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Del Rivero J, Else T, Hallanger-Johnson J, Kiseljak-Vassiliades K, Raj N, Reidy-Lagunes D, Srinivas S, Gilbert J, Vaidya A, Aboujaoude E, Bancos I, Tito Fojo A. A review of mitotane in the management of adrenocortical cancer. Oncologist 2024:oyae084. [PMID: 39037424 DOI: 10.1093/oncolo/oyae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 04/18/2024] [Indexed: 07/23/2024] Open
Abstract
IMPORTANCE Mitotane (Lysodren, o,p'-DDD [1-(o-chlorophenyl)-1-(p-chlorophenyl)-2,2-dichloroethane)] is currently the only United States Food and Drug Administration and European Medicines Agency-approved product for the treatment of adrenocortical carcinoma. OBSERVATIONS Mitotane is challenging to administer; however, its toxicities (specifically adrenal insufficiency) are well known, and the management of adverse consequences has established approaches. While often viewed through the prism of a cytotoxic agent, it can also interfere with hormone production making it a valuable asset in managing functional ACC. A recently completed prospective trial has shed some light on its use in the adjuvant setting, but further clarity is needed. Many think mitotane has a role in the advanced or metastatic setting, although prospective data are lacking and retrospective analyses are often difficult to interpret. CONCLUSIONS AND RELEVANCE When used carefully and thoughtfully, especially in patients with hormonal excess, mitotane is an important component of the treatment armamentarium for ACC.
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Affiliation(s)
- Jaydira Del Rivero
- Developmental Therapeutics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, United States
| | - Tobias Else
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48104, United States
| | | | - Katja Kiseljak-Vassiliades
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine at Colorado Anschutz Medical Campus Aurora, CO 80309, United States
| | - Nitya Raj
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
| | | | - Sandy Srinivas
- Stanford University School of Medicine, Stanford, CA 94305, United States
| | - Jill Gilbert
- Division of Hematology and Oncology, Vanderbilt University School of Medicine, Nashville, TN 37203, United States
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | | | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, United States
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Flynn A, Galettis P, Gurney H, Michael M, Desar I, Westerdijk K, Schneider J, Martin J. Therapeutic drug monitoring in anticancer agents: perspectives of Australian medical oncologists. Intern Med J 2024. [PMID: 38767393 DOI: 10.1111/imj.16415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/20/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND In the development of anticancer agents for solid tumours, body surface area continues to be used to personalise dosing despite minimal evidence for its use over other dosing strategies. With the development of tyrosine kinase inhibitors and other oral targeted anticancer agents, dosing using therapeutic drug monitoring (TDM) is now utilised in many health systems but has had limited uptake in Australia. AIM To determine attitudes and barriers to the implementation of TDM among Australian oncologists. METHODS A comprehensive questionnaire was developed by the Dutch Pharmacology Oncology Group from semistructured interviews of stakeholders. Seventy-nine questions across seven domains were developed with three free-text responses. This was rationalised to 17 questions with three free-text responses for Australian medical oncologists who identified limited experience with TDM. RESULTS Fifty-seven responses were received, with 49 clinicians (86%) identifying limited experience of performing TDM in daily practice. Clinicians were positive (62-91% agree/strongly agree across seven questions) about the advantages of TDM. There was a mixed response for cost-effectiveness and scientific evidence being a barrier to implementation, but strong agreement that prospective studies were needed (75% agreed or strongly agreed); that national treatment guidelines would enable practice (80%) and that a 'pharmacology of oncolytics' education programme would be useful (96%) to provide knowledge for dose individualisation. CONCLUSION Despite the limited experience of TDM in oncology in Australia, medical oncologists appear positive about the potential benefit to their patients. We have identified three barriers to implementation that could be targeted for increased adoption of TDM in oncology in Australia.
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Affiliation(s)
- Alexandra Flynn
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter Galettis
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Howard Gurney
- Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Michael Michael
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ingrid Desar
- Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Kim Westerdijk
- Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Jennifer Martin
- University of Newcastle, Newcastle, New South Wales, Australia
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Pak C, Yoon S, Lee JL, Yun T, Park I. Current Status and Future Direction in the Treatment of Advanced Adrenocortical Carcinoma. Curr Oncol Rep 2024; 26:307-317. [PMID: 38381366 DOI: 10.1007/s11912-024-01510-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE OF REVIEW To provide a comprehensive overview of the current understanding and developments in the treatment options for adrenocortical carcinoma (ACC), focusing on the strategies utilized for advanced disease. RECENT FINDINGS Research has delved into the genomic landscape of ACC, revealing potential targets for therapy. Despite the failure of inhibitors aimed at the insulin like growth factor 1(IGF-1) receptor, other approaches, including vascular endothelial growth factor receptor (VEFGR) tyrosine kinase inhibitors and immune checkpoint inhibitors, are being investigated. There are also ongoing trials of combination treatments such as lenvatinib with pembrolizumab and cabozantinib with atezolizumab. ACC remains a challenging malignancy with limited effective treatment options. Although EDP-M stands as the frontline treatment, the search for effective second-line therapies is ongoing. Targeted therapies and immunotherapies, especially in combination regimens, are demonstrating potential and are the subject of continued research. The evolving genomic landscape emphasizes the significance of targeted therapies and the need for further in-depth studies to solidify effective treatment regimens for ACC.
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Affiliation(s)
- Chulkue Pak
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Shinkyo Yoon
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jae Lyun Lee
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Tak Yun
- Division of Hematology-Oncology, Rare Cancers Clinic, Center for Specific Organs Center, National Cancer Center, Goyang, Republic of Korea
| | - Inkeun Park
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
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Riedmeier M, Antonini SRR, Brandalise S, Costa TEJB, Daiggi CM, de Figueiredo BC, de Krijger RR, De Sá Rodrigues KE, Deal C, Del Rivero J, Engstler G, Fassnacht M, Fernandes Luiz Canali GC, Molina CAF, Gonc EN, Gültekin M, Haak HR, Guran T, Hendriks Allaird EJ, Idkowiak J, Kuhlen M, Malkin D, Meena JP, Pamporaki C, Pinto E, Puglisi S, Ribeiro RC, Thompson LDR, Yalcin B, Van Noesel M, Wiegering V. International consensus on mitotane treatment in pediatric patients with adrenal cortical tumors: indications, therapy, and management of adverse effects. Eur J Endocrinol 2024; 190:G15-G24. [PMID: 38552173 DOI: 10.1093/ejendo/lvae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/17/2024] [Accepted: 02/19/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE Mitotane is an important cornerstone in the treatment of pediatric adrenal cortical tumors (pACC), but experience with the drug in the pediatric age group is still limited and current practice is not guided by robust evidence. Therefore, we have compiled international consensus statements from pACC experts on mitotane indications, therapy, and management of adverse effects. METHODS A Delphi method with 3 rounds of questionnaires within the pACC expert consortium of the international network groups European Network for the Study of Adrenal Tumors pediatric working group (ENSAT-PACT) and International Consortium of pediatric adrenocortical tumors (ICPACT) was used to create 21 final consensus statements. RESULTS We divided the statements into 4 groups: environment, indications, therapy, and adverse effects. We reached a clear consensus for mitotane treatment for advanced pACC with stages III and IV and with incomplete resection/tumor spillage. For stage II patients, mitotane is not generally indicated. The timing of initiating mitotane therapy depends on the clinical condition of the patient and the setting of the planned therapy. We recommend a starting dose of 50 mg/kg/d (1500 mg/m²/d) which can be increased up to 4000 mg/m2/d. Blood levels should range between 14 and 20 mg/L. Duration of mitotane treatment depends on the clinical risk profile and tolerability. Mitotane treatment causes adrenal insufficiency in virtually all patients requiring glucocorticoid replacement shortly after beginning. As the spectrum of adverse effects of mitotane is wide-ranging and can be life-threatening, frequent clinical and neurological examinations (every 2-4 weeks), along with evaluation and assessment of laboratory values, are required. CONCLUSIONS The Delphi method enabled us to propose an expert consensus statement, which may guide clinicians, further adapted by local norms and the individual patient setting. In order to generate evidence, well-constructed studies should be the focus of future efforts.
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Affiliation(s)
- Maria Riedmeier
- University Hospital Würzburg, Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Wuerzburg, Wuerzburg 97080, Germany
| | - Sonir R R Antonini
- Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo 14051-200, Brazil
| | - Silvia Brandalise
- Boldrini Children's Hospital, Department of Pediatrics, São Paulo 13083-210, Brazil
| | - Tatiana El Jaick B Costa
- Service of Pediatric Oncology, Hospital Infantil Joana de Gusmão, Florianópolis, SC 88025-301, Brazil
| | - Camila M Daiggi
- Boldrini Children's Hospital, Department of Pediatrics, São Paulo 13083-210, Brazil
| | | | - Ronald R de Krijger
- Department of Pathology, University Medical Center Utrecht, Utrecht 3584 CS, The Netherlands
| | | | - Cheri Deal
- Research Center, CHU Sainte-Justine and University of Montreal, Montreal, Québec H3T 1C5, Canada
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, United States
| | - Gernot Engstler
- St. Anna Kinderspital, Department of Pediatrics, Medical University Vienna, Vienna 1090, Austria
| | - Martin Fassnacht
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg 97080, Germany
| | | | - Carlos A Fernandes Molina
- Department of Surgery and Anatomy, Ribeirao Preto Medical School, University of Sao 15 Paulo, Ribeirao Preto, Sao Paulo 14049-900, Brazil
| | - Elmas Nazli Gonc
- Department of Pediatric Endocrinology, Faculty of Medicine, Hacettepe University, Ankara 06230, Turkey
| | - Melis Gültekin
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | - Harm R Haak
- Department of Internal Medicine, Máxima MC, Eindhoven 5631 BM/Veldhoven 5504 DB, The Netherlands
- CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht University, Maastricht 616 6200 MD, The Netherlands
| | - Tulay Guran
- Department of Paediatric Endocrinology and Diabetes, Marmara University School of Medicine, Istanbul 34722, Turkey
| | - Emile J Hendriks Allaird
- Department of Paediatrics, University of Cambridge, Cambridge CB20QQ, United Kingdom
- Department of Paediatric Endocrinology and Diabetes, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB20QQ, United Kingdom
| | - Jan Idkowiak
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B152TT, United Kingdom
- Department of Endocrinology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B46NH, United Kingdom
| | - Michaela Kuhlen
- Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg 86135, Germany
| | - David Malkin
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario M5G1X8, Canada
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, Mother & Child Block, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, TU Dresden, Dresden 01307, Germany
| | - Emilia Pinto
- St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano 10043, Italy
| | - Raul C Ribeiro
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Lester D R Thompson
- Pathology, Head and Neck Pathology Consultations, Woodland Hills, CA 91364, United States
| | - Bilgehan Yalcin
- Department of Pediatric Oncology, Faculty of Medicine, Hacettepe University, Ankara 06230, Turkey
| | - Max Van Noesel
- Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht 3584 CS, The Netherlands
- Division Imaging & Cancer, University Medical Center Utrecht, Utrecht 3584 CS, The Netherlands
| | - Verena Wiegering
- University Hospital Würzburg, Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Wuerzburg, Wuerzburg 97080, Germany
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Ehrlich MI, Labadie BW, Bates SE, Fojo T. Mitotane and the myth of 14 mg/L. Lancet Oncol 2024; 25:12-15. [PMID: 38181804 DOI: 10.1016/s1470-2045(23)00537-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 01/07/2024]
Affiliation(s)
- Matthew I Ehrlich
- Department of Medicine, Columbia University, New York, NY 10032, USA
| | - Brian W Labadie
- Division of Hematology/Oncology, Columbia University, New York, NY 10032, USA
| | - Susan E Bates
- Division of Hematology/Oncology, Columbia University, New York, NY 10032, USA; James J Peters Veterans Administration Medical Center, New York, NY, USA
| | - Tito Fojo
- Division of Hematology/Oncology, Columbia University, New York, NY 10032, USA; James J Peters Veterans Administration Medical Center, New York, NY, USA.
