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Casey RT, Hendriks E, Deal C, Waguespack SG, Wiegering V, Redlich A, Akker S, Prasad R, Fassnacht M, Clifton-Bligh R, Amar L, Bornstein S, Canu L, Charmandari E, Chrisoulidou A, Freixes MC, de Krijger R, de Sanctis L, Fojo A, Ghia AJ, Huebner A, Kosmoliaptsis V, Kuhlen M, Raffaelli M, Lussey-Lepoutre C, Marks SD, Nilubol N, Parasiliti-Caprino M, Timmers HHJLM, Zietlow AL, Robledo M, Gimenez-Roqueplo AP, Grossman AB, Taïeb D, Maher ER, Lenders JWM, Eisenhofer G, Jimenez C, Pacak K, Pamporaki C. International consensus statement on the diagnosis and management of phaeochromocytoma and paraganglioma in children and adolescents. Nat Rev Endocrinol 2024:10.1038/s41574-024-01024-5. [PMID: 39147856 DOI: 10.1038/s41574-024-01024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2024] [Indexed: 08/17/2024]
Abstract
Phaeochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumours that arise not only in adulthood but also in childhood and adolescence. Up to 70-80% of childhood PPGL are hereditary, accounting for a higher incidence of metastatic and/or multifocal PPGL in paediatric patients than in adult patients. Key differences in the tumour biology and management, together with rare disease incidence and therapeutic challenges in paediatric compared with adult patients, mandate close expert cross-disciplinary teamwork. Teams should ideally include adult and paediatric endocrinologists, oncologists, cardiologists, surgeons, geneticists, pathologists, radiologists, clinical psychologists and nuclear medicine physicians. Provision of an international Consensus Statement should improve care and outcomes for children and adolescents with these tumours.
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Affiliation(s)
- Ruth T Casey
- Department of Medical Genetics, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK.
- Department of Endocrinology, Cambridge Cancer Centre and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Emile Hendriks
- Department of Paediatric Diabetes and Endocrinology, Cambridge Cancer Centre and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Cheri Deal
- Endocrine and Diabetes Service, CHU Sainte-Justine and University of Montreal, Montreal, Québec, Canada
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Verena Wiegering
- University Children's Hospital, Department of Paediatric Hematology, Oncology and Stem Cell Transplantation, University of Würzburg, Würzburg, Germany
| | - Antje Redlich
- Paediatric Oncology Department, Otto von Guericke University Children's Hospital, Magdeburg, Germany
| | - Scott Akker
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Rathi Prasad
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Martin Fassnacht
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Roderick Clifton-Bligh
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Laurence Amar
- Université de Paris, Paris, France
- Hypertension Unit, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Stefan Bornstein
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, Azienda Ospedaliera Universitaria (AOU) Careggi, Florence, Italy
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Paediatrics, National and Kapodistrian University of Athens Medical School, 'Aghia Sophia' Children's Hospital, Athens, Greece
| | | | - Maria Currás Freixes
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Centre (CNIO) and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - Ronald de Krijger
- Princess Maxima Center for Paediatric Oncology, Utrecht, Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Luisa de Sanctis
- Department of Public Health and Paediatric Sciences, University of Turin, Turin, Italy
| | - Antonio Fojo
- Division of Hematology/Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Amol J Ghia
- Department of Radiation Oncology, University Hospital of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Angela Huebner
- Department of Paediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
- Blood and Transplant Research Unit in Organ Donation and Transplantation, National Institute for Health Research, University of Cambridge, Cambridge, UK
| | - Michaela Kuhlen
- Paediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Marco Raffaelli
- U.O.C. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Charlotte Lussey-Lepoutre
- Service de médecine nucléaire, Inserm U970, Sorbonne université, Groupe hospitalier Pitié-Salpétrière, Paris, France
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR GOSH Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mirko Parasiliti-Caprino
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti, Turin, Italy
| | - Henri H J L M Timmers
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Anna Lena Zietlow
- Clinical Child and Adolescent Psychology, Institute of Clinical Psychology and Psychotherapy, Department of Psychology, TU Dresden, Dresden, Germany
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Centre (CNIO) and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - Anne-Paule Gimenez-Roqueplo
- Université Paris Cité, PARCC, INSERM, Paris, France
- Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Ashley B Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
- ENETS Centre of Excellence, Royal Free Hospital, London, UK
| | - David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
| | - Eamonn R Maher
- Department of Medical Genetics, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD, USA
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Pacak K, Taieb D, Lin FI, Jha A. Approach to the Patient: Concept and Application of Targeted Radiotherapy in the Paraganglioma Patient. J Clin Endocrinol Metab 2024; 109:2366-2388. [PMID: 38652045 PMCID: PMC11319006 DOI: 10.1210/clinem/dgae252] [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: 01/23/2024] [Revised: 03/30/2024] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Abstract
Paragangliomas can metastasize, posing potential challenges both in symptomatic management and disease control. Systemic targeted radiotherapies using 131I-MIBG and 177Lu-DOTATATE are a mainstay in the treatment of metastatic paragangliomas. This clinical scenario and discussion aim to enhance physicians' knowledge of the stepwise approach to treat these patients with paraganglioma-targeted radiotherapies. It comprehensively discusses current approaches to selecting paraganglioma patients for targeted radiotherapies and how to choose between the two radiotherapies based on specific patient and tumor characteristics, when either therapy is feasible, or one is superior to another. The safety, efficacy, toxicity profiles, and optimization of these radiotherapies are also discussed, along with other therapeutic options including radiotherapies, available for patients besides these two therapies. Perspectives in radiotherapies of paraganglioma patients are outlined since they hold promising approaches in the near future that can improve patient outcomes.
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Affiliation(s)
- Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892-1109, USA
| | - David Taieb
- Department of Nuclear Medicine, Aix-Marseille University, La Timone University Hospital, 13385 Marseille, France
| | - Frank I Lin
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Abhishek Jha
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892-1109, USA
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Sukrithan V, Perez K, Pandit-Taskar N, Jimenez C. Management of metastatic pheochromocytomas and paragangliomas: when and what. Curr Probl Cancer 2024; 51:101116. [PMID: 39024846 DOI: 10.1016/j.currproblcancer.2024.101116] [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: 03/25/2024] [Accepted: 05/22/2024] [Indexed: 07/20/2024]
Abstract
Recently, the treatment landscape for metastatic pheochromocytomas and paragangliomas (MPPGL) has seen both progress and setbacks. We provide an up-to-date review of the multimodality management of MPPGL and discuss novel opportunities and current challenges in the treatment landscape. Given the unique clinical presentation of MPPGL, we discuss the management of hormone-related clinical sequelae and traditional modalities of therapy. Advances in the understanding of the molecular biology of these diverse tumors have enabled novel strategies such as augmenting DNA damage by targeted delivery of radionuclides such as 131I and 177Lu, abrogating tumor angiogenesis, hypoxia resistance, and DNA damage repair. Despite progress, we address the significant challenges still faced by patients and researchers engaged in efforts to improve outcomes in these rare cancers.
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Affiliation(s)
- Vineeth Sukrithan
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States.
| | - Kimberly Perez
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Neeta Pandit-Taskar
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Kobayakawa M, Shiga T, Takahashi K, Sugawara S, Nomura K, Hanada K, Ishizuka N, Ito H. Evaluation of pharmacokinetics, safety, and efficacy of [211At] meta-astatobenzylguanidine ([211At] MABG) in patients with pheochromocytoma or paraganglioma (PPGL): A study protocol. PLoS One 2024; 19:e0303623. [PMID: 38805424 PMCID: PMC11132457 DOI: 10.1371/journal.pone.0303623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 04/24/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Pheochromocytoma, or paraganglioma (PPGL), is a tumor that arises from catecholamine-producing chromaffin cells of the adrenal medulla or paraganglion. Systemic therapy, such as the combination of cyclophosphamide, vincristine, and dacarbazine or therapeutic radiopharmaceuticals such as [131I] meta-iodobenzylguanidine (MIBG), may be administered in cases of locally advanced tumors or distant metastases. However, the current therapies are limited in terms of efficacy and implementation. [211At] meta-astatobenzylguanidine (MABG) is an alpha-emitting radionuclide-labeled ligand that has demonstrated remarkable tumor-reducing effects in preclinical studies, and is expected to have a high therapeutic effect on pheochromocytoma cells. METHODS We are currently conducting an investigator-initiated first-in-human clinical trial to evaluate the pharmacokinetics, safety, and efficacy of [211At] MABG. Patients with locally unresectable or metastatic PPGL refractory to standard therapy and scintigraphically positive [123I] MIBG aggregation are being recruited, and a 3 + 3 dose escalation design was adopted. The initial dose of [211At] MABG is 0.65 MBq/kg, with a dose escalation in a 1:2:4 ratio in each cohort. Dose-limiting toxicity is observed for 6 weeks after a single bolus dose of [211At] MABG, and the patients are observed for 3 months to explore safety and efficacy profiles. The primary endpoint is dose-limiting toxicity to determine both maximum tolerated and recommended doses. The secondary endpoints include radiopharmacokinetics, urinary radioactive excretion rate, urinary catecholamine response rate, objective response rate, progression free survival, [123I] MIBG scintigraphy on reducing tumor accumulation, and quality of life. TRIALS REGISTRATION jRCT2021220012 registered on 17 June 2022.
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Affiliation(s)
- Masao Kobayakawa
- Medical Research Center, Fukushima Medical University, Fukushima, Japan
| | - Tohru Shiga
- Advanced Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
| | - Kazuhiro Takahashi
- Advanced Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
| | - Shigeyasu Sugawara
- Advanced Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
| | - Kaori Nomura
- Advanced Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
| | - Kazuhiko Hanada
- Department of Pharmacometrics and Pharmacokinetics, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan
| | - Naoki Ishizuka
- Center for Digital Transformation of health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Ito
- Advanced Research Center, Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
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Jeeyavudeen MS, Mathiyalagan N, Fernandez James C, Pappachan JM. Tumor metabolism in pheochromocytomas: clinical and therapeutic implications. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:349-373. [PMID: 38745767 PMCID: PMC11090696 DOI: 10.37349/etat.2024.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/27/2023] [Indexed: 05/16/2024] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) have emerged as one of the most common endocrine tumors. It epitomizes fascinating crossroads of genetic, metabolic, and endocrine oncology, providing a canvas to explore the molecular intricacies of tumor biology. Predominantly rooted in the aberration of metabolic pathways, particularly the Krebs cycle and related enzymatic functionalities, PPGLs manifest an intriguing metabolic profile, highlighting elevated levels of oncometabolites like succinate and fumarate, and furthering cellular malignancy and genomic instability. This comprehensive review aims to delineate the multifaceted aspects of tumor metabolism in PPGLs, encapsulating genetic factors, oncometabolites, and potential therapeutic avenues, thereby providing a cohesive understanding of metabolic disturbances and their ramifications in tumorigenesis and disease progression. Initial investigations into PPGLs metabolomics unveiled a stark correlation between specific genetic mutations, notably in the succinate dehydrogenase complex (SDHx) genes, and the accumulation of oncometabolites, establishing a pivotal role in epigenetic alterations and hypoxia-inducible pathways. By scrutinizing voluminous metabolic studies and exploiting technologies, novel insights into the metabolic and genetic aspects of PPGLs are perpetually being gathered elucidating complex interactions and molecular machinations. Additionally, the exploration of therapeutic strategies targeting metabolic abnormalities has burgeoned harboring potential for innovative and efficacious treatment modalities. This review encapsulates the profound metabolic complexities of PPGLs, aiming to foster an enriched understanding and pave the way for future investigations and therapeutic innovations in managing these metabolically unique tumors.
