Prolonged bleeding time due to mitotane therapy

Alternative Management of Cushing's Syndrome During Covid-19 Pandemic

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Cushing's syndrome results from prolonged exposure to glucocorticoids. Surgery is often the first-line treatment for this condition, regardless of etiology. However, the COVID-19 pandemic caused a decrease in surgical procedures due to the risk of infection transmission. There are still emergency cases of Cushing’s syndrome that are admitted to the hospital and require urgent management. The current treatment should be focused on medical management and endovascular embolization in selective cases. Embolization can be performed in facilities where there aretrained personnel with experience in adrenal embolization. Surgery, which traditionally is a first-line therapy, can increase the risk of infection, therefore, it should be avoided. The current review provides a brief description of the possible options for the management of adrenal Cushing’s syndrome during the COVID-19 pandemic.

Pharmacological management of Cushing's syndrome: an update

The treatment of choice for Cushing's syndrome remains surgical. The role for medical therapy is twofold. Firstly it is used to control hypercortisolaemia prior to surgery to optimize patient's preoperative state and secondly, it is used where surgery has failed and radiotherapy has not taken effect. The main drugs used inhibit steroidogenesis and include metyrapone, ketoconazole, and mitotane. Drugs targeting the hypothalamic-pituitary axis have been investigated but their roles in clinical practice remain limited although PPAR-gamma agonist and somatostatin analogue som-230 (pasireotide) need further investigation. The only drug acting at the periphery targeting the glucocorticoid receptor remains Mifepristone (RU486). The management of Cushing syndrome may well involve combination therapy acting at different pathways of hypercortisolaemia but monitoring of therapy will remain a challenge.

Adrenal cortical carcinoma--review of current knowledge and treatment practices

Adrenal cortical carcinoma is a rare endocrine malignancy with a poor long-term prognosis. Accurate diagnosis and preoperative evaluation of the patient presenting with an adrenal mass maximize the opportunity for optimal treatment planning. Surgery still offers the best chance for cure. Despite curability with complete surgical resection, the rate of recurrence is unacceptably high. In metastatic or recurrent disease, systemic treatment options are limited to chemotherapy with or without mitotane. Therapeutic options are often outdated and associated with significant toxicities. A multidisciplinary approach has the best chance for offering optimized management of this lethal disease. Improved understanding of the molecular pathogenesis of this rare malignancy will lead to advancement in the available therapies that may improve this outcome.

Mitotane associated with cisplatin, etoposide, and doxorubicin in advanced childhood adrenocortical carcinoma: mitotane monitoring and tumor regression

PURPOSE

To define a mitotane dose for pediatric patients with adrenocortical cancer (ACC) that maintains therapeutic plasma levels (TL) between 14 and 20 microg/mL and to verify its antitumor efficacy in association with 8 cycles of cisplatin, etoposide, and doxorubicin (CED).

METHODS

Powdered mitotane was dissolved in a medium chain triglyceride oil and administered to 11 children with ACC (2.4 to 15.4 y of age); an initial low dose was increased to 4 g/m2/d. Ten of the 11 children had a germline TP53 R337H mutation. Mitotane plasma levels were determined using high-performance liquid chromatography.

RESULTS

The mitotane dose to maintain TL in 7 patients ranged from 1.0 to 5.3 g/m2/d. Six children reached mitotane levels of 10 microg/mL in 3.6 months (1.5 to 5.0 mo), whereas 5 children took 8 months (6.5 to 12.5 mo). Minor to partial tumor remission was found in 5 patients (<1 y) and complete remission was found in 2 patients. Of the 3 patients who are alive at the time of report, 1 patient has been without disease for 16 months, and 2 patients have progressive disease. All patients had recurrent metastatic disease (2 to 9 times). Mitotane toxic effects were nausea, diarrhea, vomiting, neurologic alterations, gynecomastia, a rare case of hypertensive encephalopathy, and CED-related hematologic toxic effects.

CONCLUSIONS

Mitotane daily dose to maintain TL is variable and monitoring should start 1.5 months after the beginning of treatment. CED combined with mitotane is the best available pharmacologic treatment for ACC, but further studies are required to characterize different profiles of therapeutic response.

Management of adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare neoplasm with poor prognosis. Patients present with signs of steroid hormone excess (e.g. Cushing's syndrome, virilization) or an abdominal mass. Tumour size at presentation (mean diameter at diagnosis > 10 cm) is the most important indicator of malignancy. In addition, computed tomography (CT) typically demonstrates an inhomogeneous adrenal lesion with irregular margins and variable enhancement of solid components after intravenous contrast media. Magnetic resonance imaging (MRI) is equally effective as CT and is particularly helpful to visualize invasion into large vessels. Complete tumour removal (R0 resection) offers by far the best chance for long-term survival and therefore surgery is the treatment of choice in stage I-III ACC. Despite tumour resection for cure most patients will eventually develop local recurrence or distant metastases. Thus adjuvant treatment options need to be evaluated in high-risk patients (e.g. radiation therapy of the tumour bed and/or chemotherapy). In tumour recurrence re-operation should always be considered. In metastatic disease (stage IV ACC) not amenable to surgery mitotane (o,p'DDD) remains the first-line therapy. Drug monitoring is needed for effective treatment aiming at concentrations between 14 and 20 mg/l. Patients not responding to mitotane may benefit from cytotoxic chemotherapy (23% partial remissions, 4% complete remissions). Only large prospective multicentre trials comparing different treatment options will allow to make systematic progress in the management of ACC.