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Stadler G, de Almeida Veiga A, Rita Corso C, Bach de Assis C, de Toledo Nogueira B, Regina Rocha Martins L, Cruz Bonk B, Lada Degaut Pontes F, Cavalcante de Figueiredo B, Mera de Souza L. Two-dimensional chromatography for enantiomeric analysis of mitotane and its metabolite o,p'-DDA in patients with adrenocortical carcinoma indicates enantioselective metabolism. Bioorg Chem 2023; 141:106835. [PMID: 37713949 DOI: 10.1016/j.bioorg.2023.106835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/21/2023] [Accepted: 09/02/2023] [Indexed: 09/17/2023]
Abstract
Mitotane is a chiral drug used to treat adrenocortical carcinoma, being metabolized to the o,p'-dichlorodiphenyl acetic acid (o,p'-DDA), also a chiral compound. Despite of its therapeutic significance, the overall ratios and enantiomers have not been known. In this study, we analyzed the enantiomers of mitotane and o,p'-DDA in the plasma of patients by a newly developed chiral-phase method employed in two-dimensional chromatography. Important differences were observed in the ratio of (S)/(R)-mitotane, which varied substantially from 1:1.2 to 1:10 whereas the (S)/(R)-o,p'-DDA ratio was relatively conserved, at approximately 2:1. These findings provide evidence for the enantioselective metabolism and provide a method for further analyses of mitotane and metabolites, which can explain the variation in the therapeutic response.
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Affiliation(s)
- Gabriela Stadler
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Alan de Almeida Veiga
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Claudia Rita Corso
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Camila Bach de Assis
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Beatriz de Toledo Nogueira
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | | | - Beatriz Cruz Bonk
- Universidade Tecnológica Federal do Paraná, Curitiba 81280-340, Brazil
| | - Flávia Lada Degaut Pontes
- Departamento de Bioquímica e Biologia Molecular, Universidade Federal do Paraná, Curitiba 81531-990, Brazil
| | - Bonald Cavalcante de Figueiredo
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil
| | - Lauro Mera de Souza
- Instituto de Pesquisa Pelé Pequeno Príncipe, Curitiba 80250-060, Brazil; Faculdades Pequeno Príncipe, Curitiba 80230-020, Brazil.
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Westerdijk K, Steeghs N, Tacke CSJ, van der Graaf WTA, van Erp NP, van Oortmerssen G, Hermens RPMG, Desar IME. Therapeutic drug monitoring to personalize dosing of imatinib, sunitinib, and pazopanib: A mixed methods study on barriers and facilitators. Cancer Med 2023; 12:21041-21056. [PMID: 37902257 PMCID: PMC10709747 DOI: 10.1002/cam4.6663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/20/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Personalized dosing based on measurement of individual drug levels and adjusting the dose accordingly can improve efficacy and decrease unnecessary toxicity of oncological treatment. For imatinib, sunitinib, and pazopanib, this therapeutic drug monitoring (TDM)-guided dosing is, however, not routinely used, despite accumulating evidence favoring individualized dosing. Therefore, we aimed to identify and quantify (potential) barriers and facilitators in TDM-guided dosing for imatinib, sunitinib, and pazopanib. METHODS We performed a mixed methods study among all stakeholders involved: patients, healthcare professionals (HCPs), pharmaceutical companies, and health insurance companies. During the first qualitative part of this study, we performed semi-structured individual interviews and one focus group interview to identify all (potential) barriers and facilitators, and during the second quantitative part of this study, we used a web-based survey to quantify these findings. The interviews addressed the six domains of the implementation of change model of Grol and Wensing: (1) the innovation itself; (2) the HCP; (3) the patient; (4) social context; (5) organizational context; and (6) finances, law, and governance. RESULTS In the qualitative study, we interviewed 20 patients, 18 HCPs and 10 representatives of pharmaceutical and health insurance companies and identified 72 barriers and 90 facilitators. In the quantitative study, the survey was responded by 66 HCPs and 58 patients. Important barriers were on the domain of the HCP, such as a lack of experience with TDM (36.4%), on the domain of the patient, such as lack of awareness of TDM (39.7%), and the processing time for measurement and interpretation of the TDM result (40.9%) (organizational domain). Important facilitators were education of HCPs (95.5%), education of patients (87.9%) and facilitating an overview of when and where TDM measurements are being performed (86.4%). CONCLUSION We identified and quantified important barriers and facilitators for the implementation of TDM-guided dosing for imatinib, sunitinib, and pazopanib. Based on our results, the implementation strategy should mainly focus on educating both HCPs and patients and on the organizational aspect of TDM.
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Affiliation(s)
- Kim Westerdijk
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | - Neeltje Steeghs
- Department of Medical OncologyNetherlands Cancer Institute, Antoni van LeeuwenhoekAmsterdamThe Netherlands
| | - Casper S. J. Tacke
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | - Winette T. A. van der Graaf
- Department of Medical OncologyNetherlands Cancer Institute, Antoni van LeeuwenhoekAmsterdamThe Netherlands
- Department of Medical OncologyErasmus MC Cancer Institute, Erasmus Medical Center RotterdamRotterdamThe Netherlands
| | - Nielka P. van Erp
- Department of PharmacyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
| | | | | | - Ingrid M. E. Desar
- Department of Medical OncologyResearch Institute for Medical Innovation, Radboud University Medical CenterNijmegenThe Netherlands
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Beninato T, Duh QY, Long KL, Kiernan CM, Miller BS, Patel S, Randle RW, Wachtel H, Zanocco KA, Zern NK, Drake FT. Challenges and controversies in adrenal surgery: A practical approach. Curr Probl Surg 2023; 60:101374. [PMID: 37770163 DOI: 10.1016/j.cpsurg.2023.101374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Affiliation(s)
- Toni Beninato
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Quan-Yang Duh
- Veterans Affairs Medical Center, San Francisco, San Francisco, CA
| | | | - Colleen M Kiernan
- Vanderbilt University Medical Center, Veterans Affairs Medical Center, Tennessee Valley Health System, Nashville, TN
| | - Barbra S Miller
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Snehal Patel
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Kyle A Zanocco
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
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9
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Puglisi S, Basile V, Sperone P, Terzolo M. Pregnancy in patients with adrenocortical carcinoma: a case-based discussion. Rev Endocr Metab Disord 2023; 24:85-96. [PMID: 36414840 DOI: 10.1007/s11154-022-09769-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 11/24/2022]
Abstract
Although adrenocortical carcinoma (ACC) during pregnancy is rare, a retrospective review of a case series at our hospital revealed that almost one third of our patients were women in childbearing age. Given that the age of maternity is increasing, dealing with a tumor diagnosis during pregnancy and the need for fertility planning in cancer survivors is likely to become more frequent.We thus carried out a case-based discussion regarding: i) diagnosing and treating an ACC during pregnancy; ii) patients conceiving while on mitotane; iii) ACC survivors with a maternal desire.In each of these cases, it is important to provide patients with sufficient information, to offer medical advice and psychological support, to personalize treatments in accordance with the wishes of the patient and her relatives, and to collaborate with other specialists since a multidisciplinary expert team is required to manage each case individually.
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Affiliation(s)
- Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - Vittoria Basile
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy
| | - Paola Sperone
- Medical Oncology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - Massimo Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043, Orbassano, Italy.
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10
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Shirley M. Mitotane in adrenocortical carcinoma: a profile of its use. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00958-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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11
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Cárdenas-Salas J, Castelo B, Regojo RM, González-Sanchez JA, Álvarez-Escolá C. Long-term complete remission of metastatic adrenocortical carcinoma. Horm Mol Biol Clin Investig 2022; 44:67-71. [PMID: 36069780 DOI: 10.1515/hmbci-2022-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/20/2022] [Indexed: 11/15/2022]
Abstract
OBJETIVES To report a rare case of a metastatic adrenocortical carcinoma (ACC) that achieve a complete and a long-term remission. CASE PRESENTATION AAC is a rare and aggressive tumor, with a high risk of recurrence and that present metastases in 21% of cases at diagnosis. Treatment of advanced ACC is challenging, mitotane is the only available adrenolytic treatment, with modest and unpredictable responses. Response rates to systemic chemotherapy are not encouraging. We describe the case of a 39-year-old woman with a metastatic ACC, that achieve a complete and long-term remission after chemotherapy, mitotane treatment and surgery of primary tumor and liver metastases. CONCLUSIONS A complete remission of a metastatic adrenocortical carcinoma is possible in some rare cases after a multimodal treatment.
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Affiliation(s)
- Jersy Cárdenas-Salas
- Department of Endocrinology, "Fundación Jiménez-Diaz" University Hospital, Madrid, Spain
| | - Beatriz Castelo
- Department of Oncology, "La Paz" University Hospital, Madrid, Spain
| | - Rita María Regojo
- Department of Pathology, "La Paz" University Hospital, Madrid, Spain
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Heo YJ, Yoo JH, Choe YS, Park SH, Lee SB, Kim HA, Choi JY, Lee YA, Lim BC, Chueh HW. Low-dose mitotane-induced neurological and endocrinological complication in a 5-year-old girl with adrenocortical carcinoma. Ann Pediatr Endocrinol Metab 2022; 27:236-241. [PMID: 34670067 PMCID: PMC9537676 DOI: 10.6065/apem.2142044.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/31/2021] [Indexed: 12/02/2022] Open
Abstract
Mitotane is an adrenolytic drug that exhibits therapeutic effects within a narrow target range (14-20 μg/dL). Various complications develop if the upper limit is exceeded. We present the case of a 5-year-old girl with breast development, acne, and pubic hair who was diagnosed with an adrenal mass that was subsequently excised. The pathological finding was adrenocortical carcinoma with a high risk of malignancy, and adjuvant therapy (combined mitotane and radiation therapy) was recommended. Mitotane was initiated at a low dose to allow monitoring of the therapeutic drug level, and high-dose hydrocortisone was also administered. However, the patient exhibited elevated adrenocorticotropic hormone levels and vague symptoms such as general weakness and difficulty concentrating. It was important to determine if these symptoms were signs of the neurological complications that develop when mitotane level is elevated. Encephalopathy progression and pubertal signs appeared 6 months after diagnosis, induced by high mitotane level. The mitotane decreased to subtherapeutic level several months after its discontinuation, at which time endocrinopathy (central hypothyroidism, hypercholesterolemia, and secondary central precocious puberty) developed. The case shows that low-dose mitotane can trigger neurological and endocrinological complications in a pediatric patient, indicating that the drug dose should be individualized with frequent monitoring of the therapeutic level.
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Affiliation(s)
- You Joung Heo
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Ho Yoo
- Department of Pediatrics, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Yun Soo Choe
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hee Park
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Bok Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun A Kim
- Department of Pediatrics, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Jung Yoon Choi
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Chan Lim
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Won Chueh
- Department of Pediatrics, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea,Address for correspondence: Hee Won Chueh Department of Pediatrics, Dong-A University Hospital, Dong-A University College of Medicine, 32 Daesingongwon-ro, Seo-gu, Busan 49201, Korea
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Sex-Based Evaluation of Lipid Profile in Postoperative Adjuvant Mitotane Treatment for Adrenocortical Carcinoma. Biomedicines 2022; 10:biomedicines10081873. [PMID: 36009421 PMCID: PMC9405852 DOI: 10.3390/biomedicines10081873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/28/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background: A wide interindividual variability in mitotane concentrations and treatment-related dyslipidemia have been reported. Here, we aimed to underline the sex-related differences in the lipid profile in patients that underwent radical surgery of adrenocortical carcinoma during treatment with adjuvant mitotane. Methods: A chromatographic method was used to quantify the drug in plasma collected from adult patients with complete tumor resection, also considering active metabolite o,p’-DDE. Results: We observed different lipid profiles between males and females and between pre- and post-menopausal women. Considering the mitotane-related effects on lipid levels, we observed that higher drug concentrations were correlated with higher HDL in all the considered groups (p < 0.001), with total cholesterol both in males (p = 0.005) and females (p = 0.036), with triglycerides in postmenopausal females (p = 0.002) and with LDL in male patients (p < 0.001). Increases in o,p’-DDE were positively correlated with HDL levels in all the groups (p < 0.001) and negatively with LDL in all the groups (males p = 0.008, pre- and post-menopausal females p < 0.001), with total cholesterol in pre- (p = 0.016) and post-menopausal women (p = 0.01) and with triglycerides in premenopausal females (p = 0.005). Conclusions: This is the first study designed to evaluate sex differences in lipoprotein and lipid levels during mitotane adjuvant treatment; the results suggest that a gender and personalized approach could be useful to prevent and manage alterations in the lipid profile.