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Affiliation(s)
| | - Navin Mathiyalagan
- Department of Medical Oncology, Nottingham University Hospitals NHS Trust, NG5 1PB Nottingham, UK
| | - Cornelius Fernandez James
- Department of Endocrinology & Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, PE21 9QS Boston, UK
| | - Joseph M. Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, PR2 9HT Preston, UK
- Faculty of Science, Manchester Metropolitan University, M15 6BH Manchester, UK
- Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL Manchester, UK
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Fischer A, Kloos S, Remde H, Dischinger U, Pamporaki C, Timmers HJLM, Robledo M, Fliedner SMJ, Wang K, Maurer J, Reul A, Bechmann N, Hantel C, Mohr H, Pellegata NS, Bornstein SR, Kroiss M, Auernhammer CJ, Reincke M, Pacak K, Grossman AB, Beuschlein F, Nölting S. Responses to systemic therapy in metastatic pheochromocytoma/paraganglioma: a retrospective multicenter cohort study. Eur J Endocrinol 2023; 189:546-565. [PMID: 37949483 DOI: 10.1093/ejendo/lvad146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/02/2023] [Accepted: 09/19/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE The therapeutic options for metastatic pheochromocytomas/paragangliomas (mPPGLs) include chemotherapy with cyclophosphamide/vincristine/dacarbazine (CVD), temozolomide monotherapy, radionuclide therapies, and tyrosine kinase inhibitors such as sunitinib. The objective of this multicenter retrospective study was to evaluate and compare the responses of mPPGLs including those with pathogenic variants in succinate dehydrogenase subunit B (SDHB), to different systemic treatments. DESIGN This is a retrospective analysis of treatment responses of mPPGL patients (n = 74) to systemic therapies. METHODS Patients with mPPGLs treated at 6 specialized national centers were selected based on participation in the ENSAT registry. Survival until detected progression (SDP) and disease-control rates (DCRs) at 3 months were evaluated based on imaging reports. RESULTS For the group of patients with progressive disease at baseline (83.8% of 74 patients), the DCR with first-line CVD chemotherapy was 75.0% (n = 4, SDP 11 months; SDHB [n = 1]: DCR 100%, SDP 30 months), with somatostatin peptide receptor-based radionuclide therapy (PPRT) 85.7% (n = 21, SDP 17 months; SDHB [n = 10]: DCR 100%, SDP 14 months), with 131I-meta-iodobenzylguanidine (131I-MIBG) 82.6% (n = 23, SDP 43 months; SDHB [n = 4]: DCR 100%, SDP 24 months), with sunitinib 100% (n = 7, SDP 18 months; SDHB [n = 3]: DCR 100%, SDP 18 months), and with somatostatin analogs 100% (n = 4, SDP not reached). The DCR with temozolomide as second-line therapy was 60.0% (n = 5, SDP 10 months; SDHB [n = 4]: DCR 75%, SDP 10 months). CONCLUSIONS We demonstrate in a real-life clinical setting that all current therapies show reasonable efficacy in preventing disease progression, and this is equally true for patients with germline SDHB mutations.
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Affiliation(s)
- Alessa Fischer
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Simon Kloos
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Hanna Remde
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Ulrich Dischinger
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Henri J L M Timmers
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Center (CNIO), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras, Institute de Salud Carlos III, Madrid, Spain
| | - Stephanie M J Fliedner
- First Department of Medicine, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Katharina Wang
- Department of Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Julian Maurer
- Department of Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Astrid Reul
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse, Dresden, Germany
| | - Constanze Hantel
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hermine Mohr
- Institute for Diabetes and Cancer, Helmholtz Zentrum München, Neuherberg, Germany
| | - Natalia S Pellegata
- Institute for Diabetes and Cancer, Helmholtz Zentrum München, Neuherberg, Germany
- Department of Biology and Biotechnology, University of Pavia, Pavia, Italy
| | - Stefan R Bornstein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Matthias Kroiss
- Department of Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Christoph J Auernhammer
- Department of Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martin Reincke
- Department of Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Karel Pacak
- Eunice Kennedy Shriver NICHD, NIH, Bethesda, MD, United States
| | - Ashley B Grossman
- Green Templeton College, University of Oxford, Oxford, United Kingdom
- NET Unit, ENETS Center of Excellence, Royal Free Hospital, London, United Kingdom
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- Department of Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), Zurich, Switzerland
- Department of Medicine IV, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
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Mastrangelo S, Romano A, Attinà G, Maurizi P, Ruggiero A. Timing and chemotherapy association for 131-I-MIBG treatment in high-risk neuroblastoma. Biochem Pharmacol 2023; 216:115802. [PMID: 37696454 DOI: 10.1016/j.bcp.2023.115802] [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: 07/01/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Abstract
Prognosis of high-risk neuroblastoma is dismal, despite intensive induction chemotherapy, surgery, high-dose chemotherapy, radiotherapy, and maintenance. Patients who do not achieve a complete metastatic response, with clearance of bone marrow and skeletal NB infiltration, after induction have a significantly lowersurvival rate. Thus, it's necessary to further intensifytreatment during this phase. 131-I-metaiodobenzylguanidine (131-I-MIBG) is a radioactive compound highly effective against neuroblastoma, with32% response rate in relapsed/resistant cases, and only hematological toxicity. 131-I-MIBG wasutilized at different doses in single or multiple administrations, before autologous transplant or combinedwith high-dose chemotherapy. Subsequently, it was added to consolidationin patients with advanced NB after induction, but an independent contribution against neuroblastoma and for myelotoxicity is difficult to determine. Despiteresults of a 2008 paper demonstratedefficacy and mild hematological toxicity of 131-I-MIBG at diagnosis, no center had included it with intensive chemotherapy in first-line treatment protocols. In our institution, at diagnosis, 131-I-MIBG was included in a 5-chemotherapy drug combination and administered on day-10, at doses up to 18.3 mCi/kg. Almost 87% of objective responses were observed 50 days from start with acceptable hematological toxicity. In this paper, we review the literature data regarding 131-I-MIBG treatment for neuroblastoma, and report on doses and combinations used, tumor responses and toxicity. 131-I-MIBG is very effective against neuroblastoma, in particular if given to patients at diagnosis and in combination with chemotherapy, and it should be included in all induction regimens to improve early responses rates and consequently long-term survival.
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Affiliation(s)
- Stefano Mastrangelo
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Gemelli, 8, 00168 Rome, Italy.
| | - Alberto Romano
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy
| | - Giorgio Attinà
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy
| | - Palma Maurizi
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Gemelli, 8, 00168 Rome, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Gemelli, 8, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Gemelli, 8, 00168 Rome, Italy
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Parente A, Kamarajah SK, Thompson JP, Crook C, Aspinall S, Melvin R, Stechman MJ, Perry H, Balasubramanian SP, Pannu A, Palazzo FF, Van Den Heede K, Eatock F, Anderson H, Doran H, Wang K, Hubbard J, Aldrees A, Shore SL, Fung C, Waghorn A, Ayuk J, Bennett D, Sutcliffe RP. Risk factors for postoperative complications after adrenalectomy for phaeochromocytoma: multicentre cohort study. BJS Open 2023; 7:zrad090. [PMID: 37757753 PMCID: PMC10533033 DOI: 10.1093/bjsopen/zrad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/13/2023] [Accepted: 07/16/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND To determine the incidence and risk factors for postoperative complications and prolonged hospital stay after adrenalectomy for phaeochromocytoma. METHODS Demographics, perioperative outcomes and complications were evaluated for consecutive patients who underwent adrenalectomy for phaeochromocytoma from 2012 to 2020 in nine high-volume UK centres. Odds ratios were calculated using multivariable models. The primary outcome was postoperative complications according to the Clavien---Dindo classification and secondary outcome was duration of hospital stay. RESULTS Data were available for 406 patients (female n = 221, 54.4 per cent). Two patients (0.5 per cent) had perioperative death, whilst 148 complications were recorded in 109 (26.8 per cent) patients. On adjusted analysis, the age-adjusted Charlson Co-morbidity Index ≥3 (OR 8.09, 95 per cent c.i. 2.31 to 29.63, P = 0.001), laparoscopic converted to open (OR 10.34, 95 per cent c.i. 3.24 to 36.23, P <0.001), and open surgery (OR 11.69, 95 per cent c.i. 4.52 to 32.55, P <0.001) were independently associated with postoperative complications. Overall, 97 of 430 (22.5 per cent) had a duration of stay ≥5 days and this was associated with an age-adjusted Charlson Co-morbidity Index ≥3 (OR 4.31, 95 per cent c.i. 1.08 to 18.26, P = 0.042), tumour size (OR 1.15, 95 per cent c.i. 1.05 to 1.28, P = 0.006), laparoscopic converted to open (OR 32.11, 95 per cent c.i. 9.2 to 137.77, P <0.001), and open surgery (OR 28.01, 95 per cent c.i. 10.52 to 83.97, P <0.001). CONCLUSION Adrenalectomy for phaeochromocytoma is associated with a very low mortality rate, whilst postoperative complications are common. Several risk factors, including co-morbidities and operative approach, are independently associated with postoperative complications and/or prolonged hospitalization, and should be considered when counselling patients.
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Affiliation(s)
- Alessandro Parente
- HPB Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sivesh K Kamarajah
- HPB Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | | | | | - Ross Melvin
- Department of General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - Helen Perry
- Department of Endocrine Surgery, University Hospital Wales, Cardiff, UK
| | | | - Arslan Pannu
- Department of General Surgery, Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Fausto F Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, London, UK
| | | | - Fiona Eatock
- Department of Endocrine Surgery, Royal Victoria Hospital, Belfast, UK
| | - Hannah Anderson
- Department of Endocrine Surgery, Royal Victoria Hospital, Belfast, UK
| | - Helen Doran
- Department of Endocrine Surgery, Salford Royal Hospital, Salford, UK
| | - Kelvin Wang
- Department of Endocrine Surgery, Salford Royal Hospital, Salford, UK
| | | | | | - Susannah L Shore
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Clare Fung
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Alison Waghorn
- Department of Endocrine and Breast Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - John Ayuk
- Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, UK
| | - Davinia Bennett
- Department of Anaesthetics, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert P Sutcliffe
- HPB Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Zhang X, Wakabayashi H, Hiromasa T, Kayano D, Kinuya S. Recent Advances in Radiopharmaceutical Theranostics of Pheochromocytoma and Paraganglioma. Semin Nucl Med 2023; 53:503-516. [PMID: 36641337 DOI: 10.1053/j.semnuclmed.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023]
Abstract
As a rare kind of non-epithelial neuroendocrine neoplasms, paragangliomas (PGLs) exhibit various clinical characteristics with excessive catecholamine secretion and have been a research focus in recent years. Although several modalities are available nowadays, radiopharmaceuticals play an integral role in the management of PGLs. Theranostics utilises radiopharmaceuticals for diagnostic and therapeutic intentions by aiming at a specific target in tumour and has been considered a possible means in diagnosis, staging, monitoring and treatment planning. Numerous radiopharmaceuticals have been developed over the past decades. 123/131-Metaiodobenzylguanidine (123/131I-MIBG), the theranostics pair target on norepinephrine transporter system, has remained a fantastic protocol for patients with PGLs because of disease control with limited toxicity. The high-specific-activity 131I-MIBG was authorised by the Food and Drug Administration as a systemic treatment method for metastatic PGLs in 2018. Afterward, peptide receptor radionuclide therapy, which uses radiolabelled somatostatin (SST) analogues, has been exploited as a superior substitute. 68Ga-somatostatin analogue (SSA) PET showed significant performance in diagnosing PGLs than MIBG scintigraphy, especially in patients with head and neck PGLs or SDHx mutation. 90Y/177Lu-DOTA-SSA is highly successful and has preserved favourable safety with mounting evidence regarding objective response, disease stabilisation, symptomatic and hormonal management and quality of life preservation. Besides the ordinary beta emitters, alpha-emitters such as 211At-MABG and 225Ac-DOTATATE have been investigated intensively in recent years. However, many studies are still in the pre-clinical stage, and more research is necessary. This review summarises the developments and recent advances in radiopharmaceutical theranostics of PGLs.
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Affiliation(s)
- Xue Zhang
- Department of Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Hiroshi Wakabayashi
- Department of Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan.
| | - Tomo Hiromasa
- Department of Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Daiki Kayano
- Department of Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Seigo Kinuya
- Department of Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
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10
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Klieser E, Neumayer B, Di Fazio P, Mayr C, Neureiter D, Kiesslich T. HDACs as an emerging target in endocrine tumors: a comprehensive review. Expert Rev Endocrinol Metab 2023; 18:143-154. [PMID: 36872882 DOI: 10.1080/17446651.2023.2183840] [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] [Received: 11/10/2022] [Accepted: 02/20/2023] [Indexed: 02/26/2023]
Abstract
INTRODUCTION The pathogenic role of deregulated histone (de-)acetylation by histone deacetyles (HDACs) has been demonstrated in several human cancers. While some HDAC inhibitors (HDACi) have been approved for individual entities, for endocrine tumors such translation into clinical practice has not yet been achieved. AREAS COVERED Relevant results identified by structured searches in PubMed as well as in reference lists are summarized in a narrative review to discuss the current knowledge of HDAC involvement and their therapeutic relevance in endocrine tumors. For thyroid, neuroendocrine, and adrenal tumors, various oncogenic mechanisms of HDAC deregulation and effects of HDAC inhibitors (HDACi) have been identified in preclinical studies including direct cancer cell toxicity and modification of differentiation status. EXPERT OPINION Based on positive pre-clinical results, the research on HDAC (inhibition) in the various endocrine tumors should be intensified - yet, it needs to be considered that i) HDACs' oncogenic actions might constitute only a part of epigenetic mechanisms driving cancer, ii) individual HDAC has different roles in different endocrine tumor entities, iii) inhibition of HDACs might be especially attractive in combination with conventional or other targeted therapies, and iv) new HDAC-inhibiting drugs with improved specificity or functionally modified HDACi might further improve their efficacy.
