitary-directed drugs like pasireotide, the glucocorticoid receptor blocker mifepristone and 'new generation' steroid synthesis inhibitors. Future studies will focus on tumor-shrinking effects of neuromodulatory drugs, the optimal order and combination of pharmacotherapy, long-term efficacy and safety and new targets for medical treatment of CS.
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Affiliation(s)
- Sara G Creemers
- Erasmus Medical Center, Department of Internal Medicine, Division of Endocrinology , Dr. Molewaterplein 50, 3015GE Rotterdam , The Netherlands +31 10 7040704 ; +31 10 7044862 ;
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Ferrari L, Claps M, Grisanti S, Berruti A. Systemic Therapy in Locally Advanced or Metastatic Adrenal Cancers: A Critical Appraisal and Clinical Trial Update. Eur Urol Focus 2015; 1:298-300. [PMID: 28723406 DOI: 10.1016/j.euf.2015.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Revised: 05/16/2015] [Accepted: 06/07/2015] [Indexed: 11/26/2022]
Abstract
Mitotane and chemotherapy with etoposide, doxorubicin, and cisplatin plus mitotane (EDP-M) are the only therapies with demonstrated efficacy in advanced adrenocortical carcinoma. Prognostic and predictive factors are needed to identify patients who could obtain the best benefit from these treatments. Despite the strong rationale for their use, clinical trials on molecular targeted therapies have failed to demonstrate that these drugs are efficacious in the management of this extremely rare disease.
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Affiliation(s)
- Laura Ferrari
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Mélanie Claps
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Salvatore Grisanti
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Alfredo Berruti
- Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy.
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Abstract
Recent developments in the treatment of adrenocortical carcinoma (ACC) include diagnostic and prognostic risk stratification algorithms, increasing evidence of the impact of historical therapies on overall survival, and emerging targets from integrated epigenomic and genomic analyses. Advances include proper clinical and molecular characterization of all patients with ACC, standardization of proliferative index analyses, referral of these patients to large cancer referral centers at the time of first surgery, and development of new trials in patients with well-characterized ACC. Networking and progress in the molecular characterization of ACC constitute the basis for significant future therapeutic breakthroughs.
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Affiliation(s)
- Eric Baudin
- Département de Médecine, Gustave Roussy, 114, rue Édouard-Vaillant, Paris South University, Villejuif Cedex 94805, France; Département de Nucléaire et de Cancérologie Endocrinienne, Gustave Roussy, 114, rue Édouard-Vaillant, Paris South University, Villejuif Cedex 94805, France; Faculté de Médecine, INSERM UMR 1185, 63 rue Gabriel Péri, F-94276 Le Kremlin-Bicêtre, Université Paris Sud, Paris, France.
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65
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Mihai R. Diagnosis, treatment and outcome of adrenocortical cancer. Br J Surg 2015; 102:291-306. [PMID: 25689291 DOI: 10.1002/bjs.9743] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/31/2014] [Accepted: 11/11/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Adrenocortical cancer (ACC) is a rare disease with a dismal prognosis. The majority of patients are diagnosed with advanced disease and raise difficult management challenges. METHODS All references identified in PubMed, published between 2004 and 2014, using the keywords 'adrenocortical cancer' or 'adrenal surgery' or both, were uploaded into a database. The database was interrogated using keywords specific for each field studied. RESULTS In all, 2049 publications were identified. There is ongoing debate about the feasibility and oncological outcomes of laparoscopic adrenalectomy for small ACCs, and data derived from institutional case series have failed to provide an evidence level above expert opinion. The use of mitotane (1-(2-chlorophenyl)-1-(4-chlorophenyl)-2,2-dichloroethane) in combination with chemotherapy in the treatment of metastatic disease has been assessed in an international randomized trial (FIRM-ACT trial) involving patients with ACC. Based on this trial, mitotane plus etoposide, doxorubicin and cisplatin is now the established first-line cytotoxic therapy owing to a higher response rate and longer median progression-free survival than achieved with streptozocin-mitotane. For patients with tumours smaller than 5 cm and with no signs of lymph node or distant metastases, survival is favourable with a median exceeding 10 years. However, the overall 5-year survival rate for all patients with ACC is only 30 per cent. CONCLUSION Open and potentially laparoscopic adrenalectomy for selected patients is the main treatment for non-metastatic ACC, but the overall 5-year survival rate remains low.