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Cremaschi V, Abate A, Cosentini D, Grisanti S, Rossini E, Laganà M, Tamburello M, Turla A, Sigala S, Berruti A. Advances in adrenocortical carcinoma pharmacotherapy: what is the current state of the art? Expert Opin Pharmacother 2022; 23:1413-1424. [PMID: 35876101 DOI: 10.1080/14656566.2022.2106128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Surgery, followed or not by adjuvant mitotane, is the current mainstay of therapy for patients with early-stage adrenocortical carcinoma (ACC). Mitotane, either alone or in association with EDP (Etoposide-Doxorubicin-Cisplatin) combination chemotherapy, is the standard approach for patients with metastatic ACC. AREAS COVERED The activity of newer cytotoxic drugs, radioligands, targeted therapies and immunotherapy, both in preclinical and in clinical studies, will be reviewed in this paper. EXPERT OPINION ADIUVO trial revealed that the administration of adjuvant mitotane is not advantageous in patients with good prognosis. Future strategies are to intensify efforts in adjuvant setting in patients with high risk of relapse. In patients with advanced/metastatic disease, modern targeted therapies have shown significant cytotoxicity in preclinical studies, however, studies in ACC patients reported disappointing results so far. The absence of targeted agents specifically inhibiting the major molecular pathways of ACC growth is the main cause of the failure of these drugs. Since ACC is often antigenic but poorly immunogenic, the results of immunotherapy trials appeared inferior to those achieved in the management of patients with other malignancies. Radioligand therapy may also be a promising approach. Combination of chemotherapy plus immunotherapy could be interesting to be tested in the future.
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Affiliation(s)
- Valentina Cremaschi
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Andrea Abate
- Section of Pharmacology, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - Deborah Cosentini
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Salvatore Grisanti
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Elisa Rossini
- Section of Pharmacology, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - Marta Laganà
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Mariangela Tamburello
- Section of Pharmacology, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - Antonella Turla
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Sandra Sigala
- Section of Pharmacology, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, 25123, Brescia, Italy
| | - Alfredo Berruti
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Piazzale Spedali Civili 1, 25123, Brescia, Italy
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Quercetin-Rich Extracts from Onions ( Allium cepa) Play Potent Cytotoxicity on Adrenocortical Carcinoma Cell Lines, and Quercetin Induces Important Anticancer Properties. Pharmaceuticals (Basel) 2022; 15:ph15060754. [PMID: 35745673 PMCID: PMC9228762 DOI: 10.3390/ph15060754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 02/07/2023] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare subtype of cancer, with a poor prognosis in children and adults. Mitotane is the only approved adrenolytic drug for the treatment of ACC, which has controversies regarding its efficacy and side effects on patients. Onion (Allium cepa), a worldwide consumed food, is associated with many health benefits. Along with its glycosides, the flavonoid quercetin is abundant in onions. After evaluating the cytotoxicity of A. cepa extracts on adrenocortical carcinoma cell line (H295R), the rich quercetin fractions had better results. Then, we aimed to compare the quercetin vs. mitotane effectiveness, using adrenocortical carcinoma cell lines H295R and SW-13. Quercetin showed a higher cytotoxicity response on both cancerous cell lines after 10 µM concentration, while mitotane only after 30 µM. Cell cycle dynamics were altered upon quercetin treatments, with G2 phase increase with 30 µM of quercetin on H295R cell line and G1 arrest on SW-13 cell line with 15 µM. Early and late apoptosis, alongside intracellular calcium, were increased on SW-13 treated with 30 µM of quercetin, and ROS rates were reduced by quercetin on H295R. Therefore, quercetin-rich onions have the potential to be a natural source of anticancer agents for adrenocortical carcinoma.
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Al-Ward R, Zsembery C, Habra MA. Adjuvant therapy in adrenocortical carcinoma: prognostic factors and treatment options. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R90-R101. [PMID: 37435451 PMCID: PMC10259337 DOI: 10.1530/eo-22-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/26/2022] [Indexed: 07/13/2023]
Abstract
Adrenocortical carcinoma (ACC) is a rare cancer with high recurrence rates and heterogeneous clinical behavior. The role of adjuvant therapy remains unclear because of the challenges in collecting high-quality data for a rare cancer. The current treatment recommendations and guidelines for adjuvant therapy are mostly derived retrospectively from national databases and the treatment outcomes of patients seen in referral centers. To better select patients for adjuvant therapy, multiple factors need to be considered including staging, markers of cellular proliferation (such as Ki67%), resection margins, hormonal function, and possibly genetic alterations of the tumor as well as patient-related factors such as age and performance status. Adjuvant mitotane remains the most commonly used adjuvant therapy in ACC based on clinical practice guidelines, though emerging data from ADIUVO trial (mitotane vs observation in low-risk ACC) suggest that mitotane use in low-risk patients may not be needed. An ongoing clinical trial (ADIUVO-2) is evaluating the role of mitotane vs mitotane combined with chemotherapy in high-risk ACC. The use of adjuvant therapy has been controversial but can be justified in select patients with positive resection margins or after the resection of localized recurrence. A prospective study is needed to study the role of adjuvant radiation in ACC as radiation is expected to help only with local control without impact on distant microscopic metastases. There are no recommendations or published data about using adjuvant immunotherapy in ACC, but this may be a future study after establishing the efficacy and safety profile of immunotherapy in metastatic ACC.
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Affiliation(s)
- Ruaa Al-Ward
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, Texas, USA
| | - Celeste Zsembery
- Departments of Medicine and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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17
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Altieri B, Lalli E, Faggiano A. Mitotane treatment in adrenocortical carcinoma: mechanisms of action and predictive markers of response to therapy. Minerva Endocrinol (Torino) 2021; 47:203-214. [PMID: 34881855 DOI: 10.23736/s2724-6507.21.03601-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Adrenocortical carcinoma (ACC) is a rare malignancy with a high risk of recurrence even in cases with complete surgical tumor resection. Mitotane represents the cornerstone of the adjuvant therapy as well as the first line of medical treatment in advanced cases. However, evidence on mitotane efficacy is mostly based on retrospective studies and the use of mitotane continues to represent a clinical challenge. EVIDENCE ACQUISITION Mitotane causes selective damage to adrenocortical cells, causing an increase of cell apoptosis through a disruption of mitochondria and the induction of the endoplasmic reticulum stress. Different clinical and molecular markers predicting response to mitotane have been proposed with uncertain results. Attainment of mitotane plasma levels within the target range of 14 to 20 mg/L represent the strongest predictor of mitotane effectiveness both in adjuvant and advanced tumor setting. The occurrence of late recurrence after primary ACC diagnosis and changes in metabolic activity on FDG-PET are only weakly associated with mitotane response. Among the proposed molecular markers associated with mitotane efficacy, the investigation of the CYP2W1*6 and CYP2B6*6 single nucleotide polymorphisms appears to be currently the most promising predictive molecular markers of mitotane therapy. However, none of the evaluated markers has been validated for clinical use. CONCLUSIONS In the era of precision medicine, a better insight into mitotane molecular mechanisms as well as the potential use in the daily clinical practice of clinical parameters and molecular markers predicting the individual response to mitotane are urgently needed.
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Affiliation(s)
- Barbara Altieri
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany -
| | - Enzo Lalli
- Institut de Pharmacologie Moléculaire et Cellulaire CNRS UMR 7275, Valbonne, France.,Université Côte d'Azur, Valbonne, France.,INSERM, Valbonne, France
| | - Antongiulio Faggiano
- Endocrinology Unit, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Subramanian C, McCallister R, Kuszynski D, Cohen MS. Re-Evaluation of Combinational Efficacy and Synergy of the Italian Protocol In Vitro: Are We Truly Optimizing Benefit or Permitting Unwanted Toxicity? Biomedicines 2021; 9:biomedicines9091190. [PMID: 34572375 PMCID: PMC8467159 DOI: 10.3390/biomedicines9091190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Adrenocortical carcinoma (ACC) is a rare endocrine malignancy, with very poor prognosis as a majority of the patients have advanced disease at the time of diagnosis. Currently, adjuvant therapy for most patients consists of either mitotane (M) alone or in combination with multi-drug chemotherapeutics such as etoposide (E), doxorubicin (D), and cisplatin (P), known as the Italian protocol (IP; EDPM). This multi-drug treatment regimen, however, carries significant toxicity potential for patients. One way to improve toxicity profiles with these drugs in combination is to understand where their synergy occurs and over what dosing range so that lower dose regimens could be applied in combination with equal or improved efficacy. We hypothesize that a better understanding of the synergistic effects as well as the regulation of steroidogenic enzymes during combination therapy may provide more optimized combinational options with good potency and lower toxicity profiles. Methods: Two human ACC cell lines, NCI-H295R (hormonally active) and SW13 (hormonally inactive), were grown in 2D culture in appropriate growth medium. The viability of the cells after treatment with varying concentrations of the drugs (E, D, and P) either alone or in combinations with M was determined using the CellTiter Glow assay after 72 h, and the combination index for each was calculated using Compusyn by the Chou–Talalay method. The expression levels of enzymes associated with steroidogenesis were evaluated by RT-PCR in NCI-H295R. Results: When both cell lines were treated with M (ranging 25–50 μM), +E (ranging 18.75–75 μM), and +D (ranging 0.625–2.5 μM) we observed a synergistic effect (CI < 1) with potency equivalent to the full Italian protocol (IP), whereas combining M + P + D had an antagonistic effect (CI > 1) indicating the negative effect of adding cisplatin in the combination. Comparing the hormonally active and inactive cell lines, M + P + E was antagonistic in NCI-H295R and synergistic in SW13. Treatment of NCI-H295R cells with antagonistic combinations (M + P + D, M + P + E) resulted in a significant decrease in the levels of steroidogenic enzymes STAR, CYP11A1, and CYP21A2 compared to IP (p < 0.05) while M + E + D resulted in increased expression or no significant effect compared to IP across all genes tested. Conclusions: The synergistic effect for M + E + D was significant and equivalent in potency to the full IP in both cell lines and resulted in a steroidogenic gene expression profile similar to or better than that of full IP, warranting further evaluation. Future in vivo evaluation of the combination of M + E + D (with removal of P from the IP regimen) may lower toxicity while maintaining anticancer efficacy in ACC.
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Affiliation(s)
- Chitra Subramanian
- Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA; (R.M.); (D.K.)
- Correspondence: (C.S.); (M.S.C.)
| | - Reid McCallister
- Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA; (R.M.); (D.K.)
| | - Dawn Kuszynski
- Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA; (R.M.); (D.K.)
| | - Mark S. Cohen
- Department of Surgery, Michigan Medicine, Ann Arbor, MI 48109, USA; (R.M.); (D.K.)
- Department of Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
- Correspondence: (C.S.); (M.S.C.)
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Uchihara M, Tanioka M, Kojima Y, Nishikawa T, Sudo K, Shimoi T, Noguchi E, Maeshima AM, Yonemori K. Clinical management and outcomes associated with etoposide, doxorubicin, and cisplatin plus mitotane treatment in metastatic adrenocortical carcinoma: a single institute experience. Int J Clin Oncol 2021; 26:2275-2281. [PMID: 34468885 DOI: 10.1007/s10147-021-02021-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare and aggressive disease that is often diagnosed at an advanced stage. There is no standard treatment for metastatic ACC; EDP-M (etoposide, doxorubicin, and cisplatin plus mitotane) is one treatment option. A randomized controlled trial (FIRM-ACT) evaluating the efficacy of EDP-M showed progression-free survival (PFS) was 5.0 months, overall survival (OS) was 14.8 months, the response rate was 19%, and adrenal insufficiency occurred in 3.4% of patients. However, the efficacy and safety of this regimen in Asia are not fully reported. METHODS We retrospectively analyzed 43 patients diagnosed with metastatic ACC at the National Cancer Center Hospital between 1997 and 2020. We evaluated PFS, OS, and response in 17 patients who received EDP-M as first-line therapy. RESULTS The median age at treatment initiation was 45 years (range 18-74). Eight patients (47%) had autonomous hormone production, including six patients with hypercortisolism. The best response of partial response and stable disease was seen in two (12%) and ten (59%) patients, respectively. The median PFS was 6.2 months [95% confidence interval (CI): 4.3-10.0]. The median OS was 15.4 months (95% CI 11.6-not reached). Three patients received only one cycle due to adverse effects associated with hypercortisolism. Grade 3/4 adverse events associated with adrenal insufficiency occurred in three (17%) cases, resulting in EDP-M discontinuation. CONCLUSIONS The EDP-M regimen had similar PFS to that observed in FIRM-ACT. Adrenal insufficiency was more frequent in the current study, but this could be managed with supportive endocrinological care such as cortisol replacement.