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Affiliation(s)
- Eckhard Klieser
- Institute of Pathology, Paracelsus Medical University/University Hospital Salzburg (SALK), Salzburg, Austria
- Cancer Cluster Salzburg, Salzburg, Austria
| | - Bettina Neumayer
- Institute of Pathology, Paracelsus Medical University/University Hospital Salzburg (SALK), Salzburg, Austria
- Cancer Cluster Salzburg, Salzburg, Austria
| | - Pietro Di Fazio
- Department of Visceral Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Christian Mayr
- Center for Physiology, Pathophysiology and Biophysics, Institute of Physiology and Pathophysiology, Paracelsus Medical University, Salzburg, Austria
- Department of Internal Medicine I, Paracelsus Medical University/University Hospital Salzburg (SALK), Salzburg, Austria
| | - Daniel Neureiter
- Institute of Pathology, Paracelsus Medical University/University Hospital Salzburg (SALK), Salzburg, Austria
- Cancer Cluster Salzburg, Salzburg, Austria
| | - Tobias Kiesslich
- Center for Physiology, Pathophysiology and Biophysics, Institute of Physiology and Pathophysiology, Paracelsus Medical University, Salzburg, Austria
- Department of Internal Medicine I, Paracelsus Medical University/University Hospital Salzburg (SALK), Salzburg, Austria
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11
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Jimenez C, Chin BB, Noto RB, Dillon JS, Solnes L, Stambler N, DiPippo VA, Pryma DA. Biomarker response to high-specific-activity I-131 meta-iodobenzylguanidine in pheochromocytoma/paraganglioma. Endocr Relat Cancer 2023; 30:e220236. [PMID: 36472300 PMCID: PMC9874967 DOI: 10.1530/erc-22-0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
The objective of this study is to present the complete biomarker response dataset from a pivotal trial evaluating the efficacy and safety of high-specific-activity I-131 meta-iodobenzylguanidine in patients with advanced pheochromocytoma or paraganglioma. Biomarker status was assessed and post-treatment responses were analyzed for catecholamines, metanephrines, and serum chromogranin A. Complete biomarker response (normalization) or partial response, defined as at least 50% reduction from baseline if above the normal range, was evaluated at specified time points over a 12-month period. These results were correlated with two other study objectives: blood pressure control and objective tumor response as per RECIST 1.0. In this open-label, single-arm study, 68 patients received at least one therapeutic dose (~18.5 GBq (~500 mCi)) of high-specific-activity I-131 meta-iodobenzylguanidine. Of the patients, 79% and 72% had tumors associated with elevated total plasma free metanephrines and serum chromogranin A levels, respectively. Best overall biomarker responses (complete or partial response) for total plasma free metanephrines and chromogranin A were observed in 69% (37/54) and 80% (39/49) of patients, respectively. The best response for individual biomarkers was observed 6-12 months following the first administration of high-specific-activity I-131 meta-iodobenzylguanidine. Biochemical tumor marker response was significantly associated with both reduction in antihypertensive medication use (correlation coefficient 0.35; P = 0.006) as well as objective tumor response (correlation coefficient 0.36; P = 0.007). Treatment with high-specific-activity I-131 meta-iodobenzylguanidine resulted in long-lasting biomarker responses in patients with advanced pheochromocytoma or paraganglioma that correlated with blood pressure control and objective response rate. ClinicalTrials.gov number: NCT00874614.
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Affiliation(s)
- Camilo Jimenez
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bennett B Chin
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Richard B Noto
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Lilja Solnes
- Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Nancy Stambler
- Progenics Pharmaceuticals, Inc., a Lantheus Company, North Billerica, Massachusetts, USA
| | - Vincent A DiPippo
- Progenics Pharmaceuticals, Inc., a Lantheus Company, North Billerica, Massachusetts, USA
| | - Daniel A Pryma
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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12
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Araujo-Castro M, Pascual-Corrales E, Alonso-Gordoa T, Molina-Cerrillo J, Martínez Lorca A. Papel de las pruebas de imagen con radionúclidos en el diagnóstico y tratamiento de los feocromocitomas y paragangliomas. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Araujo-Castro M, Pascual-Corrales E, Alonso-Gordoa T, Molina-Cerrillo J, Martínez Lorca A. Role of imaging test with radionuclides in the diagnosis and treatment of pheochromocytomas and paragangliomas. ENDOCRINOL DIAB NUTR 2022; 69:614-628. [PMID: 36402734 DOI: 10.1016/j.endien.2022.11.011] [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] [Received: 06/11/2021] [Accepted: 09/29/2021] [Indexed: 06/16/2023]
Abstract
Radionuclide imaging tests with [123I] Metaiodobenzylguanidine (MIBG), [18F] -fluorodeoxyglucose, [18F]-fluorodopa, or 68Ga-DOTA(0)-Tyr(3)-octreotate are useful for the diagnosis, staging and follow-up of pheochromocytomas (PHEOs) and paragangliomas (PGLs) (PPGLs). In addition to their ability to detect and localize the disease, they allow a better molecular characterization of the tumours, which is useful for planning targeted therapy with iodine-131 (131I) -labelled MIBG or with peptide receptor radionuclide therapy (PRRT) with [177Lu]-labelled DOTATATE or other related agents in patients with metastatic disease. In this review we detail the main characteristics of the radiopharmaceuticals used in the functional study of PPGLs and the role of nuclear medicine tests for initial evaluation, staging, selection of patients for targeted molecular therapy, and radiation therapy planning. It also offers a series of practical recommendations regarding the functional imaging according to the different clinical and genetic scenarios in which PPGLs occur, and on the indications and efficacy of therapy with [131I]-MIBG and 177Lu-DOTATATE.
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Affiliation(s)
- Marta Araujo-Castro
- Unidad de Neuroendocrinología, Servicio de Endocrinología y Nutrición, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain; Universidad de Alcalá, Departamento de Ciencias de la Salud, Madrid, Spain.
| | - Eider Pascual-Corrales
- Unidad de Neuroendocrinología, Servicio de Endocrinología y Nutrición, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Teresa Alonso-Gordoa
- Servicio de Oncología Médica, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Javier Molina-Cerrillo
- Servicio de Oncología Médica, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Alberto Martínez Lorca
- Servicio de Medicina Nuclear, IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain.
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14
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Zhang X, Wakabayashi H, Kayano D, Inaki A, Kinuya S. I-131 metaiodobenzylguanidine therapy is a significant treatment option for pheochromocytoma and paraganglioma. Nuklearmedizin 2022; 61:231-239. [PMID: 35668668 DOI: 10.1055/a-1759-2050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumours of chromaffin cells. Several modalities are currently available to treat patients with PPGL. These treatment modalities include surgery, chemotherapy, molecular targeted therapy and radiopharmaceuticals. METHODS I-131 metaiodobenzylguanidine (mIBG), a classic radiopharmaceutical, can be taken up through specific receptors and sited into many, but not all, PPGL cells. RESULTS Many studies have investigated the efficacy and toxicity of I-131 mIBG therapy. These studies reported significant results in terms of objective, hormonal and symptomatic responses as well as tolerable toxicities in patients. CONCLUSION This article reviews the reported experiences of patients who underwent I-131 mIBG therapy for PPGL with a focus on functions and deficiencies of the therapy.
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Affiliation(s)
- Xue Zhang
- Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | | | - Daiki Kayano
- Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Anri Inaki
- Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Seigo Kinuya
- Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Japan
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15
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Nölting S, Bechmann N, Taieb D, Beuschlein F, Fassnacht M, Kroiss M, Eisenhofer G, Grossman A, Pacak K. Personalized Management of Pheochromocytoma and Paraganglioma. Endocr Rev 2022; 43:199-239. [PMID: 34147030 PMCID: PMC8905338 DOI: 10.1210/endrev/bnab019] [Citation(s) in RCA: 142] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Indexed: 02/07/2023]
Abstract
Pheochromocytomas/paragangliomas are characterized by a unique molecular landscape that allows their assignment to clusters based on underlying genetic alterations. With around 30% to 35% of Caucasian patients (a lower percentage in the Chinese population) showing germline mutations in susceptibility genes, pheochromocytomas/paragangliomas have the highest rate of heritability among all tumors. A further 35% to 40% of Caucasian patients (a higher percentage in the Chinese population) are affected by somatic driver mutations. Thus, around 70% of all patients with pheochromocytoma/paraganglioma can be assigned to 1 of 3 main molecular clusters with different phenotypes and clinical behavior. Krebs cycle/VHL/EPAS1-related cluster 1 tumors tend to a noradrenergic biochemical phenotype and require very close follow-up due to the risk of metastasis and recurrence. In contrast, kinase signaling-related cluster 2 tumors are characterized by an adrenergic phenotype and episodic symptoms, with generally a less aggressive course. The clinical correlates of patients with Wnt signaling-related cluster 3 tumors are currently poorly described, but aggressive behavior seems likely. In this review, we explore and explain why cluster-specific (personalized) management of pheochromocytoma/paraganglioma is essential to ascertain clinical behavior and prognosis, guide individual diagnostic procedures (biochemical interpretation, choice of the most sensitive imaging modalities), and provide personalized management and follow-up. Although cluster-specific therapy of inoperable/metastatic disease has not yet entered routine clinical practice, we suggest that informed personalized genetic-driven treatment should be implemented as a logical next step. This review amalgamates published guidelines and expert views within each cluster for a coherent individualized patient management plan.
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Affiliation(s)
- Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), CH-8091 Zurich, Switzerland.,Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, 13273 Marseille, France
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), CH-8091 Zurich, Switzerland.,Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Martin Fassnacht
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Matthias Kroiss
- Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany.,Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford OX2 6HG, UK.,Centre for Endocrinology, Barts and the London School of Medicine, London EC1M 6BQ, UK.,ENETS Centre of Excellence, Royal Free Hospital, London NW3 2QG, UK
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD 20847, USA
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16
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Lopez Quiñones AJ, Vieira LS, Wang J. Clinical Applications and the Roles of Transporters in Disposition, Tumor Targeting, and Tissue Toxicity of meta-Iodobenzylguanidine (mIBG). Drug Metab Dispos 2022; 50:DMD-MR-2021-000707. [PMID: 35197314 PMCID: PMC9488973 DOI: 10.1124/dmd.121.000707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/01/2022] [Accepted: 02/17/2022] [Indexed: 11/22/2022] Open
Abstract
Transporters on the plasma membrane of tumor cells are promising molecular "Trojan horses" to deliver drugs and imaging agents into cancer cells. Radioiodine-labeled meta-iodobenzylguanidine (mIBG) is used as a diagnostic agent (123I-mIBG) and a targeted radiotherapy (131I-mIBG) for neuroendocrine cancers. mIBG enters cancer cells through the norepinephrine transporter (NET) where the radioactive decay of 131I causes DNA damage, cell death, and tumor necrosis. mIBG is predominantly eliminated unchanged by the kidney. Despite its selective uptake by neuroendocrine tumors, mIBG accumulates in several normal tissues and leads to tissue-specific radiation toxicities. Emerging evidences suggest that the polyspecific organic cation transporters play important roles in systemic disposition and tissue-specific uptake of mIBG. In particular, human organic cation transporter 2 (hOCT2) and toxin extrusion proteins 1 and 2-K (hMATE1/2-K) likely mediate renal secretion of mIBG whereas hOCT1 and hOCT3 may contribute to mIBG uptake into normal tissues such as the liver, salivary glands, and heart. This mini-review focuses on the clinical applications of mIBG in neuroendocrine cancers and the differential roles of NET, OCT and MATE transporters in mIBG disposition, response and toxicity. Understanding the molecular mechanisms governing mIBG transport in cancer and normal cells is a critical step for developing strategies to optimize the efficacy of 131I-mIBG while minimizing toxicity in normal tissues. Significance Statement Radiolabeled mIBG has been used as a diagnostic tool and as radiotherapy for neuroendocrine cancers and other diseases. NET, OCT and MATE transporters play differential roles in mIBG tumor targeting, systemic elimination, and accumulation in normal tissues. The clinical use of mIBG as a radiopharmaceutical in cancer diagnosis and treatment can be further improved by taking a holistic approach considering mIBG transporters in both cancer and normal tissues.
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Affiliation(s)
| | | | - Joanne Wang
- Dept. of Pharmaceutics, University of Washington, United States
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17
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Pheochromocytomas and Abdominal Paragangliomas: A Practical Guidance. Cancers (Basel) 2022; 14:cancers14040917. [PMID: 35205664 PMCID: PMC8869962 DOI: 10.3390/cancers14040917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare. They can be discovered incidentally by imaging with computed tomography or magnetic resonance imaging and during hormonal surveillance in patients with known genetic variants that are associated with PPGLs. As most PPGLs are functioning, a hormonal work-up evaluating for catecholamine excess is recommended. Classical symptoms, such as tachycardia, hypertension and headache, can be present, but when the PPGL is discovered as an incidentaloma, symptoms may be lacking or be more discrete. PPGLs carry malignant potential, and patients should undergo close surveillance, as recurrence of disease or metastasis may develop. Genetic susceptibility for multifocal disease has gained more attention, and germline variants are commonly detected, thus facilitating detection of hereditary cases and afflicted family members. Any patient with a PPGL should be managed by an expert multidisciplinary team consisting of endocrinologists, radiologists, surgeons, pathologists and clinical geneticists. Abstract Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare tumors arising from the adrenal medulla or the sympathetic nervous system. This review presents a practical guidance for clinicians dealing with PPGLs. The incidence of PPGLs has risen. Most cases are detected via imaging and less present with symptoms of catecholamine excess. Most PPGLs secrete catecholamines, with diffuse symptoms. Diagnosis is made by imaging and tests of catecholamines. Localized disease can be cured by surgery. PPGLs are the most heritable of all human tumors, and germline variants are found in approximately 30–50% of cases. Such variants can give information regarding the risk of developing recurrence or metastases as well as the risk of developing other tumors and may identify relatives at risk for disease. All PPGLs harbor malignant potential, and current histological and immunohistochemical algorithms can aid in the identification of indolent vs. aggressive tumors. While most patients with metastatic PPGL have slowly progressive disease, a proportion of patients present with an aggressive course, highlighting the need for more effective therapies in these cases. We conclude that PPGLs are rare but increasing in incidence and management should be guided by a multidisciplinary team.