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Affiliation(s)
- R Mihai
- Department of Endocrine Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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66
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Fay AP, Signoretti S, Callea M, Telό GH, McKay RR, Song J, Carvo I, Lampron ME, Kaymakcalan MD, Poli-de-Figueiredo CE, Bellmunt J, Hodi FS, Freeman GJ, Elfiky A, Choueiri TK. Programmed death ligand-1 expression in adrenocortical carcinoma: an exploratory biomarker study. J Immunother Cancer 2015; 3:3. [PMID: 25767716 PMCID: PMC4357210 DOI: 10.1186/s40425-015-0047-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 01/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare tumor in which prognostic factors are still not well established. Programmed Death Ligand-1 (PD-L1) expression in ACC and its association with clinico-pathological features and survival outcomes are unknown. METHODS Formalin-fixed paraffin-embedded (FFPE) specimens were obtained from 28 patients with ACC. PD-L1 expression was evaluated by immunohistochemistry (IHC) in both tumor cell membrane and tumor infiltrating mononuclear cells (TIMC). PD-L1 positivity on tumor cells was defined as ≥5% tumor cell membrane staining. TIMC were evaluated by IHC using a CD45 monoclonal antibody. For PD-L1 expression in TIMC, a combined score based on the extent of infiltrates and percentage of positive cells was developed. Any score greater that zero was considered PD-L1 positive. Baseline clinico-pathological characteristics and follow up data were retrospectively collected. Comparisons between PD-L1 expression and clinico-pathological features were evaluated using unpaired t-test and Fisher's exact test. Kaplan-Meier method and log-rank test were used to assess association between PD-L1 expression and 5-year overall survival (OS). RESULTS Among 28 patients with surgically treated ACC, 3 (10.7%) were considered PD-L1 positive on tumor cell membrane. On the other hand, PD-L1 expression in TIMC was performed in 27 specimens and PD-L1 positive staining was observed in 19 (70.4%) patients. PD-L1 positivity in either tumor cell membrane or TIMC was not significantly associated with higher stage at diagnosis, higher tumor grade, excessive hormone secretion, or OS. CONCLUSIONS PD-L1 expression can exist in ACC in both tumor cell membrane and TIMC with no relationship to clinico-pathologic parameters or survival.
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Affiliation(s)
- André P Fay
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
- />Programa de Pós-Graduação em Medicina e Ciências da Saúde, Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul, Av. Ipiranga 6690, Porto Alegre, RS 90619-900 Brazil
| | - Sabina Signoretti
- />Brigham and Women’s Hospital, 75 Francis Street (Thorn Building 504A), Boston, MA 02215 USA
- />Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Marcella Callea
- />Brigham and Women’s Hospital, 75 Francis Street (Thorn Building 504A), Boston, MA 02215 USA
| | - Gabriela H Telό
- />Joslin Diabetes Center, One Joslin Place, Boston, MA 02215 USA
| | - Rana R McKay
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
- />Brigham and Women’s Hospital, 75 Francis Street (Thorn Building 504A), Boston, MA 02215 USA
- />Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Jiaxi Song
- />Brigham and Women’s Hospital, 75 Francis Street (Thorn Building 504A), Boston, MA 02215 USA
| | - Ingrid Carvo
- />Brigham and Women’s Hospital, 75 Francis Street (Thorn Building 504A), Boston, MA 02215 USA
| | - Megan E Lampron
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
| | - Marina D Kaymakcalan
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
| | - Carlos E Poli-de-Figueiredo
- />Programa de Pós-Graduação em Medicina e Ciências da Saúde, Faculdade de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul, Av. Ipiranga 6690, Porto Alegre, RS 90619-900 Brazil
| | - Joaquim Bellmunt
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
- />Brigham and Women’s Hospital, 75 Francis Street (Thorn Building 504A), Boston, MA 02215 USA
- />Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - F Stephen Hodi
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
- />Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
- />Center of Immuno-Oncology, 450 Brookline Avenue, Boston, MA 02215 USA
| | - Gordon J Freeman
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
- />Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Aymen Elfiky
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
- />Brigham and Women’s Hospital, 75 Francis Street (Thorn Building 504A), Boston, MA 02215 USA
- />Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - Toni K Choueiri
- />Dana-Farber Cancer Institute, 450 Brookline Avenue (DANA 1230), Boston, MA 02215 USA
- />Brigham and Women’s Hospital, 75 Francis Street (Thorn Building 504A), Boston, MA 02215 USA
- />Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
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67