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Affiliation(s)
- Masaki Uchihara
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan.,Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Toyama 1-21-1, Shinjuku-ku City, Tokyo, 162-8655, Japan
| | - Maki Tanioka
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Yuki Kojima
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tadaaki Nishikawa
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kazuki Sudo
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tatsunori Shimoi
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Emi Noguchi
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Akiko Miyagi Maeshima
- Department of Diagnostic Pathology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kan Yonemori
- Department of Medical Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan
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Shah MH, Goldner WS, Benson AB, Bergsland E, Blaszkowsky LS, Brock P, Chan J, Das S, Dickson PV, Fanta P, Giordano T, Halfdanarson TR, Halperin D, He J, Heaney A, Heslin MJ, Kandeel F, Kardan A, Khan SA, Kuvshinoff BW, Lieu C, Miller K, Pillarisetty VG, Reidy D, Salgado SA, Shaheen S, Soares HP, Soulen MC, Strosberg JR, Sussman CR, Trikalinos NA, Uboha NA, Vijayvergia N, Wong T, Lynn B, Hochstetler C. Neuroendocrine and Adrenal Tumors, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:839-868. [PMID: 34340212 DOI: 10.6004/jnccn.2021.0032] [Citation(s) in RCA: 238] [Impact Index Per Article: 79.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Neuroendocrine and Adrenal Gland Tumors focus on the diagnosis, treatment, and management of patients with neuroendocrine tumors (NETs), adrenal tumors, pheochromocytomas, paragangliomas, and multiple endocrine neoplasia. NETs are generally subclassified by site of origin, stage, and histologic characteristics. Appropriate diagnosis and treatment of NETs often involves collaboration between specialists in multiple disciplines, using specific biochemical, radiologic, and surgical methods. Specialists include pathologists, endocrinologists, radiologists (including nuclear medicine specialists), and medical, radiation, and surgical oncologists. These guidelines discuss the diagnosis and management of both sporadic and hereditary neuroendocrine and adrenal tumors and are intended to assist with clinical decision-making. This article is focused on the 2021 NCCN Guidelines principles of genetic risk assessment and counseling and recommendations for well-differentiated grade 3 NETs, poorly differentiated neuroendocrine carcinomas, adrenal tumors, pheochromocytomas, and paragangliomas.
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Affiliation(s)
- Manisha H Shah
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Al B Benson
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Pamela Brock
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Paxton V Dickson
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | - Jin He
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | - Arash Kardan
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | | | | | | | | | | | | | | | | | - Nikolaos A Trikalinos
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | - Beth Lynn
- National Comprehensive Cancer Network
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21
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Determination of Mitotane (DDD) and Principal Metabolite by a Simple HPLC-UV Method and Its Validation in Human Plasma Samples. SEPARATIONS 2021. [DOI: 10.3390/separations8050063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Mitotane (DDD) is prescribed in adrenocortical renal carcinoma. Its principal metabolite, dichlorodiphenylethene (DDE), can accumulate in fat tissues and from a toxicological point of view, is probably more interesting than the other metabolite dichlorodiphenylacetate (DDA). Therapeutic Drug Monitoring (TDM) of DDD plasma concentrations is required to combine therapeutic efficacy with acceptable toxicity. Therefore, we developed a simple and fast HPLC-UV method to monitor plasma concentrations after a liquid–liquid extraction of plasma calibration samples, quality controls, and anonymous plasma samples with unknown DDD and DDE concentrations. Samples were injected into an HPLC instrument and peaks of mitotane (DDD), DDE and aldrin (internal standard, IS) were resolved by a stationary phase C18 column (250 mm × 4.6 mm, 5 μm), maintained at 35 °C. Mobile phase, made by water/acetonitrile (10/90, v/v), was pumped at a flow of 1.0 mL/min, and absorbance was monitored at a wavelength of 226 nm. Average recovery was 95% for all analytes, and the method was linear for both DDD (r2 = 0.9988, range 1–50 mg/L) and DDE (r2 = 0.9964, range 1–40 mg/L). The values of limit of detection and quantitation were 0.102 and 0.310 mg/L for DDD and 0.036 and 0.108 mg/L for DDE, respectively. The retention time values of DDD, DDE and IS were 7.06, 9.42 and 12.60 min, respectively. The method was successfully validated according to FDA guidelines and finally adopted for routine TDM.
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22
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Steenaard RV, Ettaieb MHT, Kerkhofs TMA, Haak HR. How close are we to personalized mitotane dosing in the treatment of adrenocortical carcinoma? State of the art and future perspectives. Expert Opin Drug Metab Toxicol 2021; 17:677-683. [PMID: 33886381 DOI: 10.1080/17425255.2021.1921146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Mitotane is the only drug registered specifically for adrenocortical carcinoma. Finding the optimal dose for a patient is difficult due to large differences in bioavailability, toxicity and effect. We therefore look to improve personalized dosing of mitotane. AREAS COVERED We searched PubMed for studies related to mitotane dosing, pharmacokinetics, pharmacogenetics and combination therapy. Comparison of different dosing strategies have not resulted in an optimal advice. Several computerized pharmacokinetic models have been proposed to predict plasma levels. The current pharmacokinetic models do not explain the full variance in plasma levels. Pharmacogenetics have been proposed to find the unexplained variance. Studies on combination therapy have not yet led to a potential dose adjustment for mitotane. EXPERT OPINION Computerized pharmacokinetics models are promising tools to predict plasma levels, further validation is needed. Pharmacogenetics are introduced in these models, but more research is required before clinical application. We believe that in the near future, personalized mitotane dosage will be aided by a validated web-based pharmacokinetic model with good predictive ability based primarily on clinical characteristics, adjustable for actual plasma levels and dosage.
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Affiliation(s)
- Rebecca V Steenaard
- Department of Internal Medicine, Máxima MC, Veldhoven, Eindhoven, The Netherlands.,Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Madeleine H T Ettaieb
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Thomas M A Kerkhofs
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Harm R Haak
- Department of Internal Medicine, Máxima MC, Veldhoven, Eindhoven, The Netherlands.,Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands.,Department of Internal Medicine, Division of General Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Huang X, Liang C, Yang H, Li X, Deng X, Liang X, Li L, Huang Z, Lu D, Ma Y, Luo Z. Curcumin induces apoptosis and inhibits the growth of adrenocortical carcinoma: Identification of potential candidate genes and pathways by transcriptome analysis. Oncol Lett 2021; 21:476. [PMID: 33907586 PMCID: PMC8063251 DOI: 10.3892/ol.2021.12737] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/19/2021] [Indexed: 02/06/2023] Open
Abstract
Adrenocortical carcinoma (ACC) is an endocrine tumour with high malignancy, high invasiveness and poor prognosis. Curcumin, a major component in turmeric, has been reported to have good efficacy and biological safety in treating cancer. However, the role and mechanism of curcumin in ACC have not yet been fully investigated and were thus the focus of this study. In vitro, ACC SW-13 and NCI-H295R cells were treated with curcumin and their viability, migration and invasion were assessed by CCK-8 and Transwell assays. Apoptosis was detected via flow cytometry and western blotting. High-throughput sequencing and comprehensive bioinformatics analyses were performed to elucidate the molecular processes underlying curcumin activity. In vivo, SW-13 cells were injected into nude mice, and the tumour volumes and weights were observed after 2 weeks of curcumin treatment. Organelle changes were observed by electron microscopy, and potential candidate genes and pathways were analysed by RT-qPCR and western blotting. The role of the CHOP target gene in curcumin-induced ACC cell apoptosis was verified via lentiviral transfection experiments. Curcumin inhibited the viability, migration and invasion, and induced the apoptosis of ACC cells. Transcriptome sequencing analysis showed that curcumin treatment markedly changed the gene expression levels. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses showed that the MAPK and endoplasmic reticulum (ER) stress pathways were the predominant pathways associated with curcumin-induced apoptosis of ACC cells. Subsequent in vivo and in vitro results demonstrated that the JNK, p38 MAPK and ER stress pathways were activated in curcumin-treated ACC cells, and that C/EBP homologous protein induction was responsible for curcumin-induced apoptosis of ACC cells. In summary, curcumin induced ACC cell apoptosis and inhibited tumour growth by activating the JNK, p38 MAPK and ER stress pathways. Thus, curcumin may be a potential therapeutic drug for ACC.
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Affiliation(s)
- Xuemei Huang
- Department of Endocrinology, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530022, P.R. China
| | - Chunfeng Liang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Haiyan Yang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Xin Li
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Xiujun Deng
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Xinghuan Liang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Li Li
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Zhenxing Huang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Decheng Lu
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Yan Ma
- Department of Ultrasonic Diagnosis, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
| | - Zuojie Luo
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530021, P.R. China
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Alyateem G, Nilubol N. Current Status and Future Targeted Therapy in Adrenocortical Cancer. Front Endocrinol (Lausanne) 2021; 12:613248. [PMID: 33732213 PMCID: PMC7957049 DOI: 10.3389/fendo.2021.613248] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/25/2021] [Indexed: 12/11/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. The current treatment standards include complete surgical resection for localized resectable disease and systemic therapy with mitotane alone or in combination with etoposide, doxorubicin, and cisplatin in patients with advanced ACC. However, the efficacy of systemic therapy in ACC is very limited, with high rates of toxicities. The understanding of altered molecular pathways is critically important to identify effective treatment options that currently do not exist. In this review, we discuss the results of recent advanced in molecular profiling of ACC with the focus on dysregulated pathways from various genomic and epigenetic dysregulation. We discuss the potential translational therapeutic implication of molecular alterations. In addition, we review and summarize the results of recent clinical trials and ongoing trials.
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Paragliola RM, Corsello A, Locantore P, Papi G, Pontecorvi A, Corsello SM. Medical Approaches in Adrenocortical Carcinoma. Biomedicines 2020; 8:biomedicines8120551. [PMID: 33260476 PMCID: PMC7760807 DOI: 10.3390/biomedicines8120551] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/15/2020] [Accepted: 11/27/2020] [Indexed: 12/15/2022] Open
Abstract
Adrenocortical carcinoma (ACC) represents one of the most aggressive endocrine tumors. In spite of a correct therapeutic strategy based on a multidisciplinary approach between endocrinologist, surgeon and oncologist, the prognosis is often poor. Surgery is the mainstay treatment in ACC. Mitotane, a dichloro-diphenyl-trichloro-ethane derivate, represents the main medical treatment of ACC in consideration of its adrenocytolitic activity and it is mainly employed as adjuvant treatment after complete surgical resection and for the treatment of advanced ACC. However, the use of mitotane as adjuvant therapy is still controversial, also in consideration of the retrospective nature of several studies. The recurrence of disease is frequent, especially in advanced disease at the diagnosis. Therefore, in these contexts, conventional chemotherapy must be considered in association with mitotane, being the combination etoposide, doxorubicin and cisplatin (EDP) the standard of care in this setting. A more modern therapeutic approach, based on the need of a salvage therapy for advanced ACC that progresses through first-line EDP, is focused on molecular-targeted therapies. However, robust clinical trials are necessary to assess the real efficacy of these treatments.
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26
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Liu X, Fu Q, Tang Y, Deng JH, Mei D, Zhang B. A case report of neurological adverse events caused by short-term and low-dose treatment of mitotane: The role of therapeutic drug monitoring. Medicine (Baltimore) 2020; 99:e22620. [PMID: 33019484 PMCID: PMC7535773 DOI: 10.1097/md.0000000000022620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Low-dose mitotane has been widely used for many decades in patients with advanced adrenocortical carcinoma (ACC), which exhibited good safety profiles compared with the high-dose regimen. The clinical efficacy and toxicity of mitotane are closely related to its plasma concentration, and therapeutic drug monitoring (TDM) is recommended. Until now, no severe adverse drug reaction (ADR) related to the toxic plasma level after a short-term treatment of low-dose mitotane has been published. PATIENT CONCERNS A 50-year-old Chinese female presented with severe neurological adverse events related to a toxic plasma levels of 42.8 mg/L after 4 months treatment of low-dose mitotane. DIAGNOSES During the course of therapy, no other medication could cause neurological adverse events. Therefore, we suspected a high sensitivity to the side effect of mitotane related to a toxic plasma level. INTERVENTIONS Treatment of mitotane was stopped. OUTCOMES The trough plasma concentration of mitotane decreased to 18.7 mg/mL after one and a half months, and the neurological symptoms gradually improved after drug discontinuance. LESSONS The present case provides the first report of severe neurological adverse events induced by the short-term use of low-dose mitotane for adjuvant treatment in a patient with ACC, indicating that potentially severe ADR can also occur when using low-dose regimen in the early stage of treatment. TDM and early recognition could result in a favorable outcome.