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van Nuland M, Ververs TF, Lam MGEH. Dosing Therapeutic Radiopharmaceuticals in Obese Patients. Int J Mol Sci 2022; 23:ijms23020818. [PMID: 35055005 PMCID: PMC8775906 DOI: 10.3390/ijms23020818] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 02/07/2023] Open
Abstract
The prevalence of obesity has increased dramatically in the Western population. Obesity is known to influence not only the proportion of adipose tissue but also physiological processes that could alter drug pharmacokinetics. Yet, there are no specific dosing recommendations for radiopharmaceuticals in this patient population. This could potentially lead to underdosing and thus suboptimal treatment in obese patients, while it could also lead to drug toxicity due to high levels of radioactivity. In this review, relevant literature is summarized on radiopharmaceutical dosing and pharmacokinetic properties, and we aimed to translate these data into practical guidelines for dosing of radiopharmaceuticals in obese patients. For radium-223, dosing in obese patients is well established. Furthermore, for samarium-153-ethylenediaminetetramethylene (EDTMP), dose-escalation studies show that the maximum tolerated dose will probably not be reached in obese patients when dosing on MBq/kg. On the other hand, there is insufficient evidence to support dose recommendations in obese patients for rhenium-168-hydroxyethylidene diphosphonate (HEDP), sodium iodide-131, iodide 131-metaiodobenzylguanidine (MIBG), lutetium-177-dotatate, and lutetium-177-prostate-specific membrane antigen (PSMA). From a pharmacokinetic perspective, fixed dosing may be appropriate for these drugs. More research into obese patient populations is needed, especially in the light of increasing prevalence of obesity worldwide.
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Affiliation(s)
- Merel van Nuland
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; (M.v.N.); (T.F.V.)
| | - Tessa F. Ververs
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; (M.v.N.); (T.F.V.)
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Marnix G. E. H. Lam
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Correspondence:
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Nyakale Elizabeth N, Kabunda J. Nuclear medicine therapy of malignant pheochromocytomas, neuroblastomas and ganglioneuromas. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00174-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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20
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Hiromasa T, Wakabayashi H, Kayano D, Inaki A, Watanabe S, Mori H, Akatani N, Yamase T, Kunita Y, Saito S, Kinuya S. Prognostic factors for refractory pheochromocytoma and paraganglioma after 131I-metaiodobenzylguanidine therapy. Ann Nucl Med 2022; 36:61-69. [PMID: 34647244 DOI: 10.1007/s12149-021-01685-6] [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: 08/11/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Given the rarity of refractory pheochromocytoma and paraganglioma (PPGL), outcomes and prognostic factors after 131I-metaiodobenzylguanidine (131I-mIBG) treatment still remain unclear. Therefore, this study evaluated whether baseline characteristics at initial 131I-mIBG therapy and imaging response to repeated 131I-mIBG therapy could be prognostic factors for refractory PPGL. METHODS All patients [n = 59 (male/female = 35/24), median age; 49.3 years] with refractory PPGL who received 131I-mIBG therapy at our institution between September 2009 and September 2019 were retrospectively reviewed for the effects of the following factors on overall survival: age, sex, hypertension, diabetes mellitus, palpitations, constipation, cancer pain, catecholamines values, past history of therapy (external beam radiation for bone metastasis, operation, and chemotherapy), metastasis sites, and response to 131I-mIBG treatments. RESULTS Throughout the follow-up period, 18 patients died from disease exacerbation. The estimated 5- and 10-year survival rates were 79.4% and 67.2% from the initial diagnoses of refractory PPGL and 68.5% and 49.9% from the first 131I-mIBG therapy, respectively. The multivariate Cox proportional hazards model showed that progressive disease (PD) [hazard ratio (HR) 96.3, P = 0.011] and constipation (HR 8.2, P = 0.024) were adverse prognostic factors for overall survival after initial 131I-mIBG therapy. The log-rank test demonstrated that PD in response to 131I-mIBG therapies (P < 0.0001) and constipation (P < 0.01) were correlated with poor survival rates. CONCLUSIONS Response to repeated 131I-mIBG treatment can be a strong predictor of prognosis after initial 131I-mIBG therapy for refractory PPGL. Repeated 131I-mIBG therapy may be a good option for controlling refractory PPGL.
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Affiliation(s)
- Tomo Hiromasa
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Hiroshi Wakabayashi
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Daiki Kayano
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Anri Inaki
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Satoru Watanabe
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroshi Mori
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Norihito Akatani
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Takafumi Yamase
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Yuji Kunita
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Shintaro Saito
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Seigo Kinuya
- Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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21
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Takács-Vellai K, Farkas Z, Ősz F, Stewart GW. Model systems in SDHx-related pheochromocytoma/paraganglioma. Cancer Metastasis Rev 2021; 40:1177-1201. [PMID: 34957538 PMCID: PMC8825606 DOI: 10.1007/s10555-021-10009-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/04/2021] [Indexed: 11/17/2022]
Abstract
Pheochromocytoma (PHEO) and paraganglioma (PGL) (together PPGL) are tumors with poor outcomes that arise from neuroendocrine cells in the adrenal gland, and sympathetic and parasympathetic ganglia outside the adrenal gland, respectively. Many follow germline mutations in genes coding for subunits of succinate dehydrogenase (SDH), a tetrameric enzyme in the tricarboxylic acid (TCA) cycle that both converts succinate to fumarate and participates in electron transport. Germline SDH subunit B (SDHB) mutations have a high metastatic potential. Herein, we review the spectrum of model organisms that have contributed hugely to our understanding of SDH dysfunction. In Saccharomyces cerevisiae (yeast), succinate accumulation inhibits alpha-ketoglutarate-dependent dioxygenase enzymes leading to DNA demethylation. In the worm Caenorhabditis elegans, mutated SDH creates developmental abnormalities, metabolic rewiring, an energy deficit and oxygen hypersensitivity (the latter is also found in Drosophila melanogaster). In the zebrafish Danio rerio, sdhb mutants display a shorter lifespan with defective energy metabolism. Recently, SDHB-deficient pheochromocytoma has been cultivated in xenografts and has generated cell lines, which can be traced back to a heterozygous SDHB-deficient rat. We propose that a combination of such models can be efficiently and effectively used in both pathophysiological studies and drug-screening projects in order to find novel strategies in PPGL treatment.
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Affiliation(s)
| | - Zsolt Farkas
- Department of Biological Anthropology, Eötvös Loránd University, Budapest, Hungary
| | - Fanni Ősz
- Department of Biological Anthropology, Eötvös Loránd University, Budapest, Hungary
| | - Gordon W Stewart
- Division of Medicine, University College London, Gower Street, London, WC1E 6BT, UK
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22
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Carrasquillo JA, Chen CC, Jha A, Pacak K, Pryma DA, Lin FI. Systemic Radiopharmaceutical Therapy of Pheochromocytoma and Paraganglioma. J Nucl Med 2021; 62:1192-1199. [PMID: 34475242 PMCID: PMC8882896 DOI: 10.2967/jnumed.120.259697] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/16/2021] [Indexed: 11/16/2022] Open
Abstract
Whereas benign pheochromocytomas and paragangliomas are often successfully cured by surgical resection, treatment of metastatic disease can be challenging in terms of both disease control and symptom control. Fortunately, several options are available, including chemotherapy, radiation therapy, and surgical debulking. Radiolabeled metaiodobenzylguanidine (MIBG) and somatostatin receptor imaging have laid the groundwork for use of these radiopharmaceuticals as theranostic agents. 131I-MIBG therapy of neuroendocrine tumors has a long history, and the recent approval of high-specific-activity 131I-MIBG for metastatic or inoperable pheochromocytoma or paraganglioma by the U.S. Food and Drug Administration has resulted in general availability of, and renewed interest in, this treatment. Although reports of peptide receptor radionuclide therapy of pheochromocytoma and paraganglioma with 90Y- or 177Lu-DOTA conjugated somatostatin analogs have appeared in the literature, the approval of 177Lu-DOTATATE in the United States and Europe, together with National Comprehensive Cancer Network guidelines suggesting its use in patients with metastatic or inoperable pheochromocytoma and paraganglioma, has resulted in renewed interest. These agents have shown evidence of efficacy as palliative treatments in patients with metastatic or inoperable pheochromocytoma or paraganglioma. In this continuing medical education article, we discuss the therapy of pheochromocytoma and paraganglioma with 131I-MIBG and 90Y- or 177Lu-DOTA-somatostatin analogs.
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Affiliation(s)
- Jorge A Carrasquillo
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, New York;
- Molecular Imaging Branch, National Cancer Institute, Bethesda, Maryland
| | - Clara C Chen
- Department of Radiology, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Abhishek Jha
- Section on Medical Neuroendocrinology, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; and
| | - Karel Pacak
- Section on Medical Neuroendocrinology, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; and
| | - Daniel A Pryma
- Department of Radiology, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank I Lin
- Molecular Imaging Branch, National Cancer Institute, Bethesda, Maryland
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23
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Granberg D, Juhlin CC, Falhammar H. Metastatic Pheochromocytomas and Abdominal Paragangliomas. J Clin Endocrinol Metab 2021; 106:e1937-e1952. [PMID: 33462603 PMCID: PMC8063253 DOI: 10.1210/clinem/dgaa982] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PPGLs) are believed to harbor malignant potential; about 10% to 15% of pheochromocytomas and up to 50% of abdominal paragangliomas will exhibit metastatic behavior. EVIDENCE ACQUISITION Extensive searches in the PubMed database with various combinations of the key words pheochromocytoma, paraganglioma, metastatic, malignant, diagnosis, pathology, genetic, and treatment were the basis for the present review. DATA SYNTHESIS To pinpoint metastatic potential in PPGLs is difficult, but nevertheless crucial for the individual patient to receive tailor-made follow-up and adjuvant treatment following primary surgery. A combination of histological workup and molecular predictive markers can possibly aid the clinicians in this aspect. Most patients with PPGLs have localized disease and may be cured by surgery. Plasma metanephrines are the main biochemical tests. Genetic testing is important, both for counseling and prognostic estimation. Apart from computed tomography and magnetic resonance imaging, molecular imaging using 68Ga-DOTATOC/DOTATATE should be performed. 123I-MIBG scintigraphy may be performed to determine whether 131I-MIBG therapy is a possible option. As first-line treatment in patients with metastatic disease, 177Lu-DOTATATE or 131I-MIBG is recommended, depending on which shows best expression. In patients with very low proliferative activity, watch-and-wait or primary treatment with long-acting somatostatin analogues may be considered. As second-line treatment, or first-line in patients with high proliferative rate, chemotherapy with temozolomide or cyclophosphamide + vincristine + dacarbazine is the therapy of choice. Other therapies, including sunitinib, cabozantinib, everolimus, and PD-1/PDL-1 inhibitors, have shown modest effect. CONCLUSIONS Metastatic PPGLs need individualized management and should always be discussed in specialized and interdisciplinary tumor boards. Further studies and newer treatment modalities are urgently needed.
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Affiliation(s)
- Dan Granberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Carl Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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Abstract
Neuroendocrine tumors (NETs) are a heterogeneous group of tumors that originate in endocrine tissues throughout the body. Peptide receptor radionuclide therapy (PRRT) has emerged as a promising therapeutic option for patients with locally advanced and/or metastatic disease refractory to standard of care treatment. The landmark international phase III NETTER-1 trial led to the approval of 177Lu-DOTATATE (Lutathera) in the treatment of somatostatin receptor-positive gastroenteropancreatic NETs. Similarly, data from the multicenter, phase II Study IB12B led to the approval of meta-[131I]Iodo-Benzyl-Guanidine (I31I-MIBG) for treatment of iobenguane scan-positive, unresectable, locally advanced or metastatic pheochromocytoma or paraganglioma. With the clinical approval of these novel radiopharmaceuticals for managing select patients with NETs, additional studies are needed to refine patient selection, predict and assess therapy response, and optimize radiopharmaceutical delivery and clinical outcomes.
