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Fan Y, Guo S, Tao C, Fang H, Mou A, Feng M, Wu Z. Noninvasive radiomics approach predicts dopamine agonists treatment response in patients with prolactinoma: a multicenter study. Acad Radiol 2024:S1076-6332(24)00672-X. [PMID: 39332989 DOI: 10.1016/j.acra.2024.09.023] [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: 07/28/2024] [Revised: 09/05/2024] [Accepted: 09/06/2024] [Indexed: 09/29/2024]
Abstract
RATIONALE AND OBJECTIVES The first-line treatment for prolactinoma is drug therapy with dopamine agonists (DAs). However, some patients with resistance to DA treatment should prioritize surgical treatment. Therefore, it is crucial to accurately identify the drug treatment response of prolactinoma before treatment. The present study was performed to determine the DA treatment response of prolactinoma using a clinical radiomic model that incorporated radiomic and clinical features before treatment. MATERIALS AND METHODS In total, 255 patients diagnosed with prolactinoma were retrospectively divided to training and validation sets. An elastic net algorithm was used to screen the radiomic features, and a fusion radiomic model was established. A clinical radiomic model was then constructed to integrate the fusion radiomic model and the most important clinical features through multivariate logistic regression analysis for individual prediction. The calibration, discrimination, and clinical applicability of the established models were evaluated. 60 patients with prolactinoma from other centers were used to validate the performance of the constructed model. RESULTS The fusion radiomic model was constructed from three significant radiomic features, and the area under the curve in the training set and validation set was 0.930 and 0.910, respectively. The clinical radiomic model was constructed using the radiomic model and three clinical features. The model exhibited good recognition and calibration abilities as evidenced by its area under the curve of 0.96, 0.92, and 0.92 in the training, validation, and external multicenter validation set, respectively. Analysis of the decision curve showed that the fusion radiomic model and clinical radiomic model had good clinical application value for DA treatment response prediction in patients with prolactinoma. CONCLUSION Our clinical radiomic model demonstrated high sensitivity and excellent performance in predicting DA treatment response in prolactinoma. This model holds promise for the noninvasive development of individualized diagnosis and treatment strategies for patients with prolactinoma.
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Affiliation(s)
- Yanghua Fan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing, China
| | - Shuaiwei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuming Tao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hua Fang
- Department of Neurosurgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Anna Mou
- Department of Radiology, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdu, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Stumpf MAM, Galliano SA, Bueno CBF, Glezer A. Long-term use of clomiphene in male macroprolactinomas with persistent hypogonadism. Endocrine 2024; 85:152-157. [PMID: 38578401 DOI: 10.1007/s12020-024-03817-0] [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: 02/05/2024] [Accepted: 04/01/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Men with macroprolactinoma can present persistent hypogonadism despite normoprolactinemia achieved with clinical and/or neurosurgical treatment. Usually, testosterone replacement therapy is indicated. Nevertheless, although off-label, clomiphene citrate (CC), a selective estrogen receptor modulator, has also been used, mainly when fertility is an issue. The aim of this study is to evaluate the effectiveness of CC in recovering the gonadal axis in men with macroprolactinoma, with or without hyperprolactinemia, and evaluate its safety as a long-term therapy. METHODS This is a retrospective study including 10 men with macroprolactinoma on cabergoline treatment and persistent hypogonadism. All patients received initially 50 mg/d of CC. RESULTS The median age at diagnosis of prolactinomas was 34 (range, 26-60) years old. All patients were treated with cabergoline at a median maximum dose of 2 (1-7) mg/week, with a median time of treatment of 8.5 (2-15) years. Prolactin was still above the normal range when CC was introduced only in two patients. The mean duration of CC therapy was 3.2 (±2.8) years. Prolactin levels maintained stable (p = 0.252) and testosterone increased (p = 0.027) significantly on CC therapy. Tumor size remained stable. Eight patients (80%) maintained testosterone above 300 ng/dL and were classified as responders. Three responders succeeded in using a lower dose of CC and one of them completed withdrawal CC and maintained eugonadism. There were no side effects or safety concerns reported. CONCLUSION CC should be seen as a safe treatment option for men with macroprolactinoma and persistent hypogonadism.