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Affiliation(s)
| | | | | | - Jian-hua Deng
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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27
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Unwanted Hormonal and Metabolic Effects of Postoperative Adjuvant Mitotane Treatment for Adrenocortical Cancer. Cancers (Basel) 2020; 12:cancers12092615. [PMID: 32937772 PMCID: PMC7565701 DOI: 10.3390/cancers12092615] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Mitotane is the only drug approved for treatment of adrenocortical cancer. Although mitotane is a derivative of the pesticide dichlorodiphenyltrichloroethane (DDT), limited data are available on its toxicity. Herein, we reported on the type and frequency of mitotane adverse events and on supportive therapies used to deal with toxicity in 74 mitotane-treated patients. Beyond the expected glucocorticoid insufficiency, a significant number of patients had a deficit of mineralocorticoid hormones, hypothyroid state and impaired testicular function, while fertile women frequently developed ovarian cysts during mitotane treatment. Multiple hormone replacement therapies were needed in >30% of patients. Statins were used in 50% of patients for significant hypercholesterolemia. Supportive therapies were able to revert the biochemical alterations, although higher doses were frequently used due to pharmacokinetic interactions with mitotane. Our study underlines the need of a careful and global approach to manage mitotane toxicity, to make adjuvant therapy safer and easier for patients. Abstract Mitotane is widely used for the treatment of adrenocortical cancer (ACC), although the drug-related toxicity complicates its use. The aim of this study is to assess comprehensively the different endocrine and metabolic unwanted effects of the drug, and to provide data on the supportive therapies. We retrospectively analyzed 74 ACC patients adjuvantly treated with mitotane for ≥12 months. During the treatment period (40 months, 12–195), 32.4% of patients needed replacement therapy for mineralocorticoid deficit, 36.2% for hypothyroidism and 34.3% for male hypogonadism. In fertile women, hypogonadism was uncommon, while 65.4% of women developed ovarian cysts. Although no significant change in low-density lipoprotein (LDL) was observed, statins were started in 50% of patients for a significant increase in total cholesterol and triglycerides. Dyslipidemia occurred early, after a median time of 6 months from mitotane start. Conversely, testosterone replacement was usually started after >2 years. In many cases, ranging from 29.4% to 50% according to the side effect, toxicity occurred well before the achievement of the target mitotane concentrations. Supportive therapies were able to revert the biochemical alterations induced by mitotane, although higher doses were needed for a likely pharmacokinetic interaction of exogenous steroids and statins with mitotane. In conclusion, adjuvant mitotane therapy is associated with a spectrum of unwanted effects encompassing the function of different endocrine glands and requires a careful clinical and biochemical assessment associated with the therapeutic drug monitoring.
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28
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Weigand I, Altieri B, Lacombe AMF, Basile V, Kircher S, Landwehr LS, Schreiner J, Zerbini MCN, Ronchi CL, Megerle F, Berruti A, Canu L, Volante M, Paiva I, Della Casa S, Sbiera S, Fassnacht M, Fragoso MCBV, Terzolo M, Kroiss M. Expression of SOAT1 in Adrenocortical Carcinoma and Response to Mitotane Monotherapy: An ENSAT Multicenter Study. J Clin Endocrinol Metab 2020; 105:5843694. [PMID: 32449514 DOI: 10.1210/clinem/dgaa293] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/20/2020] [Indexed: 12/18/2022]
Abstract
CONTEXT Objective response rate to mitotane in advanced adrenocortical carcinoma (ACC) is approximately 20%, and adverse drug effects are frequent. To date, there is no marker established that predicts treatment response. Mitotane has been shown to inhibit sterol-O-acyl transferase 1 (SOAT1), which leads to endoplasmic reticulum stress and cell death in ACC cells. OBJECTIVE To investigate SOAT1 protein expression as a marker of treatment response to mitotane. PATIENTS A total of 231 ACC patients treated with single-agent mitotane as adjuvant (n = 158) or advanced disease therapy (n = 73) from 12 ENSAT centers were included. SOAT1 protein expression was determined by immunohistochemistry on formalin-fixed paraffin-embedded specimens. SETTING Retrospective study at 12 ACC referral centers. MAIN OUTCOME MEASURE Recurrence-free survival (RFS), progression-free survival (PFS), and disease-specific survival (DSS). RESULTS Sixty-one of 135 patients (45%) with adjuvant mitotane treatment had recurrences and 45/68 patients (66%) with mitotane treatment for advanced disease had progressive disease. After multivariate adjustment for sex, age, hormone secretion, tumor stage, and Ki67 index, RFS (hazard ratio [HR] = 1.07; 95% confidence interval [CI], 0.61-1.85; P = 0.82), and DSS (HR = 1.30; 95% CI, 0.58-2.93; P = 0.53) in adjuvantly treated ACC patients did not differ significantly between tumors with high and low SOAT1 expression. Similarly, in the advanced stage setting, PFS (HR = 1.34; 95% CI, 0.63-2.84; P = 0.45) and DSS (HR = 0.72; 95% CI, 0.31-1.70; P = 0.45) were comparable and response rates not significantly different. CONCLUSIONS SOAT1 expression was not correlated with clinical endpoints RFS, PFS, and DSS in ACC patients with mitotane monotherapy. Other factors appear to be relevant for mitotane treatment response and ACC patient survival.
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Affiliation(s)
- Isabel Weigand
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Barbara Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Amanda M F Lacombe
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM42, Serviço de Endocrinologia e Metabologia, Hospital de Clínicas; Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, Brazil, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vittoria Basile
- Department of Clinical and Biological Sciences, University of Turin at San Luigi Hospital, Orbassano, Italy
| | - Stefan Kircher
- Institute of Pathology, University of Würzburg, Würzburg, Germany
| | - Laura-Sophie Landwehr
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Jochen Schreiner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Maria C N Zerbini
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM42, Serviço de Endocrinologia e Metabologia, Hospital de Clínicas; Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, Brazil, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Cristina L Ronchi
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Felix Megerle
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Alfredo Berruti
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia at ASST Spedali Civili, Brescia, Italy
| | - Letizia Canu
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Marco Volante
- Department of Oncology, University of Turin, Orbassano, Turin, Italy
| | - Isabel Paiva
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário of Coimbra, Coimbra, Portugal
| | - Silvia Della Casa
- Division of Endocrinology and Metabolism, Fondazione Policlinico Gemelli, Catholic University, Rome, Italy
| | - Silviu Sbiera
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Maria Candida B V Fragoso
- Unidade de Suprarrenal, Laboratório de Hormônios e Genética Molecular LIM42, Serviço de Endocrinologia e Metabologia, Hospital de Clínicas; Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, Brazil, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, University of Turin at San Luigi Hospital, Orbassano, Italy
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
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Hasanovic A, Simsir M, Choveau FS, Lalli E, Mus-Veteau I. Astemizole Sensitizes Adrenocortical Carcinoma Cells to Doxorubicin by Inhibiting Patched Drug Efflux Activity. Biomedicines 2020; 8:biomedicines8080251. [PMID: 32751066 PMCID: PMC7460240 DOI: 10.3390/biomedicines8080251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 01/01/2023] Open
Abstract
Adrenocortical carcinoma (ACC) presents a high risk of relapse and metastases with outcomes not improving despite extensive research and new targeted therapies. We recently showed that the Hedgehog receptor Patched is expressed in ACC, where it strongly contributes to doxorubicin efflux and treatment resistance. Here, we report the identification of a new inhibitor of Patched drug efflux, the anti-histaminergic drug astemizole. We show that astemizole enhances the cytotoxic, proapoptotic, antiproliferative and anticlonogenic effects of doxorubicin on ACC cells at concentrations of astemizole or doxorubicin that are not effective by themselves. Our results suggest that a low concentration of astemizole sensitizes ACC cells to doxorubicin, which is a component of the standard treatment for ACC composed of etoposide, doxorubicin, cisplatin and mitotane (EDPM). Patched uses the proton motive force to efflux drugs. This makes its function specific to cancer cells, thereby avoiding toxicity issues that are commonly observed with inhibitors of ABC multidrug transporters. Our data provide strong evidence that the use of astemizole or a derivative in combination with EDPM could be a promising therapeutic option for ACC by increasing the treatment effectiveness at lower doses of EDPM, which would reduce the severe side effects of this regimen.
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30
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Leong D, Nyantoro M, Shedzad H, Robins P, Henley D, Ryan S, Nguyen H, Lisewski D. Management of adrenocortical carcinoma in Western Australia: a perspective over 14 years. ANZ J Surg 2020; 91:62-67. [PMID: 32627365 DOI: 10.1111/ans.16111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/24/2020] [Accepted: 06/07/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adrenocortical carcinoma is a rare but aggressive form of endocrine neoplasm that confers a poor prognosis. To date, the only Australian data published is from New South Wales. This paper describes our experience in Western Australia with a focus on surgical approach and outcomes. METHODS A retrospective study of patients treated for adrenocortical carcinoma in Western Australia over 14 years was performed. RESULTS Over the 14-year period, a total of 33 patients underwent surgery for adrenocortical carcinoma. Resection outcomes were superior in an open en bloc approach with an 85% R0 margin (P = 0.007). Local recurrence rates were lowest in an open en bloc approach (11%) compared to laparoscopic (75%). Multivariate analysis showed that an en bloc resection is highly correlated with an R0 resection (P < 0.05) and significantly associated with lower (odds ratio = 0.06) local recurrence (P = 0.009). Higher volume surgeons (>5 cases) had lower operative times and blood loss. Compliance with mitotane was significantly improved with close monitoring of levels. The European Network for the Study of Adrenal Tumours (ENSAT) stage at presentation was most predictive of long-term survival with 100% of stage I patients alive compared to 53% of stage II, 25% of stage III and 17% of stage IV patients at the end of the follow-up period. CONCLUSION An open en bloc approach with a low threshold for multi-visceral resection performed by high volume surgeons have improved outcomes in local recurrence, operative times and blood loss.
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Affiliation(s)
- David Leong
- Department of Endocrine Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Munyaradzi Nyantoro
- Department of General Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Hira Shedzad
- Department of Endocrine Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Peter Robins
- Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - David Henley
- Department of Endocrine Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - Simon Ryan
- Department of Endocrine Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hieu Nguyen
- Department of Endocrine Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Dean Lisewski
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia.,Department of Endocrine Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Puglisi S, Calabrese A, Basile V, Pia A, Reimondo G, Perotti P, Terzolo M. New perspectives for mitotane treatment of adrenocortical carcinoma. Best Pract Res Clin Endocrinol Metab 2020; 34:101415. [PMID: 32179008 DOI: 10.1016/j.beem.2020.101415] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Adrenocortical carcinoma (ACC) is an aggressive cancer characterized by poor survival. Apart from radical surgery, there is a limited range of therapeutic options and mitotane remains the cornerstone of medical treatment of ACC in either adjuvant or palliative settings. The aim of adjuvant mitotane therapy is to reduce the risk of ACC recurrence following surgical removal of the tumor. Use of mitotane in an adjuvant setting is off-label, but the recent guidelines endorsed by the European Society of Endocrinology (ESE) and the European Network for the Study of Adrenal Tumors (ENSAT) recommend it in ACC patients at high risk of recurrence. The palliative use of mitotane for treatment of advanced ACC aims at controlling tumor progression and, when present, hormone secretion. In this clinical setting, mitotane is used in association with chemotherapy to treat the more aggressive forms, while mitotane monotherapy is reserved for less progressive ACC. Many years after its introduction in clinical practice, there are still uncertainties surrounding the use of this old drug and the derived benefits. Moreover, physicians who use mitotane should recognize and manage the systemic effects of the drug that need a complex supporting therapy.
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Affiliation(s)
- S Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - A Calabrese
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - V Basile
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - A Pia
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - G Reimondo
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - P Perotti
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy
| | - M Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, Italy.
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Puglisi S, Calabrese A, Basile V, Ceccato F, Scaroni C, Altieri B, Della Casa S, Loli P, Pivonello R, De Martino MC, Canu L, Russo M, Badalamenti G, Torlontano M, Stigliano A, Ferraù F, Arnaldi G, Saba L, Quirino A, Perotti P, Berchialla P, Terzolo M. Mitotane Concentrations Influence Outcome in Patients with Advanced Adrenocortical Carcinoma. Cancers (Basel) 2020; 12:E740. [PMID: 32245135 PMCID: PMC7140087 DOI: 10.3390/cancers12030740] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 12/15/2022] Open
Abstract
Mitotane is the main option of treatment for advanced adrenocortical carcinoma (ACC). However, limited evidence is available regarding the impact of plasma mitotane levels on patient outcome. To address this question, we retrospectively analyzed patients with advanced ACC treated with mitotane for ≥3 months, with ≥3 measurements of plasma mitotane reported in the Lysosafe Online® database (HRA Pharma, France), followed at 12 tertiary centers in Italy from 2005 to 2017. We identified 80 patients, initially treated with mitotane alone (56.2%) or plus chemotherapy (43.8%). The preference toward combination therapy was given to de novo stage IV ACC and younger patients. After the first line of treatment, 25% of valid cases experienced clinical benefit (14.5% objective response, 10.5% stabilization of disease) and 75% progression, without differences between the groups of treatment. Patients with progression had a lower time in the target range (TTR) of plasma mitotane and an unfavorable outcome. Death occurred in 76.2% of cases and multivariate analysis showed that clinical benefit after first treatment and longer TTR were favorable predictors of overall survival (OS). In conclusion, the present findings support the importance of mitotane monitoring and strengthen the concept of a therapeutic window for mitotane.