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Affiliation(s)
- Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Francis S Wu
- Department of Radiology, St. Louis University, St. Louis, MO
| | - Yusuf Menda
- Department of Radiology, University of Iowa, Iowa City, IA
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
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Jungels C, Karfis I. 131I-metaiodobenzylguanidine and peptide receptor radionuclide therapy in pheochromocytoma and paraganglioma. Curr Opin Oncol 2021; 33:33-39. [PMID: 33093336 DOI: 10.1097/cco.0000000000000691] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Pheochromocytomas and paragangliomas are rare tumors arising, respectively, from the adrenal medulla and extra-adrenal sympathetic or parasympathetic paraganglia. The main therapeutic objectives in case of metastatic disease are the reduction of tumor burden and the control of symptoms resulting from excessive catecholamine secretion. Treatment choices constitute not only a wait and see attitude, locoregional approaches, chemotherapy regiments but also radiopharmaceutical agents, and they should be discussed in a specialized multidisciplinary board. This review will briefly discuss the radiopharmaceutical modalities in patients with pheochromocytomas and paragangliomas (I-MIBG and PRRT). RECENT FINDINGS I-MIBG (Azedra) has received FDA approval for patients with iobenguane-scan-positive, unresectable, locally advanced or metastatic pheochromocytomas and paragangliomas who require systemic anticancer therapy, whereas peptide receptor radionuclide therapy using radiolabelled somatostatin analogues is currently performed in compassionate use, with very promising results. No prospective head-to-head comparison between the modalities has been conducted to date. SUMMARY Promising results have been reported for both radiopharmaceutical agents, mostly in the setting of retrospective series. No prospective head-to-head comparison between the modalities is yet available.
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Affiliation(s)
| | - Ioannis Karfis
- Department of Nuclear Medicine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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26
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Yoshinaga K, Abe T, Okamoto S, Uchiyama Y, Manabe O, Ito YM, Tamura N, Ito N, Yoshioka N, Washino K, Shinohara N, Tamaki N, Shiga T. Effects of Repeated 131I- Meta-Iodobenzylguanidine Radiotherapy on Tumor Size and Tumor Metabolic Activity in Patients with Metastatic Neuroendocrine Tumors. J Nucl Med 2020; 62:685-694. [PMID: 33067337 DOI: 10.2967/jnumed.120.250803] [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: 06/03/2020] [Accepted: 09/15/2020] [Indexed: 12/30/2022] Open
Abstract
131I-meta-iodobenzylguanidine (131I-MIBG) radiotherapy has shown some survival benefits in metastatic neuroendocrine tumors (NETs). European Association of Nuclear Medicine clinical guidelines for 131I-MIBG radiotherapy suggest a repeated treatment protocol, although none currently exists. The existing single-high-dose 131I-MIBG radiotherapy (444 MBq/kg) has been shown to have some benefits for patients with metastatic NETs. However, this protocol increases adverse effects and requires alternative therapeutic approaches. Therefore, the aim of this study was to evaluate the effects of repeated 131I-MIBG therapy on tumor size and tumor metabolic response in patients with metastatic NETs. Methods: Eleven patients with metastatic NETs (aged 49.2 ± 16.3 y) prospectively received repeated 5,550-MBq doses of 131I-MIBG therapy at 6-mo intervals. In total, 31 treatments were performed. The mean number of treatments was 2.8 ± 0.4, and the cumulative 131I-MIBG dose was 15,640.9 ± 2,245.1 MBq (286.01 MBq/kg). Tumor response was observed by CT and 18F-FDG PET or by 18F-FDG PET/CT before and 3-6 mo after the final 131I-MIBG treatment. Results: On the basis of the CT findings with RECIST, 3 patients showed a partial response and 6 patients showed stable disease. The remaining 2 patients showed progressive disease. Although there were 2 progressive-disease patients, analysis of all patients showed no increase in summed length diameter (median, 228.7 mm [interquartile range (IQR), 37.0-336.0 mm] to 171.0 mm [IQR, 38.0-270.0 mm]; P = 0.563). In tumor region-based analysis with partial-response and stable-disease patients (n = 9), 131I-MIBG therapy significantly reduced tumor diameter (79 lesions; median, 16 mm [IQR, 12-22 mm] to 11 mm [IQR, 6-16 mm]; P < 0.001). Among 5 patients with hypertension, there was a strong trend toward systolic blood pressure reduction (P = 0.058), and diastolic blood pressure was significantly reduced (P = 0.006). Conclusion: Eighty-two percent of metastatic NET patients effectively achieved inhibition of disease progression, with reduced tumor size and reduced metabolic activity, through repeated 131I-MIBG therapy. Therefore, this relatively short-term repeated 131I-MIBG treatment may have potential as one option in the therapeutic protocol for metastatic NETs. Larger prospective studies with control groups are warranted.
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Affiliation(s)
- Keiichiro Yoshinaga
- Diagnostic and Therapeutic Nuclear Medicine, Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, Chiba, Japan
| | - Takashige Abe
- Department of Urological Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shozo Okamoto
- Department of Diagnostic Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan .,Department of Radiology, Obihiro Kosei Hospital, Obihiro, Japan
| | - Yuko Uchiyama
- Department of Diagnostic Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Osamu Manabe
- Department of Diagnostic Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoichi M Ito
- Research Center for Medical and Health Data Science, Institute of Statistical Mathematics, Tokyo, Japan; and
| | - Naomi Tamura
- Research Center for Medical and Health Data Science, Institute of Statistical Mathematics, Tokyo, Japan; and
| | - Natsue Ito
- Diagnostic and Therapeutic Nuclear Medicine, Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, Chiba, Japan
| | - Naho Yoshioka
- Diagnostic and Therapeutic Nuclear Medicine, Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, Chiba, Japan
| | - Komei Washino
- Diagnostic and Therapeutic Nuclear Medicine, Quantum and Radiological Science and Technology, National Institute of Radiological Sciences, Chiba, Japan
| | - Nobuo Shinohara
- Department of Urological Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural Medical University, Kyoto, Japan
| | - Tohru Shiga
- Department of Diagnostic Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Abstract
PURPOSE OF REVIEW Although the majority of pheochromocytoma and paraganglioma are benign, 15-17% develop metastatic disease, being present at the initial diagnosis in about 11-31% of cases. The natural course of metastasized disease is highly heterogeneous, with an overall 5-year survival rate varying between 40% and 85%. For individual patients, overall survival, progression-free survival, and clinical outcome are difficult to predict. Management of metastasized pheochromocytoma and paraganglioma is challenging. Currently available therapeutic options are surgical debulking, treatment with radiopharmaceuticals (I-MIBG, Y and Lu-DOTATATE), chemotherapy and targeted therapy. RECENT FINDINGS The pathogenesis of pheochromocytoma and paraganglioma (PPGL) is largely driven by genomic alterations in PPGL susceptibility genes related to three different clusters: altered pseudo-hypoxic signaling (cluster-1), altered MAP-kinase signaling (cluster-2) and altered Wnt signaling (cluster-3). Novel targeted therapies (tyrosine kinase inhibitors) and potential future therapeutic options, guided by improved knowledge about the oncogenic cluster 1-3 signaling pathways, will be discussed. SUMMARY Treatment of metastasized pheochromocytoma and paraganglioma remains challenging. Profiling of gene expression and methylation can serve as a powerful tool for characterizing disease clusters and for guiding targeted therapy to improve selectivity and efficacy. Current knowledge of signatures involved in molecular signaling, metabolism, and resistance mechanisms of PPGLs suggests that therapeutic regimens can be optimized to each molecular subtype.
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Ilanchezhian M, Jha A, Pacak K, Del Rivero J. Emerging Treatments for Advanced/Metastatic Pheochromocytoma and Paraganglioma. Curr Treat Options Oncol 2020; 21:85. [PMID: 32862332 PMCID: PMC7456409 DOI: 10.1007/s11864-020-00787-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT The incidence of metastatic pheochromocytoma (PHEO) and paraganglioma (PGL) may occur in as many as 35% of patients particularly with PGL and even more frequently in those with specific mutations. Biochemical, morphological, and molecular markers have been investigated for use in the distinction of benign from malignant PHEO/PGL. PHEO/PGL metastasizes via hematogenous or lymphatic routes and shows differences based on mutational status. The most common sites of involvement in patients that have an SDHB mutation are the bone (78%), lungs (45%), lymph nodes (36%), and liver (35%). In patients with sporadic PHEO/PGL, the most common sites of metastasis are the bones (64%), lungs (47%), lymph nodes (36%), and liver (32%). Metastases may be present at presentation or may occur later. Metastases to the liver and lungs are associated with a shorter survival. Overall, the estimated 5-year survival rates are between 34 and 74%. Currently, treatments for metastatic PHEO/PGL are essentially palliative. Surgery is potentially curative; however, tumor dissemination limits the chance for a curative resection. When surgical intervention is not amenable, the therapeutic options include radiolabeled MIBG (Azedra®-iobenguane 131 was recently FDA-approved for patients > 12 years and older with iobenguane scan positive) or systemic chemotherapy with cyclophosphamide, vincristine, and dacarbazine (CVD) with an overall objective response rate (ORR) of less than 40%; however, it is not clear if the administration of CVD impacts overall survival, as nearly all patients develop progressive and ultimately fatal disease. Other treatment modalities under investigation include cytoreductive techniques, novel radiopharmaceuticals, chemotherapy, radiotherapy, immunotherapy, and experimental therapies. Here we are discussing emerging treatment for advanced/metastatic PHEO/PGL.
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Affiliation(s)
- Maran Ilanchezhian
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Abhishek Jha
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA.
- Medical Oncology & Clinical Endocrinology, Center for Cancer Research, National Cancer Institute/National Institutes of Health, 10 Center Drive, MSC 1906, Building 10, CRC 13C-434, Bethesda, MD, 20892, USA.
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Jimenez C, Núñez R, Wendt R. High-specific-activity iodine 131 metaiodobenzylguanidine for the treatment of metastatic pheochromocytoma or paraganglioma: a novel therapy for an orphan disease. Curr Opin Endocrinol Diabetes Obes 2020; 27:162-169. [PMID: 32250976 DOI: 10.1097/med.0000000000000544] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Pheochromocytomas and paragangliomas represent less than 1% of all endocrine tumors. Approximately 15-20% of these tumors are malignant. The definition of malignancy relies on the presence of metastasis. Metastatic pheochromocytomas and paragangliomas are usually advanced, incurable tumors with limited therapeutic options. About 50-60% of these tumors express the noradrenaline transporter in their cell membranes. Recently, the United States Food and Drug Administration approved high-specific-activity iodine 131 metaiodobenzylguanidine (HSA-I-131-MIBG) for the treatment of metastatic pheochromocytomas and paragangliomas that express the noradrenaline transporter. This review reports the benefits and toxicity of HSA-I-131-MIBG, its physical and dosimetric aspects, and radiation safety precautions, as well as its potential therapeutic value for other malignancies (neuroblastoma, gastroenteropancreatic neuroendocrine tumors, and medullary thyroid carcinoma). RECENT FINDINGS A phase 2 clinical trial with HSA-I-131-MIBG reported an impressive clinical benefit rate, acceptable toxicity and long-term benefits. SUMMARY HSA-I-131-MIBG is an effective medication for metastatic pheochromocytomas and paragangliomas that express the noradrenaline transporter.
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Affiliation(s)
- Camilo Jimenez
- Departments of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center
| | | | - Richard Wendt
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Cerqueira A, Seco T, Costa A, Tavares M, Cotter J. Pheochromocytoma and Paraganglioma: A Review of Diagnosis, Management and Treatment of Rare Causes of Hypertension. Cureus 2020; 12:e7969. [PMID: 32523826 PMCID: PMC7273359 DOI: 10.7759/cureus.7969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pheochromocytomas (PHEO) and paragangliomas (PGL) are rare tumors originated in cells derived from the neural crest. The first ones are located in the adrenal medulla, and the second ones in the sympathetic and parasympathetic nervous system. These kind of tumors may secrete excess catecholamines, including epinephrine, norepinephrine, dopamine and/or their metabolite metanephrine, normetanephrine and 3-methoxytyramine, respectively. Its clinical manifestations depend on the location, the secretory profile and the malignant potential of the tumor. These tumors are frequently benign in their presentation. Some arise in the context of familiar syndromes, accounting for up to one-third of the total of diagnosis. The metastatic form is the most common presentation of the tumors with familiar origin and due to their rarity, their diagnosis and management is often difficult. Over the years, our knowledge and perception of PHEO and PGL has greatly expanded and changed. This review article aims to focus on the genetic, clinical, diagnostic, therapeutic and prognostic approaches, to give the clinician knowledge of the most recent updates regarding these themes.