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Affiliation(s)
- Matheo A M Stumpf
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of São Paulo Medical School Hospital, São Paulo, Brazil.
| | - Stefano A Galliano
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - Cristina B F Bueno
- Serviço de Endocrinologia e Metabologia, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Andrea Glezer
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of São Paulo Medical School Hospital, São Paulo, Brazil
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Zhu Z, Hu B, Zhu D, Li X, Chen D, Wu N, Rao Q, Zhang Z, Wang H, Zhu Y. Bromocriptine sensitivity in bromocriptine-induced drug-resistant prolactinomas is restored by inhibiting FGF19/FGFR4/PRL. J Endocrinol Invest 2024:10.1007/s40618-024-02408-0. [PMID: 38926262 DOI: 10.1007/s40618-024-02408-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/03/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE At present, various treatment strategies are available for pituitary adenomas, including medications, surgery and radiation. The guidelines indicate that pharmacological treatments, such as bromocriptine (BRC) and cabergoline (CAB), are important treatments for prolactinomas, but drug resistance is an urgent problem that needs to be addressed. Therefore, exploring the mechanism of drug resistance in prolactinomas is beneficial for clinical treatment. METHODS In our research, BRC-induced drug-resistant cells were established. Previous RNA sequencing data and an online database were used for preliminary screening of resistance-related genes. Cell survival was determined by Cell Counting Kit-8 (CCK-8) assay, colony formation assays and flow cytometry. Quantitative real-time polymerase chain reaction (qRT‒PCR), western blotting, immunohistochemistry, immunofluorescence and Co-immunoprecipitation (Co-IP) were used to assess the molecular changes and regulation. The therapeutic efficacy of BRC and FGFR4 inhibitor fisogatinib (FISO) combination was evaluated in drug-resistant cells and xenograft tumors in nude mice. RESULTS Consistent with the preliminary results of RNA sequencing and database screening, fibroblast growth factor 19 (FGF19) expression was elevated in drug-resistant cells and tumor samples. With FGF19 silencing, drug-resistant cells exhibited increased sensitivity to BRC and decreased intracellular phosphorylated fibroblast growth factor receptor 4 (FGFR4) levels. After confirming that FGF19 binds to FGFR4 in prolactinoma cells, we found that FGF19/FGFR4 regulated prolactin (PRL) synthesis through the ERK1/2 and JNK signaling pathways. Regarding the effect of targeting FGF19/FGFR4 on BRC efficacy, FISO and BRC synergistically inhibited the growth of tumor cells, promoted apoptosis and reduced PRL levels. CONCLUSION Overall, our study revealed FGF19/FGFR4 as a new mechanism involved in the drug resistance of prolactinomas, and combination therapy targeting the pathway could be helpful for the treatment of BRC-induced drug-resistant prolactinomas.
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Affiliation(s)
- Z Zhu
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, No.74 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - B Hu
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - D Zhu
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - X Li
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, No.74 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - D Chen
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, No.74 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - N Wu
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, No.74 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Q Rao
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, No.74 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - Z Zhang
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, No.74 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China
| | - H Wang
- Department of Neurosurgery and Pituitary Tumor Center, The First Affiliated Hospital, Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
| | - Y Zhu
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, No.74 Zhongshan Road 2, Guangzhou, 510080, Guangdong, China.
- Department of Histology and Embryology, School of Medicine, Sun Yat-Sen University, Shenzhen, 518107, Guangdong, China.
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Iglesias P. Aggressive and Metastatic Pituitary Neuroendocrine Tumors: Therapeutic Management and Off-Label Drug Use. J Clin Med 2023; 13:116. [PMID: 38202123 PMCID: PMC10779494 DOI: 10.3390/jcm13010116] [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: 11/11/2023] [Revised: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Pituitary neuroendocrine tumors (PitNETs) are the most common pituitary tumors and the second most common brain tumors. Although the vast majority (>90%) are benign, a small percentage (<2%) are aggressive. These aggressive PitNETs (AgPitNETs) are defined by the presence of radiological invasion, a high rate of cell proliferation, resistance to conventional treatments, and/or a high propensity for recurrence. Lastly, there are the rare pituitary carcinomas, also known as metastatic PitNETs (MetPitNETs), which account for only 0.2% of cases and are defined by the presence of craniospinal or distant metastases. At present, there are no definitive factors that allow us to predict with certainty the aggressive behavior of PitNETs, making the therapeutic management of AgPitNETs a real challenge. Surgery is considered the first-line treatment for AgPitNETs and MetPitNETs. Radiation therapy can be effective in controlling tumor growth and regulating hormone hypersecretion. Currently, there are no approved non-endocrine medical therapies for the management of AgPitNETs/MetPitNETs, mainly due to the lack of randomized controlled clinical trials. As a result, many of the medical therapies used are off-label drugs, and several are under investigation. Temozolomide (TMZ) is now recognized as the primary medical treatment following the failure of standard therapy (medical treatment, surgery, and radiotherapy) in AgPitNETs/MetPitNETs due to its ability to improve overall and progression-free survival rates in responding patients over 5 years. Other therapeutic options include pituitary-targeted therapies (dopamine agonists and somatostatin analogs), hormonal antisecretory drugs, non-hormonal targeted therapies, radionuclide treatments, and immunotherapy. However, the number of patients who have undergone these treatments is limited, and the results obtained to date have been inconsistent. As a result, it is imperative to expand the cohort of patients undergoing treatment to better determine the therapeutic efficacy and safety of these drugs for individuals with AgPitNETs/MetPitNETs.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), 28222 Madrid, Spain