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Affiliation(s)
- Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Anna Calabrese
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Vittoria Basile
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, 35128 Padua, Italy; (F.C.); (C.S.)
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, 35128 Padua, Italy; (F.C.); (C.S.)
| | - Barbara Altieri
- Division of Endocrinology and Metabolic Diseases, University-Hospital Gemelli, IRCSS, Catholic University of the Sacred Heart, 00168 Rome, Italy; (B.A.); (S.D.C.)
| | - Silvia Della Casa
- Division of Endocrinology and Metabolic Diseases, University-Hospital Gemelli, IRCSS, Catholic University of the Sacred Heart, 00168 Rome, Italy; (B.A.); (S.D.C.)
| | - Paola Loli
- Endocrinology, Hospital Niguarda Ca’ Granda, 20121 Milan, Italy;
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy; (R.P.); (M.C.D.M.)
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy; (R.P.); (M.C.D.M.)
| | - Letizia Canu
- Endocrinology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134 Florence, Italy;
| | - Marco Russo
- Endocrinology Division, Department of Clinical and Experimental Medicine, ARNAS Garibaldi, University of Catania, 95122 Catania, Italy;
| | - Giuseppe Badalamenti
- Department of Surgical, Oncological, and Oral Sciences, Section of Medical Oncology, University of Palermo, 90127 Palermo, Italy;
| | - Massimo Torlontano
- Unit of Endocrinology, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Antonio Stigliano
- Endocrinology, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy;
| | - Francesco Ferraù
- Department of Human Pathology of Adulthood and Childhood ‘G. Barresi’, University of Messina, 98125 Messina, Italy;
| | - Giorgio Arnaldi
- Division of Endocrinology, Department of Clinical and Molecular Sciences (DISCLIMO), Polytechnic University of Marche, 60121 Ancona, Italy;
| | - Laura Saba
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Alessandra Quirino
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Paola Perotti
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
| | - Paola Berchialla
- Statistical Unit, Department of Clinical and Biological Sciences, Orbassano, University of Turin, 10143 Orbassano, Italy;
| | - Massimo Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, 10043 Turin, Italy; (S.P.); (V.B.); (L.S.); (A.Q.); (P.P.); (M.T.)
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Seidel E, Walenda G, Messerschmidt C, Obermayer B, Peitzsch M, Wallace P, Bahethi R, Yoo T, Choi M, Schrade P, Bachmann S, Liebisch G, Eisenhofer G, Beule D, Scholl UI. Generation and characterization of a mitotane-resistant adrenocortical cell line. Endocr Connect 2020; 9:122-134. [PMID: 31910152 PMCID: PMC6993260 DOI: 10.1530/ec-19-0510] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 01/06/2020] [Indexed: 12/11/2022]
Abstract
Mitotane is the only drug approved for the therapy of adrenocortical carcinoma (ACC). Its clinical use is limited by the occurrence of relapse during therapy. To investigate the underlying mechanisms in vitro, we here generated mitotane-resistant cell lines. After long-term pulsed treatment of HAC-15 human adrenocortical carcinoma cells with 70 µM mitotane, we isolated monoclonal cell populations of treated cells and controls and assessed their respective mitotane sensitivities by MTT assay. We performed exome sequencing and electron microscopy, conducted gene expression microarray analysis and determined intracellular lipid concentrations in the presence and absence of mitotane. Clonal cell lines established after pulsed treatment were resistant to mitotane (IC50 of 102.2 ± 7.3 µM (n = 12) vs 39.4 ± 6.2 µM (n = 6) in controls (biological replicates, mean ± s.d., P = 0.0001)). Unlike nonresistant clones, resistant clones maintained normal mitochondrial and nucleolar morphology during mitotane treatment. Resistant clones largely shared structural and single nucleotide variants, suggesting a common cell of origin. Resistance depended, in part, on extracellular lipoproteins and was associated with alterations in intracellular lipid homeostasis, including levels of free cholesterol, as well as decreased steroid production. By gene expression analysis, resistant cells showed profound alterations in pathways including steroid metabolism and transport, apoptosis, cell growth and Wnt signaling. These studies establish an in vitro model of mitotane resistance in ACC and point to underlying molecular mechanisms. They may enable future studies to overcome resistance in vitro and improve ACC treatment in vivo.
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Affiliation(s)
- Eric Seidel
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nephrology and Medical Intensive Care, BCRT – Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Department of Nephrology, School of Medicine, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Gudrun Walenda
- Department of Nephrology, School of Medicine, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Clemens Messerschmidt
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Core Unit Bioinformatics, Berlin Institute of Health, Berlin, Germany
| | - Benedikt Obermayer
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Core Unit Bioinformatics, Berlin Institute of Health, Berlin, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paal Wallace
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rohini Bahethi
- Department of Nephrology, School of Medicine, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Taekyeong Yoo
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Murim Choi
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Petra Schrade
- Charité – Universitaetsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Vegetative Anatomie, Berlin, Germany
| | - Sebastian Bachmann
- Charité – Universitaetsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Vegetative Anatomie, Berlin, Germany
| | - Gerhard Liebisch
- Institute of Clinical Chemistry and Laboratory Medicine, Regensburg University Hospital, Regensburg, Germany
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Dieter Beule
- Core Unit Bioinformatics, Berlin Institute of Health, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Ute I Scholl
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nephrology and Medical Intensive Care, BCRT – Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
- Department of Nephrology, School of Medicine, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
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Westerdijk K, Desar IME, Steeghs N, van der Graaf WTA, van Erp NP. Imatinib, sunitinib and pazopanib: From flat-fixed dosing towards a pharmacokinetically guided personalized dose. Br J Clin Pharmacol 2020; 86:258-273. [PMID: 31782166 PMCID: PMC7015742 DOI: 10.1111/bcp.14185] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/21/2019] [Accepted: 11/07/2019] [Indexed: 12/13/2022] Open
Abstract
Tyrosine kinase inhibitors (TKIs) are anti‐cancer drugs that target tyrosine kinases, enzymes that are involved in multiple cellular processes. Currently, multiple oral TKIs have been introduced in the treatment of solid tumours, all administered in a fixed dose, although large interpatient pharmacokinetic (PK) variability is described. For imatinib, sunitinib and pazopanib exposure‐treatment outcome (efficacy and toxicity) relationships have been established and therapeutic windows have been defined, therefore dose optimization based on the measured blood concentration, called therapeutic drug monitoring (TDM), can be valuable in increasing efficacy and reducing the toxicity of these drugs. In this review, an overview of the current knowledge on TDM guided individualized dosing of imatinib, sunitinib and pazopanib for the treatment of solid tumours is presented. We summarize preclinical and clinical data that have defined thresholds for efficacy and toxicity. Furthermore, PK models and factors that influence the PK of these drugs which partly explain the interpatient PK variability are summarized. Finally, pharmacological interventions that have been performed to optimize plasma concentrations are described. Based on current literature, we advise which methods should be used to optimize exposure to imatinib, sunitinib and pazopanib.
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Affiliation(s)
- Kim Westerdijk
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ingrid M E Desar
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Neeltje Steeghs
- Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Medical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands
| | - Nielka P van Erp
- Department of Clinical Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
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35
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Haider MS, Schreiner J, Kendl S, Kroiss M, Luxenhofer R. A Micellar Mitotane Formulation with High Drug-Loading and Solubility: Physico-Chemical Characterization and Cytotoxicity Studies in 2D and 3D In Vitro Tumor Models. Macromol Biosci 2019; 20:e1900178. [PMID: 31596553 DOI: 10.1002/mabi.201900178] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/16/2019] [Indexed: 01/26/2023]
Abstract
Adrenocortical carcinoma (ACC) is a rare tumor and prognosis is overall poor but heterogeneous. Mitotane (MT) has been used for treatment of ACC for decades, either alone or in combination with cytotoxic chemotherapy. Even at doses up to 6 g per day, more than half of the patients do not achieve targeted plasma concentration (14-20 mg L-1 ) even after many months of treatment due to low water solubility, bioavailability, and unfavorable pharmacokinetic profile. Here a novel MT nanoformulation with very high MT concentrations in physiological aqueous media is reported. The MT-loaded nanoformulations are characterized by Fourier transform infrared spectroscopy, differential scanning calorimetry, and powder X-ray diffraction which confirms the amorphous nature of the drug. The polymer itself does not show any cytotoxicity in adrenal and liver cell lines. By using the ACC model cell line NCI-H295 both in monolayers and tumor cell spheroids, micellar MT is demonstrated to exhibit comparable efficacy to its ethanol solution. It is postulated that this formulation will be suitable for i.v. application and rapid attainment of therapeutic plasma concentrations. In conclusion, the micellar formulation is considered a promising tool to alleviate major drawbacks of current MT treatment while retaining bioactivity toward ACC in vitro.
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Affiliation(s)
- Malik Salman Haider
- Functional Polymer Materials, Chair for Chemical Technology of Material Synthesis, Faculty of Chemistry and Pharmacy, University of Würzburg and Bavarian Polymer Institute, Röntgenring 11, 97070, Würzburg, Germany
| | - Jochen Schreiner
- University Hospital Würzburg, Department of Internal Medicine I, Division of Endocrinology/Diabetology, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Sabine Kendl
- University Hospital Würzburg, Department of Internal Medicine I, Division of Endocrinology/Diabetology, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Matthias Kroiss
- University Hospital Würzburg, Department of Internal Medicine I, Division of Endocrinology/Diabetology, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Robert Luxenhofer
- Functional Polymer Materials, Chair for Chemical Technology of Material Synthesis, Faculty of Chemistry and Pharmacy, University of Würzburg and Bavarian Polymer Institute, Röntgenring 11, 97070, Würzburg, Germany
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36
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Liu L, Wang GL, Ma LL, Lu M, Liu C, Hou XF. [Diagnosis and surgical treatment of massive adrenal area tumor with tumor thrombus]. JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:684-688. [PMID: 31420622 DOI: 10.19723/j.issn.1671-167x.2019.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To summarize the experience of diagnosis and operation related to massive adrenal area tumor with venous tumor thrombus in clinic. METHODS From October 2017 to March 2019, a total of 8 cases of massive adrenal area tumor (>7 cm) with venous tumor thrombus were admitted at Peking University Third Hospital including 5 males and 3 females with mean age 50.6 years (31-62 years). There were 6 cases on the right side and 2 cases on the left side. The first symptoms included abdominal discomfort, hypertension, Cushing syndrome and abnormal menstruation; special past history included cirrhosis and lung cancer. Computed tomography (CT) and routine endocrine hormone tests were examined. Preoperative imaging confirmed 5 cases masses with tumor thrombus in inferior vena cava (IVC) and 1 case with tumor thrombus in left renal vein. Two cases presented with tumor thrombus in central adrenal vein were found intraoperatively. Open adrenalectomy and thrombectomy were performed in 4 cases of right side complicated with high tumor thrombus of inferior vena cava. Laparoscopic adrenalectomy and thrombectomy were performed in 3 cases, including 2 cases on the right and 1 case on the left. The case with tumor thrombus in left renal vein gave up operation. The patients were followed up with outpatient and telephone. RESULTS The mean size of the tumor was 8.9 cm (7-11 cm), the mean operative time was 319 min (120-510 min), while the estimated blood loss was 629 mL (50-1 200 mL). Intraoperative blood transfusion was required in 2 cases and 1 case encountered wound infection. The pathological types included pheochromocytoma, adrenocortical carcinoma, adrenal metastases of haptic carcinoma, and leiomyosarcoma. The case with left lung carcinoma who underwent left pneumonectomy one month before was highly suspected adrenal metastases of lung carcinoma. Tumor thrombus of pheochromocytoma was combined with blood thrombus. Capsule of adrenocortical carcinoma was fragile in adrenocortical carcinoma. Abundant blood supply existed in adrenal metastases. The leiomyosarcoma had unabundant blood supply and invaded IVC to form tumors thrombus. The mean follow-up time was 8.4 months (1-15 months). One case with adrenocortical carcinoma died after 1 year in the follow-up. CONCLUSION We present the rare cases of different pathological types of massive adrenal tumors with tumor thrombus extending into the IVC extension or other vein. Preoperative diagnosis needs comprehensive evaluation and perfect preoperative preparation. Surgery is difficult and varied. Open approach as well as retroperitoneal laparoscopic approach is feasible.