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Affiliation(s)
- Ana Cerqueira
- Internal Medicine, Hospital Senhora Da Oliveira, Guimarães, PRT
| | - Tiago Seco
- Internal Medicine, Hospital Senhora Da Oliveira, Guimarães, PRT
| | - Ana Costa
- Internal Medicine, Hospital Senhora Da Oliveira, Guimarães, PRT
| | - Maria Tavares
- Internal Medicine, Hospital Senhora Da Oliveira, Guimarães, PRT
| | - Jorge Cotter
- Internal Medicine, Hospital Senhora Da Oliveira, Guimarães, PRT
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Thorpe MP, Kane A, Zhu J, Morse MA, Wong T, Borges-Neto S. Long-Term Outcomes of 125 Patients With Metastatic Pheochromocytoma or Paraganglioma Treated With 131-I MIBG. J Clin Endocrinol Metab 2020; 105:5588089. [PMID: 31614368 PMCID: PMC10147393 DOI: 10.1210/clinem/dgz074] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/02/2019] [Indexed: 02/03/2023]
Abstract
CONTEXT Prognosis of metastatic pheochromocytoma/paraganglioma following 131-Iodine metaiodobenzylguanidine (MIBG) is incompletely characterized due to small samples and shorter follow-up in these rare, often indolent tumors. OBJECTIVE To describe long-term survival, frequency, and prognostic impact of imaging, biochemical, and symptomatic response to 131-I MIBG. DESIGN Retrospective chart and imaging review at a tertiary referral center. PATIENTS Six hundred sixty-eight person-years of follow-up in 125 patients with metastatic pheochromocytoma/paraganglioma with progression through prior multimodal treatment. INTERVENTION Median 18 800 MBq 131-I MIBG. MAIN OUTCOME MEASURES Overall survival, Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST) imaging response, symptomatic response per chart review, and biochemical response (20% change over 2 consecutive assays of catecholamines, vanillylmandelic acid, metanephrines, or chromogranin A). RESULTS Median survival standard deviation [SD] from diagnosis was 11.5 years [2.4]; following metastasis, 6.5 years [0.8]; post treatment, 4.3 years [0.7]. Among 88 participants with follow-up imaging, 1% experienced complete response, 33% partial response, 53% stability, and 13% progression. Fifty-one percent showed subsequent progression, median progression-free survival [SD] of 2.0 years [0.6]. Stability/response vs progression at first imaging follow-up (3-6 months) predicted improved survival, 6.3 vs 2.4 years (P = 0.021). Fifty-nine percent of 54 patients demonstrated biochemical response. Fifty percent of these relapsed, with median time to laboratory progression [SD] of 2.8 years [0.7]. Biochemical response did not predict extended survival. Seventy-five percent of 83 patients reported improvement in pretreatment symptoms, consisting primarily of pain (42%), fatigue (27%), and hypertension (14%). Sixty-one percent of these patients experienced subsequent symptomatic progression at median [SD] 1.8 years [0.4]. Symptomatic response did not predict extended survival. CONCLUSIONS Imaging, symptomatic, and laboratory response to multimodal treatment including high-dose 131-I MIBG were achieved on long-term follow-up in metastatic pheochromocytoma or paraganglioma. Imaging response at 3 to 6 months was prognostic.
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Affiliation(s)
| | - Ari Kane
- Department of Radiology, University of California San Francisco, San Francisco, California
| | - Jason Zhu
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Michael A Morse
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Terence Wong
- Department of Medicine, Division of Hematology and Oncology, Duke University Medical Center, Durham, North Carolina
| | - Salvador Borges-Neto
- Department of Medicine, Division of Hematology and Oncology, Duke University Medical Center, Durham, North Carolina
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Jasim S, Jimenez C. Metastatic pheochromocytoma and paraganglioma: Management of endocrine manifestations, surgery and ablative procedures, and systemic therapies. Best Pract Res Clin Endocrinol Metab 2020; 34:101354. [PMID: 31685417 DOI: 10.1016/j.beem.2019.101354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metastatic pheochromocytomas and paragangliomas (MPPGs) are rare neuroendocrine tumors. Most patients present with advanced disease that is associated with manifestations of catecholamine release. Surgical resection of the primary tumor and ablative therapies of metastases-whenever possible-may improve clinical outcomes and, perhaps, lengthen the patient's overall survival. Significant steps in understanding the genetic alterations linked to MPPGs and scientific progress made on cancers that share a similar pathogenesis are leading to the recognition of potential systemic therapeutic options. Data derived from clinical trials evaluating targeted therapies such as tyrosine kinase inhibitors, radiopharmaceuticals, immunotherapy, and combinations of these will likely improve the outcomes of patients with advanced and progressive MPPGs. Exemplary of this success is the recent approval in the United States of the high-specific-activity iodine131 meta-iodine-benzylguanidine (MIBG) for patients with unresectable and progressive MPPGs that express the noradrenaline transporter. This review will discuss the therapeutic approaches for patients with MPPGs.
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Affiliation(s)
- Sina Jasim
- The Division of Endocrinology, Metabolism and Lipid Research, Campus box 8127, Washington University, School of Medicine, 660 S. Euclid Ave., St. Louis, Missouri 63110, USA
| | - Camilo Jimenez
- The Department of Endocrine Neoplasia and Hormonal Disorders at the University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1461, Houston, TX 77030, USA.
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Patel D, Phay JE, Yen TWF, Dickson PV, Wang TS, Garcia R, Yang AD, Kim LT, Solórzano CC. Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine and Head and Neck Disease Site Working Group, Part 2 of 2: Perioperative Management and Outcomes of Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2020; 27:1338-1347. [PMID: 32112213 DOI: 10.1245/s10434-020-08221-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 01/10/2023]
Abstract
This is the second part of a two-part review on pheochromocytoma and paragangliomas (PPGLs). In this part, perioperative management, including preoperative preparation, intraoperative, and postoperative interventions are reviewed. Current data on outcomes following resection are presented, including outcomes after cortical-sparing adrenalectomy for bilateral adrenal disease. In addition, pathological features of malignancy, surveillance considerations, and the management of advanced disease are also discussed.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Roberto Garcia
- Division of Surgical Oncology, National Cancer Institute of Panama/Paitilla Medical Center, Panama City, Panama
| | - Anthony D Yang
- Division of Surgical Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lawrence T Kim
- Division of Surgical Oncology and Endocrine Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
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Jimenez C, Erwin W, Chasen B. Targeted Radionuclide Therapy for Patients with Metastatic Pheochromocytoma and Paraganglioma: From Low-Specific-Activity to High-Specific-Activity Iodine-131 Metaiodobenzylguanidine. Cancers (Basel) 2019; 11:cancers11071018. [PMID: 31330766 PMCID: PMC6678905 DOI: 10.3390/cancers11071018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/03/2019] [Accepted: 07/17/2019] [Indexed: 12/13/2022] Open
Abstract
Low-specific-activity iodine-131–radiolabeled metaiodobenzylguanidine (I-131-MIBG) was introduced last century as a potential systemic therapy for patients with malignant pheochromocytomas and paragangliomas. Collective information derived from mainly retrospective studies has suggested that 30–40% of patients with these tumors benefit from this treatment. A low index of radioactivity, lack of therapeutic standardization, and toxicity associated with intermediate to high activities (absorbed radiation doses) has prevented the implementation of I-131-MIBG’s in clinical practice. High-specific-activity, carrier-free I-131-MIBG has been developed over the past two decades as a novel therapy for patients with metastatic pheochromocytomas and paragangliomas that express the norepinephrine transporter. This drug allows for a high level of radioactivity, and as yet is not associated with cardiovascular toxicity. In a pivotal phase two clinical trial, more than 90% of patients achieved partial responses and disease stabilization with the improvement of hypertension. Furthermore, many patients exhibited long-term persistent antineoplastic effects. Currently, the high-specific-activity I-131-MIBG is the only approved therapy in the US for patients with metastatic pheochromocytomas and paragangliomas. This review will discuss the historical development of high-specific-activity I-131-MIBG, its benefits and adverse events, and future directions for clinical practice applicability and trial development.
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Affiliation(s)
- Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1461, Houston, TX 77030, USA.
| | - William Erwin
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1461, Houston, TX 77030, USA
| | - Beth Chasen
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Abstract
Carney-Stratakis Syndrome (CSS) comprises of paragangliomas (PGLs) and gastrointestinal stromal tumors (GISTs). Several of its features overlap with Carney Triad (CT) - PGLs, GISTs, and pulmonary chondromas. CSS has autosomal dominant inheritance, incomplete penetrance, and greater relative frequency of PGL over GISTs. The PGLs in CSS are multicentric and GISTs are multifocal in all the patients, suggesting an inherited susceptibility and associating the two manifestations. In this review, we highlight the clinical, pathological, and molecular characteristics of CSS, along with its diagnostic and therapeutic implications.
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Affiliation(s)
- Arushi Khurana
- VCU Massey Cancer Center - Hematology Oncology, Richmond, Virginia, USA
| | - Lin Mei
- VCU Massey Cancer Center - Hematology Oncology, Richmond, Virginia, USA
| | - Anthony C Faber
- Virginia Commonwealth University - Philips Institute for Oral Health Research, Richmond, Virginia, USA
| | - Steven C Smith
- Virginia Commonwealth University - Pathology, Richmond, Virginia, USA
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A phase I clinical trial for [ 131I]meta-iodobenzylguanidine therapy in patients with refractory pheochromocytoma and paraganglioma. Sci Rep 2019; 9:7625. [PMID: 31110198 PMCID: PMC6527850 DOI: 10.1038/s41598-019-43880-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/03/2019] [Indexed: 12/13/2022] Open
Abstract
Refractory pheochromocytoma and paraganglioma (PPGL) have a poor prognosis and the treatment strategy remains to be established. This multi-institutional phase I study was performed to determine the safety, dose-limiting toxicity (DLT), and efficacy of [131I]-meta-iodobenzylguanidine (131I-mIBG) therapy for refractory PPGLs. Twenty patients with refractory PPGL were enrolled in this study. We administered fixed doses of 131I-mIBG to all patients, delivering a second and third course of 131I-mIBG to eight and three patients, respectively. During the 20 weeks after 131I-mIBG injection, the authors surveyed the adverse events in accordance with the Common Terminology Criteria for Adverse Events. All patients experienced adverse events and adverse reactions, but none experienced a grade 4 adverse event. Twelve weeks after 131I-mIBG injection, examinations for the evaluation of therapeutic effects was performed in accordance with the Response Evaluation Criteria in Solid Tumours (RECIST). The best overall response rates (based on RECIST categories) were 10% (complete response), 65% (stable disease), 15% (progressive disease), and 10% (not all evaluated). The efficacy and safety of 131I-mIBG therapy was shown in patients with refractory PPGL, and DLT was observed in neither single nor repeated 131I-mIBG therapy, indicating a tolerability for 131I-mIBG therapy.
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37
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Nölting S, Grossman A, Pacak K. Metastatic Phaeochromocytoma: Spinning Towards More Promising Treatment Options. Exp Clin Endocrinol Diabetes 2019; 127:117-128. [PMID: 30235495 PMCID: PMC7443617 DOI: 10.1055/a-0715-1888] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Phaeochromocytomas (PCC) and paragangliomas (PGL) are rare tumours arising from the chromaffin cells of the adrenal medulla (PCC) or the paraganglia located outside the adrenal gland (PGL). However, their incidence is likely to be underestimated; around 10% of all PCC/PGL are metastatic, with higher metastatic potential of PGLs compared to PCCs. If benign, surgery is the treatment of choice, but if metastatic, therapy is challenging. Here we review the currently existing therapy options for metastatic PCCs/PGLs including conventional chemotherapy (the original Averbuch scheme, but updated), radiopharmaceutical treatments (131I-MIBG, 90Y- and 177Lu-DOTATATE) and novel targeted therapies (anti-angiogenic tyrosine kinase inhibitors and mTORC1 inhibitors), emphasising future therapeutic approaches (HIF-2α and PARP inhibitors, temozolomide alone, metronomic temozolomide, somatostatin analogues) based on the oncogenic signalling pathways related to three different clusters comprising more than 20 well-characterised PCC/PGL susceptibility genes. We suggest that targeted combination therapies including repurposed agents may offer more effective future options worthy of exploration.
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Affiliation(s)
- Svenja Nölting
- Medizinische Klinik und Poliklinik IV, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEntero-Pancreatic System (GEPNET-KUM), Klinikum der Universität München (KUM), Ludwig-Maximilians-University, Munich, Germany
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, Royal Free Hospital ENETS Centre of Excellence, London, and Barts and the London Scool of Medicine, London, UK
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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38
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Mak IYF, Hayes AR, Khoo B, Grossman A. Peptide Receptor Radionuclide Therapy as a Novel Treatment for Metastatic and Invasive Phaeochromocytoma and Paraganglioma. Neuroendocrinology 2019; 109:287-298. [PMID: 30856620 DOI: 10.1159/000499497] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/09/2019] [Indexed: 11/19/2022]
Abstract
At present there is no clinical guideline or standardised protocol for the treatment of metastatic or invasive phaeochromocytoma and paraganglioma (collectively known as PPGL) due to the rarity of the disease and the lack of prospective studies or extended national databases. Prognosis is mainly determined by genetic predisposition, tumour burden, rate of disease progression, and location of metastases. For patients with progressive or symptomatic disease that is not amenable to surgery, there are various palliative treatment options available. These include localised therapies including radiotherapy, radiofrequency, or cryoablation, as well as liver-directed therapies for those patients with hepatic metastases (e.g., transarterial chemoembolisation) and systemic therapies including chemotherapy or molecular targeted therapies. There is currently intense research interest in the value of radionuclide therapy for neuroendocrine tumours, including phaeochromocytoma and paraganglioma, with either iodine-131 (131I)-radiolabelled metaiodobenzylguanidine or very recently peptide receptor radionuclide therapy (PRRT), and the most important contemporary clinical studies will be highlighted in this review. The studies to date suggest that PRRT may induce major clinical, biochemical, and radiological changes, with 177Lu-DOTATATE being most efficacious and presenting less toxicity than 90Y-DOTATATE. Newer combination therapies with combined radioisotopes, or combinations with chemotherapeutic agents, also look promising. Given the favourable efficacy, logistic, and safety profiles, we believe that PRRT will probably become the standard treatment for inoperable metastatic PPGL in the near future, but we await data from definitive randomised controlled trials to understand its role.