Cortisol and the renal handling of electrolytes: role in glucocorticoid-induced hypertension and bone disease

Hypertension and osteoporosis are characteristic clinical features in patients with Cushing's syndrome or in those on glucocorticoid (GC) treatment. These two distinct complications of GC excess share one common denominator: an abnormal handling of cations, sodium (Na(+)) and calcium (Ca(2+)), either primarily or in part by the kidney tubule. The principal mechanism of GC-induced hypertension is overstimulation of the non-selective mineralocorticoid receptor (MR), resulting in renal Na(+) retention, volume expansion and finally to an increase in blood pressure. In mineralocorticoid target organs, such as the kidney, the MR is protected from GC occupation by the enzyme 11beta-hydroxysteroid dehydrogenase type 2 (11betaHSD2), a gate-keeping enzyme, which converts cortisol to receptor-inactive cortisone. This enzyme allows aldosterone to be the physiological agonist of the MR despite significantly higher circulating levels of cortisol. Kinetic properties of 11betaHSD2 suggest that saturability of this enzyme can already be achieved at high-normal physiological plasma cortisol levels, thereby leading to ovestimualtion of the MR by cortisol in states of GC excess. The mechanisms of GC action on bone turnover are more complex. GCs increase bone resorption, inhibit bone formation and have an indirect action on bone by decreasing intestinal Ca(2+) absorption, but also inducing a sustained renal Ca(2+) excretion. The latter appears to be mediated through stimulation of the MR by GC. The prevention and treatment of GC-induced hypertension and osteoporosis include the use of the minimal effective dose of GC, some general measures, and the use of some specific drugs. Modulation of renal Na(+) and Ca(2+) excretion with some, but not all, diuretics represents an important specific (for hypertension) or supportive (for bone disease) therapeutic intervention.

The medical management of Cushing's syndrome

Cushing's syndrome results from prolonged exposure to excessive circulating glucocorticosteroids, and is associated with significant morbidity and mortality. While the treatment of choice in most patients is surgical, the metabolic consequences of the syndrome, including increased tissue fragility, poor wound healing, hypertension, and diabetes mellitus, increase the risks of such surgery. The hypercortisolemia and its sequelae can be efficiently reversed using medical therapy, either as a temporary measure prior to definitive treatment, or longer term in more difficult cases. Drug treatment has been targeted at the hypothalamic/pituitary level, the adrenal glands, and also at the glucocorticoid receptor level. In this review we discuss the pharmacotherapeutic agents that have been used in Cushing's syndrome, and their efficacy, the monitoring of treatment, and potential therapies that may prove useful in the future in this complex endocrinological disorder.

Hodgkin's disease and the malignant lymphomas

The unanticipated finding of a subcutaneous swelling, typically an enlarged lymph node in the neck, is legitimate cause for concern. After excluding benign or reactive conditions, this sign should initiate a series of investigations to characterize the neoplasm and, in the case of a lymphoma, lead to prompt treatment aimed at cure. The classic description of such cervical adenopathy is that by Thomas Hodgkin, who clearly recorded both the clinical behavior and the macroscopic findings evident at dissection. Subsequent histologic study revealed the multinucleate giant cells that characterize the tumor that now bears his name and linked it to those of Greenfield, Sternberg, and Reed. Initial debate centered on whether this entity was inflammatory or malignant, with the issue further clouded by the frequent coexistence of tuberculosis. Although a number of features exist in favor of both concepts, current consensus places it among the neoplastic processes. Hodgkin's disease was separated from other malignant lymphomas as agreement on diagnostic criteria emerged. The next major step forward was the demonstration, first by Vera Peters and then by Henry Kaplan, that adequate doses of radiotherapy were curative when delivered to treatment fields that encompassed the tumor. A further milestone was the introduction by Vincent DeVita, Jr., and his colleagues of combination chemotherapy that was effective in late stage of disseminated disease. The established cornerstones of managing these patients are accurate diagnosis; precise anatomic staging, modified as appropriate by associated factors known to have prognostic value; and selection of irradiation, chemotherapy, or whatever combination will result in the best possible patient survival. However, success is not universal, and death due to resistant or relapsing disease is encountered all too frequently. It is here that the benefits of a multidisciplinary approach are evident, because a substantial level of expertise coupled with sound judgment is needed to salvage these individuals, often by means of investigational programs. Some of the latter are limited by profound myelosuppression, and safety may center on the use of cytokines in the form of interleukins and growth factors, with or without bone marrow transplantation. In such situations, benefit must be balanced against risks in well-structured clinical trials that embody informed consent. Herein lies one of the major goals for the next decade. The non-Hodgkin's lymphomas can conveniently be considered in two broad categories. Some follow an indolent clinical course, in which the lymph node retains a follicular pattern with small component cells, and others are aggressive tumors, in which primitive blasts have diffusely effaced the glandular architecture.(ABSTRACT TRUNCATED AT 400 WORDS)