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Affiliation(s)
- L Liu
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - G L Wang
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - L L Ma
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - M Lu
- Department of Pathology, Peking University Third Hospital, Beijing 100191, China
| | - C Liu
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - X F Hou
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
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37
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Friedl B, Kurlbaum M, Kroiss M, Fassnacht M, Scherf-Clavel O. A method for the minimally invasive drug monitoring of mitotane by means of volumetric absorptive microsampling for a home-based therapeutic drug monitoring. Anal Bioanal Chem 2019; 411:3951-3962. [PMID: 31093700 DOI: 10.1007/s00216-019-01868-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/24/2019] [Accepted: 04/24/2019] [Indexed: 11/25/2022]
Abstract
Mitotane is the only currently approved treatment for adrenocortical carcinoma (ACC), a rare endocrine malignancy. Plasma levels within the range of 14 to 20 mg L-1 are correlated with higher clinical efficacy and manageable toxicity. Because of this narrow therapeutic index and slow pharmacokinetics, therapeutic drug monitoring is an essential element of mitotane therapy. A small step towards the therapeutic drug monitoring (TDM) by volumetric absorptive microsampling (VAMS) was made with this work. A simple method enabling the patient to collect capillary blood at home for the control of mitotane blood concentration was developed and characterized using MITRA™ VAMS 20 μL microsampler. Dried blood samples were extracted prior to HPLC-UV analysis. Mitotane and the internal standard dicofol (DIC) were detected at 230 nm by ultra-violet detection after separation on a C8 reversed phase column. The assay was validated in the range of 1 to 50 mg L-1. Dried samples were stable at room temperature and at 2-8 °C for 1 week. At 37 °C, a substantial amount of the analyte was lost probably due to evaporation. Hematocrit bias, a common problem of conventional dried blood techniques, was acceptable in the tested range. However, a significant difference in recovery from spiked and authentic patient blood was detected. Comparison of mitotane concentration in dried blood samples (CDBS) by VAMS with venous plasma in patients on mitotane therapy demonstrated poor correlation of CDBS with the concentration in plasma (CP). In conclusion, application of VAMS in clinical routine for mitotane TDM appears to be of limited value in the absence of a method-specific target range.
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Affiliation(s)
- Bettina Friedl
- Institute for Pharmacy and Food Chemistry, University of Würzburg, Am Hubland, 97074, Würzburg, Germany
| | - Max Kurlbaum
- Department of Internal Medicine I, Division of Endocrinology/Diabetology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.,Central Laboratory, Clinical Chemistry and Laboratory Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology/Diabetology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.,Comprehensive Cancer Center, University of Würzburg, Josef-Schneider-Str. 6, 97080, Würzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology/Diabetology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.,Comprehensive Cancer Center, University of Würzburg, Josef-Schneider-Str. 6, 97080, Würzburg, Germany
| | - Oliver Scherf-Clavel
- Institute for Pharmacy and Food Chemistry, University of Würzburg, Am Hubland, 97074, Würzburg, Germany.
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38
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Chabre O, Cristante J. TREATMENT OF CUSHING'S SYNDROME : WHAT PLACE FOR MEDICAL TREATMENT? ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2019; 15:237-243. [PMID: 31508183 PMCID: PMC6711638 DOI: 10.4183/aeb.2019.237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Surgery plays a major role as a first-line treatment of the different etiologies of Cushing's syndrome (CS) and bilateral adrenalectomy (BA) is extremely effective as a second line, so that there seems to be little room for medical treatment (MT). However, during the past years several drugs acting either on ACTH secretion or cortisol synthesis have been developed, so that MT of CS might be reassessed. After briefly analyzing the efficiency and tolerance of surgical and medical treatments of CS we try to distinguish consensual and controversial indications for MT. We believe the former include "pre-operative treatment" in rare patients in whom the severity of CS is likely to increase the risks of surgery; "inoperability" for rare patients who cannot be operated even when CS is controlled and "surgical failure or recurrence", mainly in patients Cushing's disease (CD) not in remission after TSS. Controversial indications include "unavailability of an expert surgeon", which we believe does not make sense when the cost of MT is taken into consideration. Finally in patients with the "surgical failure or recurrence" indication the balance between efficacy and side effects of MT should be balanced with the efficacy and side effects of BA.
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Affiliation(s)
- O. Chabre
- Grenoble Alpes University Hospital (CHUGA) - Endocrinology, Grenoble, France
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39
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Di Paolo A, Ciofi L, Bacca A, Bernini G. A case report of a TDM-guided optimization of mitotane for a safe and effective long-term treatment. J Chemother 2019; 31:105-108. [DOI: 10.1080/1120009x.2018.1552502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Clinical Pharmacology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Laura Ciofi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Clinical Pharmacology Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandra Bacca
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- First Internal Medicine Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giampaolo Bernini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- First Internal Medicine Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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40
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Creemers SG, van Koetsveld PM, De Herder WW, Dogan F, Franssen GJH, Feelders RA, Hofland LJ. MDR1 inhibition increases sensitivity to doxorubicin and etoposide in adrenocortical cancer. Endocr Relat Cancer 2019; 26:367-378. [PMID: 30650062 DOI: 10.1530/erc-18-0500] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/03/2019] [Indexed: 12/17/2022]
Abstract
Chemotherapy for adrenocortical carcinoma (ACC) has limited efficacy and is accompanied by severe toxicity. This lack of effectiveness has been associated with high tumoral levels of the multidrug resistance (MDR) pump P-glycoprotein (P-gp), encoded by the MDR1 gene. In this study, effects of P-gp inhibition on the sensitivity of ACC cells to cytotoxic drugs were evaluated. MDR1 mRNA and P-gp expression were determined in human adrenal tissues and cell lines. H295R, HAC15 and SW13 cells were treated with mitotane, doxorubicin, etoposide, cisplatin and streptozotocin, with or without the P-gp inhibitors verapamil and tariquidar. Cell growth and surviving fraction of colonies were assessed. MDR1 mRNA and P-gp protein expression were lower in ACCs than in adrenocortical adenomas (P < 0.0001; P < 0.01, respectively). MDR1 and P-gp expression were positively correlated in ACC (P < 0.0001, ρ = 0.723). Mitotane, doxorubicin, cisplatin and etoposide dose dependently inhibited cell growth in H295R, HAC15 and SW13. Tariquidar, and in H295R also verapamil, increased the response of HAC15 and H295R to doxorubicin (6.3- and 7.5-fold EC50 decrease in H295R, respectively; all P < 0.0001). Sensitivity to etoposide was increased in H295R and HAC15 by verapamil and tariquidar (all P < 0.0001). Findings were confirmed when assessing colony formation. We show that cytotoxic drugs, except streptozotocin, used for ACC treatment, inhibit ACC cell growth and colony formation at clinically achievable concentrations. P-gp inhibition increases sensitivity to doxorubicin and etoposide, suggesting that MDR1 is involved in sensitivity to these drugs and could be a potential target for cytotoxic treatment improvement in ACC.
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Affiliation(s)
- S G Creemers
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - P M van Koetsveld
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - W W De Herder
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - F Dogan
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - G J H Franssen
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - R A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - L J Hofland
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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41
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Arshad U, Taubert M, Kurlbaum M, Frechen S, Herterich S, Megerle F, Hamacher S, Fassnacht M, Fuhr U, Kroiss M. Enzyme autoinduction by mitotane supported by population pharmacokinetic modelling in a large cohort of adrenocortical carcinoma patients. Eur J Endocrinol 2018; 179:287-297. [PMID: 30087117 DOI: 10.1530/eje-18-0342] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/03/2018] [Accepted: 08/06/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Mitotane is used for the treatment of adrenocortical carcinoma. High oral daily doses of typically 1- 6 g are required to attain therapeutic concentrations. The drug has a narrow therapeutic index and patient management is difficult because of a high volume of distribution, very long elimination half-life, and drug interaction through induction of metabolizing enzymes. The present evaluation aimed at the development of a population pharmacokinetic model of mitotane to facilitate therapeutic drug monitoring. METHODS Appropriate dosing information, plasma concentrations (1137 data points) and covariates were available from therapeutic drug monitoring (TDM) of 76 adrenocortical carcinoma patients treated with mitotane. Using nonlinear mixed effects modeling, a simple structural model was first developed, with subsequent introduction of metabolic autoinduction. Covariate data were analyzed to improve overall model predictability. Simulations were performed to assess the attainment of therapeutic concentrations with clinical dosing schedules. RESULTS A one-compartment pharmacokinetic model with first order absorption was found suitable to describe the data, with an estimated central volume of distribution of 6086 L related to a high interindividual variability of 81.5%. Increase in clearance of mitotane during treatment could be modeled by a linear enzyme autoinduction process. Body mass index was found to have an influence upon disposition kinetics of mitotane. Model simulations favor a high dose regimen to rapidly attain therapeutic concentrations, with the first TDM suggested on day 16 of treatment to avoid systemic toxicity. CONCLUSION The proposed model describes mitotane pharmacokinetics and can be used to facilitate therapy by predicting plasma concentrations.
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Affiliation(s)
- U Arshad
- Department I of Pharmacology, University Hospital Cologne, Cologne, Germany
| | - M Taubert
- Department I of Pharmacology, University Hospital Cologne, Cologne, Germany
| | - M Kurlbaum
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - S Frechen
- Department I of Pharmacology, University Hospital Cologne, Cologne, Germany
| | - S Herterich
- Clinical Chemistry and Laboratory Medicine, University Hospital Würzburg, Würzburg, Germany
| | - F Megerle
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - S Hamacher
- Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - M Fassnacht
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
- Clinical Chemistry and Laboratory Medicine, University Hospital Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - U Fuhr
- Department I of Pharmacology, University Hospital Cologne, Cologne, Germany
| | - M Kroiss
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
- Clinical Chemistry and Laboratory Medicine, University Hospital Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
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42
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Fassnacht M, Dekkers O, Else T, Baudin E, Berruti A, de Krijger R, Haak H, Mihai R, Assie G, Terzolo M. European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2018; 179:G1-G46. [PMID: 30299884 DOI: 10.1530/eje-18-0608] [Citation(s) in RCA: 484] [Impact Index Per Article: 80.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Adrenocortical carcinoma (ACC) is a rare and in most cases steroid hormone-producing tumor with variable prognosis. The purpose of these guidelines is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with ACC based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions, which we judged as particularly important for the management of ACC patients and performed systematic literature searches: (A) What is needed to diagnose an ACC by histopathology? (B) Which are the best prognostic markers in ACC? (C) Is adjuvant therapy able to prevent recurrent disease or reduce mortality after radical resection? (D) What is the best treatment option for macroscopically incompletely resected, recurrent or metastatic disease? Other relevant questions were discussed within the group. Selected Recommendations: (i) We recommend that all patients with suspected and proven ACC are discussed in a multidisciplinary expert team meeting. (ii) We recommend that every patient with (suspected) ACC should undergo careful clinical assessment, detailed endocrine work-up to identify autonomous hormone excess and adrenal-focused imaging. (iii) We recommend that adrenal surgery for (suspected) ACC should be performed only by surgeons experienced in adrenal and oncological surgery aiming at a complete en bloc resection (including resection of oligo-metastatic disease). (iv) We suggest that all suspected ACC should be reviewed by an expert adrenal pathologist using the Weiss score and providing Ki67 index. (v) We suggest adjuvant mitotane treatment in patients after radical surgery that have a perceived high risk of recurrence (ENSAT stage III, or R1 resection, or Ki67 >10%). (vi) For advanced ACC not amenable to complete surgical resection, local therapeutic measures (e.g. radiation therapy, radiofrequency ablation, chemoembolization) are of particular value. However, we suggest against the routine use of adrenal surgery in case of widespread metastatic disease. In these patients, we recommend either mitotane monotherapy or mitotane, etoposide, doxorubicin and cisplatin depending on prognostic parameters. In selected patients with a good response, surgery may be subsequently considered. (vii) In patients with recurrent disease and a disease-free interval of at least 12 months, in whom a complete resection/ablation seems feasible, we recommend surgery or alternatively other local therapies. Furthermore, we offer detailed recommendations about the management of mitotane treatment and other supportive therapies. Finally, we suggest directions for future research.