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Affiliation(s)
- Ingrid Y F Mak
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom,
| | - Aimee R Hayes
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom
| | - Bernard Khoo
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom
| | - Ashley Grossman
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom
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Pryma DA, Chin BB, Noto RB, Dillon JS, Perkins S, Solnes L, Kostakoglu L, Serafini AN, Pampaloni MH, Jensen J, Armor T, Lin T, White T, Stambler N, Apfel S, DiPippo VA, Mahmood S, Wong V, Jimenez C. Efficacy and Safety of High-Specific-Activity 131I-MIBG Therapy in Patients with Advanced Pheochromocytoma or Paraganglioma. J Nucl Med 2018; 60:623-630. [PMID: 30291194 PMCID: PMC6495236 DOI: 10.2967/jnumed.118.217463] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/17/2018] [Indexed: 12/18/2022] Open
Abstract
Patients with metastatic or unresectable (advanced) pheochromocytoma and paraganglioma (PPGL) have poor prognoses and few treatment options. This multicenter, phase 2 trial evaluated the efficacy and safety of high-specific-activity 131I-meta-iodobenzylguanidine (HSA 131I-MIBG) in patients with advanced PPGL. Methods: In this open-label, single-arm study, 81 PPGL patients were screened for enrollment, and 74 received a treatment-planning dose of HSA 131I-MIBG. Of these patients, 68 received at least 1 therapeutic dose (∼18.5 GBq) of HSA 131I-MIBG intravenously. The primary endpoint was the proportion of patients with at least a 50% reduction in baseline antihypertensive medication use lasting at least 6 mo. Secondary endpoints included objective tumor response as assessed by Response Evaluation Criteria in Solid Tumors version 1.0, biochemical tumor marker response, overall survival, and safety. Results: Of the 68 patients who received at least 1 therapeutic dose of HSA 131I-MIBG, 17 (25%; 95% confidence interval, 16%–37%) had a durable reduction in baseline antihypertensive medication use. Among 64 patients with evaluable disease, 59 (92%) had a partial response or stable disease as the best objective response within 12 mo. Decreases in elevated (≥1.5 times the upper limit of normal at baseline) serum chromogranin levels were observed, with confirmed complete and partial responses 12 mo after treatment in 19 of 28 patients (68%). The median overall survival was 36.7 mo (95% confidence interval, 29.9–49.1 mo). The most common treatment-emergent adverse events were nausea, myelosuppression, and fatigue. No patients had drug-related acute hypertensive events during or after the administration of HSA 131I-MIBG. Conclusion: HSA 131I-MIBG offers multiple benefits, including sustained blood pressure control and tumor response in PPGL patients.
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Affiliation(s)
- Daniel A Pryma
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Bennett B Chin
- Department of Radiology-Nuclear Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado
| | - Richard B Noto
- Division of Nuclear Medicine, Rhode Island Hospital/Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joseph S Dillon
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Lilja Solnes
- Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, Maryland
| | - Lale Kostakoglu
- Department of Nuclear Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aldo N Serafini
- Division of Nuclear Medicine, University of Miami School of Medicine, Miami, Florida
| | - Miguel H Pampaloni
- Department of Radiology and Biomedical Imaging, University of California at San Francisco School of Medicine, San Francisco, California
| | - Jessica Jensen
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Thomas Armor
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Tess Lin
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Theresa White
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Nancy Stambler
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Stuart Apfel
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Vincent A DiPippo
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Syed Mahmood
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Vivien Wong
- Department of Research and Development, Progenics Pharmaceuticals, Inc., New York, New York; and
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas M.D. Anderson Cancer Center, Houston, Texas
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40
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Agrawal A, Rangarajan V, Shah S, Puranik A, Purandare N. MIBG (metaiodobenzylguanidine) theranostics in pediatric and adult malignancies. Br J Radiol 2018; 91:20180103. [PMID: 30048149 DOI: 10.1259/bjr.20180103] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Metaiodobenzylguanidine, a guanithidine analog, labeled with 123I and 131I, is used for imaging and therapy of neuroblastomas and various neural crest tumors like paragangliomas, pheochromocytomas, medullary cancer of thyroid and carcinoids since the past three to four decades. In this review article, we shall revisit metaiodobenzylguanidine as a radiopharmaceutical and its various applications in neural crest tumors.
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Affiliation(s)
- Archi Agrawal
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
| | - Venkatesh Rangarajan
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
| | - Sneha Shah
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
| | - Ameya Puranik
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
| | - Nilendu Purandare
- 1 Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital , Mumbai , India
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Inaki A, Yoshimura K, Murayama T, Imai Y, Kuribayashi Y, Higuchi T, Jinguji M, Shiga T, Kinuya S. A phase I clinical trial for [ 131I]meta-iodobenzylguanidine therapy in patients with refractory pheochromocytoma and paraganglioma: a study protocol. THE JOURNAL OF MEDICAL INVESTIGATION 2018; 64:205-209. [PMID: 28954983 DOI: 10.2152/jmi.64.205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective Pheochromocytoma and paraganglioma (PPGLs) are rare neuroendocrine tumors derived from the adrenal medulla or extra-adrenal paraganglioma from extra-adrenal chromaffin tissue. Although malignant PPGLs has miserable prognosis, the treatment strategy remains to be established. An internal radiation therapy using [131I]meta-iodobenzylguanidine (131I-mIBG) called MIBG therapy has been attempted as one of the systemic treatment of malignant PPGLs. The aim of this study is therefore to evaluate the safety and the efficacy of MIBG therapy for refractory PPGLs. Methods Patients with refractory PPGLs will be enrolled in this study. The total number of patients for registration is 20. The patients receive a fixed dose of 7,400 MBq of 131I-mIBG. Adverse events are surveyed during 20 weeks after 131I-mIBG injection and all severe adverse events will be documented and reported in detail in accordance with the Common Terminology Criteria for Adverse Events (CTCAE). Examination and imaging diagnosis are performed in 12 weeks after 131I-mIBG injection for the evaluation of therapeutic effect in accordance with the Response Evaluation in Solid Tumours (RECIST). Conclusion The current study is the first multi-institutional prospective study of MIBG therapy and thereby will play a significant role in improving the patients' prognosis of refractory PPGLs. J. Med. Invest. 64: 205-209, August, 2017.
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Affiliation(s)
- Anri Inaki
- Department of Nuclear Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University
| | - Kenichi Yoshimura
- Department of Biostatistics, Innovative Clinical Research Center, Kanazawa University Hospital
| | | | - Yasuhito Imai
- Department of Data Center, Innovative Clinical Research Center, Kanazawa University Hospital
| | - Yoshikazu Kuribayashi
- Department of Monitoring and Auditing in Clinical Trials, Innovative Clinical Research Center, Kanazawa University Hospital
| | - Tetsuya Higuchi
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine
| | - Megumi Jinguji
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences
| | - Tohru Shiga
- Department of Nuclear Medicine, Hokkaido University
| | - Seigo Kinuya
- Department of Nuclear Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University
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42
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Kayano D, Kinuya S. Current Consensus on I-131 MIBG Therapy. Nucl Med Mol Imaging 2018; 52:254-265. [PMID: 30100938 DOI: 10.1007/s13139-018-0523-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/27/2018] [Accepted: 04/12/2018] [Indexed: 12/24/2022] Open
Abstract
Metaiodobenzylguanidine (MIBG) is structurally similar to the neurotransmitter norepinephrine and specifically targets neuroendocrine cells including some neuroendocrine tumors. Iodine-131 (I-131)-labeled MIBG (I-131 MIBG) therapy for neuroendocrine tumors has been performed for more than a quarter-century. The indications of I-131 MIBG therapy include treatment-resistant neuroblastoma (NB), unresectable or metastatic pheochromocytoma (PC) and paraganglioma (PG), unresectable or metastatic carcinoid tumors, and unresectable or metastatic medullary thyroid cancer (MTC). I-131 MIBG therapy is one of the considerable effective treatments in patients with advanced NB, PC, and PG. On the other hand, I-131 MIBG therapy is an alternative method after more effective novel therapies are used such as radiolabeled somatostatin analogs and tyrosine kinase inhibitors in patients with advanced carcinoid tumors and MTC. No-carrier-aided (NCA) I-131 MIBG has more favorable potential compared to the conventional I-131 MIBG. Astatine-211-labeled meta-astatobenzylguanidine (At-211 MABG) has massive potential in patients with neuroendocrine tumors. Further studies about the therapeutic protocols of I-131 MIBG including NCA I-131 MIBG in the clinical setting and At-211 MABG in both the preclinical and clinical settings are needed.
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Affiliation(s)
- Daiki Kayano
- 1Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641 Japan.,2Department of Nuclear Medicine, Fukushima Medical University Hospital, 1 Hikariga-oka, Fukushima, 960-1295 Japan
| | - Seigo Kinuya
- 1Department of Nuclear Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, 920-8641 Japan
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43
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Noto RB, Pryma DA, Jensen J, Lin T, Stambler N, Strack T, Wong V, Goldsmith SJ. Phase 1 Study of High-Specific-Activity I-131 MIBG for Metastatic and/or Recurrent Pheochromocytoma or Paraganglioma. J Clin Endocrinol Metab 2018; 103:213-220. [PMID: 29099942 DOI: 10.1210/jc.2017-02030] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/18/2017] [Indexed: 02/13/2023]
Abstract
CONTEXT No therapies are approved for the treatment of metastatic and/or recurrent pheochromocytoma or paraganglioma (PPGL) in the United States. OBJECTIVE To determine the maximum tolerated dose (MTD) of high-specific-activity I-131 meta-iodobenzylguanidine (MIBG) for the treatment of metastatic and/or recurrent PPGL. DESIGN Phase 1, dose-escalating study to determine the MTD via a standard 3 + 3 design, escalating by 37 MBq/kg starting at 222 MBq/kg. SETTING Three centers. PATIENTS Twenty-one patients were eligible, received study drug, and were evaluable for MTD, response, and toxicity. INTERVENTION Open-label use of high-specific-activity I-131 MIBG therapy. MAIN OUTCOME MEASURES Dose-limiting toxicities, adverse events, radiation absorbed dose estimates, radiographic tumor response, biochemical response, and survival. RESULTS The MTD was determined to be 296 MBq/kg on the basis of two observed dose-limiting toxicities at the next dose level. The highest mean radiation absorbed dose estimates were in the thyroid and lower large intestinal wall (each 1.2 mGy/MBq). Response was evaluated by total administered activity: four patients (19%), all of whom received >18.5 GBq of study drug, had radiographic tumor responses of partial response by Response Evaluation Criteria in Solid Tumors. Best biochemical responses (complete or partial response) for serum chromogranin A and total metanephrines were observed in 80% and 64% of patients, respectively. Overall survival was 85.7% at 1 year and 61.9% at 2 years after treatment. The majority (84%) of adverse events were considered mild or moderate in severity. CONCLUSIONS These findings support further development of high-specific-activity I-131 MIBG for the treatment of metastatic and/or recurrent PPGL at an MTD of 296 MBq/kg.
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Affiliation(s)
- Richard B Noto
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daniel A Pryma
- Department of Radiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | | | - Tess Lin
- Progenics Pharmaceuticals, Inc., New York, New York
| | | | | | - Vivien Wong
- Progenics Pharmaceuticals, Inc., New York, New York
| | - Stanley J Goldsmith
- Radiology and Medicine, Weill Medical College of Cornell University, New York, New York
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[A CASE OF MALIGNANT PARAGANGLIOMA OF THE URINARY BLADDER TREATED WITH CYCLOPHOSPHAMIDE, VINCRISTINE, AND DACARBAZINE CHEMOTHERAPY AND METAIODOBENZYLGUANIDINE THERAPY]. Nihon Hinyokika Gakkai Zasshi 2018; 109:106-110. [PMID: 31006739 DOI: 10.5980/jpnjurol.109.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A 34-year-old man, diagnosed with paraganglioma of the urinary bladder, was referred to our hospital. Computed tomography showed a bladder tumor measuring 64 mm along with right obturator lymphadenopathy. Abnormal uptake was observed on 123I-MIBG scintigraphy. The tumor was, therefore, diagnosed as malignant paraganglioma. We performed cystectomy, pelvic lymph node dissection, and neobladder reconstruction. Pathological examination revealed a malignant paraganglioma of the urinary bladder with right obturator lymph node metastasis. Postoperatively, both the uptake on 123I-MIBG scintigraphy and catecholamine levels in blood and urine normalized. However, 22 months later, positoron emission tomography-computed tomography showed the presence of 2 recurrent tumors in the pelvis. The patient underwent 9 courses of cyclophosphamide, vincristine, and dacarbazine chemotherapy and MIBG radiotherapy twice, following which the tumor size decreased by 35% and catecholamine levels normalized once again. At about 2 years of follow-up, the patient was found to be free of recurrence.