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Alzahrani AS, Bin Nafisah A, Alswailem M, Moria Y, Poprawski D, Al-Hindi H, Pacak K. An aggressive cabergoline-resistant, temozolomide-responsive macroprolactinoma due to a germline SDHB pathogenic variant in the absence of paraganglioma or pheochromocytoma. Front Endocrinol (Lausanne) 2023; 14:1273093. [PMID: 38152133 PMCID: PMC10751293 DOI: 10.3389/fendo.2023.1273093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/24/2023] [Indexed: 12/29/2023] Open
Abstract
Context Germline succinate dehydrogenase subunit B (SDHB) pathogenic variants are characteristic of familial paraganglioma (PGL) syndrome type 4. This syndrome frequently presents with abdominal PGL and has high tendency for locally aggressive behavior and distant metastasis. The vast majority of pituitary adenomas (PAs) are sporadic. However, PAs can be part of a number of familial tumor syndromes such as multiple endocrine neoplasia type 1 (MEN 1) or more rarely in association with pheochromocytoma and PGL (referred to as 3P syndrome). Only a limited number of PAs in association with SDHB-related PGL has been reported and the vast majority occurred subsequently or simultaneously with pheochromocytoma/PGL (collectively abbreviated as PPGL). In this report, we describe a young patient who had a giant pituitary macroprolactinoma resistant to large doses of cabergoline (CBG) and external beam radiotherapy (XRT). The patient did not have personal history of PPGL but was found to carry a germline SDHB pathogenic variant. Case report A 38-year-old woman presented with headache, visual disturbances and galactorrhea and was found to have a 34-mm macroprolactinoma. She was treated with CBG 3-4 mg per week but PA continued to grow and caused significant cranial pressure symptoms. She underwent two transsphenoidal surgeries with rapid tumor recurrence after each one. She received XRT but PA continued to grow. She was finally treated with temozolomide with excellent response. Whole exome and subsequent Sanger sequencing confirmed that she has a pathogenic monoallelic SDHB mutation (NM_003000:c.C343T, p.R115*). PA tissue showed loss of heterozygosity for the same mutation and absent SDHB immunostaining confirming the pathogenic role of this SDHB mutation. Conclusion Germline SDHB mutations can rarely cause PA in the absence of PPGL. They should be considered as a possible cause of aggressiveness and resistance to dopamine agonists in similar cases.
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Affiliation(s)
- Ali S. Alzahrani
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Abdulghani Bin Nafisah
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- College of Science, King Saud University, Riyadh, Saudi Arabia
| | - Meshael Alswailem
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Yosra Moria
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Dagmara Poprawski
- Oncology Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Hindi Al-Hindi
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, United States
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Sosa-Eroza E, Espinosa-Cárdenas E. Long-term Discontinuation of Dopamine Agonist Treatment in Patients with Prolactinomas Revisited. Arch Med Res 2023; 54:102893. [PMID: 37806785 DOI: 10.1016/j.arcmed.2023.102893] [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: 05/31/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Abstract
The most common type of functioning pituitary adenomas is prolactinomas; unlike other types, they are treated medically with dopamine agonists (DA). This treatment aims to normalize PRL levels and decrease tumor size by 50% or more. These objectives are typically achieved by 90% of patients with microprolactinoma, two-thirds of those with macroprolactinomas, and about half of those with giant prolactinomas. Life-long pharmacological treatment implies costs, discomfort, and the possibility of side effects, therefore, it has been suggested that DA discontinuation could be attempted in some patients. Long-term remission seems more likely in who, after 2 years of therapy achieve clinical, biochemical, and imaging remission criteria: no evidence of hypogonadism, a normal PRL level (preferably <5 ng/mL), and a >50% of tumor size reduction. Long-term remission seems to be more likely if the patient has been treated with cabergoline (CBG) for a minimum of 2 years, the PRL levels have normalized, tumor size has decreased by at least 50%, and the DA dose can gradually be tapered down to 0.25-0.5 mg per week. After treatment withdrawal, about 65% of patients experience a recurrence of hyperprolactinemia within the first 12 months of DA discontinuation. Although in most patients in whom DA discontinuation has been attempted, the hyperprolactinemia will recur, not all of them will require re-initiation of treatment. A good clinical judgement is crucial to identify those patients who need life-long treatment.
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Affiliation(s)
- Ernesto Sosa-Eroza
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Etual Espinosa-Cárdenas
- Endocrinology Department, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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