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Ross JS, Wang K, Rand JV, Gay L, Presta MJ, Sheehan CE, Ali SM, Elvin JA, Labrecque E, Hiemstra C, Buell J, Otto GA, Yelensky R, Lipson D, Morosini D, Chmielecki J, Miller VA, Stephens PJ. Next-generation sequencing of adrenocortical carcinoma reveals new routes to targeted therapies. J Clin Pathol 2014; 67:968-73. [PMID: 25078331 PMCID: PMC4215283 DOI: 10.1136/jclinpath-2014-202514] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Aims Adrenocortical carcinoma (ACC) carries a poor prognosis and current systemic cytotoxic therapies result in only modest improvement in overall survival. In this retrospective study, we performed a comprehensive genomic profiling of 29 consecutive ACC samples to identify potential targets of therapy not currently searched for in routine clinical practice. Methods DNA from 29 ACC was sequenced to high, uniform coverage (Illumina HiSeq) and analysed for genomic alterations (GAs). Results At least one GA was found in 22 (76%) ACC (mean 2.6 alterations per ACC). The most frequent GAs were in TP53 (34%), NF1 (14%), CDKN2A (14%), MEN1 (14%), CTNNB1 (10%) and ATM (10%). APC, CCND2, CDK4, DAXX, DNMT3A, KDM5C, LRP1B, MSH2 and RB1 were each altered in two cases (7%) and EGFR, ERBB4, KRAS, MDM2, NRAS, PDGFRB, PIK3CA, PTEN and PTCH1 were each altered in a single case (3%). In 17 (59%) of ACC, at least one GA was associated with an available therapeutic or a mechanism-based clinical trial. Conclusions Next-generation sequencing can discover targets of therapy for relapsed and metastatic ACC and shows promise to improve outcomes for this aggressive form of cancer.
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Affiliation(s)
- J S Ross
- Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, New York, USA Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - K Wang
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - J V Rand
- Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, New York, USA
| | - L Gay
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - M J Presta
- Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, New York, USA
| | - C E Sheehan
- Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, New York, USA
| | - S M Ali
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - J A Elvin
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - E Labrecque
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - C Hiemstra
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - J Buell
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - G A Otto
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - R Yelensky
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - D Lipson
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - D Morosini
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - J Chmielecki
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - V A Miller
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
| | - P J Stephens
- Foundation Medicine, Inc., Cambridge, Massachusetts, USA
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68
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Terzolo M, De Francia S, Ardito A, Perotti P, Ferrari L, Berruti A. A current perspective on treatment of adrenocortical carcinoma. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.931222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Ronchi CL, Kroiss M, Sbiera S, Deutschbein T, Fassnacht M. EJE prize 2014: current and evolving treatment options in adrenocortical carcinoma: where do we stand and where do we want to go? Eur J Endocrinol 2014; 171:R1-R11. [PMID: 24714084 DOI: 10.1530/eje-14-0273] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Adrenocortical carcinoma (ACC) is not only a rare and heterogeneous disease but also one of the most aggressive endocrine tumors. Despite significant advances in the last decade, its pathogenesis is still only incompletely understood and overall therapeutic means are unsatisfactory. Herein, we provide our personal view of the currently available treatment options and suggest the following research efforts that we consider timely and necessary to improve therapy: i) for better outcome in localized ACCs, surgery should be restricted to experienced centers, which should then collaborate closely to address the key surgical questions (e.g. best approach and extent of surgery) in a multicenter manner. ii) For the development of better systemic therapies, it is crucial to elucidate the exact molecular mechanisms of action of mitotane. iii) A prospective trial is needed to address the role of cytotoxic drugs in the adjuvant setting in aggressive ACCs (e.g. mitotane vs mitotane+cisplatin). iv) For metastatic ACCs, new regimens should be investigated as first-line therapy. v) Several other issues (e.g. the role of radiotherapy and salvage therapies) might be answered - at least in a first step - by large retrospective multicenter studies. In conclusion, although it is unrealistic to expect that the majority of ACCs can be cured within the next decade, international collaborative efforts (including multiple translational and clinical studies) should allow significant improvement of clinical outcome of this disease. To this end, it might be reasonable to expand the European Network for the Study of Adrenal Tumors (ENSAT) to a truly worldwide international network - INSAT.
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Affiliation(s)
- Cristina L Ronchi
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyCentral LaboratoryUniversity Hospital Würzburg, Würzburg, Germany
| | - Matthias Kroiss
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyCentral LaboratoryUniversity Hospital Würzburg, Würzburg, Germany
| | - Silviu Sbiera
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyCentral LaboratoryUniversity Hospital Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyCentral LaboratoryUniversity Hospital Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyCentral LaboratoryUniversity Hospital Würzburg, Würzburg, GermanyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyCentral LaboratoryUniversity Hospital Würzburg, Würzburg, GermanyEndocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyCentral LaboratoryUniversity Hospital Würzburg, Würzburg, Germany
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