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45
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Crona J, Taïeb D, Pacak K. New Perspectives on Pheochromocytoma and Paraganglioma: Toward a Molecular Classification. Endocr Rev 2017; 38:489-515. [PMID: 28938417 PMCID: PMC5716829 DOI: 10.1210/er.2017-00062] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/01/2017] [Indexed: 02/07/2023]
Abstract
A molecular biology-based taxonomy has been proposed for pheochromocytoma and paraganglioma (PPGL). Data from the Cancer Genome Atlas revealed clinically relevant prognostic and predictive biomarkers and stratified PPGLs into three main clusters. Each subgroup has a distinct molecular-biochemical-imaging signature. Concurrently, new methods for biochemical analysis, functional imaging, and medical therapies have also become available. The research community now strives to match the cluster biomarkers with the best intervention. The concept of precision medicine has been long awaited and holds great promise for improved care. Here, we review the current and future PPGL classifications, with a focus on hereditary syndromes. We discuss the current strengths and shortcomings of precision medicine and suggest a condensed manual for diagnosis and treatment of both adult and pediatric patients with PPGL. Finally, we consider the future direction of this field, with a particular focus on how advanced molecular characterization of PPGL can improve a patient's outcome, including cures and, ultimately, disease prevention.
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Affiliation(s)
- Joakim Crona
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health.,Department of Medical Sciences, Uppsala University, Sweden
| | - David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, European Center for Research in Medical Imaging, Aix Marseille Université, France
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
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46
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Abstract
PURPOSE OF REVIEW The purpose of this manuscript is to review the progress in the field of therapeutics for malignant pheochromocytomas and sympathetic paraganglioma (MPPG) over the past 5 years. RECENT FINDINGS The manuscript will describe the clinical predictors of survivorship and their influence on the first TNM staging classification for pheochromocytomas and sympathetic paragangliomas, the treatment of hormonal complications, and the rationale that supports the resection of the primary tumor and metastases in patients with otherwise incurable disease. Therapeutic options for patients with bone metastasis to the spine will be presented. The manuscript will also review chemotherapy and propose a maintenance regimen with dacarbazine for patients initially treated with cyclophosphamide, vincristine, and dacarbazine. Finally, the manuscript will review preliminary results of several phase 2 clinical trials of novel radiopharmaceutical agents and tyrosine kinase inhibitors. MPPGs are very rare neuroendocrine tumors. MPPGs are usually characterized by a large tumor burden, excessive secretion of catecholamines, and decreased overall survival. Recent discoveries have enhanced our knowledge of the pathogenesis and phenotypes of MPPG. This knowledge is leading to a better understanding of the indications and limitations of the currently available localized and systemic therapies as well as the development of phase 2 clinical trials for novel medications.
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47
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Pandit-Taskar N, Modak S. Norepinephrine Transporter as a Target for Imaging and Therapy. J Nucl Med 2017; 58:39S-53S. [PMID: 28864611 DOI: 10.2967/jnumed.116.186833] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 07/19/2017] [Indexed: 01/01/2023] Open
Abstract
The norepinephrine transporter (NET) is essential for norepinephrine uptake at the synaptic terminals and adrenal chromaffin cells. In neuroendocrine tumors, NET can be targeted for imaging as well as therapy. One of the most widely used theranostic agents targeting NET is metaiodobenzylguanidine (MIBG), a guanethidine analog of norepinephrine. 123I/131I-MIBG theranostics have been applied in the clinical evaluation and management of neuroendocrine tumors, especially in neuroblastoma, paraganglioma, and pheochromocytoma. 123I-MIBG imaging is a mainstay in the evaluation of neuroblastoma, and 131I-MIBG has been used for the treatment of relapsed high-risk neuroblastoma for several years, however, the outcome remains suboptimal. 131I-MIBG has essentially been only palliative in paraganglioma/pheochromocytoma patients. Various techniques of improving therapeutic outcomes, such as dosimetric estimations, high-dose therapies, multiple fractionated administration and combination therapy with radiation sensitizers, chemotherapy, and other radionuclide therapies, are being evaluated. PET tracers targeting NET appear promising and may be more convenient options for the imaging and assessment after treatment. Here, we present an overview of NET as a target for theranostics; review its current role in some neuroendocrine tumors, such as neuroblastoma, paraganglioma/pheochromocytoma, and carcinoids; and discuss approaches to improving targeting and theranostic outcomes.
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Affiliation(s)
| | - Shakeel Modak
- Memorial Sloan Kettering Cancer Center, New York, New York
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48
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Lee M, Minaskan N, Wiedemann T, Irmler M, Beckers J, Yousefi BH, Kaissis G, Braren R, Laitinen I, Pellegata NS. Targeting PI3K/mTOR signaling exerts potent antitumor activity in pheochromocytoma in vivo. Endocr Relat Cancer 2017; 24:1-15. [PMID: 27811202 DOI: 10.1530/erc-16-0324] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 11/03/2016] [Indexed: 12/16/2022]
Abstract
Pheochromocytomas (PCCs) are mostly benign tumors, amenable to complete surgical resection. However, 10-17% of cases can become malignant, and once metastasized, there is no curative treatment for this disease. Given the need to identify the effective therapeutic approaches for PCC, we evaluated the antitumor potential of the dual-PI3K/mTOR inhibitor BEZ235 against these tumors. We employed an in vivo model of endogenous PCCs (MENX mutant rats), which closely recapitulate the human tumors. Mutant rats with PCCs were treated with 2 doses of BEZ235 (20 and 30 mg/kg), or with placebo, for 2 weeks. Treatment with BEZ235 induced cytostatic and cytotoxic effects on rat PCCs, which could be appreciated by both staining the tumors ex vivo with appropriate markers and non-invasively by functional imaging (diffusion-weighted magnetic resonance imaging) in vivo Transcriptomic analyses of tumors from rats treated with BEZ235 or placebo-identified potential mediators of therapy response were performed. Slc6a2, encoding the norepinephrine transporter (NET), was downregulated in a dose-dependent manner by BEZ235 in rat PCCs. Moreover, BEZ235 reduced Slc6a2/NET expression in PCC cell lines (MPC) also. Studies of a BEZ235-resistant derivative of the MPC cell line confirmed that the reduction of NET expression associates with the response to the drug. Reduction of NET expression after BEZ235 treatment in vivo could be monitored by positron emission tomography (PET) using a tracer targeting NET. Altogether, here we demonstrate the efficacy of BEZ235 against PCC in vivo, and show that functional imaging can be employed to monitor the response of PCC to PI3K/mTOR inhibition therapy.
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Affiliation(s)
- Misu Lee
- Institute for Diabetes and CancerHelmholtz Zentrum München, Neuherberg, Germany
| | - Ninelia Minaskan
- Institute for Diabetes and CancerHelmholtz Zentrum München, Neuherberg, Germany
| | - Tobias Wiedemann
- Institute for Diabetes and CancerHelmholtz Zentrum München, Neuherberg, Germany
| | - Martin Irmler
- Institute of Experimental GeneticsHelmholtz Zentrum München, Neuherberg, Germany
| | - Johannes Beckers
- Institute of Experimental GeneticsHelmholtz Zentrum München, Neuherberg, Germany
- German Center for Diabetes Research (DZD)Neuherberg, Germany
- Technische Universität MünchenChair of Experimental Genetics, Freising, Germany
| | - Behrooz H Yousefi
- Department of Pharmaceutical RadiochemistryTechnische Universität München, Garching, Germany
| | - Georgios Kaissis
- Institute for Diagnostic and Interventional RadiologyKlinikum rechts der Isar der Technische Universität München, Munich, Germany
| | - Rickmer Braren
- Institute for Diagnostic and Interventional RadiologyKlinikum rechts der Isar der Technische Universität München, Munich, Germany
| | - Iina Laitinen
- Department of Nuclear MedicineKlinikum rechts der Isar der Technische Universität München, Munich, Germany
| | - Natalia S Pellegata
- Institute for Diabetes and CancerHelmholtz Zentrum München, Neuherberg, Germany
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49
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Carrasquillo JA, Pandit-Taskar N, Chen CC. I-131 Metaiodobenzylguanidine Therapy of Pheochromocytoma and Paraganglioma. Semin Nucl Med 2016; 46:203-14. [PMID: 27067501 DOI: 10.1053/j.semnuclmed.2016.01.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pheochromocytomas and paragangliomas are rare tumors arising from chromaffin cells. Available therapeutic modalities consist of chemotherapy, tyrosine kinase inhibitors, and I-131 metaiodobenzylguanidine (MIBG). I-131 MIBG is taken up via specific receptors and localizes into many but not all pheochromocytomas and paragangliomas. Because these tumors are rare, most therapy studies are retrospective presentations of clinical experience. Numerous retrospective studies and a few prospective studies have shown favorable responses in this disease, including symptomatic, biochemical, and objective responses. In this report, we review the experience of using I-131 MIBG therapy for targeting pheochromocytoma and paragangliomas.
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Affiliation(s)
- Jorge A Carrasquillo
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering, New York, NY; Department of Radiology, Weill Cornell Medical Center, New York, NY.
| | - Neeta Pandit-Taskar
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering, New York, NY; Department of Radiology, Weill Cornell Medical Center, New York, NY
| | - Clara C Chen
- Nuclear Medicine, Department of Radiology & Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD
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50
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Leinhäuser I, Richter A, Lee M, Höfig I, Anastasov N, Fend F, Ercolino T, Mannelli M, Gimenez-Roqueplo AP, Robledo M, de Krijger R, Beuschlein F, Atkinson MJ, Pellegata NS. Oncogenic features of the bone morphogenic protein 7 (BMP7) in pheochromocytoma. Oncotarget 2016; 6:39111-26. [PMID: 26337467 PMCID: PMC4770760 DOI: 10.18632/oncotarget.4912] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/07/2015] [Indexed: 12/29/2022] Open
Abstract
BMP7 is a growth factor playing pro- or anti-oncogenic roles in cancer in a cell type-dependent manner. We previously reported that the BMP7 gene is overexpressed in pheochromocytomas (PCCs) developing in MENX-affected rats and human patients. Here, analyzing a large cohort of PCC patients, we found that 72% of cases showed elevated levels of the BMP7 protein. To elucidate the role of BMP7 in PCC, we modulated its levels in PCC cell lines (overexpression in PC12, knockdown in MPC and MTT cells) and conducted functional assays. Active BMP signaling promoted cell proliferation, migration, and invasion, and sustained survival of MENX rat primary PCC cells. In PCC, BMP7 signals through the PI3K/AKT/mTOR pathway and causes integrin β1 up-regulation. Silencing integrin β1 in PC12 cells suppressed BMP7-mediated oncogenic features. Treatment of MTT cells with DMH1, a novel BMP antagonist, suppressed proliferation and migration. To verify the clinical applicability of our findings, we evaluated a dual PI3K/mTOR inhibitor (NVP-BEZ235) in MENX-affected rats in vivo. PCCs treated with NVP-BEZ235 had decreased proliferation and integrin β1 levels, and higher apoptosis. Altogether, BMP7 activates pro-oncogenic pathways in PCC. Downstream effectors of BMP7-mediated signaling may represent novel targets for treating progressive/inoperable PCC, still orphan of effective therapy.
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Affiliation(s)
- Ines Leinhäuser
- Institute of Pathology, Helmholtz Zentrum München, Neuherberg, Germany.,Institute of Radiation Biology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Andrea Richter
- Institute of Pathology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Misu Lee
- Institute of Pathology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Ines Höfig
- Institute of Radiation Biology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Nataša Anastasov
- Institute of Radiation Biology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Falko Fend
- Institute of Pathology and Neuropathology Comprehensive Cancer Center Tübingen and University of Tübingen, Tübingen, Germany
| | - Tonino Ercolino
- Azienda Ospedaliero-Universitaria di Careggi, Endocrine Unit, Florence, Italy
| | - Massimo Mannelli
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Anne-Paule Gimenez-Roqueplo
- INSERM, UMR U970, Paris Cardiovascular Research Center-PARCC, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France.,Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Department of Genetics, Paris, France
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
| | - Ronald de Krijger
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Felix Beuschlein
- Endocrine Research Unit, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Michael J Atkinson
- Institute of Radiation Biology, Helmholtz Zentrum München, Neuherberg, Germany
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