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Affiliation(s)
- Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Olaf Dekkers
- Department of Clinical Epidemiology
- Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tobias Else
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric Baudin
- Endocrine Oncology and Nuclear Medicine, Institut Gustave Roussy, Villejuif, France
- INSERM UMR 1185, Faculté de Médecine, Le Kremlin-Bicêtre, Université Paris Sud, Paris, France
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia at ASST Spedali Civili, Brescia, Italy
| | - Ronald de Krijger
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Pathology, Reinier de Graaf Hospital, Delft, the Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Harm Haak
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands
- Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Guillaume Assie
- Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Reference Center dor Rare Adrenal Cancers, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Institut Cochin, Institut National de la Santé et de la Recherche Médicale U1016, Centre National de la Recherche Scientifique UMR8104, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Hospital, University of Turin, Orbassano, Italy
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43
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Zantour B, Charrada I, Elati Z, Ammari FL, Boubaker F, Arfa S, Berriche O, Alaya W, Sfar MH. [Corticosurrenaloma: an exceptional cause of primary hyperaldosteronism]. Pan Afr Med J 2018; 31:60. [PMID: 30923605 PMCID: PMC6431414 DOI: 10.11604/pamj.2018.31.60.16973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 09/15/2018] [Indexed: 11/21/2022] Open
Abstract
Corticosurrenaloma is a rare malignant tumor of the adrenal gland that often secretes corticosteroids, sex steroids and precursors. Aldosterone-producing corticosurrenaloma is very rare, accounting for 1 case/10million inhabitants. We report the case of a 38-year old man presenting with severe arterial hypertension associated with deep hypokalaemia (2.2 mmol/L). Exploration showed primary hyperaldosteronism (aldosterone = 2645 pmol/l, aldosterone/renin ratio = 327 pmol/MUI), with hypersecretion of glucocorticoids. Abdominopelvic CT scan revealed left poorly differentiated and heterogeneous adrenal mass measuring 9cm, infiltrating into the surrounding adipose tissue and the diaphragm, extending into the left renal vein, with regional adenopathy and hepatic nodule measuring 4cm. The patient underwent radical nephrectomy followed by right hepatectomy two months after resulting in remission. A year after the patient developed lung metastases. This study highlights that corticosurrenaloma should be suspected in patients with primary aldosteronism despite its rarity.
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Affiliation(s)
- Baha Zantour
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
| | - Ines Charrada
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
| | - Zohra Elati
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
| | - Fatma Larbi Ammari
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
| | - Fadia Boubaker
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
| | - Sondes Arfa
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
| | - Olfa Berriche
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
| | - Wafa Alaya
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
| | - Mohamed Habib Sfar
- Service d'Endocrinologie et Médecine Interne, Hôpital Tahar Sfar, Mahdia, Tunisie
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44
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Paragliola RM, Torino F, Papi G, Locantore P, Pontecorvi A, Corsello SM. Role of Mitotane in Adrenocortical Carcinoma - Review and State of the art. EUROPEAN ENDOCRINOLOGY 2018; 14:62-66. [PMID: 30349596 PMCID: PMC6182924 DOI: 10.17925/ee.2018.14.2.62] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/29/2018] [Indexed: 12/29/2022]
Abstract
Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine tumour deriving from the adrenal cortex. A correct therapeutic strategy requires a multidisciplinary approach between endocrinologist, surgeon and oncologist. Surgery is the mainstay treatment in ACC while mitotane, deriving from the insecticide dichloro-diphenyl-trichloro-ethane, is the main base of the medical treatment of ACC in consideration of its adrenocytolitic activity. However, the use of mitotane as adjuvant therapy is still controversial, also in consideration of the retrospective nature of several studies. A prospective randomised trial (ADIUVO), recruiting patients with low-intermediate risk of recurrence, is evaluating the utility of adjuvant treatment with mitotane in this setting. The therapeutic response is observed with plasma levels of mitotane >14 mg/L. However, the major difficulty in the management of mitotane treatment is related to side effects and to the risk of toxicity, which is related to plasmatic levels >20 mg/L, that is considered the upper limit of the therapeutic window. Mitotane therapy results in adrenal insufficiency, and glucocorticoid replacement therapy has to be administered at higher doses than those used in other aetiologies of primary adrenal insufficiency. Furthermore, other endocrine side effects related to mitotane should be considered, in particular on thyroid hormone and testosterone metabolism. Waiting for new medical strategies on molecular targets, it will be mandatory to optimise the current knowledge by prospective trials and, in consideration of the rarity of the disease, collaborative studies between endocrinologists and oncologists are necessary.
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Affiliation(s)
- Rosa Maria Paragliola
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Francesco Torino
- Department of Systems Medicine, Medical Oncology, University of Rome Teor Vergata, Rome, Italy
| | - Giampaolo Papi
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pietro Locantore
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Alfredo Pontecorvi
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Salvatore Maria Corsello
- Unit of Endocrinology, Università Cattolica del Sacro Cuore, Rome, Italy.,Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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45
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Farooq AU, Amjad W, Kochar T, Adhikari S. Mitotane-induced dyspnoea: an unusual side effect. BMJ Case Rep 2018; 2018:bcr-2018-225490. [DOI: 10.1136/bcr-2018-225490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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46
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Puglisi S, Perotti P, Pia A, Reimondo G, Terzolo M. Adrenocortical Carcinoma with Hypercortisolism. Endocrinol Metab Clin North Am 2018; 47:395-407. [PMID: 29754640 DOI: 10.1016/j.ecl.2018.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Adrenocortical carcinoma (ACC) is a rare and aggressive tumor. ACC may be associated with different syndromes of hormone excess, most frequently Cushing's syndrome with or without hypersecretion of androgens. Recent data suggest that cortisol excess is a negative prognostic factor in advanced and localized ACC. Surgery with radical intent, when feasible, is the most effective treatment for ACC with hypercortisolism. Mitotane is the medical treatment of choice, both postoperatively and in inoperable or metastatic cases. Because of its slow onset of action, combination with other antisecretory agents (ie, metyrapone) is helpful to achieve more rapid and effective control of hypercortisolism.
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Affiliation(s)
- Soraya Puglisi
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Regione Gonzole 10, Orbassano 10043, Italy
| | - Paola Perotti
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Regione Gonzole 10, Orbassano 10043, Italy
| | - Anna Pia
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Regione Gonzole 10, Orbassano 10043, Italy
| | - Giuseppe Reimondo
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Regione Gonzole 10, Orbassano 10043, Italy
| | - Massimo Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Regione Gonzole 10, Orbassano 10043, Italy.
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47
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Parameswaran R, Tan WB, Nga ME, Soon GST, Ngiam KY, Brooks SA, Sadler GP, Mihai R. Binding of aberrant glycoproteins recognizable by Helix pomatia agglutinin in adrenal cancers. BJS Open 2018; 2:353-359. [PMID: 30263987 PMCID: PMC6156166 DOI: 10.1002/bjs5.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 03/16/2018] [Indexed: 01/28/2023] Open
Abstract
Background Aberrant glycosylation is a hallmark of cancer cells and plays an important role in oncogenesis and cancer progression including metastasis. This study aimed to assess alteration in cellular glycosylation, detected by lectin Helix pomatia agglutinin (HPA) binding, in adrenal cancers and to determine whether such altered glycosylation has prognostic significance. Methods HPA binding lectin histochemistry was performed on archival paraffin wax‐embedded specimens of adrenocortical cancers excised from patients attending two tertiary referral centres. Benign tumours were used as controls. Demographic, histological and survival data were collected and compared between patients with HPA‐positive and HPA‐negative tumours. Results Thirty‐two patients were treated for adrenal cancer between 2000 and 2016; their median age was 49 (range 23–79) years. Fifteen patients had functioning tumours (14 adrenal Cushing's tumours and 1 Conn's tumour). Mean(s.d.) tumour size was 127·71(49·70) mm. None of 10 control tumours expressed HPA‐binding glycoproteins. Invasion was associated with HPA‐binding glycoproteins (P = 0·018). Local recurrence or metastatic disease did not significantly differ between HPA‐positive and HPA‐negative adrenocortical cancers. Overall survival was significantly longer in patients with HPA‐negative tumours (median survival not reached versus 22 months in patients with HPA‐positive tumours; P = 0·002). Conclusion Altered cellular glycosylation detected by lectin HPA is associated with poor survival in patients with adrenocortical cancer.
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Affiliation(s)
- R Parameswaran
- Department of Endocrine Surgery National University Hospital Singapore
| | - W B Tan
- Department of Endocrine Surgery National University Hospital Singapore
| | - M E Nga
- Department of Pathology National University Hospital Singapore
| | - G S T Soon
- Department of Pathology National University Hospital Singapore
| | - K Y Ngiam
- Department of Endocrine Surgery National University Hospital Singapore
| | - S A Brooks
- School of Biological and Medical Sciences, Oxford Brookes University Oxford UK
| | - G P Sadler
- Department of Endocrine Surgery Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - R Mihai
- Department of Endocrine Surgery Oxford University Hospitals NHS Foundation Trust Oxford UK
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48
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Megerle F, Herrmann W, Schloetelburg W, Ronchi CL, Pulzer A, Quinkler M, Beuschlein F, Hahner S, Kroiss M, Fassnacht M. Mitotane Monotherapy in Patients With Advanced Adrenocortical Carcinoma. J Clin Endocrinol Metab 2018; 103:1686-1695. [PMID: 29452402 DOI: 10.1210/jc.2017-02591] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/09/2018] [Indexed: 02/06/2023]
Abstract
CONTEXT Although mitotane is the only approved drug for the treatment of adrenocortical carcinoma (ACC), data on monotherapy in advanced disease are still scarce. OBJECTIVE To assess the efficacy of mitotane in advanced ACC in a contemporary setting and to identify predictive factors. DESIGN AND SETTING Multicenter cohort study of three German referral centers. PATIENTS One hundred twenty-seven patients with advanced ACC treated with mitotane monotherapy. OUTCOME MEASURES Response Evaluation Criteria in Solid Tumors evaluation, progression-free survival (PFS) and overall survival (OS) by Kaplan-Meier method, and predictive factors by Cox regression. RESULTS Twenty-six patients (20.5%) experienced objective response, including three with complete remission. Overall, median PFS was 4.1 months (range 1.0 to 73) and median OS 18.5 months (range 1.3 to 220). Multivariate analysis indicated two main predictive factors: low tumor burden (<10 tumoral lesions), hazard ratio (HR) for progression of 0.51 (P = 0.002) and for death of 0.59 (P = 0.017); and initiation of mitotane at delayed advanced recurrence, HR 0.35(P < 0.001) and 0.34 (P < 0.001), respectively. Accordingly, 67% of patients with low tumor burden and mitotane initiation ≥360 days after primary diagnosis experienced a clinical benefit (stable disease >180 days). Patients who achieved mitotane levels >14 mg/L had significantly longer OS (HR 0.42; P = 0.003). CONCLUSIONS At 20.5% the objective response rate was slightly lower than previously reported. However, >20% of patients experienced long-term disease control at >1 year. In general, patients with late diagnosis of advanced disease and low tumor burden might especially benefit from mitotane monotherapy, whereas patients with early advanced disease and high tumor burden are probably better candidates for combined therapy of mitotane and cytotoxic drugs.
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Affiliation(s)
- Felix Megerle
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Wiebke Herrmann
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Wiebke Schloetelburg
- Department of Diagnostic and Interventional Radiology, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Cristina L Ronchi
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, United Kingdom
| | - Alina Pulzer
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | | | - Felix Beuschlein
- Department of Internal Medicine IV, Klinikum der Universität München, Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, Universitätsspital Zürich, Zurich, Switzerland
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Matthias Kroiss
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
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49
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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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50
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Pape E, Feliu C, Yéléhé-Okouma M, Colling N, Djerada Z, Gambier N, Weryha G, Scala-Bertola J. High-Dose Mitotane-Induced Encephalopathy in the Treatment of Adrenocortical Carcinoma. Oncologist 2017; 23:389-390. [PMID: 29192018 PMCID: PMC5905686 DOI: 10.1634/theoncologist.2017-0426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Elise Pape
- Department of Clinical Pharmacology and Toxicology, University Hospital of Nancy, Nancy, France
- Ingénierie Moléculaire et Physiopathologie Articulaire, UMR 7365 CNRS-UL, University of Lorraine, Vandœuvre-lès-Nancy, France
| | - Catherine Feliu
- Laboratory of Pharmacology and Toxicology, University Hospital of Reims, Reims, France
| | | | - Natacha Colling
- Department of Clinical Pharmacology and Toxicology, University Hospital of Nancy, Nancy, France
| | - Zoubir Djerada
- Laboratory of Pharmacology and Toxicology, University Hospital of Reims, Reims, France
| | - Nicolas Gambier
- Department of Clinical Pharmacology and Toxicology, University Hospital of Nancy, Nancy, France
- Ingénierie Moléculaire et Physiopathologie Articulaire, UMR 7365 CNRS-UL, University of Lorraine, Vandœuvre-lès-Nancy, France
| | - Georges Weryha
- Department of Endocrinology, University Hospital of Nancy, Vandœuvre-lès-Nancy, France
| | - Julien Scala-Bertola
- Department of Clinical Pharmacology and Toxicology, University Hospital of Nancy, Nancy, France
- Ingénierie Moléculaire et Physiopathologie Articulaire, UMR 7365 CNRS-UL, University of Lorraine, Vandœuvre-lès-Nancy, France
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